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Thyroid and parathyroid surgery: technique and complications

The three key complications of thyroid surgery are recurrent laryngeal nerve injury (hoarseness, and with bilateral injury — airway obstruction), parathyroid hypofunction (hypocalcaemia) and a neck haematoma that threatens the airway; nerve monitoring, preserving the parathyroids and following calcium and PTH reduce them.

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Why it matters in the exam

Recurrent laryngeal nerve injury causes one-sided vocal fold palsy with breathy hoarseness; bilateral injury leaves the folds paramedian with stridor and sometimes the need for intubation or tracheostomy. Under AAO-HNS 2013, voice assessment and examination of the folds are done before and after surgery. With intraoperative nerve monitoring (IONM), loss of signal on the first side is a reason to consider staging the second side, to avoid bilateral injury. Damage to the superior laryngeal nerve's external branch (which supplies the cricothyroid muscle) causes loss of high pitch and voice fatigue — especially important in singers. A right "non-recurrent" laryngeal nerve occurs in about 0.5% to 1%, together with an aberrant right subclavian artery.

Transient hypocalcaemia is common after total thyroidectomy; permanent (over 6 to 12 months) occurs in about 1% to 3%. A low PTH in the first hours after surgery predicts hypocalcaemia. Signs: tingling around the mouth and in the fingers, Chvostek and Trousseau signs. Treatment: oral calcium and calcitriol; IV calcium gluconate for severe symptoms. A haematoma usually appears within 24 hours, most within the first 6 hours; with respiratory distress the wound is opened at the bedside and the clot evacuated, and only then the patient goes to theatre.

In parathyroid surgery for primary hyperparathyroidism the adenoma is localised before surgery (ultrasound, sestamibi scan or 4D-CT). A fall of more than 50% in intraoperative PTH 10 minutes after excision (Miami criterion) confirms success. Indications for surgery in an asymptomatic patient (under the Fifth International Workshop, 2022): calcium 1 mg/dL or more above the upper limit, age under 50, osteoporosis or vertebral fracture, eGFR under 60, and kidney stones or nephrocalcinosis. "Hungry bone syndrome" causes severe hypocalcaemia after surgery for long-standing disease with bone involvement.

Key points

• Recurrent nerve: hoarseness; bilateral: airway.
• External branch of the superior nerve: high pitch.
• Hypocalcaemia: low PTH, calcium and calcitriol.
• Haematoma: open at the bedside.
• Miami: PTH falls by more than 50% after 10 minutes.

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Sources

• AAO-HNS Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery, 2013 — Laryngoscopy and nerve monitoring
• American Thyroid Association statement on postoperative hypoparathyroidism, 2018 — Diagnosis and management
• Fifth International Workshop on the Management of Primary Hyperparathyroidism, 2022 — Surgical indications and intraoperative PTH

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.