Anesthesia for patients with thyroid disease and

for patients who undergo thyroid or parathyroid

surgery
Author: Amy C Robertson, MD
Section Editor: Stephanie B Jones, MD
Deputy Editor: Marianna Crowley, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2024. | This topic last updated: Oct 11, 2023.

INTRODUCTION

Thyroid disease and thyroid surgery present specific challenges for anesthesiologists.

This topic reviews the perioperative anesthetic management of patients with thyroid
disease and anesthetic management of patients who undergo thyroid or parathyroid
surgery. Preoperative medical management of patients with thyroid disease,
perioperative surgical management of patients undergoing thyroid surgery, and
urgent management of severe and life-threatening overt thyroid storm are reviewed
separately. (See "Nonthyroid surgery in the patient with thyroid disease" and "Surgical
management of hyperthyroidism" and "Thyroidectomy" and "Thyroid storm".)

Perioperative risk as it relates to the degree of thyroid dysfunction is also discussed

separately. (See "Nonthyroid surgery in the patient with thyroid disease", section on
'Surgical outcomes' and "Nonthyroid surgery in the patient with thyroid disease",
section on 'Clinical manifestations that may impact perioperative outcome'.)

Parathyroidectomy may be performed for patients with primary or secondary

hyperparathyroidism. Clinical manifestations of hyperparathyroidism and indications
for surgery are discussed separately.
● (See "Primary hyperparathyroidism: Clinical manifestations".)
● (See "Primary hyperparathyroidism: Management".)
 ● (See "Refractory hyperparathyroidism and indications for parathyroidectomy in
adult patients on dialysis".)

MULTIORGAN SYSTEM EFFECTS OF THYROID DISEASE

Patients with existing hyper- or hypothyroidism have associated physiologic changes

that may affect anesthetic care and perioperative outcomes. Most such changes
resolve with treatment as the patient becomes euthyroid.

Hyperthyroidism — Hyperthyroidism can be classified as subclinical (ie, low thyroid-

stimulating hormone [TSH] with normal free T4 and T3), or overt (ie, suppressed TSH
with elevated free T4 and/or T3). As the degree of hyperthyroidism increases, clinical
manifestations are more prominent and have a greater potential impact on
anesthetic care. In patients with overt hyperthyroidism surgery can, rarely, precipitate
thyroid storm, a potentially life-threatening condition. (See "Overview of the clinical
manifestations of hyperthyroidism in adults" and "Nonthyroid surgery in the patient
with thyroid disease", section on 'Overt hyperthyroidism'.)
● Cardiovascular changes may lead to perioperative hemodynamic instability.
Hyperthyroid patients have increased heart rate, circulating blood volume,
cardiac contractility, and myocardial oxygen consumption, as well as enhanced
diastolic relaxation and reduced systemic vascular resistance ( table 1). Patients
with hyperthyroidism are also prone to sinus tachycardia and atrial fibrillation,
coronary spasm, and ischemia, and may develop cardiomyopathy over time [1-9].
(See "Cardiovascular effects of hyperthyroidism".)
● Hyperthyroidism does not increase minimum alveolar concentration (MAC)
requirement [10,11]. However, induction of anesthesia may be slower and may
require increased concentrations of inhaled anesthetics because of elevated
cardiac output in patients with hyperthyroidism, and resultant effects on uptake
and distribution of anesthetics. Patients with hyperthyroidism may have
increased anesthetic requirements, primarily to control blood pressure and heart
rate. There are no existing data supporting an increased MAC with contemporary
inhaled anesthetics. Older animal studies demonstrated no clinically significant
 increase in halothane requirements [11]. (See "Inhalation anesthetic agents:
Properties and delivery", section on 'Cardiovascular factors'.)
● Vasoactive medications should be chosen based on clinical and patient factors,
independent of thyroid function ( table 2 and table 3).

Patients with hyperthyroidism have been thought to exhibit increased sensitivity

to catecholamines. Thus, the typical recommendation is that hypotension should
be treated with direct acting vasoconstrictors (eg, phenylephrine) rather than
with catecholamines or medications that release catecholamines (eg, ephedrine).
However, evidence in support of this recommendation is indirect and conflicting.
Some in vitro human studies have reported an increase in beta adrenergic
receptor density in the heart in patients with hyperthyroidism [12-14]. However,
there is also evidence that the increased receptor density may be counteracted to
a degree by cellular changes that reduce adrenergic receptor responsiveness to
catecholamines [15]. The net effect may be that cardiac adrenergic
responsiveness is unaltered in patients with hyperthyroidism. (See
"Cardiovascular effects of hyperthyroidism", section on 'Adrenergic effects'.)
● Respiratory muscle weakness occurs with hyperthyroidism, and in patients with
severe hyperthyroidism, this may mandate postoperative mechanical ventilatory
support after general anesthesia [16,17]. (See "Respiratory function in thyroid
disease".)

Intraoperative thyroid storm — Thyroid storm is a rare, life-threatening condition

characterized by severe clinical manifestations of thyrotoxicosis [18]. It has been
reported during surgery and in the first 18 hours after thyroid and non-thyroid
surgery in hyperthyroid patients, though the incidence is very low in patients who
receive preoperative antithyroid treatment. (See "Nonthyroid surgery in the patient
with thyroid disease", section on 'Thyroid storm'.)

The diagnosis of thyroid storm is based upon the presence of severe and life-
threatening signs and symptoms (eg, hyperthermia, cardiac dysfunction, altered
mentation) in a patient with biochemical evidence of hyperthyroidism. (See "Thyroid
storm", section on 'Diagnosis'.)
During anesthesia, thyroid storm can be difficult to differentiate from malignant
hyperthermia, which may share clinical characteristics.
● If clinical signs of thyroid storm develop during or shortly after surgery in a
patient with known hyperthyroidism, therapeutic measures should be initiated
immediately, including administration of a beta blocker unless contraindicated.
An endocrinologist should be consulted urgently, and further treatment will likely
include administration of a thionamide (eg, methimazole or propylthiouracil),
though these drugs cannot readily be administered intravenously (see "Thyroid
storm", section on 'Thionamides'). Other supportive measures include aggressive
treatment of hyperpyrexia with cooling blankets and acetaminophen,
administration of a glucocorticoid (eg, hydrocortisone), and treatment of
metabolic abnormalities.
● In patients without known hyperthyroidism, and prior to laboratory confirmation
of hyperthyroidism, it is reasonable to also manage the patient for malignant
hyperthermia crisis (ie, administer dantrolene and discontinue potent inhaled
anesthetics). (See "Malignant hyperthermia: Diagnosis and management of acute
crisis", section on 'Acute management of suspected MH' and "Malignant
hyperthermia: Diagnosis and management of acute crisis", section on 'Others'.)

Ongoing support and monitoring in the critical care setting is strongly

recommended after surgery since the mortality rate is substantial in patients with
thyroid storm [19]. (See "Thyroid storm", section on 'Initial management' and
"Nonthyroid surgery in the patient with thyroid disease", section on 'Thyroid
storm'.)

Hypothyroidism — Hypothyroidism may be classified as mild, moderate, or severe,

as follows:
● Mild hypothyroidism – Subclinical, elevated TSH with normal serum free T4
● Moderate hypothyroidism – Elevated TSH, low free T4, without clinical features
of severe hypothyroidism
● Severe hypothyroidism – Severe clinical symptoms such as altered mentation,
pericardial effusion, or heart failure; myxedema coma; or very low levels of total
T4 (eg, <1.0 mcg/dL) or free T4 (eg, <0.5 ng/dL). (See "Nonthyroid surgery in the
 patient with thyroid disease", section on 'Defining the severity of
hypothyroidism'.)

Severe hypothyroidism has a greater impact on anesthetic care than mild or well-
treated disease. Patients with moderate or severe hypothyroidism may exhibit
exaggerated responses to anesthetic agents, sedatives and opioids, and appear
to be at increased risk of perioperative complications. Case reports have
described significant respiratory depression from opioids, vasopressor-resistant
hypotension, and prolonged recovery from anesthetic agents in patients with
severe hypothyroidism [20,21]. Studies of the pharmacokinetics and
pharmacodynamics of sedatives and anesthetic medications in these patients are
lacking, and it is unclear whether prolonged effects relate to reduced cardiac
output and/or other physiologic effects, or are a direct result of thyroid
dysfunction [22]. There is no evidence that these patients have a reduced MAC for
contemporary inhaled anesthetics [23,24]. (See "Nonthyroid surgery in the
patient with thyroid disease", section on 'Defining the severity of hypothyroidism'
and "Nonthyroid surgery in the patient with thyroid disease", section on 'Surgical
outcomes'.)

Physiologic effects of hypothyroidism that may affect anesthetic management include

the following:
● Cardiovascular abnormalities may lead to perioperative hemodynamic instability
or myocardial ischemia. Clinically hypothyroid patients may have bradycardia,
diminished response to adrenergic agents, diastolic dysfunction, increased
systemic vascular resistance, and impaired venous return ( table 4) [1,2,25-27].
Patients with hypothyroidism, even subclinical disease, are at increased risk for
ischemic heart disease [28,29]. (See "Clinical manifestations of hypothyroidism",
section on 'Cardiovascular system'.)
● Hypothyroid patients may have a diminished response to alpha and beta
adrenergic agents, and larger than usual doses of vasopressors may be required
[30-32]. (See "Cardiovascular effects of hypothyroidism", section on 'Cardiac
contractility'.)
 ● Obstructive sleep apnea is more common and should be suspected in patients
with hypothyroidism (see "Respiratory function in thyroid disease", section on
'Obstructive sleep apnea').

Perioperative management of patients with obstructive sleep apnea is discussed

separately.

• (See "Surgical risk and the preoperative evaluation and management of adults
with obstructive sleep apnea".)

• (See "Intraoperative management of adults with obstructive sleep apnea".)

• (See "Postoperative management of adults with obstructive sleep apnea".)
● Respiratory effects of the hypothyroid state include impaired ventilatory drive
and respiratory muscle weakness, which can lead to alveolar hypoventilation [33-
35]. Also, hypothyroid patients are extremely sensitive to the effects of drugs that
depress respiratory drive, such as opioids and sedatives [20,21,36].
● Patients with severe clinical hypothyroidism are at risk for delayed emergence
and may require prolonged ventilatory support. (See "Respiratory function in
thyroid disease".)
● Metabolic abnormalities may include hyponatremia due to a reduction in free
water clearance, reversible increases in serum creatinine, and reduced clearance
of hypnotic and opioid medications [37]. Other concerns include hypoglycemia,
anemia, and hypothermia.

PREANESTHESIA EVALUATION

Preanesthesia evaluation always includes a medical history and anesthesia-focused

physical examination, including airway examination. Testing should be determined by
the patient's medical status and the surgical procedure. Preanesthesia evaluation is
discussed in detail separately. (See "Preoperative evaluation for anesthesia for
noncardiac surgery".)

Perioperative thyroid medication management is discussed separately. (See

"Perioperative medication management", section on 'Drugs used for thyroid disease'.)
Euthyroid patients — For patients with known, treated thyroid disease, clinical
euthyroid status should be confirmed during preanesthesia evaluation. Patients
taking a stable dose of thyroid medication with documented euthyroid status within
the past three to six months do not need additional testing prior to surgery. (See
"Nonthyroid surgery in the patient with thyroid disease", section on 'Is preoperative
measurement of TSH necessary?'.)

Patients with abnormal thyroid function — If history and physical examination

suggest thyroid disease, it is reasonable to try to make a diagnosis, starting with
laboratory thyroid function tests, since it can affect perioperative management. (See
"Diagnosis of and screening for hypothyroidism in nonpregnant adults", section on
'Diagnosis' and "Diagnosis of hyperthyroidism", section on 'Diagnosis'.)

Elective surgery should be delayed in patients with recently diagnosed thyroid disease
and in those who remain hyperthyroid or severely hypothyroid, until treatment results
in a documented euthyroid state. If urgent or emergency surgery is required, patients
with severe hypothyroidism or hyperthyroidism should receive treatment of their
disease prior to surgery, as time allows, in order to minimize complications. (See
"Nonthyroid surgery in the patient with thyroid disease", section on 'Hypothyroidism'
and "Nonthyroid surgery in the patient with thyroid disease", section on
'Hyperthyroidism'.)

For emergency surgery in patients with moderately severe or severe hypothyroidism,

advanced intraoperative monitoring (eg, continuous intraarterial blood pressure
monitoring) may be indicated, and such patients may require intensive care
postoperatively. Preoperative thyroid hormone replacement and postoperative
concerns in such patients are discussed separately. (See "Nonthyroid surgery in the
patient with thyroid disease", section on 'Management'.)

Airway evaluation — Preanesthesia evaluation always includes an airway

assessment with the goal of predicting any potential difficulty with airway
management (see "Airway management for induction of general anesthesia", section
on 'Airway assessment'). While an enlarged thyroid (goiter) may cause airway
compromise due to invasion of airway structures, extension into the mediastinum,
and compression of the trachea, we do not routinely order imaging studies
specifically to assess the airway in patients with thyroid disease or a goiter [38-40]. In
two prospective studies of intubation in thyroidectomy patients, difficult endotracheal
intubation was predicted most often by the usual anatomic predictive factors
( table 5), rather than the size of the goiter or the presence of tracheal compression
or deviation [38,41]. In a meta-analysis of 8 studies (5800 patients) of airway
management in patients who had thyroid surgery, tracheal deviation was the only
thyroid-specific factor associated with difficult intubation [42]. Other identified risk
factors were a high Mallampati score, a short thyromental distance, a low interincisor
gap, obesity, and male gender. In practice, the presence of a large benign goiter
without symptoms of obstruction seldom changes airway management plans.

Surgical evaluation prior to thyroidectomy usually includes laryngoscopy to evaluate

vocal cord function, as well as thyroid ultrasound (see "Thyroidectomy", section on
'Preoperative evaluation and preparation'). If respiratory symptoms are present or
substernal goiter is suspected, computed tomography or magnetic resonance
imaging is often obtained to assess the size of a goiter, its caudal extent, the extent of
tracheal compression, and the location of the mass (eg, anterior or posterior
mediastinum) [40,43]. Other studies may have been ordered to evaluate the full
extent of the mass and its effects upon surrounding structures. (See "Clinical
presentation and evaluation of goiter in adults", section on 'Goiter with obstructive
symptoms or suspected substernal goiter'.)

All available studies should be reviewed by the anesthesiologist, with particular

attention to the following clinical entities:
● Cancerous goiter – The presence of a cancerous goiter may be a risk factor for
difficult intubation, possibly due to tissue infiltration with associated fibrosis,
which may reduce the mobility of laryngeal structures and impede the view of the
glottic opening during laryngoscopy [38]. The limited literature on this issue is
conflicting. In one prospective review of 320 patients who underwent
thyroidectomy, presence of a cancerous goiter was an independent risk factor for
difficult intubation [38]. In contrast, in another prospective study of 324
thyroidectomy patients, thyroid malignancy was not associated with difficult
intubation [41]. Neither study provided details on the severity of thyroid
malignancy or related imaging.
 ● Obstructive or substernal goiter – Extension of the thyroid below the sternal
notch (ie, substernal goiter) results in respiratory symptoms in 90 percent of
patients and dysphagia in one-third [40]. Respiratory symptoms, including
hoarseness, dyspnea, wheezing, obstructive sleep apnea, or cough, may be
caused by tracheal compression or nerve involvement. (See "Clinical presentation
and evaluation of goiter in adults", section on 'Obstructive symptoms'.)

Substernal mediastinal goiters can cause obstruction of airway and major

cardiovascular structures with induction of anesthesia. (See 'Induction of
anesthesia' below and "Anesthesia for patients with an anterior mediastinal
mass", section on 'Anesthetic preparation and management'.)

ANESTHETIC MANAGEMENT FOR THYROID AND/OR PARATHYROID

SURGERY

Anesthetic management is generally similar for thyroid and parathyroid surgery,

except as noted in the following discussion.

Choice of anesthetic technique — Thyroid and parathyroid surgery (open or

minimally invasive) can be performed with general anesthesia or with local/regional
anesthesia, which usually includes a cervical plexus block. Excision of a single
parathyroid gland can often be performed with local infiltration alone, without a
nerve block. The choice of anesthetic technique should be based on patient factors
and patient, surgeon, and anesthesiologist preference.

We prefer general anesthesia for thyroid or parathyroid surgery, unless local or

regional anesthesia is requested by the patient and/or the surgeon. However, practice
varies, and in some high volume endocrine surgery centers, local or regional
anesthesia is used more commonly than general anesthesia [44,45]. General
anesthesia provides a secure airway from the start of anesthesia and an immobile
surgical field. Regional anesthesia allows intraoperative voice monitoring, avoidance
of endotracheal intubation, and may have other benefits for patients with some
comorbidities, such as avoidance of hemodynamic changes in patients with cardiac
disease. (See 'Recurrent laryngeal nerve monitoring' below.)
Several studies that compared general with regional anesthesia for thyroid surgery
have reported reduced length of stay and costs with regional anesthesia, and similar
clinical outcomes [44,46,47].

Surgical contraindications to a local/regional anesthetic technique include a plan for

sternotomy or lateral neck dissection. Patient factors that are contraindications for
local/regional anesthesia include cervical lymphadenopathy, locally invasive cancer,
local anesthetic allergy, and patient refusal. [45,48]. General anesthesia is usually
preferred for prolonged surgical procedures, for patients who cannot communicate,
cooperate, or lie still or with their neck extended for the length of the surgery, for
patients with severe anxiety, and for patients who are claustrophobic. General
anesthesia with secure airway control may also be preferred for patients with
predicted difficulty with airway management, or expected airway difficulty during
sedation (eg, patients with obstructive sleep apnea or morbid obesity). In large case
series, 2 to 12 percent of patients undergoing thyroidectomy with local or regional
anesthesia require conversion to general anesthesia because of anxiety, inadequate
anesthesia, surgical difficulty, or airway problems [45,47-49].

Local/regional anesthesia can be used for minimally invasive thyroid surgery, unless
alternative incision sites are used (eg, axillary or retroauricular). (See
"Thyroidectomy", section on 'Minimally invasive thyroid surgery'.)

Local or regional anesthesia — Regional anesthesia for thyroid or parathyroid

surgery usually involves the use of a cervical plexus block along with local infiltration
by the surgeon, as well as monitored anesthesia care and sedation. Superficial
cervical plexus block is the regional anesthetic technique of choice for thyroid and
parathyroid surgery. Deep cervical plexus block is more difficult to perform, less
effective, and associated with more anesthesia-related complications than superficial
block. (See "Scalp block and cervical plexus block techniques", section on 'Cervical
plexus blocks'.)

We do not typically perform superficial cervical plexus blocks solely for postoperative
analgesia after routine thyroid surgery. Pain is usually modest after uncomplicated
thyroidectomy and is typically well controlled with local anesthetic wound infiltration
and multimodal nonopioid analgesics, with addition of opioids if necessary.
Some institutions have implemented enhanced recovery after surgery (ERAS)
protocols that include superficial cervical plexus blocks. However, the available
literature has not shown clear benefits of superficial cervical plexus block in this
setting, and studies have not typically compared these blocks with multimodal
analgesic regimens. A 2018 meta-analysis of 14 randomized trials (1150 patients) that
compared superficial cervical plexus blocks with saline or no block for thyroid surgery
found small improvements in pain scores with blocks, with a mean difference 0.5 to
0.7 on a 0 to 10 visual analog scale (VAS) over the course of 24 hours [50]. There was
longer time until first request for analgesia with the use of superficial cervical plexus
block (mean 143 versus 38 minutes), and reduced hospital length of stay (two trials,
mean 2.1 versus 2.4 days). Several subsequently published studies have reported
statistically significant but likely clinically irrelevant reductions in postoperative pain
scores and analgesic consumption in patients who had superficial cervical plexus
blocks [51-53].

Intraoperative anesthetic management

Monitoring — Standard physiologic monitoring (ie, electrocardiography, noninvasive

blood pressure monitoring, pulse oximetry, and capnography) is sufficient for most
patients who undergo thyroid or parathyroid surgery ( table 6). Advanced
monitoring (eg, intra-arterial continuous blood pressure monitoring) may be
indicated based on patient comorbidities. Special monitoring that may be used during
these procedures include the following:

Recurrent laryngeal nerve monitoring — If recurrent laryngeal nerve

monitoring is to be used during the procedure, either a specialized endotracheal tube
(ETT) may be used, or a conventional ETT with electrodes applied above the ETT cuff.
The electrodes must be placed at the level of the vocal cords during intubation.
Neuromuscular blockade should then be avoided during maintenance of anesthesia.
Intraoperative nerve monitoring is discussed separately. (See "Thyroidectomy",
section on 'Intraoperative nerve monitoring'.)

Parathyroid hormone monitoring — Intraoperative parathyroid hormone

monitoring may be performed during parathyroidectomy for hyperparathyroidism, to
indicate when hyperfunctioning parathyroid tissue has been excised. One or more
blood samples can be drawn from a peripheral vein, an arterial catheter, or by the
surgeon from the internal jugular vein. The decision to place an arterial catheter or a
second intravenous (IV) catheter should be individualized; we usually draw the
necessary sample from a vein in the foot or lower leg for these samples, since the
patient's arms are tucked at the side and inaccessible. Another common approach is
to place an IV catheter in an antecubital vein just below a blood pressure cuff (and use
the cuff as a tourniquet prior to withdrawing a blood sample). Some surgeons simply
prefer to draw a sample from the internal jugular vein in the operative field. (See
"Parathyroid exploration for primary hyperparathyroidism", section on 'Intraoperative
parathyroid hormone monitoring'.)

Induction of anesthesia — The choice of induction technique and medications

depends on patient factors, and is discussed separately. (See "Induction of general
anesthesia: Overview".)

If nerve monitoring is to be used during the procedure, neuromuscular blockade

must be avoided during testing. Thus a short-acting neuromuscular blocking agent
(NMBA), or no NMBA, should be used for endotracheal intubation. Options include
succinylcholine, rocuronium or vecuronium reversed with sugammadex prior to
testing, or a remifentanil intubation (eg, remifentanil 2.5 to 4 mcg/kg IV with propofol
2 mg/kg IV and ephedrine 10 to 15 mg IV, modified for patient factors). (See "Rapid
sequence induction and intubation (RSII) for anesthesia", section on 'Alternatives to
succinylcholine'.)

Substernal goiters are present in 2 to 19 percent of patients having thyroidectomy

[54], and are located in the anterior mediastinum in 75 to 90 percent of cases [55].
Induction of anesthesia in patients with a very large or obstructing mediastinal mass
may result in obstruction of major airways or major cardiovascular structures.
Management of anesthesia for patients with mediastinal masses is discussed
separately. (See "Anesthesia for patients with an anterior mediastinal mass".)

Airway management — We routinely perform endotracheal intubation for thyroid

or parathyroid surgery, though supraglottic airways (SGAs) can be used for these
procedures as well [56-58].
ETTs provide a secure airway throughout the procedure, and are mandatory if
recurrent laryngeal nerve monitoring is used. SGAs are more likely to require
adjustment after neck extension for surgical positioning or during tracheal
manipulation during surgery, but may result in less coughing during emergence from
anesthesia.

The airway may be managed with standard intubation techniques in most patients
with thyroid disease. However, for patients with a goiter that is symptomatic, invasive,
or substernal, the approach to induction and intubation may need to be altered. (See
'Airway evaluation' above and "Management of the difficult airway for general
anesthesia in adults".)

Patients with stridor due to severe tracheal compression should be intubated awake
to limit the risk of complete airway obstruction when spontaneous ventilation ceases.
The surgical team should be prepared and ready to perform an emergent
tracheotomy (which may be difficult in a patient with a goiter) or rigid bronchoscopy
for patients with airway compromise [40] (see "Management of the difficult airway for
general anesthesia in adults", section on 'Awake intubation').

Individual case reports have described the use of venovenous extracorporeal

membrane oxygenation (ECMO) prior to induction of anesthesia [59] or for airway
rescue [60] in patients with large thyroid masses.

Positioning for surgery — The patient is typically positioned on the operating table
in a supine position with the head elevated, with the arms tucked at the sides. The
neck is typically extended, with either a roll or an inflatable bag (ie, a "thyroid bag")
under the patient's shoulders. The patient's ability to extend the neck should be
assessed preoperatively, and patients with known cervical spine disease should be
assessed by an orthopedic surgeon or neurosurgeon for the safety of neck extension.
(See "Thyroidectomy", section on 'Patient position and skin preparation'.)
● After positioning, the patient's occiput should be resting on a head support (eg,
foam donut or blanket), rather than floating or suspended.
● The airway device may require adjustment after positioning with neck extension.
Neck extension may move the electrodes for nerve monitoring of the ETT out of
correct position relative to the vocal cords and can unseat an SGA.
Maintenance of anesthesia — The choice of anesthetic agents for maintenance of
anesthesia depends on patient factors, and is discussed separately. (See
"Maintenance of general anesthesia: Overview".)

The effects of abnormal thyroid function on the choice of anesthetic agents and
intraoperative management are discussed above. (See 'Multiorgan system effects of
thyroid disease' above.)

Concerns specific to thyroid or parathyroid surgery include the following:

● When recurrent laryngeal nerve monitoring is used, NMBAs should be avoided
during maintenance of anesthesia.
● Manipulation of the trachea during surgery is stimulating, and can cause cough
or patient movement. Remifentanil infusion (eg, 0.03 to 0.3 mcg/kg per minute,
modified for patient factors and other anesthetic agents) can be used to suppress
these responses without unnecessary postoperative opioid effect. Low dose
remifentanil infusion can also be administered during emergence and extubation
to minimize cough. (See 'Emergence and extubation' below.)
● We use standard oxygen supplementation for patients who undergo thyroid or
parathyroid surgery, with fraction of inspired oxygen typically approximately 30
percent, modified for patient factors (see "Mechanical ventilation during
anesthesia in adults", section on 'Fraction of inspired oxygen'). Whereas one
study suggested a beneficial effect of a high fraction of inspired oxygen (80
percent during and after surgery) on certain complication rates, these data are
preliminary and require confirmation [61].

Prophylaxis for postoperative nausea and vomiting — We employ preventive

measures for postoperative nausea and vomiting for all patients who undergo thyroid
surgery to minimize the risk of wound hematoma due to retching or vomiting. We
administer at least one prophylactic antiemetic during surgery (eg, ondansetron 4 mg
IV), and use an opioid-sparing strategy for postoperative pain relief (eg, local
anesthetic wound infiltration, postoperative acetaminophen and nonsteroidal
antiinflammatory drugs). In high-risk patients, we also use total IV anesthesia. (See
"Postoperative nausea and vomiting".)
Emergence and extubation — Severe hypertension or coughing during emergence
and extubation may induce bleeding from the surgical site, with possible hematoma
formation. Strategies to minimize coughing include, but are not limited to, extubation
under deep anesthesia (which carries the risks of an unprotected airway in an
anesthetized patient) or administration of remifentanil, dexmedetomidine, or
lidocaine during emergence [62-65]. The choice of technique and drugs is determined
by patient risk factors for coughing (eg, smoking status), as well as the preferences
and the experience of the anesthesiologist. (See "Extubation following anesthesia",
section on 'Minimizing physiologic response to extubation'.)

Postextubation airway complications — Immediately after extubation, airway

compromise may develop due to recurrent laryngeal nerve injury, causing vocal cord
dysfunction; tracheomalacia, causing tracheal collapse in patients with long-standing
tracheal compression (extremely rare); or expansion of a cervical wound hematoma,
causing new tracheal compression. Immediate reintubation may be necessary. (See
"Thyroidectomy", section on 'Hematoma' and "Thyroidectomy", section on 'Nerve
injury/vocal cord paresis or paralysis'.)

Recurrent laryngeal nerve injury — All patients who undergo thyroid or

parathyroid surgery should be watched closely immediately after extubation for signs
of recurrent laryngeal nerve (RLN) dysfunction, including stridor, weak vocalization, or
airway obstruction, particularly after bilateral surgery. RLN injury may be suspected
by the surgeon or suggested by nerve monitoring, but may be apparent only after
extubation without intraoperative evidence of injury.

The RLN innervates most of the intrinsic laryngeal muscles. Injury to the nerve can be
partial and result in weak vocal cord motion, or complete and result in paralysis of the
affected vocal cord. The involved vocal cord assumes a median or paramedian
position. Unilateral RLN injury causes hoarseness but no airway obstruction, whereas
bilateral RLN paralysis can result in stridor, and possibly complete airway obstruction.
Immediate reintubation, and occasionally tracheostomy, may be necessary. (See
"Thyroidectomy", section on 'Nerve injury/vocal cord paresis or paralysis'.)

Injury to the superior laryngeal nerve (in contrast with the RLN) has no effect on
postoperative airway status. Rather, it manifests as voice fatigue and changes in voice
quality [66].

Neck hematoma — Postoperative neck hematoma requiring emergency

surgical evacuation is a rare but potentially serious complication of thyroidectomy.
Bleeding and hematoma formation may cause venous congestion of airway
structures, and airway compromise may develop rapidly due to compression of the
trachea or laryngeal edema as soft tissue swelling develops and as the hematoma
expands. When surgical bleeding causes airway compromise, emergency re-operation
may be required to evacuate the hematoma. Head-up position to lower venous
pressures, nebulized epinephrine, and systemic steroids may be useful temporizing
strategies; however, definitive treatment should not be delayed [67,68]. (See
"Thyroidectomy", section on 'Hematoma'.)

If time permits, the patient should be returned to the operating room for re-
exploration; however, rapidly developing airway compromise may require bedside
evacuation of the hematoma as an immediate airway protection maneuver. Soft
tissue swelling may be so severe that reopening the incision fails to fully normalize
the airway anatomy. Since substantial distortion of the airway may persist after the
hematoma has been evacuated, the safest method for intubation may be an awake
intubation. No matter what approach is taken, intubation should not be delayed; it
should be performed expeditiously by the most experienced member of the team
( table 7).

Tracheomalacia — Longstanding tracheal compression by a goiter may lead to

tracheomalacia [55]. Although extremely rare, prolonged compression may cause
atrophy and erosion of cartilaginous tracheal rings. After thyroid resection, the
tracheal wall may collapse in an anteroposterior direction, leading to airway
obstruction. Incidence and management of tracheomalacia due to goiter are
discussed separately. (See "Treatment of benign obstructive or substernal goiter",
section on 'Tracheomalacia'.)

In patients with longstanding large goiters, we perform a cuff leak test to assess the
adequacy of air flow around the endotracheal tube prior to extubation (see
"Extubation following anesthesia", section on 'Cuff-leak test'). If there is no leak, we
extubate over a tube exchanger to facilitate rapid reintubation if necessary.
Postoperative care — Most patients are transferred to the post-anesthesia care unit
for recovery from anesthesia, with monitoring and discharge criteria similar to
patients who have other types of surgery. These issues are discussed separately. (See
"Overview of post-anesthetic care for adult patients".)

After thyroid surgery, patients may be admitted to the hospital for overnight
observation and management, or in select cases, may be discharged home within a
few hours of surgery. Inpatient versus outpatient surgery is discussed separately. (See
"Thyroidectomy", section on 'Inpatient versus outpatient surgery'.)

SUMMARY AND RECOMMENDATIONS

● Preanesthesia evaluation

• Thyroid dysfunction causes physiologic changes that may affect anesthetic

care and perioperative outcomes. Most of these changes resolve with
treatment as the patient becomes euthyroid. (See 'Multiorgan system effects of
thyroid disease' above.)

• For patients with known, treated thyroid disease, euthyroid status should be
confirmed during preanesthesia evaluation. Patients taking a stable dose of
thyroid medication, with documented euthyroid status within the past three to
six months, do not need additional testing prior to surgery. (See 'Euthyroid
patients' above.)

• For patients with recently diagnosed thyroid disease, elective surgery should
be delayed until treatment results in a documented euthyroid state. Patients
with severe hypothyroidism or hyperthyroidism who need urgent or
emergency surgery should receive immediate treatment prior to surgery. (See
'Patients with abnormal thyroid function' above.)
● Choice of anesthetic technique – We prefer general anesthesia for thyroid or
parathyroid surgery. Advantages of general anesthesia include secured control of
the airway and an immobile surgical field, as well as avoidance of the need for
urgent conversion from local/regional to general anesthesia. However, clinical
 outcomes do not differ in patients who receive local or regional versus general
anesthesia. (See 'Choice of anesthetic technique' above.)
● Airway concerns

• An enlarged thyroid gland (goiter) can cause difficulty with airway

management for anesthesia, particularly cancerous, substernal, or obstructing
goiters. (See 'Airway evaluation' above.)

• A smaller than usual endotracheal tube (ETT) size may be required in patients
with potential airway problems related to a goiter. Patients with stridor due to
tracheal compression are intubated awake, with the surgical team standing by
ready to perform emergent tracheotomy or rigid bronchoscopy. (See
'Induction of anesthesia' above.)

• After thyroid surgery, post-extubation airway compromise may develop,

caused by vocal cord dysfunction due to recurrent laryngeal nerve injury,
tracheal compression due to an expanding wound hematoma, or
tracheomalacia due to long-standing tracheal compression. Immediate
reintubation may be necessary, as well as emergency surgical decompression
of any wound hematoma. (See 'Postextubation airway complications' above.)
● Recurrent laryngeal nerve monitoring – If recurrent laryngeal nerve
monitoring is used during thyroid or parathyroid surgery, neuromuscular
blockade should be avoided during testing. (See 'Recurrent laryngeal nerve
monitoring' above.)

ACKNOWLEDGMENT

The editorial staff at UpToDate acknowledge William R Furman, MD, who contributed
to an earlier version of this topic review.
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