Definitive Surgical Management of Thyroid Disease in Adults
Publication Date: February 1, 2020
Last Updated: March 14, 2022
Recommendations
INITIAL EVALUATION
1. Evaluation of thyroid disease should include specific inquiry about personal history, family history, clinical characteristics, and symptoms. (, )
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2. The preoperative physical examination should include voice assessment. (, )
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3. TSH should be measured in patients with nodular thyroid disease. Additional laboratory studies may help in specific circumstances. (, )
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4. A diagnostic US should be performed in all patients with a suspected thyroid nodule. (, )
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5a. US assessment of bilateral central and lateral lymph node ( LN) compartments should be performed in the preoperative evaluation of patients with cytologic evidence of thyroid carcinoma. (, )
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5b. US assessment of bilateral central and lateral LN compartments may be performed in the preoperative evaluation of patients with indeterminate cytologic evidence of thyroid carcinoma. (Strong “We recommend”, Insufficient)
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6. CT or MRI with intravenous contrast should be used preoperatively as an adjunct to US in selected patients with clinical suspicion for advanced locoregional thyroid cancer. (Strong “We recommend”, Low)
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FINE NEEDLE ASPIRATION BIOPSY (FNAB) DIAGNOSIS
7a. FNAB is a standard component of thyroid nodule evaluation, and its indications should follow established guidelines based on US characteristics, size, and clinical findings. (Strong “We recommend”, Moderate)
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7b. FNAB of a sonographically suspicious cervical LN should be performed when the results will alter the treatment plan. (Strong “We recommend”, Low)
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8. In most circumstances, FNAB yield and adequacy may be optimized using US-guidance, with or without onsite cytologic assessment. (Strong “We recommend”, Moderate)
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9. The Bethesda System for Reporting Thyroid Cytopathology should be used to report and stratify the risk of malignancy in a thyroid nodule. (Strong “We recommend”, High)
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MOLECULAR TESTING (MT)
10. If thyroidectomy is preferred for clinical reasons, then MT is unnecessary. (Strong “We recommend”, Moderate)
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11. When the need for thyroidectomy is unclear after consideration of clinical, imaging, and cytologic features, MT may be considered as a diagnostic adjunct for cytologically indeterminate nodules. (Strong “We recommend”, Moderate)
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12. Accuracy of MT relies on institutional malignancy rates and should be locally examined for optimal extrapolation of results to thyroid cancer risk. (Strong “We recommend”, Moderate)
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INDICATIONS, EXTENT, AND OUTCOMES OF SURGERY
13. Patients with a thyroid nodule, goiter or thyroiditis who exhibit local compressive symptoms or progressive enlargement should be considered for thyroidectomy. (Strong “We recommend”, Low)
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14. Thyroidectomy is one of several options for treatment of hyperthyroidism and should be preferentially considered when RAI or medical therapy is contraindicated or undesirable. (Strong “We recommend”, Moderate)
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15. For nodules that are cytologically categorized as Bethesda III, clinical factors, radiologic features, and patient preference should inform decision-making regarding whether to proceed with repeat biopsy, MT, diagnostic thyroidectomy, or observation. (Strong “We recommend”, Moderate)
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16. Diagnostic thyroidectomy and/or MT are accepted options for patients with nodules cytologically categorized as Bethesda IV. (Strong “We recommend”, Moderate)
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17. Thyroidectomy is indicated for thyroid nodules >1 cm cytologically categorized as Bethesda V or VI. (Strong “We recommend”, Moderate)
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18. When possible, thyroidectomy should be performed by a high-volume thyroid surgeon. (Strong “We recommend”, Moderate)
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PREOPERATIVE CARE
19. Antimicrobial prophylaxis is not necessary in most cases of standard transcervical thyroid surgery. (Strong “We recommend”, High)
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20. Prior to thyroidectomy, in the absence of contraindications, a single preoperative dose of dexamethasone should be considered to reduce nausea, vomiting, and pain. (Strong “We recommend”, High)
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21. If surgery is chosen as treatment for GD:
Ideally patients should be rendered clinically euthyroid preoperatively. (Strong “We recommend”, Low)
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b. A potassium iodide containing preparation can be considered prior to surgery. (Conditional (weak) “We suggest”, Low)
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22. Gastric bypass patients should be counseled about a higher risk of severe postoperative hypocalcemia after total or completion thyroidectomy. (Strong “We recommend”, Low)
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23. Prior to thyroid surgery for GD, calcium and 25-hydroxy vitamin D levels may be assessed and repleted or supplemented prophylactically. (Strong “We recommend”, Moderate)
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24. Chemical VTE prophylaxis should be reserved for selected patients determined to be at high risk for VTE after thyroidectomy. (Strong “We recommend”, Low)
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INITIAL THYROIDECTOMY
25. The superior pole vessels should be ligated close to the thyroid capsule to avoid potential external branch of the superior laryngeal nerve (EBSLN) injury. (Strong “We recommend”, Insufficient)
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26. The recurrent laryngeal nerve (RLN) should be identified to help preserve it. (Strong “We recommend”, Low)
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27a. Dissection should be performed along the thyroid capsule to help preserve the parathyroid glands. (Strong “We recommend”, Low)
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27b. If a parathyroid gland cannot be preserved, parathyroid autotransplantation should be performed. (Strong “We recommend”, Low)
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PERIOPERATIVE TISSUE DIAGNOSIS
28. Core needle biopsy should be rarely utilized in the initial evaluation of a thyroid nodule. (Strong “We recommend”, Low)
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29. Thyroid intraoperative pathologic evaluation (IOPE) should only be utilized in settings in which the information it provides has a high likelihood of altering the operative procedure. (Strong “We recommend”, Low)
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30. IOPE has value in confirming identification of parathyroid tissue. (Strong “We recommend”, Moderate)
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31. IOPE has value in identification of cervical lymph node (CLN) metastases when the information may alter extent of surgery. (Strong “We recommend”, Moderate)
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32. A standardized synoptic pathology report is recommended when reporting thyroid neoplasms. (Strong “We recommend”, Low)
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NODAL DISSECTION
33. During initial thyroidectomy for papillary thyroid cancer (PTC), the central compartment should be assessed for suspicious lymphadenopathy. If clinical or imaged lymph node metastasis (LNM) is present (ie, macroscopic disease), a therapeutic cervical node dissesction (CND) is recommended. (Strong “We recommend”, High)
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34a. A compartment-oriented therapeutic lateral node dissection (ND) is recommended for lateral LNM. (Strong “We recommend”, High)
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34b. Prophylactic lateral ND is not indicated for PTC. (Strong “We recommend”, High)
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CONCURRENT PARATHYROIDECTOMY
35. Hypercalcemia should be evaluated preoperatively in a patient being evaluated for thyroid surgery. (Strong “We recommend”, Low)
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36. Patients undergoing initial thyroidectomy who are diagnosed with primary hyperparathyroidism should undergo concurrent parathyroidectomy. (Strong “We recommend”, Moderate)
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37. Evaluation for hyperparathyroidism (HPT) is recommended in patients scheduled to undergo thyroid surgery who have a history of familial primary hyperparathyroidism (pHPT). (Strong “We recommend”, Moderate)
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HYPERTHYROID CONDITIONS
38. In patients with moderate to severe Graves ophthalmopathy, total thyroidectomy should be considered as first-line definitive treatment. (Strong “We recommend”, Moderate)
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39. Due to the higher risk and greater technical difficulty, thyroidectomy in Graves disease is best performed by high volume thyroid surgeons. (Strong “We recommend”, Low)
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GOITER
40a. When surgery is indicated, total thyroidectomy is preferred for treatment of bilateral goiter. (Strong “We recommend”, Low)
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40b. When the contralateral lobe is normal, lobectomy and isthmusectomy is recommended for treatment of unilateral goiter. (Strong “We recommend”, Low)
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41. Cross sectional imaging of goiter is recommended if there is concern for a substernal component. (Strong “We recommend”, Moderate)
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42. When performing surgery for substernal goiter, good communication, preparation and cooperation of experienced surgical and anesthesia teams is recommended. (Strong “We recommend”, Low)
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ADJUNCTS AND APPROACHES
43. While it does not prevent recurrent laryngeal nerve (RLN) injury, recurrent laryngeal nerve monitoring (RLNM) is safe and may assist the surgeon during initial or reoperative thyroidectomy. (Strong “We recommend”, Moderate)
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44. During planned total thyroidectomy, after completion of the initial lobectomy, if RLNM results suggest loss of function, the surgeon may consider stopping the operation for possible completion at a later date. (Strong “We recommend”, Low)
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46. Remote-access thyroidectomy should only be performed in carefully selected patients, by surgeons experienced in the approach. (Strong “We recommend”, Low)
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LARYNGOLOGY
47. In preoperative discussion of thyroidectomy, the surgeon should disclose to the patient the possibility, likelihood, and implications of permanent vocal fold dysfunction. (Strong “We recommend”, Moderate)
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48. Prior to thyroidectomy, laryngeal examination should be performed in patients determined to have vocal abnormalities as assessed by the surgeon, pre-existing laryngeal disorders, prior at-risk surgery, or locally advanced thyroid cancer. (Strong “We recommend”, Low)
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49. Voice assessment should be performed at the postoperative visit. (Strong “We recommend”, Low)
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50. After thyroidectomy, laryngeal examination should be performed in patients with known or suspected new RLN dysfunction or aspiration. (Strong “We recommend”, Moderate)
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51. If vocal fold motion impairment is suspected or identified, early referral of the patient to a laryngologist is recommended. (Strong “We recommend”, Moderate)
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FAMILIAL THYROID CANCER
52. Germline genetic testing should include pre- and post-test counseling by a knowledgeable health care provider. (Strong “We recommend”, Low)
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53. Differentiated thyroid cancer (DTC) screening should be performed in at-risk individuals from families with three or more affected first-degree relatives. (Strong “We recommend”, Low)
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54. All patients diagnosed with medullary thyroid cancer (MTC) should undergo genetic testing for a germline RET mutation. (Strong “We recommend”, High)
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55. An experienced multidisciplinary care team should manage patients diagnosed with multiple endocrine neoplasia type 2A (MEN2A) and multiple endocrine neoplasia type 2B (MEN2B). (Strong “We recommend”, Low)
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POSTOPERATIVE CARE AND COMPLICATIONS
56a. Use of nonopioid and nonpharmacologic therapies and patient education should be the first-line pain management after thyroidectomy. (Strong “We recommend”, Moderate)
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56b. If opioids are prescribed for postoperative pain management, the lowest effective dose of immediate release opioids (<10 oral morphine equivalents) should be prescribed.
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57. Patients at higher risk for cervical hematoma should be considered for overnight observation following thyroidectomy. (Conditional (weak) “We suggest”, Moderate)
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58. Patients with suspected hematoma after thyroidectomy should be evaluated immediately with appropriate intervention as indicated. (Strong “We recommend”, Low)
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59. If unilateral RLN transection occurs during thyroidectomy, an attempt should be made at repair. (Strong “We recommend”, Moderate)
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60. To prevent and/or manage postoperative symptoms of hypocalcemia following total or completion thyroidectomy, a strategy for calcium and/or vitamin D supplementation should be considered. (Strong “We recommend”, Moderate)
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61. Patients with significant post-thyroidectomy hypocalcemia should receive oral calcium as first-line therapy, calcitriol as necessary, and intravenous calcium in severe or refractory situations. (Strong “We recommend”, Low)
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CANCER MANAGEMENT
62. An active surveillance protocol for papillary thyroid microcarcinoma (PTMC) may be appropriate for carefully selected, informed, and compliant patients. (Strong “We recommend”, Moderate)
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63. A validated postoperative staging system such as the AJCC TNM classification should be used in thyroid cancer care. (Strong “We recommend”, Moderate)
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64. Consider completion thyroidectomy for high risk disease and/or when postoperative radioactive iodine (RAI) therapy is indicated. (Strong “We recommend”, Moderate)
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65. Total thyroidectomy should be performed for patients undergoing prophylactic thyroidectomy for medullary thyroid cancer. (Strong “We recommend”, Moderate)
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REOPERATION
66. Selected patients with stable, low-volume persistent or recurrent LNM can undergo active surveillance. (Conditional (weak) “We suggest”, Low)
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Recommendation Grading
Overview
Title
Definitive Surgical Management of Thyroid Disease in Adults
Authoring Organization
American Association of Endocrine Surgeons
Publication Month/Year
February 1, 2020
Last Updated Month/Year
December 22, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.
Target Patient Population
Adults with thyroid disease
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D013502 - General Surgery, D013965 - Thyroidectomy, D013959 - Thyroid Diseases
Keywords
thyroidectomy, Thyroid Disease
Source Citation
Patel KN, Yip L, Lubitz CC, Grubbs EG, Miller BS, Shen W, Angelos P, Chen H, Doherty GM, Fahey TJ 3rd, Kebebew E, Livolsi VA, Perrier ND, Sipos JA, Sosa JA, Steward D, Tufano RP, McHenry CR, Carty SE. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg. 2020 Mar;271(3):e21-e93. doi: 10.1097/SLA.0000000000003580. PMID: 32079830.
Methodology
Number of Source Documents
1066
Literature Search Start Date
January 1, 1985
Literature Search End Date
November 9, 2018