There is limited evidence or agreement on the benefit, duration and frequency of post-operative surveillance neck ultrasound in patients with differentiated thyroid cancer treated with hemithyroidectomy alone. This study's primary aim was to assess the benefit of neck ultrasound in this situation, with a secondary aim to assess the detection of malignancy in the contralateral lobe in patients undergoing completion surgery.

A retrospective observational study was conducted involving patients who had differentiated thyroid cancer found at diagnostic hemithyroidectomy between 1 December 2013 and 31 December 2016.

Of 105 patients, 74 underwent completion thyroidectomy. Thirty-five per cent of these patients had malignancy identified in the contralateral lobe, the majority were unsuspected sonographically. Of 31 hemithyroidectomy patients, 1 had a nodule classified as ‘U3’ (indeterminate) at the first ultrasound surveillance, ultimately identified as incidental papillary microcarcinomas on completion thyroidectomy. There was no other disease recurrence or malignancy at a median of 3.8 years’ follow up.

The findings indicate a limited role for ultrasound follow up of patients with differentiated thyroid cancer treated with hemithyroidectomy alone.

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.

The British Thyroid Association and American Thyroid Association guideline definitions for low-risk differentiated thyroid cancers are susceptible to differing interpretations, resulting in different clinical management in the UK.

To explore the national effect of these guidelines on the management of low-risk differentiated thyroid cancers.

Anonymised questionnaires were sent to multidisciplinary teams performing thyroidectomies in the UK. Risk factors that multidisciplinary teams considered important when managing low-risk differentiated thyroid cancers were established.

Most surgeons (71 out of 75; 94.7 per cent) confirmed they were core multidisciplinary team members. More than 80 per cent of respondents performed at least 30 hemi- and/or total thyroidectomies per annum. A majority of multidisciplinary teams (50 out of 75; 66.7 per cent) followed British Thyroid Association guidelines. Risk factors considered important when managing low-risk differentiated thyroid cancers included: type of tumour histology findings (87.8 per cent), tumour size of greater than 4 cm (86.5 per cent), tumour stage T3b (85.1 per cent) and central neck node involvement (85.1 per cent). Extent of thyroid surgery (e.g. hemi- or total thyroidectomy) was highly variable for low-risk differentiated thyroid cancers.

Management of low-risk differentiated thyroid cancers is highly variable, leading to a heterogeneous patient experience.

This case report discusses a successful emergency Lichtenberger lateralisation procedure after immediate bilateral laryngeal immobility, occurring after total thyroidectomy.

A 63-year-old female with right-sided vocal fold paralysis due to compression by a multinodular thyroid goitre underwent total thyroidectomy, which resulted in immediate post-operative bilateral vocal fold immobility. The patient had acute-onset post-operative dyspnoea, was promptly re-intubated, and an emergency lateralisation Lichtenberger suture was placed over the right vocal fold and fixated on the outer surface of the neck.

After two weeks, her right vocal fold recovered first, with the suture still in place. At four weeks, both vocal folds regained function and the suture was extracted.

The take-away message is that an emergency lateralisation suture may be a viable option in maintaining airway patency, while allowing for normal deglutition, in patients who would otherwise be candidates for prolonged intubation, posterior cordotomy, medial arytenoidectomy or tracheostomy.

To evaluate the incidence of inadvertent parathyroidectomy, identify risk factors, determine the location of inadvertently excised glands, review pathology reporting in inadvertent parathyroidectomy, and explore relationships between inadvertent parathyroidectomy and post-surgical hypoparathyroidism or hypocalcaemia.

A retrospective cohort study of 899 thyroidectomies between 2015 and 2020 was performed. Histopathology slides of patients who had an inadvertent parathyroidectomy and a random sample of patients without a reported inadvertent parathyroidectomy were reviewed.

Inadvertent parathyroidectomy occurred in 18.5 per cent of thyroidectomy patients. Central neck dissection was an independent risk factor (inadvertent parathyroidectomy = 49.4 per cent with central neck dissection, 12.0 per cent without central neck dissection, p < 0.001). Most excised parathyroid glands were extracapsular (53.3 per cent), followed by subcapsular (29.1 per cent) and intrathyroidal (10.9 per cent). Parathyroid tissue was found in 10.2 per cent of specimens where no inadvertent parathyroidectomy was reported. Inadvertent parathyroidectomy was associated with a higher incidence of six-month post-surgical hypoparathyroidism or hypocalcaemia (19.8 per cent who had an inadvertent parathyroidectomy, 7.7 per cent without inadvertent parathyroidectomy).

Inadvertent parathyroidectomy increases the risk of post-surgical hypoparathyroidism or hypocalcaemia. The proportion of extracapsular glands contributing to inadvertent parathyroidectomy highlights the need for preventative measures.

Recurrent laryngeal nerve identification is the ‘gold standard’ in thyroidectomy, to determine nerve function security and prevent severe complications. This study assessed the topographical relationship between the recurrent laryngeal nerve and the inferior thyroid artery in patients undergoing total thyroidectomy, and determined its clinical impact.

A retrospective study was performed of patients undergoing total thyroidectomy in a single tertiary centre over a six-month period.

Sixty-four patients were included. Among the 128 recurrent laryngeal nerve dissections, the nerve was identified traversing the inferior thyroid artery anteriorly in 27.3 per cent, with equal distribution between the two sides. No significant sex association was reported. One patient had transient vocal fold palsy, and hypocalcaemia was observed in 21.9 per cent, yet there was no statistical association with the topographical variation of the recurrent laryngeal nerve.

Almost one-third of patients had an anatomical variation in which the recurrent laryngeal nerve ran superiorly to the inferior thyroid artery. Recurrent laryngeal nerve variation had no clinical impact on local complications or hypocalcaemia.

Total thyroidectomy can be used as a definitive treatment modality for thyrotoxicosis. This study assessed the outcomes of patients treated with surgery at a single secondary care site.

A retrospective cohort study was conducted analysing consecutive patients who underwent thyroid surgery for thyrotoxicosis between 24 November 2000 and 26 April 2019 (n = 595).

Total thyroidectomy was performed in 95.4 per cent of patients. Two-thirds of patients had Graves’ disease histology. Of patients, 22.8 per cent became transiently hypothyroid whilst on levothyroxine (thyroid hormone replacement therapy). Transient and persistent hypocalcaemia was present in 23.3 per cent and 2.8 per cent of patients respectively. Recurrent laryngeal nerve palsy was transient and persistent in 3.6 per cent and 0.3 per cent respectively. Of patients, 2.5 per cent developed post-operative haematomas that required surgical evacuation in the operating theatre.

The overall complication rate for thyroid surgery is higher in thyrotoxic than in euthyroid patients. Compared to other treatment modalities, total thyroidectomy appears to be the most effective, definitive means of managing Graves’ disease.

The incidence of thyroid carcinoma has been increasing worldwide and surgery is the primary treatment. Central compartment dissection of the neck is a very delicate procedure given the risks of recurrent laryngeal nerve injury and hypoparathyroidism.

This paper gives a detailed description of this surgical technique in a patient affected by papillary carcinoma of the thyroid gland, supported by highly representative iconographic materials from a tertiary department.

A stepwise description is provided, along with high-quality pictures and specific tips and tricks. Although neck dissection is a well-codified procedure, the fine details of this surgical technique are not currently available and are still the prerogative of the expert surgeon.

The central neck compartment contains several vulnerable structures; damage to these structures would affect patients’ lives, possibly permanently. Anatomical knowledge and standardisation are needed for all surgeons, particularly new surgeons (such as residents) who cannot rely simply on experience.

This systematic review aimed to establish the evidence behind the use of pre-operative calcium, vitamin D or both calcium and vitamin D to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy.

This review included prospective clinical trials on adult human patients that were published in English and which studied the effects of pre-operative supplementation with calcium, vitamin D or both calcium and vitamin D on the rate of post-operative hypocalcaemia following total thyroidectomy.

Seven out of the nine trials included reported statistically significantly reduced rates of post-operative laboratory hypocalcaemia (absolute risk reduction, 13–59 per cent) and symptomatic hypocalcaemia (absolute reduction, 11–40 per cent) following pre-operative supplementation.

Pre-operative treatment with calcium, vitamin D or both calcium and vitamin D reduces the risk of post-operative hypocalcaemia and should be considered in patients undergoing total thyroidectomy.

Thyroid lobectomy is recommended with total laryngectomy for laryngeal cancer in the National Comprehensive Cancer Network (‘NCCN’) guidelines. However, it is associated with a 32–89 per cent risk of hypothyroidism, with or without adjuvant radiotherapy.

The study aimed to determine whether preserving the whole thyroid, compared to a single lobe, does indeed significantly lower the incidence of hypothyroidism in the setting of total laryngectomy.

A retrospective study was conducted at Groote Schuur Hospital in Cape Town, South Africa.

Eighty-four patients met the inclusion criteria. The overall incidence of hypothyroidism was 45.2 per cent. The incidence of hypothyroidism was significantly reduced in patients who underwent thyroid-sparing total laryngectomy compared to hemithyroidectomy (p = 0.037). Adjuvant radiotherapy was associated with a higher incidence of hypothyroidism (p = 0.001).

Thyroid-preserving laryngectomy should be advocated in carefully selected patients with advanced laryngeal carcinoma, as it reduces the incidence of hypothyroidism.

Hypocalcaemia is the most common complication after total or completion thyroidectomy. This study assesses recent evidence on predictive factors for post-thyroidectomy hypocalcaemia in order to identify the patients affected and aid prevention.

Two authors independently assessed articles and extracted data to provide a narrative synthesis. This study was an updated systematic search and narrative review regarding predictors of post-thyroidectomy hypocalcaemia using the Ovid Medline, Embase, Cochrane and Cinahl databases. Results were limited to papers published from January 2012 to August 2019.

Sixty-three observational studies with a total of 210 401 patients met the inclusion criteria. The median incidence was 27.5 per cent for transient biochemical hypocalcaemia, 12.5 per cent for symptomatic hypocalcaemia and 2.2 per cent for permanent hypocalcaemia. The most frequent statistically significant predictor of hypocalcaemia was peri-operative parathyroid hormone level. Symptomatic hypocalcaemia and permanent hypocalcaemia were seen more frequently in patients undergoing concomitant neck dissection.

Many factors have been studied for their link to post-thyroidectomy hypocalcaemia, and this study assesses the recent evidence presented in each case.

To establish the prevalence of hypocalcaemia following laryngectomy and demonstrate that total thyroidectomy is a risk factor.

A retrospective cohort study was conducted that included all patients who underwent total laryngectomy from 1st January 2006 to 1st August 2017. Exclusion criteria were: pre-operative calcium derangement, previous thyroid or parathyroid surgery, concurrent glossectomy, pharyngectomy, or oesophagectomy.

Ninety patients were included. Sixteen patients had early hypocalcaemia (18 per cent), seven had protracted hypocalcaemia (8 per cent) and six had permanent hypocalcaemia (10 per cent). Exact logistic regression values for hypocalcaemia following total thyroidectomy compared to other patients were: early hypocalcaemia, odds ratio = 15.5 (95 per cent confidence interval = 2.2–181.9; model p = 0.002); protracted hypocalcaemia, odds ratio = 13.3 (95 per cent confidence interval = 1.5–117.1; model p = 0.01); and permanent hypocalcaemia, odds ratio = 22.7 (95 per cent confidence interval = 1.9–376.5; model p = 0.005).

This is the largest study to investigate the prevalence of hypocalcaemia following laryngectomy and the first to include follow up of longer than three months. Total thyroidectomy significantly increased the risk of hypocalcaemia at all time frames and independent of other variables.

This study is the first to evaluate scar satisfaction and body image in thyroidectomy patients using validated assessment tools.

A total of 123 thyroidectomy patients were recruited over 8 months. Both patients and clinicians completed assessment tools that included: the Manchester Scar Scale (to measure scar perception), Dysmorphic Concern Questionnaire (to assess body image), Body Dysmorphic Concern Questionnaire (to screen for body dysmorphic disorder) and EQ-5D (to measure life quality). A separate image panel comprising experts and non-experts assessed 15 scar photographs. The results were analysed using non-parametric descriptive statistics.

Poor body image was associated with poor scar perception (ρ = 0.178, p = 0.05). Poor life quality correlated with poor scar perception (ρ = −0.292, p = 0.001). Scar length did not affect scar perception. Prevalence of body dysmorphic disorder among patients was found to be 8.94 per cent, which is higher than general population rates.

Negative body image and life quality impact negatively upon scar perception.

To determine whether pre-operative serum 25-hydroxyvitamin D has an impact on post-operative parathyroid hormone and serum calcium levels in patients undergoing total thyroidectomy for benign goitre.

This single-centre, retrospective study comprised 246 unselected surgical patients who had undergone total thyroidectomy for bilateral, benign, multinodular goitre. The correlation between pre-operative serum 25-hydroxyvitamin D and post-operative serum parathyroid hormone and serum calcium was studied to determine whether low pre-operative serum 25-hydroxyvitamin D was predictive of post-operative hypocalcaemia.

Seventy-nine patients (32 per cent) had post-operative hypocalcaemia. Eighteen patients (7.32 per cent) experienced unintentional parathyroidectomy (1 parathyroid gland in 15 patients, 2 parathyroid glands in 3 patients). In univariate analysis, pre-operative serum 25-hydroxyvitamin D was not correlated with post-operative serum calcium (p = 0.69) or post-operative serum parathyroid hormone (p = 0.5804). Furthermore, in multivariate analysis, which took into account unintentional parathyroidectomy, no correlation was found (p = 0.33). Bilateral unintentional parathyroidectomy was statistically associated with post-operative hypocalcaemia (p = 0.032).

Pre-operative serum 25-hydroxyvitamin D did not appear to have any impact on post-operative serum calcium in patients undergoing total thyroidectomy for benign goitre.

This study aimed to identify the effect of lateral neck dissection on voice change in thyroidectomised patients.

Medical records from 264 patients who underwent thyroidectomy with (n = 65) or without (n = 199) lateral neck dissection were reviewed. Clinical and voice evaluation data were compared between the two groups.

Patients who underwent surgery that included lateral neck dissection had lower fundamental frequencies and speaking fundamental frequencies. They also had a higher incidence of asymmetric mucosal wave and vocal fold oedema on videostroboscopy during the first month after surgery, with the incidence of vocal fold oedema remaining significantly higher at three months. Self-assessed voice quality scores were significantly higher in lateral neck dissection patients at both one and three months after surgery.

In thyroidectomised patients, lateral neck dissection lowers the vocal pitch in the initial period after surgery and induces vocal fold oedema that persists for several months. Although most objective parameters improved within a month, subjective symptoms lasted for longer.

This study aimed to: describe the incidence of thyroid gland involvement in advanced laryngeal cancer, analyse patterns of spread to the thyroid and elucidate predictors of thyroid involvement.

A retrospective review was performed on patients who underwent laryngectomy from 1991 to 2015 as a primary or salvage treatment for squamous cell carcinoma of the larynx, hypopharynx or base of tongue. The incidence of thyroidectomy during total laryngectomy, type of thyroidectomy, incidence of gland involvement, route of spread, and positive predictors of spread were analysed and reported.

A total of 188 patients fit the inclusion criteria. Of these, 125 (66 per cent) underwent thyroidectomy. The thyroid was involved in 10 of the 125 patients (8 per cent), 9 by direct extension and 1 by metastasis. Cartilage invasion was a predictor of thyroid gland involvement, with a positive predictive value of 26 per cent.

There is a low incidence of thyroid gland involvement in laryngeal carcinoma. Most cases of gland involvement occurred by direct extension. Thyroidectomy during laryngectomy should be considered for advanced stage tumours with cartilage invasion.

Occult differentiated thyroid carcinomas are not uncommon. The initial presentation of a thyroid carcinoma is often detection of a metastatic cervical lymph node.

A retrospective review was performed of the medical records of 304 patients who underwent neck dissection between 1996 and 2008 for squamous cell carcinoma of the head and neck.

Ten patients (3.3 per cent) had nodal metastasis originating from papillary thyroid cancer. All of these patients underwent thyroidectomy and post-operative 131iodine radiometabolic therapy. No patient developed a thyroid tumour after surgery.

Despite its metastatic spread, thyroid cancer does not affect the overall prognosis of patients who are already being treated for a more aggressive malignancy. However, in otherwise healthy patients, it is worth treating this second malignancy to avoid potential complications related to local disease or metastatic thyroid cancer.

To compare the effectiveness of non-surgical versus surgical therapy in elderly patients with papillary thyroid microcarcinoma.

The study cohort included 2323 elderly patients (aged 65 years and over) diagnosed with papillary thyroid microcarcinoma between 1988 and 2009, identified in the Surveillance, Epidemiology, and End Results 18 database of the National Cancer Institute.

The five-year overall survival rate was 23 per cent for non-surgical patients compared with 91 per cent for surgical patients (p < 0.0001). Unadjusted analysis revealed significantly improved survival in surgical patients compared with non-surgical patients (hazard ratio = 0.06; p < 0.0001). Propensity score analysis also revealed significantly improved survival in surgical patients compared with non-surgical patients (hazard ratio = 0.11; p < 0.0001).

Thyroidectomy appears to provide a survival benefit for elderly patients with papillary thyroid microcarcinoma. High-quality prospective studies are needed to better evaluate the comparative effectiveness of immediate thyroidectomy versus observation for elderly patients with papillary thyroid microcarcinoma.

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.