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Thyroidectomy is surgery that involves the removal of the entire thyroid gland or parts of the gland. Indications for surgery include hyperthyroidism, thyroid cancer, thyroid lymphoma, and goiter, among others. Several postoperative complications exist following thyroidectomy:

  1. Laryngeal/vocal cord edema—This is the most common cause of stridor within the first 24 hours after thyroidectomy. It is usually associated with difficulty breathing. It is differentiated from hematoma or recurrent laryngeal nerve (RLN) injury because of no visible signs of neck discoloration or vocal disturbances, respectively. Acute management involves the use of racemic epinephrine. Preoperatively, for select patients, corticosteroids may help minimize the occurrence.

  2. Hematoma—This will often present with neck swelling, discoloration, pain and pressure. Like laryngeal edema, this will likely occur within the first 24 hours postop. Depending on the size, emergent surgical evacuation may be necessary. For large hematoma, it may be prudent to keep the patient spontaneously breathing while the surgical team makes a small incision and evacuation in order to relieve potential tracheal compression prior to securing the airway with endotracheal tube.

  3. Hypocalcemia—This is the most common complication of thyroidectomy. Depending on how many parathyroid glands that are inadvertently removed, signs and symptoms can go from mild to severe. Mild symptoms are transient and include paresthesias around the oral cavity, hands, and feet. Other moderate symptoms include twitches and frank cramps. This can be elicited in Trousseau’s sign (carpopedal spasm precipitated by cuff inflation) or Chvostek’s sign (facial twitching on tapping parotid gland). Calcium replacement should be instituted immediately to prevent hypocalcemia sequelae such as laryngospasm, cardiac irritability, QT prolongation, and subsequent arrhythmias. In rare situations, stridor and airway obstruction may occur from severe hypocalcemia usually 24–72 hours after surgery.

  4. Recurrent laryngeal nerve damage/vocal disturbances—Trauma to the recurrent laryngeal nerve can be caused by ischemia, traction, entrapment or transection of the nerve during surgery. The injury can be unilateral or bilateral. Unilateral injury will cause varying degrees of vocal cord paralysis with associated variable degrees of hoarseness, hypophonia, dysphagia, and/or respiratory difficulties. The most devastating complication is bilateral partial injury that can result in immediate postop stridor and inability to breathe. Immediate re-intubation should be done and in some rare cases, tracheostomy may be needed to maintain an adequate airway.

  5. Tracheomalacia—The possibility of tracheomalacia should be considered in those patients who have sustained tracheal compression from large goiters or tumors. Postoperatively, the tracheal wall may loose the surrounding support and can collapse in anteroposterior directions most especially during times of increased airflow thus causing respiratory obstruction. A cuff leak test prior to extubation may be reassuring but emergency airway equipment should be immediately available after extubation should reintubation be necessary.

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