Quality of life after thyroid

surgery in women with benign

euthyroid goitre: influencing
factors including Hashimotos
thyroiditis
Regina Promberger, MD, Michael Hermann MD,
Shanon Joan Pallikkunnel, MD., Rudolf Seemann,
MD./ Moritz Meusel MD, Johannes Ott, MD.

Conducted in Medical university of Vienna, Austria

Hashimotos thyroiditis:

Autoimmune, gender specific

Decreased QoL
Presence of TPO-Ab
5% to 10% of female population of childbearing age
Thyroid surgery could hypothetically lead to an
increase in QoL, given that adequate thyroid
hormone substitution is provided

Potential systemic effect of autoimmunity

Total or near total removal

All patients in study underwent thyroid surgery

Females
To evaluate
1) QoL related outcome as a major objective

2)the change in individual symptom load as a

secondary objective in the long- term

Methods

Primary hypothesis
Health related QoL
1) would increase after thyroidectomy
2) more likely to increase in women with higher TPOAb levels or histologically confirmed Hashimotos
thyroiditis and after total or near total thyroidectomy

Second study objective

Complications after thyroid surgery and evaluated
possible risk factors
Prospective cohort study
Pre and postoperative symptom and SF-36
questionnaires
Data on the operation and postoperative
complications

SF 36 Questionnaire

The lower the score the more disability. The higher the
score the less disability i.e., a score of zero is equivalent
to maximum disability and a score of 100 is equivalent to
no disability.
The eight sections are:
vitality
physical functioning
bodily pain
general health perceptions
physical role functioning
emotional role functioning
social role functioning
mental health

Uses
Evaluating individual patients health status
Researching the cost-effectiveness of a treatment
Monitoring and comparing disease burden
Limitations
The survey does not take into consideration a sleep
variable
The survey has a low response rate in the >65
population[2]

Patient population and study design

426 patients included

Criteria:
1) women planned to undergo thyroid surgery and > 19
yrs of age
Women who had TSH levels in normal range 0.25 to
4.20 microunits/ml
Women with PTH levels in normal range 0 to 63 IU/ml
Thyroid malignancies excluded retrospectively
Patients who were willing to undergo follow up
investigations, including questionnaires > 12 mths after
operation ( n=248) ie. 58.2%

Patients undergone U/l and B/l thyroid operations

Subdivided into
1) total or near total
2) those with less extensive procedures

Serum levels of TSH, FT3, and FT4 pre and

postop
Preop TPO Ab

All patients answered 2 questionnaires on day

before sx and at follow up exmtn
1) a symptom questionnaire general sx and female
health ( summarizing score)
SF-36 QoL questionnaire
Whole thyroid specimens HPE
Hashimotos thyroiditis

Focused on weight of specimen and following postop

complications:
1)Hypocalcemia or hypoparathyroidism
>12 mths permanent hypoparathyroidism
2) 2nd to 4th day after operation , all patients
examined by ENT specialist
If postop nerve injury , follow up on day 14 and after
2to 3, 6 and 12 mths.
3) post op haemorrhage
4) wound infection

Possible risk factors for transient hypocalcemia and

transient RLN injury - age, preop TPO Ab, b/l vs u/l
thyroid surgery, presence of HT, and wt. of removed
thyroid was evaluated

Results Patient characteristics

B/l total or near total in 169 pts ( 68.1%)

79 pts ( 31.9%) b/l subtotal or unilateral procedures

HPE revealed HT in 29 pts (11.7%)

Postop complications
Transient post op RLN injury 19 pts -7.7%
Transient hypocalcemia 48 19.4%
Postop haemorhage - 3- 1.2%
Wound infection 1 0.4%

None had permanent RLN injury or hypocalcemia

Significant risk factors were found for transient

hypocalcemia B/l thyroid surgery and wt. of
removed thyroid

QoL and symptom load at long term

followup

Median 26 mths

At followup, all pts. were in need of thyroid hormone

replacement (preop 61/248 24.6%)

Modules of SF 36 apart from significant

improvement in bodily pain, none was was
significantly increased or decreased in followup

For presence of histologically confirmed HT,

significant positive correlation ( P<0.001) was found
for all SF 36 modules except physical functioning.

TPO Ab levels were positively correlated with

increasing QoL levels at follow up in role emotional
and bodily pain

Extent of resection

Total or near total lower post op QoL levels for

general health, physical functioning, role physical,
vitality, role emotional and social functioning

Transient hypocalcemia negatively influenced

postop QoL levels for physical functioning, role
physical, bodily pain, vitality, role emotional and
mental health

Transient RLNI negative influence only on physical

and social functioning
Wound infection: -ve impact on general health,
bodily pain, and vitality

Summary score for general symptoms increased

from median of 4 to 5

Higher postop symptom score was significantly asso.

with higher preop symptom score and higher
preoperative TPO- Ab levels

Dysphagia- in 48/248 pts. had completely resolved in

34 of those ( 70.8%)

Comments

Considering TPO- Ab levels before surgery

Association of HT with various organ specific and

non organ specific autoimmune diseases

Polyclonal autoimmune response against organ

specific autoantigens

Elevated TPO- Ab levels could be seen as a

surrogate parameter for altered immunity. In such
cases, removal of thyroid gland is unlikely to lead to
substantial improvement in QoL

Extent of resection- Thyroidectomy is not an

appropriate tool for increasing QoL in women with
higher TPO Ab levels, suspicious of HT, except for
pts. with mechanical symptoms

Histologically confirmed HT postop QoL

improvement in majority of domains
Maybe due to reduction in local symptoms

Summary symptom score increased by median of

only one symptom minor clinical relevance

Higher postop symptom score asso. with higher

preop symptom score and TPO- Ab levels. Suggests
that thyroid sugery is not effective in reducing
womens symptom load!!

No permanent hypocalcemia and RLNI as only

benign euthyroid included and recurrent disease
excluded

Wound infections hypertrophic scars or

inflammatory rearrangement negative effect on
vitality

Complications led to high levels of distress with long

lasting impact on social functiong, role emotional and
mental health

Size of removed gland and extent of resection are of

significant impact.

Limitations

Only 60% of pts. Were filling for followup analysis

Only women were enrolled
Median followup of 26 mths
Only euthyroid women included

Conclusion

Surgical intervention should not be recommended as

a treatment option for pts. With decreased QoL due
to higher TPO- Ab levels

Transient complications can have a long lasting ve

effect on patients QoL
Thyroid surgery improves QoL in female patients
with histologically confirmed HT.
So, thyroidectomy to be recommended in selected
cases.