Outcomes of hemithyroidectomy under local with general anesthesia: A tertiary center experience

Bikram Budhathoki; Shankar Shah; Bimal K Sinha; DK Baskota

doi:10.4103/aiao.aiao_26_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 2 | Page : 45-49

Outcomes of hemithyroidectomy under local with general anesthesia: A tertiary center experience

Bikram Budhathoki¹, Shankar Shah², Bimal K Sinha³, DK Baskota³
¹ Rapti Academy of Health Sciences, Dang, Nepal
² Department of ORL and HNS, B P Koirala Institute of Health Sciences, Dharan, Nepal
³ Department of ORL and HNS, IOM, TUTH, Nepal

Date of Submission	23-Oct-2019
Date of Acceptance	07-Jan-2021
Date of Web Publication	19-Feb-2021

Correspondence Address:
Dr. Shankar Shah
Department of ENT and HNS, B.P. Koirala Institute of Health Sciences, Dharan
Nepal

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/aiao.aiao_26_19

Abstract

Context: The prevalence of thyroid neoplasm is high in the developing countries and therefore an increasing rate of thyroid surgery. Aims: We aimed to compare the outcomes of patients undergoing hemithyroidectomy under local anesthesia (LA) with general anesthesia (GA). Settings and Design: This was a prospective, comparative study. Methods: The study was conducted for a period of 22 months in 30 patients, undergoing hemithyroidectomy under LA and GA. Patients in both the groups were assessed for duration, postoperative pain, satisfaction, postoperative complications, and cost. Statistical Analysis Used: Analysis of the data was done using the Statistical Package for the Social Sciences 16 software (IBM, New York, US). Unpaired t-test was used to test the difference of mean and Fisher's exact test was used to test the association between the two groups. P < 0.05 was taken as statistically significant. Results: The mean operative time was less in Group A (LA) than Group B (GA) (79.2 min vs. 83.6 min) (P = 0.88). The mean postoperative pain score (using the Numerical Rating Scale) was high in Group A (3.4) than Group B (2.8) (P = 0.42). There was no statistical significant difference regarding satisfaction with anesthesia. One patient in each group developed recurrent laryngeal nerve (RLN) paresis, whereas two patients in Group B developed RLN paralysis. The mean cost was less in Group A (P < 0.001). Conclusions: Hemithyroidectomy under LA can be performed safely in a selected group of patients, expecting similar operative, clinical results and patient satisfaction.

Keywords: General anesthesia, hemithyroidectomy, local anesthesia

How to cite this article:
Budhathoki B, Shah S, Sinha BK, Baskota D K. Outcomes of hemithyroidectomy under local with general anesthesia: A tertiary center experience. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:45-9

How to cite this URL:
Budhathoki B, Shah S, Sinha BK, Baskota D K. Outcomes of hemithyroidectomy under local with general anesthesia: A tertiary center experience. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2023 Apr 2];4:45-9. Available from: https://www.aiaohns.in/text.asp?2020/4/2/45/309785

Introduction

The prevalence of thyroid neoplasm is high in the developing countries and therefore an increasing rate of thyroid surgery. Historically, thyroid surgery was performed under local anesthesia (LA).^[1],[2] The first detail report of thyroidectomy under LA was published by Thomas Peel Dunhill in 1907. The same year, he reported seven consecutive thyroidectomies for thyrotoxicosis under regional anesthesia.^[3] Rapid advances in anesthesiology and the widespread of even safer general anesthesia (GA) resulted in abandoning operations under LA.^[4],[5]

Over the last two decades, there has been resurgence in the number of thyroid operations performed under LA.^[5],[6],[7] Recent descriptions of thyroidectomy under LA claim similar operative, clinical results and patient satisfaction compared to GA.

Local/regional anesthesia has the advantage of being able to avoid some of the risks and many of the side effects associated with GA. Perhaps, most significant is the avoidance of endotracheal intubation. Local/regional anesthesia permits shorter postoperative recovery periods, and this potentially translates into shorter hospital stays and reduced costs.^[8] Thyroid surgery thus may be conducted in areas where facility for GA is not available and in surgical outreach camps of developing nation.

The advantages of GA are obvious for the surgeon and the patient. The surgeon is provided with a controlled, motionless operating field. As for the patient, GA produces analgesia, amnesia, and unconsciousness, thus providing a safe and comfortable operative experience. Transient side effects of GA include nausea, vomiting, headache, visual problems, disorientation, muscle pain, shivering, dizziness, or drowsiness.^[8] Although rare, some of the most serious risks of GA include myocardial infarction, cerebral vascular accident, and even death. This study was conducted prospectively to determine the effectiveness of LA compared to GA in patients undergoing hemithyroidectomy and also to determine patient satisfaction with either of the anesthetic approaches for hemithyroidectomy.

Methods

A prospective, longitudinal, and a comparative study was conducted for a period of 22 months, from December 1, 2010, to September 31, 2012. The study comprised 30 patients, 15 in each of two groups (Group A and Group B). Group A included patients in whom hemithyroidectomy was performed under LA and Group B those under GA. Patients of both genders with age 18 years and above, as indicated for hemithyroidectomy, were included in the study, whereas those with previous thyroid surgery, extent of surgery more than hemithyroidectomy, retrosternal thyroid, thyroidectomy with concomitant neck dissection, previous radiotherapy, and those with bleeding and coagulation disorders were excluded. The ethical approval was obtained from the Institutional Review Board (Ref no. 168), and informed and written consent was obtained from all of the patients.

Preoperative assessment

Patients presenting to the outpatient department with thyroid swelling were evaluated by history, clinical examination, and appropriate investigations. The patients who fulfilled the inclusion criteria were enrolled in the study. They were counseled for the type of anesthesia and posted for surgery as per their choice.

Anesthesia

Group A – Local anesthesia group

Following admission on the night before surgery, all patients received tablet alprazolam 0.5 mg orally. Half an hour before surgery, injection pethidine 50 mg mixed with injection promethazine 25 mg was given. A mixture of injection bupivacaine 0.5% and injection 2% lignocaine with 1:200,000 adrenaline was used for modified cervical plexus block.^[9] The maximum dose for bupivacaine was 3 mg/kg (1 ml = 5 mg [e.g., for 50 kg patient maximum dose 30 ml]), and the maximum dose for injection 2% lignocaine with 1:200,000 adrenaline was 7 mg/kg (1 ml = 21.3 mg [e.g., for 50 kg patient maximum dose 16 ml]).

Modified cervical plexus block

Modified cervical block^[10] employs a combination of regional blocks and infiltration. With the patient's chin elevated at a point midway along the posterior border of the sternocleidomastoid muscle, 3 ml bolus mixture of injection bupivacaine 0.5% and injection 2% lignocaine with 1:200,000 adrenaline was injected. The needletip was partially withdrawn and relocated into the substance of the sternocleidomastoid muscle and a second bolus of 3 ml given [Figure 1]. In the third step, the needle tip was withdrawn into the subcutaneous tissues of the superficial compartment and 3 ml of solution was injected [Figure 2] and [Figure 3]. The final step was to guide the needle toward the midline and 3 ml each was used to infiltrate the platysma and along the line of incision [Figure 4]. Modification in this technique was that the local anesthetic was deposited into the substance of the sternocleidomastoid muscle. Modified cervical block was given on the other side in the similar manner. Three milliliters of the solution was also given at the capsule and upper pole after the thyroid gland was exposed. Supplemental oxygen 3 L/min was given via nasal.

Figure 1: Three-milliliter bolus injected at a point midway along the posterior border of the sternocleidomastoid muscle

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Figure 2: Three milliliters of solution injected in the subcutaneous tissues of the superficial compartment of the neck

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Figure 3: Three milliliters of solution injected in the subcutaneous tissues of the superficial compartment of the neck

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Figure 4: Three milliliters to infiltrate platysma and a long line of incision

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Group B – General anesthesia

Hemithyroidectomy under GA in Group B was as per the routine protocol. All surgeries were performed by senior faculty members of the head-and-neck unit of the department according to the surgical procedure standardized by Theodor Kocher.

Outcome measure

The operative time (minutes) was noted from shifting the patient from the trolley to the operating table and then back from the operating table to the trolley. The patients were also assessed for pain measured using the Numerical Rating Scale (NRS) on the 1^st, 2^nd, and 3^rd postoperative days (PODs). The demand of analgesia in both the groups besides routine oral analgesic was noted. Patient satisfaction with anesthesia was assessed on the 1^st POD, using the Likert scale^[11] which ranged from very dissatisfied (1), dissatisfied (2), neither satisfied nor dissatisfied (3), satisfied (4), and very satisfied (5). Complications if any were noted in the pro forma. Analysis of the data was done using the Statistical Package for the Social Sciences 16 software (IBM, New York, US). Unpaired t-test was used to test the difference of mean and Fisher's exact test was used to test the association between the two groups. P < 0.05 was taken as significant.

Results

Among the 33 cases selected for the study, three were excluded – two cases underwent subtotal thyroidectomy because the thyroid nodules were extending to the other lobe which was detected on the operating table and one case was excluded because of spontaneous extrusion of the drain while shifting the patient from the recovery room. One of the patients in Group A developed seizure while giving LA. The complication was managed and the operation was cancelled that day. The patient was taken up for surgery under GA on the next operating day and was included in Group B.

Among the 30 cases who were included, there were three males and 27 females. Female population outnumbered the male (female: male = 7:1). The age ranged from 18 to 65 years, and the mean age was 36 years. There was no statistical significant difference in age distribution between the two groups (P = 0.08). The mean operative time in Group A was 79.2 min, whereas in Group B, it was 83.67 min. There was no significant statistical difference in the operative time between the two groups (P = 0.88). The mean postoperative pain score on NRS in both the groups on the 1^st POD was around 5 (Group A – 5.67 and Group B – 5.3), on the 2^nd POD was around 3 (Group A – 3.4 and Group B – 3.2), and on the 3^rd POD was 1 (Group A – 1.13 and Group B – 1.07), which was not statistically significant (P = 0.57, 0.38, and 0.16, respectively). Seven patients in each group demanded analgesia, all of which were on the 1^st POD. There was no statistical difference in the demand for analgesia between the two groups (P = 0.64).

In Group A, 33% (5/15) were most satisfied with anesthesia with a score of 5/5 and 53% (8/15) were satisfied with anesthesia with a score of 4/5. As compared to this finding, only 26% (4/15) patients in Group B were most satisfied with anesthesia and 60% (9/15) patients were satisfied with anesthesia. Two patients in each group (13.33% in each group) were neither satisfied nor dissatisfied with anesthesia with a score of 3/5. None of the patients in both the groups were neither dissatisfied nor very dissatisfied with anesthesia. The mean score in Group A was 4.20 and in Group B was 4.13, which was not statistically significant (P = 0.27).

In our study, all the patients were admitted in the hospital for 6 days following surgery. During this period, there were a total of five complications detected. Recurrent laryngeal nerve (RLN) paresis was seen in one each in both the groups. However, in Group B, two developed RLN paralysis. There were no hematoma, seroma, signs and symptoms of hypocalcemia, wound infections, and wound dehiscence. There were no statistical significant differences in complication between the two groups (P = 0.50).

The mean cost refers to the cost incurred on patient from admission till discharge. This cost includes operation charge, material cost, medicines, and general ward bed charges. The mean cost for Group A patient was Rs. 4550(US$ 65) and Rs. 7550(US$ 107.85) for Group B which was statistically significant (P < 0.001).

Discussion

Thyroid surgery is one of the most commonly performed surgeries by a head-and-neck surgeon. With increasing workloads and limited access to operating time under GA, the revival of thyroid surgery under LA offers an interesting alternative in that it can reduce the postoperative time spent in the hospital with potential health-care cost savings.^[12]

In our study, the age group ranged from 18 to 65 years. Only those cases who were ≥18 years of age were included because younger patient may not tolerate LA. This is similar to Hisham and Aina^[13] and Snyder et al.^[9] who included age 18 years and above. However, Lo Gerfo et al.^[7] included only those with 19 years and above.

In our study, the mean operative time was 79.20 min in Group A and 83.67 min in Group B which was not statistically significant, however, the mean operative time was lesser for Group A. This is comparable to the study done by Mamede and Raful^[14] (111 min under GA and 125.5 min under LA) and Snyder et al.^[9] (109 min in LA and 119 min in GA). In the study done by Specht et al.,^[15] the mean total operating room time, defined as entry into the operating room to entry into the recovery room, was 200 min in the LA group and 220 min in the GA group (P = 0.01). In the study done by Hisham and Aina,^[13] the mean operating time for LA was 80 min (range: 35–115 min) similar to ours (79.20 min).

In our study, NRS was used for assessment of postoperative pain. The NRS has good sensitivity and generates data that can be statistically analyzed for audit purposes compared to the Visual Rating Scale or the Visual Analog Scale.^[16] The mean pain score was 3.4 in Group A and 2.88 in Group B which was also not statistically significant (P = 0.42). This result was similar with Mamede and Raful^[14] where there was no difference in the pain perceived by patients in the GA or LA group. Unlike our study, literature search did not find studies comparing postoperative pain after thyroidectomy between GA and LA. Seven patients in each group demanded analgesia. This is similar to the study by Mamede and Raful,^[14] where there was no difference in the demand of analgesia between the two groups. Dieudonne et al.^[17] and Aunac et al.^[18] have stated that cervical segment anesthesia reduces the need for demand of analgesia. In our study, however, this superiority of modified cervical plexus block over GA was not confirmed, as the same number of patients requested analgesics.

For patient satisfaction, we have used a five-point Likert scale. The mean score in Group A was 4.20 and in Group B was 4.13, which was not statistically significant (P = 0.27). Similar outcome was noted by Snyder et al.^[9] In their study, most of patients in both the groups (LA – 13/28, GA – 12/28) were very satisfied with anesthesia with a score of 5/5 (P = 0.57). Similarly, in the study by Mamede and Raful,^[14] the mean levels of satisfaction (scored from 1 to 4) were 3.8 for the GA group and 3.9 for the LA group.

In our study in Group A, one patient developed RLN paresis. However, in Group B, one patient developed RLN paresis and two developed RLN paralysis. This is comparable with most other published studies where Snyder et al.^[9] had one patient in both the groups (LA/GA) each with transient vocal cord paresis. In the study by Spanknebel et al.,^[19] there were four (n = 255) temporary RLN injuries in the GA group and 16 (n = 939) in the LA group. Similarly, there were two (n = 255) permanent RLN injuries in GA and 7 (n = 939) in LA. Spanknebel et al.^[20] detected thirty RLN injuries, of which 20 (n = 1025) were temporary (2.0%) and 10 (n = 1025) were permanent (1.0%) in the LA group. Shukla et al.^[21] noted two cases of transient vocal cord paralysis in the GA group. In the study by Specht et al.,^[15] there was no RLN paralysis in the LA group, whereas there were two (n = 58) temporary RLN paralyses in the GA group.

In the study by Spanknebel et al.,^[19] hypoparathyroidism was seen in one LA patient. Wound infection was present in one patient in each group (GA = 0.4%/LA = 0.1%). In the study by Snyder et al.,^[9] three patients (15%) had hypocalcemia: two patients in the LA group and one in the GA group. In the study by Shukla et al.,^[21] seroma was seen in three patients of the LA group. In the study by Specht et al.,^[15] there were one (n = 58) case of transient hypocalcemia and one case of hematoma in the GA group. None of these complications such as hematoma, seroma, signs and symptoms of hypocalcemia, wound infections, and wound dehiscence were detected in our study. There were no other complications of LA with modified cervical plexus block.

The cost is also an important factor in the country like ours, where a vast majority of patients are poor and cannot even afford the basic necessities of life. The mean cost refers to the cost incurred on operation charges, medicines, and bed charge (general ward). The mean cost for Group A patient was Rs. 4550 (US$ 65) and Rs. 7550 (US$ 107.85) for Group B. This was statistically significant (P < 0.001). Hence, the cost obviously is lower in LA compared to GA. Hence, this technique can become a boon, being economically feasible. In the study by Spanknebel et al.^[19] and Shukla et al.,^[21] it was found that thyroidectomy under LA was economical than GA.

Conclusions

Hemithyroidectomy can be performed in a selected group of patients under either GA or LA, expecting similar operative, clinical results and patient satisfaction. It offers an effective alternative and cost-effective approach to GA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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