Stridor after total thyroidectomy
Four hours after a total thyroidectomy for multinodular goitre, a 61-year-old woman becomes agitated with noisy breathing. The wound is tense and swollen and her oxygen saturation is falling.
Questions & answers
Q1 What is happening and what do you do first?
A tension haematoma compressing the airway. This is a bedside emergency: open the skin and deep cervical sutures immediately to evacuate the clot, call for senior surgical and anaesthetic help, give oxygen, and take the patient to theatre for washout and haemostasis. Do not wait for imaging or transfer.
Q2 List the complications of thyroidectomy.
Immediate: haemorrhage and airway obstruction, recurrent laryngeal nerve injury, external branch of the superior laryngeal nerve injury (loss of high pitch). Early: hypocalcaemia from parathyroid injury, thyrotoxic storm in inadequately prepared Graves’ disease. Late: hypothyroidism, hypertrophic scar, permanent hypoparathyroidism.
Q3 How is postoperative hypocalcaemia detected and treated?
Perioral paraesthesia, cramps, Chvostek and Trousseau signs, and a prolonged QT interval. Check corrected calcium and PTH at 4–24 hours. Mild cases take oral calcium with alfacalcidol; symptomatic or severe hypocalcaemia (below about 1.9 mmol/L) needs slow intravenous calcium gluconate with cardiac monitoring.
Q4 How is recurrent laryngeal nerve function assessed?
Documented laryngoscopy before and after operation in the standard pathway. Unilateral palsy causes hoarseness and a weak cough; bilateral palsy causes stridor and may need reintubation or tracheostomy. Intraoperative nerve monitoring aids identification but does not replace careful anatomical dissection.
References
- British Association of Endocrine and Thyroid Surgeons, national guidelines.
- Bailey & Love’s Short Practice of Surgery, 28th ed., ch. 51 (The thyroid gland).