Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk.

Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed.

Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited.

Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.

Thyroid and parathyroid surgery often involves the use of heated instruments for dissection. Whilst these are beneficial, accidental thermal damage to the exposed skin edges can occur, resulting in an unsatisfactory cosmetic outcome. Tonsil swabs can be used in head and neck surgery intra-operatively to control bleeding. This paper describes an alternative use for them in protecting wound edges during the procedure.

Damp tonsil swabs are sutured onto the wound edges after the initial skin incision. They remain present for the duration of the surgery and are removed at the time of skin closure.

The tonsil swabs provide protection and help avoid accidental injury to the skin. No complications with this technique have been experienced.

This paper describes a simple, effective and practical technique for protecting the skin during neck procedures using resources readily available in a standard ENT operating theatre.

British Thyroid Association 2014 guidelines emphasised ultrasound assessment of nodules. One ultrasonographic differentiator of debatable relevance is intra-nodular vascularity. This is the first UK study conducted to address this question.

Ultrasound reports for thyroid surgery patients over 10 years were retrospectively reviewed. Reports documenting ‘intra-nodular vascularity or flow’ were analysed. Reports identifying peripheral vascularity only or no intra-nodular flow formed the control group. Concordance with final histology was used to determine the odds ratio for malignancy.

A total of 306 patients were included, and 119 (38.9 per cent) nodules demonstrated intra-nodular vascularity. Of these, 60 (50.4 per cent) were malignant compared with 42 per cent in the control group. Intra-nodular vascularity was not a statistically significant predictor of malignancy with an odds ratio of 1.39 (p = 0.18, 95 per cent confidence interval, 0.86–2.23).

Intra-nodular vascularity in isolation was not a reliable predictor of malignancy. This supports other world literature studies. Although intra-nodular flow should not be relied upon in isolation, interpretation in conjunction with other suspicious findings enhances the predictive value.

To determine the length and position of a thyroidectomy scar that is cosmetically most appealing to naïve raters.

Images of thyroidectomy scars were reproduced on male and female necks using digital imaging software. Surgical variables studied were scar position and length. Fifteen raters were presented with 56 scar pairings and asked to identify which was preferred cosmetically. Twenty duplicate pairings were included to assess rater reliability. Analysis of variance was used to determine preference.

Raters preferred low, short scars, followed by high, short scars, with long scars in either position being less desirable (p < 0.05). Twelve of 15 raters had acceptable intra-rater and inter-rater reliability.

Naïve raters preferred low, short scars over the alternatives. High, short scars were the next most favourably rated. If other factors influencing incision choice are considered equal, surgeons should consider these preferences in scar position and length when planning their thyroidectomy approach.

Inadvertent (or incidental) parathyroidectomy can occur during thyroidectomy. However, the factors associated with inadvertent parathyroidectomy remain unclear. This study aimed to report the rate of inadvertent parathyroidectomy during thyroidectomy and associated risk factors.

Variables including fine needle aspiration cytology findings, age, sex, thyroid weight, concurrent neck dissection, extent of thyroidectomy, and the presence of cancer and parathyroid tissue within the specimen were recorded for 266 patients. The incidence of post-operative hypocalcaemia was also recorded. Univariate and multivariate analysis were performed to identify factors associated with inadvertent parathyroidectomy.

The inadvertent parathyroidectomy rate was 16 per cent. Univariate analysis revealed that cancer and concurrent neck dissection predicted inadvertent parathyroidectomy. On multivariate analysis, only concurrent neck dissection remained an independent predictor of inadvertent parathyroidectomy: it was associated with a fourfold increase in inadvertent parathyroidectomy.

The inadvertent parathyroidectomy rate was 16 per cent and concurrent neck dissection was identified as an independent predictor of inadvertent parathyroidectomy.

This study aimed to investigate the prevalence and clinical significance of solitary thyroid nodules in patients who underwent thyroid surgery.

A retrospective review was performed of the case notes of all adult patients who underwent thyroid surgery from January 2003 to December 2009. All patients with solitary thyroid nodules identified by ultrasonography were included.

In total, 225 patients underwent thyroid surgery. The prevalence of solitary thyroid nodules was 27.1 per cent (61 out of 225 patients). Seventy-two per cent of patients were women and the mean age at presentation was 52 ± 16 years. In all, 75.4 per cent of solitary nodules had neoplastic pathology and the malignancy rate was 34.4 per cent. The sensitivity and specificity of fine needle aspiration cytology for neoplasm detection were 73.9 per cent and 80.0 per cent, respectively. There was no association between the various ultrasonography parameters and malignancy risk (p > 0.05).

Solitary thyroid nodules should be investigated thoroughly with a high index of suspicion because there is a high probability (34.0 per cent) of malignancy.

This study aimed to evaluate the impact of intra-operative neuromonitoring of the recurrent laryngeal nerve during total thyroidectomy for benign goitre.

A single-centre retrospective study using historical controls was conducted for a 10-year period, comprising a series of 767 patients treated by total thyroidectomy for benign goitre. Of these, 306 had intra-operative neuromonitoring of the recurrent laryngeal nerve and 461 did not. Post-operative laryngeal mobility was assessed in all patients by direct laryngoscopy before hospital discharge and at post-operative follow-up visits.

In all, 6 out of 461 patients (1.30 per cent) in the control group and 6 out of 306 patients (1.96 per cent) in the intra-operative neuromonitoring group developed permanent recurrent laryngeal nerve palsy. No statistically significant difference was observed between the two patient groups.

Intra-operative neuromonitoring does not appear to affect the post-operative recurrent laryngeal nerve palsy rate or to reliably predict post-operative recurrent laryngeal nerve palsy. However, it can accurately predict good nerve function after thyroidectomy.

Papillary microcarcinoma of the thyroid has been described as either a normal variant or a serious malignancy. We describe our experience with papillary microcarcinoma and lymph node metastases.

A total of 685 consecutive total thyroidectomies with central compartment neck dissection were reviewed for papillary microcarcinoma. Association of central compartment lymph node metastases with age, gender, tumour multifocality, bilaterality and extrathyroidal extension was analysed.

Out of 170 papillary microcarcinoma cases, multifocality was found in 72 (42.4 per cent), bilaterality in 49 (28.8 per cent) and extrathyroidal extension in 16 (9.4 per cent). In all, 23 patients (13.5 per cent) had lymph node metastases. There was a significant association (p < 0.05) between extrathyroidal extension (but no other tumour characteristics) and lymph node metastases.

In all, 13.5 per cent of papillary microcarcinomas in our series showed lymph node metastases. Lymph node metastases were associated with extrathyroidal invasion of the papillary microcarcinoma.

To evaluate the safety and effectiveness of radiofrequency dissection in conventional ‘open’ total thyroidectomy.

Thirty-nine patients scheduled for conventional total thyroidectomy were included in a prospective randomised study. Patients were randomly assigned to one of two groups: a radiofrequency dissection method was used in one group, and a knot tying technique was used in the other.

Significantly fewer surgical instruments and materials were required for the radiofrequency dissection group than the knot tying group (p < 0.01). There were no significant differences between the two groups in mean operative time, blood loss, post-operative drainage and pain, recurrent palsy, and hypocalcaemia (p > 0.05).

Radiofrequency dissection is a safe alternative to the knot tying technique, and enables a significant reduction in the number of surgical instruments required for the operation.

The thyroid gland is removed en bloc during laryngectomy. There are no objective criteria for deciding the extent of thyroid gland resection in primary hypopharyngeal cancer cases. The present study aimed to determine the incidence of thyroid gland involvement in hypopharyngeal cancer and identify the various predictors of this involvement.

This paper reports a retrospective analysis of 358 patients with hypopharyngeal cancer, who underwent total laryngectomy with partial or total pharyngectomy at Tata Memorial Hospital, Mumbai between 2004 and 2010.

The mean age of this population was 61 years. The pyriform sinus was the most common hypopharyngeal subsite involved (in 89 per cent of cases). Most patients underwent hemi-thyroidectomy as part of their surgery. The thyroid gland was involved in only 13 per cent of cases.

Thyroid gland involvement is not common in hypopharyngeal cancer. Cases that involved the post-cricoid area, subglottic extension, extralaryngeal spread or prior tracheostomy were associated with a higher risk of thyroid gland involvement. Ipsilateral thyroidectomy is sufficient in most patients undergoing surgery (laryngectomy with partial or total pharyngectomy) for hypopharyngeal cancers.

More than a century has passed since Emil Theodor Kocher first described the use of ‘Kocher's thyroid dissector’ to secure the superior thyroid pedicle.

Despite the technological advances in thyroid surgery, the dissector remains an extremely useful instrument. This paper describes a modified use of the dissector, and reports on how this facilitates safer and easier surgery.

Application of this simple, modified technique can improve the safety and efficiency of thyroid surgery, with negligible financial outlay.

During radiation therapy, unwanted scatter to healthy tissues outside the target field may occur. Children and adolescents are more sensitive to radiation injury, and the thyroid gland is particularly susceptible to these effects.

To assess acute changes in thyroid function and volume in children and adolescents undergoing radiotherapy for a variety of non-thyroid cancers.

Thirty-one children and adolescents underwent radiation therapy of various body areas in which the thyroid was not included. Thyroid-stimulating hormone (TSH), thyroxine (T4), free thyroxine (fT4), triiodothyronine (T3), anti-thyroperoxidase antibodies and thyroglobulin were measured before, on the last day and at 1 and 3 months after the end of radiotherapy. Ultrasound scans were taken and 6- and 24-hour 131I uptake was measured before and after treatment. The scattered dose to the thyroid region was estimated with a treatment planning system or measured with thermoluminescent dosimeters.

The median radiation dose scattered to the thyroid was 296·6 cGy (IQR 16·7–1,709·0). Levels of TSH (p = 0·575), T4 (p = 0·950), fT4 (p = 0·510), T3 (p = 0·842), thyroglobulin (p = 0·620) and anti-thyroid peroxidase antibodies (p = 0·546) were statistically similar at all four time points. There were no differences between pre- and post-radiotherapy thyroid volume and 131I uptake (p = 0·692 and 0·92, respectively).

More sensitive methods may be required to ascertain whether acute injury to the follicular epithelium occurs with lower radiation doses scattered to the thyroid.

To present a rare case of lingual thyroid detected using a hybrid of single photon emission computed tomography and standard computed tomography in a young woman with hypothyroidism.

A 29-year-old woman was screened for autoimmune thyroid disorders in early pregnancy, and found to have subclinical hypothyroidism. No thyroid tissue was found in the anterior neck upon ultrasonography, raising suspicions of an ectopic thyroid. The patient was treated with levothyroxine throughout the remainder of her pregnancy, and developed postpartum thyroiditis requiring an increase in levothyroxine dosage. Whole-body scintigraphy and zoomed static head and neck scintigraphy were performed. Abnormal 99mTc-pertechnetate uptake was observed in the oral region, whereas no uptake was found in the usual thyroid location. Hybrid imaging using single photon emission computed tomography and standard computed tomography was performed to improve three-dimensional representation of the area of increased activity.

The latter imaging modality detected ectopic thyroid tissue in the tongue.

Whole body 99mTc-pertechnetate scintigraphy and a hybrid of single photon emission computed tomography and standard computed tomography are effective imaging modalities for the investigation of ectopic thyroid tissue. The latter modality is particularly recommended, as it allows more precise spatial visualisation of increased isotope uptake activity in the head and neck.

The authors present a case of diffuse fatty infiltration of the thyroid gland with coexistent deposition of amyloid protein.

A case history and brief literature review concerning amyloid goitre and fatty infiltration of the thyroid are presented, and the relationship between these two phenomena is discussed.

A patient with AA amyloidosis presented with a slowly enlarging goitre, which on histological examination was extensively infiltrated with adipose tissue. Amyloid protein was found on Congo red staining.

To our best knowledge, this patient represents the first reported case of diffuse lipomatosis of the thyroid gland causing goitre in a patient with AA amyloidosis. The presence of amyloid protein within the thyroid was not sufficient to cause enlargement per se, and was therefore of unclear significance. Together with previous reports of the concurrent deposition of amyloid and fat, this case raises questions as to the relationship between these two phenomena.

We report a case of hypopharyngeal swelling secondary to a spontaneous thyroid cyst haemorrhage. Haemorrhage is a known complication of thyroid cysts, and usually presents as external swelling and localised pain.

A 93-year-old woman developed hypopharyngeal swelling, dysphagia and odynophagia. A computed tomography scan was consistent with thyroid cyst haemorrhage. The patient was treated with needle aspiration and intravenous steroid injections, with full recovery at thyroid clinic review.

To our best knowledge, there has been no previous report of a hypopharyngeal swelling occurring secondary to spontaneous thyroid cyst haemorrhage. Our case is unusual because of the risk of airway compromise at the level of the hypopharynx, secondary to thyroid cyst haemorrhage.

To demonstrate the usefulness of pre-operative selective embolisation of the thyroid arteries in an unusual case with a large, vascular thyroid tumour.

A 29-year-old man presented with a large papillary carcinoma of the thyroid (weighing approximately 300 g on palpation) with extension to the mediastinum and compression of the trachea. A computed tomography scan of the neck and thorax revealed a large tumour the solid part of which was enhanced after contrast medium application, indicating a substantial vascular supply. Pre-operative selective embolisation of both superior thyroid arteries and one inferior thyroid artery, using gelatin sponge particles, was performed 4 days before surgery, under conventional angiography. After selective embolisation of these thyroid arteries, the patient experienced mild anterior neck pain and mild fever. This procedure allowed a significant reduction in blood perfusion to the tumour, which facilitated its surgical removal without blood transfusion.

Pre-operative selective embolisation of both superior thyroid arteries and one inferior thyroid artery may be an effective, minimally invasive procedure for patients with a large, vascular thyroid tumour.

We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings.

A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998–2008 at University Hospital Aintree, Liverpool.

Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings.

Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively.

Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

We report an extremely rare case of the simultaneous occurrence of a thyroglossal duct cyst and a lingual thyroid in the absence of an orthotopic thyroid gland, in a seven-year-old girl from South India.

Case report and a review of the English language literature on the subject.

The patient presented with a mass on the tongue that had been present for three years, and an anterior neck swelling that had been present for two years. Examination revealed a midline, pinkish, firm mass present on the posterior one-third of the tongue. The neck showed a midline cystic swelling in the infrahyoid position. Radiological imaging confirmed the clinical findings, revealing the absence of her thyroid gland in the normal location. Sistrunk's procedure was performed leaving behind a lingual thyroid. At 13-month follow up, the patient was euthyroid with no recurrence.

To our knowledge the association of a lingual thyroid and a thyroglossal cyst has only been reported once in the literature. The presence of a lingual thyroid in the absence of a normally located thyroid gland or functioning thyroid tissue along the thyroglossal tract, confirmed by radionuclide and computed tomography imaging, may indicate the failure of the normal descent of the thyroid gland during embryonic development. This probable absence of the descent of the thyroid raises questions regarding the origin of thyroglossal duct cysts.