Anesthesia Considerations for Patients with Hyperthyroidism

Preoperative Considerations

The American Academy of Otolaryngology-Head and Neck Surgery recommends that the anesthesiologist review the patient's thyroid anatomy and physiology during the pre-anesthetic evaluation to assess for potential difficult airway due to enlarged thyroid gland, abnormal laryngeal structures, or presence of goiter 1, 2
Evaluate thyroid function tests (TSH, FT4, T3) to determine the degree of hyperthyroidism, as recommended by the Journal of Clinical Oncology 3

The American Academy of Otolaryngology-Head and Neck Surgery suggests that general anesthesia with endotracheal intubation is typically required for thyroidectomy, and consider fiberoptic intubation or having a difficult airway cart available if airway concerns exist 1, 2
Avoid long-acting neuromuscular blocking agents if nerve monitoring is planned, as they are absolutely contraindicated, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

For patients on corticosteroids, the Anaesthesia society recommends providing stress-dose steroids, including hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24h, and continue hydrocortisone 200 mg/24h by IV infusion while nil by mouth 4, 5, 6, 7

Assess voice function immediately postoperatively, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery, and be prepared for possible airway compromise requiring re-intubation, especially in cases of large goiters with tracheomalacia 1

Preoperative communication between surgeon and anesthesiologist is essential, according to the American Academy of Otolaryngology-Head and Neck Surgery, and discuss need for nerve monitoring, which affects choice of muscle relaxants 2
Use a pre-procedural checklist to improve team communication and decrease patient errors, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends that patients should be monitored at least every hour for the first 6 hours postoperatively, as approximately half of hematomas occur within this timeframe 8, 9
After the initial 6-hour period, the frequency of observations can be adjusted according to the individual patient's risk and local policies 8, 9
The risk of clinical deterioration should not be underestimated in case of postoperative hemorrhage, even if small, especially in the context of laryngeal edema 8, 9
Same-day discharge should be avoided if postoperative concerns arise, and the suitability for ambulatory discharge should be reevaluated 10

Surgeon‑anesthesiologist communication about abnormal laryngeal findings is essential before the patient enters the operating room. This discussion should cover vocal‑fold mobility, visibility of the laryngeal inlet, altered laryngeal anatomy (e.g., rotation, compression, tumor invasion), hypopharyngeal crowding from goiter, and planned nerve monitoring. 11
Pre‑operative laryngeal examination is recommended for patients with voice changes because 1–8 % of individuals with thyroid disease have pre‑existing vocal‑fold paralysis, with higher rates in malignant disease. 12

Deflating the endotracheal‑tube cuff while the surgical retractor is placed and gently reinflating it afterward may reduce recurrent laryngeal‑nerve compression injury. 13
Positioning the endotracheal‑tube cuff near the superior laryngeal or recurrent laryngeal nerve can cause transient voice dysfunction that may last up to 24 hours. 13

Patients with large goiters are at risk for tracheomalacia that becomes apparent after gland removal; prompt recognition and urgent re‑intubation may be required. 13
If postoperative airway obstruction develops from bleeding or edema, immediate intubation should not be delayed, although re‑intubation may be technically challenging because of airway distortion. 13

A pre‑procedural checklist and team briefing that review thyroid status, anticipated airway anatomy, and special monitoring requirements help prevent communication‑related errors. 11