However, the authors' knowledge, no investigator has compared the efficacy of these 2 procedures. How does hypoparathyroidism, result from thyroid surgery, and how is it evaluated? - The main symptom for the detection of hypocalcemia was tingling. As thyroid cancer grows, it may cause: If you experience any signs or symptoms that worry you, make an appointment with your health care provider. This vocal cord paralysis can be temporary or permanent, it will be necessary to assess the performance of a tracheostomy if the vocal cords do not recover. The New England Journal of Medicine. U.S. Nuclear Regulatory Commission. Total Thyroidectomy (Discharge Care) - Drugs.com How is hypothyroidism prevented following thyroid surgery? 2004 Aug. 199(2):243-8. There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. If you'd like to learn even more about thyroid cancer, watch our other related videos or visit mayoclinic.org. A prospective analysis was carried out of complications affecting 241 consecutive patients (mean age 65+/-19 years; 76% female) undergoing cervical exploration for thyroid disease from 2000 to 2005, with particular attention to infection, and the pertinent literature was reviewed. This has evolved to a shorter incision placed in a skin crease higher in the neck. Results: Furtado L. Thryroidectomy: post-operative care and common complications. Theyll also check the lymph nodes next to your thyroid gland and remove any that have or might have cancer cells. Unauthorized use of these marks is strictly prohibited. A Mayo Clinic expert explains, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition. [QxMD MEDLINE Link]. All SSIs are characterized by the following symptoms: Redness, swelling, and warmth: Inflammation is the body's natural [QxMD MEDLINE Link]. [Full Text]. However, the cosmetic result obtained with an appropriately sized and placed conventional incision is also good. Continuous electrophysiologic monitoring of the RLN during thyroid surgery is easily performed. Sterile surgical arenas, general anesthesia, and improved surgical techniques have made death from thyroid surgery extremely rare today. A total thyroidectomy is surgery to remove all of your thyroid gland. It enters the larynx through the thyrohyoid membrane and, therefore, should not be at risk during thyroidectomy. The changes, which doctors call mutations, tell the cells to grow and multiply rapidly. Perioperative antibiotics are not recommended for thyroid surgery. By understanding the presentation and treatment of each complication, the surgeon can handle complications expediently and avoid worsening consequences. asthenia, weight loss, anxiety, palpitations, temperature changes and changes in sleep pattern. According to the Ministry of Health and Consumption and Social Welfare, the procedures on thyroid, parathyroid and thyroglossal tract have a low percentage of mortality of 0.03% compared to other surgical procedures.2 Surgery offers an early remission of endocrine disorder and more stable than more conservative strategies and also an earlier detection of thyroid cancer.1 Goiter recurrence remains a problem that sometimes cannot be resolved with thyroxine suppressive therapy and primary surgery is a more aggressive but more effective way to prevent relapse. The study determined that for inpatient procedures, complication rates were affected by such preoperative factors as age 70 years or older, non-Caucasian race, dependent functional status, a history of congestive heart failure, a history of smoking, a bleeding disorder, wound infection, and preoperative sepsis. Sound surgical technique is essential. Improvement in phonation quality has been documented in humans after reinnervation with the ansa cervicalis, but no movement is observed. None of the thyroidectomy-treated patients had a postoperative wound infection. However, the patient must be counseled that his or her voice will likely worsen after surgery. A window in the thyroid cartilage is created at the level of the true vocal fold. Main care to avoid complications associated with From a total of 140 documents found in the search (10 Pubmed, 70 CINAHL, 60 Cochrane), 60 were excluded because they did not meet the inclusion criteria listed above (Table 2) and 50 were eliminated because they were duplicated in the different bases of data. sharing sensitive information, make sure youre on a federal Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group. What causes thyrotoxic storm during thyroid surgery? thyroidectomy surgery AND complications thyroidectomy surgery AND postoperative thyroidectomy surgery AND interventions, thyroidectomy surgery AND complications thyroidectomy surgery AND postoperative thyroidectomy surgery AND interventions, thyroidectomy surgery AND complications AND intervention. encoded search term (Complications of Thyroid Surgery) and Complications of Thyroid Surgery, Neurological Manifestations of Thyroid Disease. If you are a Mayo Clinic patient, this could Clin Ter. How is hypoparathyroidism prevented following thyroid surgery? Hyperthyroidism affects between 1-3% of the general population and is usually more frequent than affects women. Data sources include IBM Watson Micromedex (updated 2 Apr 2023), Cerner Multum (updated 17 Apr 2023), ASHP (updated 10 Apr 2023) and others. As mentioned above, thyroidectomy is considered a safe surgery because it as a low percentage of complications, but it is worth highlighting which are to know their care and prevent them. Its effects on calcium metabolism oppose those of PTH. A dressing that covers the wound may mask hematoma formation, delaying its recognition. Risk factors for postoperative complications in total thyroidectomy. -Preoperative factors that affected complication rates for thyroidectomies in hospitalized patients included: age 70 years, non-Caucasian, functional dependent status, history of congestive heart failure, history of smoking, bleeding disorder, wound infection and preoperative sepsis. Conclusions: Most thyroid cancers don't cause any signs or symptoms early in the disease. The incidence of Transient Hypoparathyroidism (THPT) ranges from 19% to 47%, and Permanent Hypoparathyroidism (PtHPT) incidence range from 0% to 30%. International Journal of Molecular Sciences. Cellulitis typically presents as erythema, warmth, and tenderness of neck skin around the incision, A superficial abscess produces fluctuance and tenderness, A deep neck abscess may manifest subtly but can produce fever, pain, leukocytosis, and tachycardia, Send purulence expressed from the wound or drained from an abscess for Gram stain and culture, CT imaging is useful when a deep neck abscess is thought to be possible, To exclude esophageal perforation in patients with a deep neck abscess, an esophageal swallow study performed with sodium amidotrizoate and meglumine amidotrizoate solution (Gastrografin) may be useful, Treat cellulitis with antibiotics that provide good coverage against gram-positive organisms (eg, staphylococci and streptococci), Drain abscesses, and direct antibiotic coverage according to culture findings, For deep neck abscesses, begin with broad-spectrum antibiotics (eg, cefuroxime, clindamycin, ampicillin-sulbactam) until definitive culture results are available. Anaplastic thyroid cancer is a very rare type of cancer that typically occurs in adults 60 and older. 70% for positive and 95% negative predictive values. Recent technological and medical advances shorten the duration of hospitalization through more advanced surgical procedures that require a shorter hospital stay, therefore there is a tendency to ambulatory surgery and go home the same day.19. Hungry-bone syndrome occurs in patients with preoperative hyperthyroidism. 148 (6 Suppl):S1-37. Routine use of perioperative antibiotics in thyroid surgery has not been proven beneficial. Nader Sadeghi, MD, FRCSC Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, McGill University Faculty of Medicine; Chief Otolaryngologist, MUHC; Director, McGill Head and Neck Cancer Program, Royal Victoria Hospital, Canada If you live within 10 miles of a nuclear power plant and are concerned about safety precautions, contact your state or local emergency management department for more information. This is an open access article distributed under the terms of the, There are studies that7 independently prescribed at discharge all patients undergoing subtotal thyroidectomy or total oral calcium therapy. Therefore, low PTH levels result in high serum phosphorus levels. For hypothyroid patients, start levothyroxine (about 1.7 mcg/kg/d). Medicine (Baltimore). Deniwar A, Bhatia P, Kandil E. Electrophysiological neuromonitoring of the laryngeal nerves in thyroid and parathyroid surgery: A review. Kang et al described a series of 338 patients that underwent a robot-assisted transaxillary thyroidectomy. Check their thyrotropin level in approximately 4-6 weeks, and adjust the dosage appropriately. 2017 Feb. 96 (5):e5752. Both groups were similar in terms of sex, diagnosis of cancer and preoperative calcium and PTH. Risk factors for hypocalcemia after thyroidectomy include Graves disease and malignancy. Qurat C, Germain N, Dumollard J, et al. In addition, a series of recommendations has been made to patients at discharge to empower the patient to be responsible for their health and to recognize early complications, know and take responsibility for medication, know how to heal the wound, etc. Vicente DA, Solomon NP, Avital I, et al. Lucy J Barr, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Lucy J Barr, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and American Rhinologic Society. The cancer cells that spread might be found when you're first diagnosed or they might be found after treatment. Voice Outcomes after Total Thyroidectomy, Partial Thyroidectomy, or Non-Neck Surgery Using a Prospective Multifactorial Assessment. You may need to return to have your bandage changed, drains removed, or more tests. Geriatric Thyroidectomy: Safety of Thyroid Surgery in Aging Population. yeast infection after thyroidectomy Summary. clip-path: url(#SVGID_2_); Diagnosis and treatment. Another frequent complication may be the appearance of hypoparathyroidism that involves hypocalcaemia.5 Generally the management of hypocalcemia is successful with calcium supplements although some may be readmitted for starting intravenous calcium treatment in refractory cases. Meltzer et al developed a model to predict the risk of 30-day complications from thyroid surgery, with the presence of thyroid cancer being the most significant variable. Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page. .st0 { Having a rapid Thyroidectomy Among the surgical complications encountered were temporary recurrent laryngeal nerve (RLN) injury (four patients), permanent RLN injury (one patient), temporary bilateral RLN injury (one patient), delayed hematoma (two patients), and transient hypocalcemia (eight patients). WebCompletion thyroidectomy: removal of any remaining thyroid tissue. Accessed Jan. 21, 2022. By developing a thorough understanding of the anatomy and of the ways to prevent each complication, the surgeon can minimize each patient's risk. Postoperatorio inmediato en pacientes sometidos a tiroidectoma total en UCI Immediate post-operative period in patients undergoing total thyroidectomy in the ICU. Calcium carbonate 1250 mg provides 500 mg of elemental calcium; therefore, the patient should take 2500-5000 mg/day. Del Rio P, Rossini M, Montana CM, et al. There is a problem with Accessibility According to Ayhan H et al.19 after a thyroidectomy, patients experienced neck pain and disability. [QxMD MEDLINE Link]. Death is unlikely if the infection is recognized and treated promptly and appropriately. An image depicting the regional anatomy can be seen below. https://www.nrc.gov/about-nrc/emerg-preparedness/about-emerg-preparedness/potassium-iodide/ki-faq.html. The type of thyroid cancer is considered in determining your treatment and prognosis. Thyroid cancer is a growth of cells that starts in the thyroid. 8600 Rockville Pike The author declares there is no conflict of interest. Hypoparathyroidism is another feared complication of thyroid surgery. And medullary thyroid cancer. In the postoperative period, the diet should be cold and not too hot in order to avoid overheating that it could induce in the blood vessels of the neck and dilate more easily and increase the risk of bleeding. The tumor can grow to invade nearby tissue and can spread (metastasize) to the lymph nodes in the neck. A thyroidectomy is the surgical removal of all or part of a thyroid gland. 17 that dealt with the stated objective and that were added to a 2002 article because of its relevance. Hypoparathyroidism can result from direct trauma to the parathyroid glands, devascularization of the glands, or removal of the glands during surgery. Most thyroid cancers can be cured with treatment. Hi, I had a thyroidectomy 2 1/2 years ago and right after a started getting yeast infections every month. Elderly patients had a similar rate of complications compared to young patients, including transient hypocalcemia (12.5% vs. However, a resultant neck scar remains. An official website of the United States government. Ann Surg Oncol. Regret for the inconvenience: we are taking measures to prevent fraudulent form submissions by extractors and page crawlers. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you. The surgeon's experience is a significant contributor to various complications during thyroid surgery. Some have suggested that pain following VAT is less when compared with conventional thyroidectomy because of limited dissection, retraction, and injury to tissues. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Postoperative morbidity rates in patients seem to be equivalent to those of patients who have undergone conventional surgery. It can develop preoperatively, intraoperatively, or postoperatively. Epub 2021 Oct 20. Recurrence is more likely if your cancer is aggressive or if it grows beyond your thyroid. M Abraham Kuriakose, MD, DDS, FRCS Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences The study involved 278 thyroid surgery patients. Repeated aspirations may be necessary. A deep neck abscess may manifest subtly, but signs such as fever, pain, leukocytosis, and tachycardia should raise clinical suspicion. } Write down your questions so you remember to ask them during your visits. Wong, et al found that the combination of immediate postoperative PTH levels < 1.5 pmol/l and morning serum calcium < 2.0 mmol/l would accurately identify patients at risk of hypocalcemia following total thyroidectomy. Mayo Clinic; 2018. Remain with the patient and be prepared to assist with airway management. However, most of the tests were performed more than 6 months after the onset of paralysis; therefore, this study revealed little regarding the usefulness of early EMG testing. Discuss your options with a genetic counselor who can explain your risk of thyroid cancer and your treatment options. You may notice changes to your voice, including hoarseness of your voice, or difficulty swallowing. [16]. The truncations used in the search, carried out in July 2018 until September, are the following: Terms used in the search (Figure 1). You suddenly feel lightheaded and short of breath. Postoperative voice and swallowing have also been shown to differ according to the method of surgery. Cardiac arrhythmias may also occur. The right RLN branches from the vagus more superiorly than does the left, at the level of the subclavian artery. Melanie WS, David JT. Permanent paralysis may result in permanent hoarseness of the voice, and some may feel more short of breath if trying to speak to quickly. Video-assisted thyroidectomy was tested successfully in animals and has been performed safely in human patients. Sometimes the cancer cells can spread beyond the neck to the lungs, bones and other parts of the body. WHAT ARE THE RISKS OF THYROIDECTOMY FOR GRAVES DISEASE? This approach may also help improve aesthetic results. Videostroboscopy demonstrates an asymmetric, mucosal traveling wave. The risk of infection depended mainly on the quality of pre-operative and post-operative care and on whether there was a break in sterile technique. The most useful laboratory test for detecting or monitoring of hypothyroidism in the patient who has undergone thyroidectomy is the measurement of thyrotropin (thyroid-stimulating hormone [TSH]) levels. Post Operative Expectations Background: [QxMD MEDLINE Link]. Your skin is itchy, swollen, or has a rash. WebSigns and symptoms of mild and moderate thyrotoxicosis include: Experiencing unexplained weight loss. Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, Royal College of Physicians and Surgeons of CanadaDisclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merck. The most important element in the management of SSI is adequate drainage of the incision These dressings obstruct the view of the neck and may delay diagnosis of a hematoma. The transaxillary robot assisted thyroidectomy approach appears to be replacing endoscopic approaches. Webthemselves or loved ones, thyroidectomy is a radiation-free alternative for definitive management of their disease. Consider exploring the neck to ensure that no reversible causes of nerve injury (eg, misplaced ligature) are present. Careers. The clinical presentation of a patient with SLN paralysis may be subtle. - 20% of patients had hypokalemia due to D2, definitive only 3%. [14]. https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1470. Ayala MA, Yencha MW. Laryngeal nerve injury is a serious complication of thyroid gland surgery. - After surgery only 2 cases of recurrence. What is the thyroid? WebSigns that you may have low calcium are numbness and a tingling feeling in your lips, hands, and the bottom of your feet, a crawly feeling in your skin, muscle cramps and Risk factors for hypocalcemia and hypoparathyroidism following thyroidectomy: a retrospective Chinese population study. Each incision is In order to evaluate the studies and determine the nursing care of patients who underwent a partial or total sea thyroidectomy and reduce the associated complications, a literature review of the literature published from 2008 to the present in English and Spanish was made. Surgical site infections (SSI) affected 2% of patients. Appropriate antibiotic coverage is indicated when infection develops post-operatively. The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: a review of 932 cases. Certain hereditary genetic syndromes may also play a role. In cases where further treatment is necessary, surgery is common. Chao TC, Lin JD, Chen MF. Depending on your cancer, your doctor may remove just a portion of the thyroid - a procedure known as thyroidectomy. Unable to load your collection due to an error, Unable to load your delegates due to an error. 1 Thyroid surgery has different complications like hemorrhage, recurrent laryngeal nerve injury resulting in change in information submitted for this request. A fever. How is recurrent laryngeal nerve (RLN) injury prevented during thyroid surgery? 14th ed. and transmitted securely. Health Education & Content Services (Patient Education). How is injury to the superior laryngeal nerve due to thyroid surgery diagnosed and managed? You may opt-out of email communications at any time by clicking on [13], A study by Chen et al indicated that compared with unilateral subtotal thyroidectomy, the risk of hypoparathyroidism is 11.86 times greater in bilateral total thyroidectomy and 8.56 times greater in radical thyroidectomy with unilateral neck lymph node dissection. The superior parathyroids also usually receive their blood supply from the inferior thyroid artery. with hx. They also had a greater risk of suffering postoperative complications and of being readmitted to the hospital and also tended to have longer hospital stays. Vocal cord paralysis Perhaps the rarest, but most concerning, potential complication of a thyroidectomy is vocal - Complications that may appear after hospitalization o during it, Table 1 Criteria for inclusion and exclusion of search in databases. Transfer of neuromuscular pedicles have been described and reportedly restore movement of the vocal fold. In a 5-year study, Miccoli et al (2004) selected 579 patients to undergo MIVAT. How are thyroid surgery complications prevented? .st2 { Control of the wound and the area due to the risk of hematoma. In the United States the incidence of thyroid storm ranged between 0.57 and 0.76 Most patients who are hypocalcemic after thyroidectomy are initially asymptomatic. Nontoxic diffuse goiter, nodular thyroid disorders and thyroid malignancies. In bilateral vocal-cord paralysis, initial treatment involves obtaining an adequate airway. All observations must be documented, drainage, volume, consistency, color and functionality of the state of the drainage equipment. [QxMD MEDLINE Link]. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, for video What is thyroid cancer? - Unilateral paralysis of the recurrent laryngeal nerve was diagnosed in 3.9% and bilateral in 0.2%. Outpatient Endocrine Surgery Doesn't Raise Readmission Risk. The updated JBI model for evidence-based healthcare. Both provide useful EMG information and help to reveal the location of the RLN. Federal government websites often end in .gov or .mil. - Postoperative wound infection occurred in 1.6% and is associated with lymph node dissection vs. those that were not performed. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. Controversy still surrounds the use of drains after thyroid surgery. It is usually secondary to the lesion of the laryngeal or inferior superior nerve. Most types grow slowly, though some types can be very aggressive. The key to preventing postoperative infection is the use of sterile surgical technique. The nonrecurrent laryngeal nerve branches from the vagus at approximately the level of the cricoid cartilage and directly enters the larynx without looping around the subclavian artery. McMullen C, Rocke D, Freeman J. In only 15% is it anterior to the artery. - After thyroidectomy, a new hemorrhage occurred in 2.1% and was associated with a more advanced age and male sex. The traditional approach to thyroidectomy involved a long, low cervical incision. In summary, if the general principals of conventional thyroid surgery are followed, video assistance may help in identifying structures and in minimizing the incision. 2022 Feb;74(1):303-308. doi: 10.1007/s13304-021-01191-4. Electrothermal bipolar vessel sealing system (EBVSS) delivers precise amount of energy, resulting in limited thermal spread to adjacent tissues, including critical structures such as the parathyroid glands and recurrent laryngeal nerve. After a completion thyroidectomy, patients will need to take thyroid hormone replacement pills 2524 N. Broadway Edmond Oklahoma 73034. 2017 Oct. 96 (43):e8245. - Techniques to improve the success of thyroid surgery. Having an irregular heartbeat ( arrhythmia ). Fiberoptic laryngoscopy may be performed to confirm the diagnosis if the patient is clinically stable. [7] One group received a suction drain at the time of surgery, whereas the other did not; hematomas occurred in 5% and 7%, respectively. Parnes et al (1985) performed laryngeal EMG in 24 patients with vocal fold paralysis due to numerous etiologies (eg, idiopathic causes, surgery, tumor, trauma, neurologic diseases). Tower 1, Capital Square, Vci t 76. It was observed that the presence of malignancy may be a predictor of increased postoperative complications. 173.212.242.8 Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine Adequacy of antibiotic prophylaxis and incidence of surgical site infections in neck surgery. The development of complications can lead to poor pain control. The accumulating cells form a mass called a tumor. If left untreated, low Temiz Z, Ozturk D, Ugras GA, et al. Creagan ET (expert opinion). The surgeon must carefully assess the airway before transferring a patient for radiologic studies. Bookshelf 32(5):693-700. 2023 May;47(5):1201-1208. doi: 10.1007/s00268-023-06932-7. AskMayoExpert. Being diagnosed with cancer can be frightening, but take comfort in the fact that most cases of this cancer are treatable. The Critical Appraisal Skills Program (CASPe) guide14 was used to critically assess the documents obtained. The mean operative time was 41 minutes (range, 15-120 min) for lobectomy and 51.6 minutes (range, 30-140 min) for total thyroidectomy. After thyroidectomy, a few people may experience neck pain and a hoarse or weak voice. This doesn't necessarily mean there's permanent damage to the nerve that controls the vocal cords. These symptoms are often short-term and may be due to irritation from the breathing tube that's inserted into the windpipe during surgery, or be a result of Type I thyroplasty is probably the most common procedure. Subscribe for free and receive an in-depth guide to coping Multiple endocrine neoplasia type 2. Conclusion: This review has been made with the aim of knowing more about the most frequent complications after a thyroidectomy and establishing the basic learning needs that patients should know at discharge to take responsibility for their health. What is the role of EMG in the prevention of recurrent laryngeal nerve injury during thyroid surgery? You can unsubscribe at any Your incision comes apart, or blood soaks through your bandage. Identification of at risk patients with low PTH levels will facilitate prompt calcium replacement therapy and safe early discharge from hospital. [15]. Surg Laparosc Endosc Percutan Tech. Fiberoptic laryngoscopy may be warranted in patients with airway issues without apparent wound hematoma to assess vocal fold function. [QxMD MEDLINE Link]. with hx. Patients who are to receive postoperative radioiodine scanning must stop taking levothyroxine before the procedure. The external SLN branch travels inferiorly along the lateral surface of the inferior constrictor until it terminates at the cricothyroid muscle. You feel very tired and cold, gain weight for no reason, and your skin is very dry. [Full Text]. Ayhan H, Tastan S, Iyigun E, et al. - Vocal disability index (VHI) was used as a simple questionnaire to identify negative voice results. If patients have deep neck abscesses, begin with broad-spectrum antibiotics (eg, cefuroxime, clindamycin, ampicillin-sulbactam) until definitive culture results are available. What are the signs and symptoms of postoperative bleeding, following thyroid surgery? This content does not have an English version. Educate the patient to use their hands to support the neck during movement and avoid hyperextension of the neck. The prevention of postoperative bleeding depends on good intraoperative hemostasis. Thyrotoxic storm is potentially lethal and must be dealt with astutely. In the case of a hematoma without impending airway obstruction, transfer the patient to the operating room as soon as is practical. The best way to preserve parathyroid gland function is to identify the glands and to maintain their blood supply. other information we have about you. The study demonstrated that the location of the inferior parathyroid glands was variable. Diagnosing an SLN injury with indirect or fiberoptic laryngoscopy is difficult.
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