Thyroidectomy: understanding the potential for complications
Thyroid hormones are responsible for several important metabolic functions in the body including, (a) controlling growth and development, (b) regulating carbohydrate and lipid metabolism, and (c) stimulating oxygen consumption by the cells. Alterations in thyroid hormone production may result in deleterious effects for the patient, often necessitating removal of the gland.
Removal of the thyroid gland (thyroidectomy) is a relatively common surgical procedure. However, as with any operative procedure, there is the possibility of serious complications. The purpose of this article is to describe the anatomy and function of the thyroid gland, and the pathophysiologic processes that may necessitate removal. Potential postoperative risks and complications are described in order for nurses to intervene early to reduce morbidity and mortality. A case study demonstrates optimal medical-surgical nursing care.
Thyroid Structure and Function
The largest of the endocrine glands, the thyroid is located in the anterior neck directly below the larynx. Shaped like a butterfly, the thyroid gland is highly vascular with two lobes, one on either side of the trachea joined by a small band of tissue called the isthmus (see Figure 1). The gland is firmly fixed by fibrous tissue to the anterior and lateral parts of the larynx and trachea. Not normally visible on inspection, the thyroid gland is palpable during swallowing when it is upwardly displaced (Kirsten, 2000).
[FIGURE 1 OMITTED]
Thyroid tissue mainly comprises follicular cells that produce and secrete thyroxine (T4) and the biologically more active triiodothyronine (T3). The remaining perifollicular cells secrete calcitonin which is essential for calcium utilization. An abundant supply of blood is provided to the gland by four major thyroid arteries. Most individuals possess a fifth artery called the thyreoidea ima that branches from the arch of the aorta, and enters the thyroid at the midline (Kemle, Shiffert, & Ayachi, 199(;).
The thyroid gland is innervated by sympathetic and parasympathetic divisions of the autonomic nervous system. Specifically, the superior laryngeal nerves (SLNs) and the recurrent laryngeal nerves (RLNs) inner-rate the thyroid gland. The SLNs provide sensation to the larynx above the level of the vocal cords and innervate the cricothyroid muscles that tense the vocal cords. The RLNs provide motor function to the laryngeal muscles that alter the tension and the length of vocal cords (Shaha & Bernard, 1998).
An important anatomical feature is the presence of the parathyroid glands that lie on either side of the thyroid (see Figure 2). Parathyroid hormone, along with Vitamin D, regulates calcium and phosphorus concentrations in the body. Surgical manipulation of the thyroid has the potential to compromise blood flow to the parathyroid glands resulting in transient hypocalcemia (Shaha & Bernard, 1998).
[FIGURE 2 OMITTED]
With the exception of the brain, spleen, testes, and uterus, the metabolic rate of all other cells within the body is dependent on adequate production and release of thyroid hormone (TH) into the systemic circulation. Altered thyroid hormone production, either in excess (hyperthyroidism) or deficit (hypothyroidism), may negatively affect cellular metabolism, cardiovascular function, gastrointestinal function, and neuromuscular function (Kirsten, 2000).
Thyroxine (T4) is manufactured solely by the thyroid gland, whereas 80% of triiodothyronine (T3) is derived from the conversion of T4 to T3 in the peripheral tissues. The remaining 20% comes from the thyroid gland (Kemle et al., 1996; Kirsten, 2000). Thyroid hormone synthesis depends upon an adequate intake of dietary iodine; the thyroid gland serves as a reservoir for ingested iodine.
The production and release of TH is regulated through a hormonal feedback-loop mechanism that involves the hypothalamus, the anterior pituitary gland, and the thyroid gland. The hypothalamus produces thyrotropin-releasing hormone (TRH), which stimulates the pituitary gland to produce thyroid-stimulating hormone (TSH). The TSH in turn activates the thyroid gland to produce and release T4 and T3.
T4 and T3 enter the systemic circulation bound to plasma proteins. Only very small amounts of T4 and T3 circulate in their biologically active free form (Kemle et al., 1996; Kirsten, 2000). The free form of T4 and T3 helps to maintain adequate levels within the body by exerting negative feedback on the hypothalamus and pituitary gland to inhibit further production and hormone release. Even small changes in biologically active free thyroid hormone concentrations result in immediate changes in TSH secretion, making TSH a very sensitive marker of thyroid status.
A variety of diagnostic tests are available to confirm thyroid dysfunction. These include: total T4 and T3, free-T4, free-T3, T3 resin uptake, and TSH levels. No single diagnostic test can be relied on exclusively. Exogenous factors such as medications and endogenous conditions such as nonthyroidal diseases may affect laboratory values. The recent development of ultra-sensitive thyroid stimulating hormone (TSH) assays has greatly facilitated the diagnosis of thyroid disease. Thyroid function testing has been transformed from thyroxine-based strategies to TSH-based strategies, with thyroxine levels acting as a confirming measurement (Braverman, Dworkin, & MacIndoe, 1997). Commonly used laboratory tests and their normal values are listed in Table 1.
Thyroid dysfunction as a result of nodules may show a normal or suppressed TSH level depending on the underlying pathology (Braverman et al., 1997). Other diagnostic studies used to evaluate thyroid nodules include scintigraphy, ultrasound, and fine-needle aspiration biopsy.
Alterations in Thyroid Function
Two conditions that may necessitate removal of the thyroid gland are hyperthyroidism and the presence of thyroid nodules. When conservative measures such as medications and radioactive iodine treatments are not successful in either restoring thyroid function to normal or ameliorating abnormal tissue growth, the patient may require a thyroidectomy.
Hyperthyroidism occurs as a result of excessive circulating levels of thyroid hormone in the blood. The disease affects more women (2%) then men (0.2%), with the typical patient being in her mid-20s or 30s (Schilling, 1997). The hallmark of hyperthyroidism is an increase in cellular metabolism. Signs and symptoms include increased heart rate, weight loss, nervousness, irritability, and insomnia (see Table 2). Treatment for hyperthyroidism may initially involve noninvasive modalities such as anti-thyroid drugs to stop thyroid hormone production, and synthesis and radioactive iodine to slow thyroid production. When noninvasive modalities are ineffective, either partial or total removal of the gland may be indicated (Schilling, 1997).
Hyperthyroidism has many causes including a toxic diffuse goiter (Graves’ disease), thyroiditis, excessive ingestion of thyroid hormone, and anterior pituitary gland abnormality (see Table 3). Manifestations of excessive circulating TH are described in Table 2. The severity of the patient’s pre sentation is related to the duration of the disorder, the magnitude of TH excess, and the patient’s age.
A comprehensive history and physical examination should be performed with an emphasis on gentle thyroid palpation and auscultation to determine size, nodularity, and vascularity. An eye exam should also be performed to detect any evidence of diplopia, photophobia, eye irritation, and exophthalmos, the forward protrusion of eyeballs (see Figure 3) associated with Graves’ disease (Kemle et al., 1996; Schilling, 1997). Three treatment modalities are typically considered for patients with hyperthyroidism: radioactive iodine, anti-thyroidal drugs, and surgical intervention.
[FIGURE 3 OMITTED]
Although not usually an initial treatment modality, surgical intervention is sometimes used to treat patients diagnosed with Graves’ disease (diffuse goiter). The thyroid gland in these patients can be enlarged two to six times the normal size (Schilling, 1997). Surgery may also be indicated for patients diagnosed with hyperthyroidism who are intolerant or refractory to standard medical modalities of treatment (Bliss, Nirmal, Guinea, Reeve, & Delbridge, 1999; George & Rowe, 1998).
Thyroid nodules, a common diagnosis, are benign or malignant growths that occur on an otherwise normal thyroid gland. Approximately 275,000 thyroid nodules were detected in the United States in 1999. Of these, 17,000 were cancerous (Ashok, 2000). Fortunately, thyroid cancer constitutes only about 1% to 2% of all malignant neoplasms. Thyroid cancer is higher in Caucasians than African-Americans and is three times more common in women than men.
Nodules are usually discovered by the patient or during a routine physical examination (Castro & Gharib, 2000). Data from palpation screening alone attests to the prevalence of thyroid nodules in the general population, which ranges from 4% to 7%. Other diagnostic studies used to evaluate nodules include serum thyrotropin (TSH) levels and imaging studies, such as scintigraphy and ultrasound. Fine-needle aspiration biopsy remains the most effective method to differentiate between benign and malignant thyroid nodules (Ashok, 2000).
Enlarged nodules may cause pain in the throat area. Although rare, some patients may complain of swallowing difficulty when a nodule becomes so large as to impede the passage of food through the esophagus. Risk factors include increasing age, female sex, iodine deficiency, and a history of head and neck irradiation.
Indications for removing thyroid nodules include malignancy and interference with ventilation as a result of enlargement and tracheal compression (see Figure 4). Proper postoperative nursing management is essential to prevent potentially life-threatening complications because of the thyroid’s anatomical relationship to the airway, surrounding nerve supply, and the abundant vascularity (Castro & Gharib, 2000; Schilling, 1997).
[FIGURE 4 OMITTED]
Since 95% of thyroid nodules are benign and do not present with symptoms, most endocrinologists agree that surgical intervention is generally indicated for malignant lesions or benign nodules that interfere with breathing or swallowing (Cohen-Kerem, Schachter, Maxim, & Baron, 2000; Moore & Haughey, 1997).
Depending on the underlying pathology, surgical intervention will involve one of five different approaches. These include: (a) partial thyroid lobectomy (removal of the upper or lower portion of one lobe), (b) thyroid lobectomy (removal of one entire lobe), (c) thyroid lobectomy with isthmusectomy (removal of one lobe and the isthmus), (d) subtotal thyroidectomy (removal of one lobe, the isthmus, and a majority of the opposite lobe), and (e) total thyroidectomy (removal of the entire gland) (George & Rowe, 1998).
Medical-surgical nurses must recognize complications that may arise as a result of the surgical procedure. Following partial or complete removal of the thyroid, complications may occur because of either the surgical procedure or secondary metabolic disturbances. Frequently seen complications include postoperative bleeding, infection, and parathyroid deficit. Complications that occur less frequently are thyroid storm, sympathetic nerve injury, and chylous fistula formation (see Table 4).
Nurses should perform a thorough assessment that provides important and physical psychosocial data (see Table 5). Assessment data should be collected including the patient’s cardiac and respiratory status, muscle strength, elimination patterns, integumentary condition, weight history, voice quality, and emotional state (Clement, 1998). Hyperthyroid patients may have thin, textured skin and edema of the lower extremities that places them at risk for injury during surgery and contributes to potential complications such as infection and poor wound healing post-operatively. Assessment of voice quality provides baseline data for the nurse to detect evidence of nerve injury postoperatively.
Various degrees of airway obstruction and dysphagia may be present in patients with thyroid problems. Therefore, enlargement of the patient’s neck and difficulty swallowing or breathing must be assessed and documented. Baseline laboratory data include complete blood count and chemistry, thyroid hormone levels, serum calcium, and phosphorus concentrations (LeMone & Burke, 2000).
Patients may express anxiety preoperatively in anticipation of the surgery. Because this incision is made at the base of the throat, altered body image and the cosmetic impact of surgery can cause concern, particularly in female clients. The nurse should openly discuss these feelings with the patient and provide appropriate interventions to alleviate stress and anxiety. The nurse should explain to the client that the scar will eventually be only a thin line that jewelry or scarves will cover. It is important to ascertain that adequate preoperative teaching has been done. The patient and family should be informed of what to expect immediately after the operation.
The initial postoperative phase begins when the patient arrives in the postanesthesia recovery room. Care should be directed to postanesthetic priorities, including monitoring cardiopulmonary status, neurologic status, comfort level, surgical wound condition, and the metabolic state.
The second postoperative phase begins when the patient is transferred to the unit. Routine postoperative care should be initiated. This includes monitoring of vital signs, intake and output, and supplemental oxygen if needed. The initial assessment of the patient should include level of consciousness, vital signs, wound dressing, and drainage tubes (amount and type). Also, any intravenous solutions should be documented in the patient care record. Cardiac rate and rhythm are assessed via the EKG monitor, and pulse oximetry should be used to determine oxygen saturation levels (see Table 6) (Clement, 1998; LeMone & Burke, 2000).
An immediate postoperative complication following surgery may involve airway obstruction. Airway obstruction may result from laryngospasm, laryngeal edema due to surgical manipulation, tracheal compression from hematoma formation, or laryngeal obstruction due to bilateral cord paralysis. Because of these potential airway complications, the nurse should continually assess and document respiratory status, oxygen saturation levels, and airway patency. Oxygen saturation levels should be greater than 95%. An emergency treatment cart with a tracheostomy tray should readily available (LeMone & Burke, 2000).
Common Complications of Thyroid Surgery
Thyroid surgery is associated with several common complications. These include bleeding, infection, and parathyroid deficit.
Bleeding. As with any surgical procedure, patients undergoing thyroid surgery are at risk for bleeding. The abundant blood supply to the thyroid and the dissection that occurs during removal of the gland contribute to the potential for postoperative bleeding. Hematoma formation surrounding the operative site may lead to tracheal compression resulting in airway obstruction. To minimize this complication, surgeons may insert a drain in the surgical site (George & Rowe, 1998).
Postoperative nursing assessment includes frequent observation of the anterior and posterior dressing where blood and secretions may accumulate with the patient in supine position. It is important for nurses to note the initial condition of the dressing to determine if postoperative bleeding or oozing occurs. Nurses must document their observations of the neck dressing. The presence of surgical drains should also be documented including the amount and consistency of drainage, and the functioning status of equipment.
Neck dressings should be monitored closely for changes in fit or comfort. The edge of the neck dressing should be inspected to detect neck swelling (LeMone & Burke, 2000). A change in the fit of the dressing or circumference of the neck may indicate the formation of a hematoma. Physiologic parameters such as hypotension and tachycardia may indicate the presence of postoperative bleeding. Changes in mental status, vital signs, dressing fit, neck size, and suspicion of bleeding must be reported to the surgeon immediately.
Infection. Postoperative infection is a risk following any type of surgery. The presence of odorous discharge should be assessed and reported. Monitoring the temperature and complete blood count for signs of infection is an important nursing function. Due to significant advances in antibiotic therapy and meticulous wound care, postoperative infections are uncommon.
Parathyroid deficit. Since the parathyroid glands lie on either side of the thyroid gland, hypoparathyroidism is a complication that may occur following thyroidectomy. Symptoms of hypo parathyroidism usually occur 24 to 72 hours postoperatively. The patient will exhibit low serum calcium levels (hypocalcemia), and may complain of numbness and tingling of the hands, feet, and lips. Intervention is aimed at restoring calcium levels to normal to prevent the occurrence of seizures and laryngeal stridor (Prim, De Diego, Hardisson, Madero, & Gavilan, 2001).
Serum calcium levels should be measured daily if patients are symptomatic. Nurses should assess for numbness or tingling around the lips or hands. Trousseau and Chvostek signs indicate hypocalcemia and the potential for tetany. A positive Trousseau’s sign is carpal spasm induced by arterial occlusion of the arm with a blood pressure cuff. A positive Chvostek’s sign is elicited by tapping the facial nerve and observing for facial nerve irritability/spasms. Symptoms of hypocalcemia are treated with calcium replacements, such as 10% calcium gluconate solution administered intravenously (Clement, 1998; LeMone & Burke, 2000).
Though rare, additional complications may occur following thyroid surgery.
Nerve injury. Laryngeal nerve damage is a potential complication following thyroid surgery. Nurses should monitor and evaluate voice quality, swallowing, and respiratory status postoperatively (LeMone & Burke, 2000). Potential injury to either the recurrent laryngeal nerves (RLNs) or superior laryngeal nerves (SLNs) may result from severing, clamping, compressing, or stretching. A bilateral RLN injury is a life-threatening complication that results in airway obstruction and necessitates immediate intervention. Patients with this type of nerve injury present with signs and symptoms of inspiratory stridor, dyspnea, tachypnea, and nasal flaring (Prim et al., 2001). A unilateral RLN injury causes the voice to be hoarse and breathy, the cough is weak and aspiration may occur. Aspiration is more likely with SLN injury. Changes in voice quality or a loss of protective airway reflexes place patients at risk for aspiration and should be reported immediately to the physician and documented in the medical record.
Thyroid storm. Thyroid storm or severe thyrotoxicosis is a life-threatening crisis. It is characterized by extremely exaggerated signs and symptoms of hyperthyroidism and usually occurs intraoperatively or up to 18 hours postoperatively (see Table 7). Causes include surgical manipulation of the gland subjecting it to stress and/or thyroid activity that has not been adequately controlled preoperatively. Patients will exhibit signs and symptoms of agitation, disorientation, hyperpyrexia, frequent watery stools, and in severe cases, congestive heart failure. If not treated aggressively, thyroid storm may progress to coma and death (Clement, 1998; Kemle et al., 1996).
Once thyroid storm is identified, treatment is aimed at symptom management. The reduction of circulatory thyroid hormone should not be delayed. Drug management includes antipyretics to reduce fever (aspirin should be avoided as it is known to increase thyroid hormone levels), antithyroid drugs, potassium iodide (SSKI), propylthiouracil (PTU), dexamethasone, and beta blockers.
Fistula formation. A chylous fistula results from damage to the thoracic duct during surgery. Signs of this complication include the presence of profuse and continuous drainage of chyle (a milky or opaque fluid) from the operative site (Moore & Haughey, 1997).
Although rare, complications following thyroidectomy may be potentially life threatening. Therefore, prompt recognition and intervention are imperative. Providing optimal nursing care for the postoperative patient is grounded on a solid foundation of knowledge concerning the structure and function of the thyroid gland. Caring for the patient can be challenging for medical-surgical nurses who must be adept at discriminating and reporting assessment findings. Medical-surgical nurses’ knowledge will help to improve patient outcomes, reduce complications, and decrease morbidity.
A 30-year-old female was transferred to the surgical floor from the postanesthesia care unit (PACU) following a complete thyroidectomy. The patient gave a history of thyroid nodules increasing in size and number after having been monitored for a period of about 1 year. In the PACU, the patient had a normal blood pressure (120-130 systolic) and sinus tachycardia at a rate of 110/minute.
At 1300 hours, she arrived on the medical-surgical unit where she was drowsy but oriented to time, person, place, and surroundings. She complained of pain at the operative site, at a level of 8 on a scale of 1 to 10. The pulse oximeter showed a tachycardia at a rate of 116/minute and an oxygen saturation of 98%. Her noninvasive blood pressure was 122/68 mmHg; respiratory rate was 22/minute and clear bilaterally. Her oral temperature was 98.4 degrees F. An infusion of 5% dextrose and 45% normal saline was infusing at a rate of 125 ml per hour.
During the admission assessment, the medical-surgical nurse noted that the patient’s airway was patent and that voice quality remained unchanged. The anterior and posterior neck dressing was clean and dry with a comfortable fit. The patient was given Demerol[R] 75 mg intramuscularly to control her pain. Subsequent documented assessments throughout the remainder of the day shift and into the evening shift stated that the vital signs stabilized at 118/72, heart rate of 92, respirations at 22, and an oral temperature of 98.8 degrees F. During the night shift, the patient was medicated once for pain and allowed to sleep undisturbed.
At 0700 hours the next morning, the day shift nurse began routine patient assessment rounds. It was noted that the patient was not easily aroused. The patient’s cardiac rhythm was sinus tachycardia at a rate of 132 beats per minute. Blood pressure was 96/50 and respiratory rate was 28 per minute. Bilateral crackles were heard at the bases of the lungs, but lung sounds were otherwise clear. Skin was pale, cool to touch, and dry. On assessment of the neck dressing, the nurse observed that the anterior dressing appeared clean and dry. Palpation of the posterior dressing revealed a moist, sticky dressing. The nurse then requested assistance to turn the patient to visually inspect the posterior neck and dressing. The nurse observed a large amount of blood that had pooled under the patient and was therefore not visible with the patient in the supine position.
The nurse placed an emergency call to the surgeon and increased the intravenous infusion to 175 ml per hour. Blood was drawn for a hematocrit and the blood bank was called to ensure that blood was on hand if needed. When the surgeon arrived, she removed the dressing and noted that the wound was oozing blood where the incision had separated. The separation was repaired at the bedside aseptically and the wound was redressed. Laboratory studies were sent and orders for strict observation of the patient and dressing were written.
The complete blood count revealed that the patient’s hematocrit was 22%. The patient was started on oxygen at 4 liters per minute by nasal cannula. Intravenous fluid therapy was changed to normal saline at a rate of 150 ml/hr and one unit of whole blood was started. The pulse oximeter remained stable at 98%. Although high, this percentage is still saturatory.
The patient was judged to be in a compensated hypovolemic shock state due to the blood loss throughout the night. During the next several hours her condition improved and her pulse and blood pressure stabilized. Three days later she was discharged home with instructions to return for further evaluation and to receive patient and family education.
Commonly Used Thyroid Function Tests with Normal Values
Test Normal Values
Serum thyroxine T4 4.5-12.0 [micro]g/dl
Free thyroxine FT4 0.7-1.9 ng/dl
Serum triiodothyronine T3 80-180 ng/dl
Free triiodothyronine FT3 230-619 pg/d
T3 Resin uptake 26%-42%
TSH Thyroid stimulating hormone 0.5-6 [micro]U/ml
Common Signs and Symptoms of Hyperthyroidism
Weight loss Alterations in appetite
Muscle weakness Fatigue
Thyroid enlargement (depending Frequent bowel movements
Diplopia or exophthalmos Sleep disturbances (including
Dependent lower-extremity edema Exertional intolerance and dyspnea
Causes of Hyperthyroidism
Toxic diffuse goiter
Toxic multinodular goiter
Excessive pituitary TSH or
Excessive ingestion of thyroid
Common Less Frequent
Laryngeal nerve injury Sympathetic nerve injury
Parathyroid deficit Chylous fistula
Postoperative bleeding Infection
Thyroidectomy: Preoperative Care
* Administer ordered antithyroid medications and iodine
preparations and monitor for side effects.
* Assess voice quality to obtain baseline.
* Teach patient to support neck by placing both hands behind
neck when sitting up in bed, moving, and coughing.
* Obtain baseline laboratory tests: CBC, thyroid hormone levels,
serum calcium, and phosphorus concentrations.
* Allow patient to verbalize concerns regarding surgical procedure.
* Provide appropriate interventions to help alleviate stress
Thyroidectomy: Postoperative Care
* Administer pain analgesic pain medications per order.
* Place patient in semi-Fowler’s position.
* Support head and neck with pillows.
Monitor for Complications
* Assess dressing and the area under the patient’s neck and
shoulders for drainage.
* Monitor blood pressure (decrease) and pulse (increase initially)
for signs and symptoms of hypovolemic shock.
* Assess neck dressing for any signs of tightness.
* Assess neck for any signs of swelling which may indicate hematoma
* Assess respiratory rate, rhythm, depth, and effort.
* Assist patient with coughing and deep breathing.
* Maintain humidification and supplemental oxygen as ordered.
* Attach patient to cardiac monitor and pulse oximetry.
* Have suction equipment and emergency tracheostomy set available.
Laryngeal Nerve Damage
* Assess voice quality, tone, and the ability to speak aloud.
* Monitor and assess for any problems with aspiration.
* Have flexible laryngoscopy equipment available.
* Thyroid storm
* Assess for exaggerated signs and symptoms of hyperthyroidism,
up to 18 hours postoperative.
* Immediate treatment should consist of supportive care and
reduction of thyroid hormone.
* Assess calcium levels.
* Assess for any tingling of toes, fingers, and lips.
* Monitor for any muscular twitches.
* Assess for positive Chvostek’s or Trousseau’s signs.
* Treat with calcium replacements intravenously.
Signs and Symptoms
* Chest pains and shortness of
* Atrial fibrillation and high
* Congestive heart failure
* Agitation, restlessness and
* Tremor, nervousness and
* Hyperpyrexia 100-106 with
flushing and sweating
* Hyperpyrexia is out of
proportion to other symptoms
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David Kumrow, MSN, RN, CNS, is an Assistant Professor of Nursing, California State University, Long Beach, CA; Director, Nursing Learning Center; and Coordinator of the Nursing Department’s Instructional Technology and Multi-Media Design Program.
Rebecca Dahlen, EdD, MSN, RN-CS, CCRN, is an Associate Professor of Nursing, California State University, Long Beach, CA.
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