n2
of litigation. As well as counselling your patient, provide
clear
n5 Be willing to work jointly with other surgical specialists,
such ascardiothoracic surgeons, when treating retrosternal
extensions.
and Thyroid Surgeons (BAETS). The Association publishes
audit
n8 Assessment (see Table 20.1).n9 Investigate:
n Biochemical evaluation is mandatory in patients with
thyroiddisease. Familiarize yourself with and check thyroid
func-tion tests (tri-iodothyronine (T3), thyroxine (T4) and
thy-roid stimulating hormone: TSH), as well as calcium andalbumin
assays, prior to considering surgery. Undiagnosedor unrecognized
thyrotoxicosis can lead to serious conse-quences during general
anaesthesia. Vitamin D levels maybe assayed in areas where
deficiency is endemic and cor-rected prior to surgery. Thyroid
auto-antibodies may alsobe requested to screen for the presence of
Hashimoto's thy-roiditis (first described by Japanese physician
HashimotoHakaru in Germany in 1912).
n Fine needle aspiration cytology (FNAC) is an efficient and
cost-effective method of evaluating thyroid nodules.
Diagnosticaccuracy is dependent on the experience of the
operator,
TA
Ayo
Iseu
Wgo
Ispr
by tumour)
Does thepatient haveobstruction?
Dysphagia,shortness of breath,inability to lay flat
Stridor, venousengorgement,Pembertons sign
through the symptoms
41results and guidelines for managing thyroid disease.
Familiarizeyourself with the website www.baets.org.uk.
neck?
3possible.n6 Re-operation in the neck carries significantly
increased morbid-ity. As a result, partial or subtotal
thyroidectomy is now lessfrequently performed in favour of either
hemi- or total thyroid-ectomy. The aim is to leave behind as little
thyroid tissue as
n7 Audit your results personally, locally and nationally. In the
UKresults are submitted to the British Association of Endocrine
1
(Hugh Pemberton,1946) facial flushingon raising both
armsindicating SVCobstruction
Can the goitrebe delivered
Longstanding goitre,significant obstructive
Retrosternal extensiondisciplinary team meeting (MDT) if you
regularly undertakemalignant thyroid surgery. Familiarize yourself
with localarrangements.documentation, especially with regard to
potential damage tothe recurrent laryngeal nerve and the
parathyroid glands.
n3 Thyroid surgery is increasingly performed in specialist
centres bysurgeons with a special interest in thyroid disorders.
Closely liaisewith endocrinologists and oncologists to achieve
satisfactoryoutcomes. Joint or combined clinics are advocated,
particularlyfor patients with complex disease.
n4 It is mandatory to have access to and attend an appropriate
multi-Carefully investigate patients about to undergo surgery
andinvolve the multidisciplinary team to avoid inappropriate or
un-necessary surgery. Thyroid surgery is a significant potential
sourcen Benign symptomatic goitren Graves' disease (named after the
Irish physician Robert James
Graves, who described a case of goitre with exophthalmos in1835.
InEuropethecondition isnamedafterKarl vonBasedow).
All thyroid surgery carries significant potential
morbidity.20
ThyroidJ.C.Watkinson, J.A. Smith
CONTENTS
Management of the solitary thyroid nodule and the
dominant nodule within a multinodular goitre 342
Management of malignant thyroid disease 343
Management of Graves thyrotoxicosis 343
Management of benign multinodular thyroid
disease 343
Thyroid operations 344
Appraise
n1 Indications for thyroid surgery fall into three categories:n
Suspected or proven malignancycancer, previousexposure to
radiation
nerve palsy, fixation,Berrys sign (loss ofcarotid
pulsationindicating invasionBLE 20.1 Assessment in the clinic
skurself:
History Examination
the patientthyroid?
Intolerance to heat andcold, weight loss,altered bowel
habit,anxiety/depression
Tachycardia, tremor,Graves eye signs, skinchanges
hat kind ofitre is this?
Physiologic, toxic Diffuse, solitarynodule, multinodular
a malignantocess likely?
Neck pain, hoarseness,family history of thyroid
Lymph nodal masses,recurrent laryngeal
