_________________________________________________________________________ Thyroid Dysfunction
4. As you swallow, look at your neck, checking for any bulges or protrusions in this area. This may need to be repeated several times to be sure you are looking in the correct place. NOTE: The “Adam’s apple” and thyroid gland are separate and should not be confused; the thyroid gland is located further down on your neck, closer to the collarbone. 5. See a physician immediately if bulges, protrusions, or enlargements are seen. If there is a problem, treatment will be initiated quickly. As with any other diagnosis, patients with thyroid disease require education about their particular disease process and the importance of following a strict regimen of treatment, as outlined by their physician. Patients should have a good understanding of the medications taken to treat hypothyroid- ism/hyperthyroidism and how to take them correctly. Patients taking levothyroxine should be instructed to take the medica- tion at the same time daily, on an empty stomach and with a full glass of water. Avoidance of antacids should be stressed. Those who are taking propylthiouracil to treat hyperthyroid- ism should be encouraged to be strictly compliant with their regimen. Avoidance of over-the-counter cold remedies that contain iodine will be necessary. Patients should also avoid driving or other hazardous activities until they know how concentration and alertness may be affected by the drug. Signs of overmedication should be reviewed, including the necessity of contacting a physician if signs arise. Patients who have been treated with radioactive iodine should be instructed regarding radiation precautions, including abstaining from close personal contact for one week after dosing. FOLLOW-UP ASSESSMENT It is critical that follow-up assessments of patients should include questions regarding weight loss or gain, appetite, heat intolerance, mood swings, or any other indications of possible hypo- or hyperthyroidism. Because patients may not be aware that these symptoms are critical, they may fail to report them without prompting. Obvious physical indications of thyroid dysfunction should also be assessed. SURGICAL MANAGEMENT Thyroidectomy is a treatment option for a variety of condi- tions, including hyperthyroidism, thyroid cancer, goiter, or nodules. Some procedures involve a partial removal (subtotal thyroidectomy or lobectomy), which leaves part of the gland available to function normally. However, others require total removal. When total removal is necessary, there is a risk of also removing or devascularizing all or part of the parathyroid glands. Treatment course, including surgical management, is determined by the type and stage of thyroid cancer, overall health of the patient, and patient preferences [46].
Patients scheduled for a thyroidectomy require adequate preop- erative preparation. It is not uncommon for preparation to take as long as two to three months, during which time medication will be administered to reduce the size and vascularity of the gland, decreasing the risk of postoperative hemorrhage. If pos- sible, the patient should be well-rested, free of any infections or viral illnesses, and in overall good health. Traditionally, the surgeon will remove the thyroid by making a 3- to 4-inch incision along the neck while the patient is under general anesthesia. The typical length of stay in the hospital after the procedure is about one day [46]. Since 1996, an endoscopic procedure has been used for patients with a smaller gland or nodule, and advancements have led to several mini- mally invasive techniques, including robotic, video-assisted, and transoral approaches. The smaller incisional length of approximately 3 cm makes endoscopic thyroidectomy an attractive option, as it is less painful in the postoperative period and has better cosmetic results. It may additionally help in identifying structures and in minimizing the incision; however, it is not appropriate for every patient [47]. It is estimated that approximately 65% of patients are candidates for laparoscopic thyroidectomy [44]. Postoperative morbidity rates in patients who have undergone laparoscopic thyroidectomy are equivalent to rates in patients who have undergone conventional surgery, although it is necessary that qualified practitioners have a thorough knowledge of underlying pathology and experience with this method [44; 47] . For the traditional thyroidectomy patient, the caregiver should be alerted of the usual complications of any surgery, which include infection or excessive bleeding. The thyroidectomy patient is at risk for thyrotoxicosis, hypocalcemia (due to pos- sible inadvertent removal of the parathyroid glands), respiratory obstruction, laryngeal edema, and vocal cord injury. Postop- eratively, it is important to monitor vital signs and observe for bleeding. It is possible for these patients to bleed excessively, but for the blood to pool at the back of the neck, making it dif- ficult to visualize. Also, it is recommended that a tracheotomy set, endotracheal tube, laryngoscope, and oxygen be readily available in the event that the patient develops a complication from swelling into the respiratory tract. The patient should be instructed to breathe deeply and cough, knowing that it will trigger increased pain at the surgical site. Be observant also for increased temperature or possible hypocalcemia. Observing serum calcium levels in the postoperative period is also helpful to verify parathyroid function [47] . It is also important to assess the ability to speak. In 2013, the American Academy of Otolaryngology issued a new guideline designed to highlight the importance of a patient’s voice in the physical examination [43]. This guideline includes a strong recommendation that clinicians performing thyroid surgery identify the recurrent laryngeal nerve or nerves. The guideline also recommends a presurgical assessment of the patient’s voice and vocal fold mobility and emphasizes the importance of patient education regarding possible effects of thyroid surgery on the patient’s voice [43] .
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Book Code: ANCCTX2027
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