A 35yo woman complains of hoarseness of voice 3h after partial thyroidectomy. She had no hx of phonation problems before the surgery. What is the single most appropriate inv?
a. Laryngoscopy
b. Bronchoscopy
c. CT neck
d. CXR
e. Barium swallow
Clincher(s) Problem of vocal cord after partial thyroidectomy.
A Can be used to detect the problem of lyranx and vocal cords
B Vocal cords can be seen but it is usually used to see different divisions of bronchi.
C Cannot be diagnostic in this case (Staging or rule out neck structure cancers- except
nose)
D Cannot be diagnostic
E Cannot be diagnostic
KEY A
Additional information Complications These are usually very few. Remove the drain the next day and
discharge the patient.The important structures that must be considered when
operating on the thyroid gland include
• Recurrent laryngeal nerve.( branch of vagus nerve which supplies all the intrinsic
muscles of the larynx except cricothyroid muscle. These muscles act to open and close
the vocal cords.
• Superior laryngeal nerve.
• Parathyroid glands.
• Trachea.
• Common carotid artery.
• Internal jugular vein (not depicted).
Management Common indications Contraindications Disadvantages/complications
Antithyroid drugs (carbimazole, propylthiouracil) First episode in patients < 40 yrs
Breastfeeding (propylthiouracil suitable)
SE:Hypersensitivity rash 2% Agranulocytosis 0.2% > 50% relapse rate usually within 2
years of stopping drug
Subtotal thyroidectomy
INDICATION::Large goitre Poor drug compliance, especially in young patients
Recurrent thyrotoxicosis after course of antithyroid drugs in young patients CI: Previous thyroid surgery Dependence upon voice, e.g. opera singer, lecturer
SE:1 Hypothyroidism (^25%) Transient hypocalcaemia (10%) Permanent
hypoparathyroidism (1%) Recurrent laryngeal nerve palsy1 (1%
Radio-iodine Patients
INDICATION > 40 yrs2 Recurrence following surgery irrespective of age
CI:Other serious comorbidity Pregnancy or planned pregnancy within 6 months of
treatment Active Graves’ ophthalmopathy
SE3 Hypothyroidism, ^40% in first year, 80% after 15 years Most likely treatment to
result in exacerbation of ophthalmopathy3
1 It is not only vocal cord palsy due to recurrent laryngeal nerve damage which alters
the voice following thyroid surgery; the superior laryngeal nerves are frequently
transected and result in minor changes in voice quality. 2 In many institutions, 131I is
used more liberally and prescribed for much younger patients. 3 The extent to which
radio-iodine exacerbates ophthalmopathy is controversial and practice varies; some
use prednisolone for 4 months to reduce this risk.