13. Patients requiring thyroid surgery
Rosie Pudner
CHAPTER CONTENTS
Anatomy and physiology229
Disorders of the thyroid gland230
Conservative management of hyperthyroidism231
Specific investigations of a patient with thyroid dysfunction231
Nursing assessment of a patient requiring thyroid surgery232
Assessment of the patient’s voice and trachea232
Specific preoperative preparation232
Surgical interventions233
Specific postoperative nursing care234
Potential problems following thyroid surgery234
Discharge planning and patient education238
Conclusion238
Introduction
Many people with a disorder of the thyroid gland will eventually require surgery, because of the effects on the body of an imbalance of the thyroid hormones, or due to malignancy. This chapter will explore issues related to the care of patients requiring thyroid surgery, recognizing issues related to the effect of an altered body image, and the potential complications that can occur.
At the end of the chapter the reader should be able to:
• describe the anatomy and physiology of the thyroid gland and related structures
• discuss the underlying conditions that require thyroid surgery
• explain the specific investigations required prior to thyroid surgery
• discuss specific issues related to nursing assessment
• discuss the relevant pre- and postoperative nursing care following surgery to the thyroid gland
• discuss the plan for a patient’s discharge, including relevant patient education.
Anatomy and physiology
The thyroid gland consists of two lobes that lie either side of the trachea, and is situated in the anterior and lateral aspects of the neck, just below the larynx. The two lobes are joined by a band of tissue called the isthmus, which lies across the anterior surface of the trachea. The thyroid gland weighs approximately 20 g and is highly vascular. The arterial blood supply to the gland comes from the superior and inferior thyroid arteries, and venous drainage is through the superior, middle and inferior thyroid veins. Lymphatic drainage is via the deep cervical chain (laterally) and to the pretracheal and mediastinal nodes (inferiorly). The recurrent laryngeal nerves, which supply the vocal cords, lie posterior to the thyroid gland and are responsible for innervating many of the intrinsic laryngeal muscles, as well as playing a vital role in voice production and airway maintenance.
The primary function of the thyroid gland is to secrete various hormones: thyroxine, triiodothyronine and calcitonin. The lobes of the thyroid gland contain numerous follicles lined with epithelial cells. The follicles are filled with colloid, which is secreted from the epithelial cells. Thyroglobulin is a complex protein molecule that is also secreted from these epithelial cells. Iodine is an essential component for the synthesis of thyroxine and triiodothyronine. Production of the thyroid hormones is controlled by thyroid-stimulating hormone (TSH) from the anterior pituitary gland and by thyroid-releasing hormone (TRH) from the hypothalamus. The thyroid hormones thyroxine (T4) and triiodothyronine (T3) are stored in the form of thyroglobulin in the follicles prior to their release into the bloodstream (Hinchliff et al, 1996). Thyroxine and triiodothyronine are essential for stimulating oxygen consumption of most cells within the body; regulating lipid and carbohydrate metabolism; normal growth and development; normal lactation; and the potentiation of the action of other hormones, e.g. insulin. Calcitonin is secreted by the parafollicular cells, in response to an increase in blood calcium levels. It plays a part in reducing the calcium concentration in body fluids, by promoting the excretion of calcium and phosphate in urine and movement into the bones.
The four parathyroid glands are attached to the posterior surface of the lateral lobes of the thyroid gland. The parathyroid glands secrete parathormone, a hormone which regulates the distribution and metabolism of calcium in the body. The blood concentration levels of calcium and phosphorus are regulated by its action on the intestine, bone and kidneys. It promotes the absorption of calcium in the intestine and the demineralization of bone and movement of calcium into the extracellular fluid. Undersecretion of the hormone can lead to low calcium levels, which will result in muscle spasm, e.g. tetany.
Disorders of the thyroid gland
Thyroid disorders tend to occur as a result of oversecretion of thyroid hormones, i.e. hyperthyroidism; undersecretion, i.e. hypothyroidism (myxoedema); or due to malignancy.
Goitre
Goitre refers to an enlargement of the thyroid gland, and can occur in response to demand on the gland, or because of a benign or malignant tumour of the gland. A deficiency of iodine in the diet can also lead to the formation of a goitre.
A goitre presents as a mass in the neck which moves on swallowing. This is because the thyroid gland is attached to the larynx by fascia. The mass may be situated on one or both sides of the trachea. In some instances the trachea may be displaced and compressed by the enlarged gland, which can lead to an alteration of tracheal, oesophageal and vocal function, and can compromise the patient’s airway. On clinical examination, the doctor should be able to distinguish the shape and texture of the goitre. Goitres are often referred to as the following:
• smooth, non-toxic or physiological goitre
• nodular, non-toxic goitre
• smooth, toxic goitre (Graves’ disease)
• toxic, nodular goitre (secondary thyrotoxicosis) (Forrest et al, 1991).
Hyperthyroidism
Hyperthyroidism, or thyrotoxicosis, can be caused by Graves’ disease (an autoimmune disorder); toxic adenoma of the thyroid; and in multinodular goitres where the small thyroid nodules secrete excess thyroid hormone (Gillespie et al, 1992).
The prevalence of hyperthyroidism in females is 0.5–2%, and is 10 times more common in women than men (Vanderpump et al, 1995). The clinical features of hyperthyroidism vary between individuals (Table 13.1). Symptoms are characterized by an excess secretion of thyroid hormones and are due to increased catabolism, increased heat production, autonomic lability and increased sensitivity to catecholamines, and increased gastrointestinal activity.
| Symptom | Problem |
|---|---|
Weight loss Muscle wasting Increased appetite Intolerance of heat Pyrexia | Altered nutrition and metabolism |
Tachycardia Raised sleeping pulse Palpitations Angina Possible atrial fibrillation Increased blood pressure Cardiac failure | Altered cardiovascular system |
| Shortness of breath | Altered respiratory activity |
Moist, warm skin Increased sweating Hair loss Retraction of eyelids | Altered skin integrity |
Weakness and fatigue Tremor of hands Increased muscle tone and reflexes Shortness of breath on exertion | Altered activity tolerance |
Emotional lability Increased anxiety Restlessness Increased irritability Insomnia | Altered emotional and mental state |
Diarrhoea Increased gastrointestinal motility | Altered bowel habits |
Oligomenorrhoea or amenorrhoea Low sex drive Impotence | Altered sexuality |
Graves’ disease can cause distressing symptoms of altered body image, because of the patient having a swollen neck, and the effect it has on the patient’s eyes. This can range from the appearance of staring, to lid lag and lid retraction, and, in its severest form, exophthalmos. Exophthalmos (an abnormal protrusion of the eyeballs) and lid lag can result in corneal ulceration, which will cause visual disturbances, and in extreme cases can lead to papilloedema and an inability to move the eyeball (Gillespie et al, 1992).
Neoplasms of the thyroid gland
Neoplasms of the thyroid gland can be benign, e.g. an adenoma, or malignant. Malignant neoplasms of the thyroid can be divided into four groups – papillary, follicular, medullary and anaplastic. Thyroid cancer is the most common endocrine malignant tumour and accounts for 1% of all cancers. The incidence of thyroid cancer appears to be slowly increasing: in 2001 the annual incidence for the UK was 3.5 per 100,000 women and 1.3 per 100,000 men. Aetiology of thyroid cancer is unknown, but risk factors include: history of neck irradiation; Hashimoto’s thyroiditis; family history of thyroid adenoma; Cowden’s syndrome; familial adenomatous polyposis; familial thyroid cancer; and exposure to nuclear fallout (e.g. following the Chernobyl accident). The prognosis depends on the type and aggressiveness of the tumour and the presence of metastases, as well as the patient’s age and overall health. Following investigations and staging of the disease, a thyroidectomy will be undertaken (British Thyroid Association/Royal College of Physicians, 2007).
Conservative management of hyperthyroidism
Hyperthyroidism is initially treated conservatively by the use of a thionamide, e.g. carbimazole or propylthiouracil. These drugs suppress the formation of the thyroid hormones and hopefully produce a euthyroid state, i.e. a normally functioning thyroid gland, and are also used in the preparation of a patient prior to thyroid surgery. If the patient has cardiac symptoms, a beta-adrenergic blocking agent may be used to decrease the heart rate, e.g. propranolol.
Radioactive iodine therapy is an effective treatment for patients over the age of 45 years. It avoids the prolonged use of drugs or the need for surgery, although there is a risk of causing hypothyroidism in the patient (British Thyroid Association/Royal College of Physicians, 2007). The patient swallows a solution of gamma-emitting radioactive sodium iodide, which destroys thyroid tissue and so reduces the production of the thyroid hormones T3 and T4.
Specific investigations of a patient with thyroid dysfunction
A variety of laboratory and other investigations are undertaken prior to surgery.
Blood tests
Serum levels of the following are measured to evaluate thyroid function, and identify hyperthyroidism and malignancy:
• free thyroxine (FT4)
• free triiodothyronine (FT3)
• thyroid-stimulating hormone (TSH)
• thyroid antibodies
• thyroglobulin (Tg)
• thyroglobulin antibodies (TgAb)
• TSH-receptor antibodies (TSH-RAb)
• thyroid auto-antibodies
• calcitonin (British Thyroid Association, 2006).
Radioactive scanning procedures
This is useful in patients with a solitary autonomous toxic nodule or with toxic multinodular disease, but is of little value in the diagnosis of malignancy. The radioactive isotopes used are:
• 99mtechnetium
• 131iodine.
Other imaging procedures
These will identify any structural abnormalities within the thyroid gland:
• ultrasound
• duplex ultrasound scan
• computerized tomography (CT) scan
• magnetic resonance imaging (MRI)
• fluorescent scan (British Thyroid Association/Royal College of Physicians, 2007).
Fine-needle biopsy
Fine-needle aspiration cytology (with or without ultrasound) allows an accurate diagnosis of the thyroid lesion to be determined, and should be used in the planning of surgery for patients with thyroid cancer.
Other investigations
These include the following:
• ECG – to detect atrial fibrillation
• cholesterol levels – to exclude hyperlipidaemia
• menstrual history – to identify abnormal menstrual cycle, fetal loss or subfertility
• a full blood count – to identify any abnormalities
• blood for typing and crossmatching (in case of haemorrhage peri- or postoperatively).
Nursing assessment of a patient requiring thyroid surgery
It is important to gain a comprehensive health history from the patient, as their health problems have often developed gradually over time and are often vague in nature. Knowledge of the effects of altered thyroid function enables the nurse to collect the relevant data and ask specific questions relating to the thyroid disorder. Using a model of nursing will also help to structure the assessment process (Box 13.1).
Box 13.1 Nursing assessment of Joanna Sweet using the Roper, Logan and Tierney model of nursing (Roper et al, 2000)
Joanna Sweet is a 30-year-old married lady with three young children aged 2, 4 and 7 years. She works as a presenter for the local television station, and her husband is a journalist. She developed hyperthyroidism and has been managed conservatively, but it is felt that surgery is now an option as the thyroid gland is causing Joanna much discomfort on eating and she is concerned by the appearance of her swollen neck. She is due for surgical removal of her thyroid gland as a short-stay patient in 2 weeks’ time.
Maintaining a safe environment
Joanna is very anxious regarding the outcome of the surgery and is concerned as to the appearance of the scar, and whether people will be able to see it.
Observations of her vital signs are as follows:
• Pulse: 86 bpm; sleeping pulse, 78 bpm. She says that she has had palpitations in the past.
• Blood pressure: 138/80 mmHg.
• Drug therapy:
– carbimazole 15 mg daily for the past 6 months
– propranolol 20 mg three times a day.
• Allergies: she is not allergic to anything that she knows of, and has had no problems with previous anaesthetics (she had an appendicectomy 10 years ago and drainage of a breast abscess 4 years ago).
Communicating
Joanna appears very anxious and asks lots of questions. She wears contact lenses as she is short sighted.
Breathing
• Respiratory rate: 18 rpm; regular. Joanna used to smoke 10 cigarettes a day before she became pregnant with her first child.
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