Otolaryngology–Head and Neck Surgery (2008) 138, 98-100

ORIGINAL RESEARCH—HEAD AND NECK CANCER

Hypothyroidism following partial thyroidectomy

Michael Vaiman, MD, PhD, Andrey Nagibin, MD, PhD, Philippe Hagag, MD,
Alex Kessler, MD, and Haim Gavriel, MD, Bat-Yam, Israel; and Ivanovo, Russia
varies between 4% in iodine-sufficient countries1 and 33%
OBJECTIVE: To compare rates of hypothyroidism following in iodine-deficient areas1,2) and the fact that it is considered
three types of partial thyroidectomy for multinodular goiter. a diffuse disease. Although MNGs are rarely unilateral, they
STUDY DESIGN AND METHODS: All cases of partial thy- pose a dilemma in terms of the extent of the thyroidectomy.
roidectomies (hemi-, near-total, or subtotal) carried out at one
STs, NTs, HTs, and TTs are currently used to treat them,
Israeli and one Russian medical center (1990-2006) were retro-
spectively studied to determine the incidence of hypothyroidism
depending on the surgeon’s preference.
after each procedure. Most earlier studies on operative strategies for thyroid-
RESULTS: There were 881 near-total, 1538 subtotal, and 1051 ectomy concentrated on the rates of well-recognized possi-
hemithyroidectomies (total 3470). Postoperative follow-up was 2 ble complications, such as permanent recurrent laryngeal
to 15 years. Twenty-eight percent of the hemithyroidectomy pa- nerve paralysis and hypoparathyroidism. We designed this
tients suffered permanent hypothyroidism compared to 100% of multicenter study to document the incidence of postopera-
the near-total and 87% of the subtotal patients. Forty-six percent of tive hypothyroidism associated with three conventional par-
the hemithyroidectomy patients suffered temporary hypothyroid- tial thyroidectomies for treating MNG.
ism compared to 100% of the near-total and 93% of the subtotal
patients.
CONCLUSION: Subtotal and near-total thyroidectomies pro-
duced a rate of hypothyroidism close to that of total thyroidectomy
compared to 28% after hemithyroidectomy. MATERIALS AND METHODS
SIGNIFICANCE: Partial thyroidectomies provide no decisive
advantage over total thyroidectomies in terms of subsequent re- Of the total of 7329 patients who were candidates for this
quirements of supplemental hormone therapy. study, 3859 were excluded for having undergone operations
© 2008 American Academy of Otolaryngology–Head and Neck other than an HT, ST, or NT (n ⫽ 3573) or were lost to
Surgery Foundation. All rights reserved. follow-up (n ⫽ 286), leaving a final study cohort of 3470
patients. There were 1452 males and 2018 females whose
mean age was 46.8 years. They had undergone an HT (n ⫽
W hile there is general consensus that the surgical treat-
ment of thyroid cancers is total thyroidectomy (TT),
the optimal operative strategies for treating benign thyroid
1051), ST (n ⫽ 1538), or NT (n ⫽ 881) for MNG over a
period of 2 to 15 years earlier and were being followed up
diseases remain controversial. The parameters that are usu- as outpatients in the two participating medical centers. Ex-
ally considered in this ongoing debate are postoperative clusion criteria were previously known malignancy and/or
hypothyroidism and the rates of surgical complications. The final pathologic results containing thyroid neoplasm requir-
various types of thyroidectomies for treating both benign ing completion thyroidectomy. Table 1 lists the distribution
and malignant thyroid pathology include TT, near-total thy- and demographic data of the study cohort and Table 2
roidectomy (NT), subtotal thyroidectomy (ST), and hemi- depicts the distribution of the three investigated procedures
thyroidectomy (HT). In the TT technique, the entire gland is in the two medical centers.
removed from the tracheoesophageal groove, while fewer Standard HT, NT, and ST procedures were performed in
than 3 g of thyroid tissue are left along the posterior aspect which the recurrent laryngeal nerves and parathyroid glands
of the contralateral lobe in the NTs. The ST approach leaves were identified. The approach used for an individual patient
no more than 25% of one lobe and it can also be a bilateral was chosen according to the surgeon’s judgment. All spec-
procedure. HT is a lobectomy and is used in cases of imens were routinely examined histologically to confirm
unilateral pathology. benignity of the pathology. All patients were hospitalized
We chose to study multinodular goiter (MNG) from and routine calcium measurements and indirect laryngosco-
among the various thyroid pathologies because of its ubiq- pies were performed. Preoperative hypothyroidism was de-
uitousness in the general population (an incidence of MNG fined as a baseline TSH level of greater than 5.5 U/mL, and

Received June 27, 2007; revised August 22, 2007; accepted September
12, 2007.

0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2007.09.015
Vaiman et al Hypothyroidism following partial thyroidectomy 99

Table 1
Distribution and demographic data of the study cohort

Hospital center No. patients M (%) F (%) Mean age, y

Assaf Harofeh (Israel) 1337 472 (35.3%) 865 (64.7%) 49.3

Ivanovo Academy (Russia) 2133 980 (46%) 1153 (54%) 44.5
Total 3470 1452 (41.8%) 2018 (58.2%) 46.8

208 patients (6%) were determined as being in a hypothy- (194 after HT, 231 after ST, and 61 after NT). A completion
roid state before the operation. Temporary postoperative thyroidectomy was performed on 285 patients and the oth-
hypothyroidism was defined as a serum thyrotropin level ers were prescribed an elevated L-thyroxin dose.
greater than 6.0 mIU/L that persisted for at least 8 weeks Thyroid hormone supplement due to hypothyroidism
after surgery. Hypothyroidism was considered as being per- was required in 28% post-HT cases, in 87% post-ST cases,
manent when it persisted at 6 months and more after sur- and in 100% post-NT cases (P ⬍ 0.05 for NT vs HT, and P
gery. Endocrinologists assessed thyroid and parathyroid ⫽ 0.12 for NT vs ST). The usual treatment protocol was
functions using conventional measurements. followed. There was no significant difference between the
Approval for this study was obtained from the Institu- two hospitals in terms of postoperative supplement require-
tional Review Boards and Medical Ethics Committees of ments.
both institutions. There were no untoward surgical complications in any of
the reported cases that might influence the results of this
Statistical analysis study. Recovery was uneventful for all three procedures.
Differences between the groups were analyzed with the
Fisher exact test. P values less than 0.05 were considered
significant.
DISCUSSION
Although the technique of performing a TT had signifi-
RESULTS cantly improved in the 1970s,3 surgeons still preferred per-
forming STs even though the reported incidence of hypo-
The rates of hypothyroidism for each of the three types of
thyroidism after ST ranged from 25%4 to as high as 87.5%.5
surgery in both hospitals are presented in Table 3. The
During the 1980s through 1990s, some surgeons favored ST
inter-hospital difference for postoperative hypothyroidism
for treating benign diseases due to its proposed lower inci-
was insignificant (P ⬎ 0.01). The median durations of
dence of surgical complications and postoperative euthyroid
hospitalizations were 2.9 days for HT, 3.3 days for NT, and
state,6-8 while others advocated TT because of similar com-
3.1 days for ST for the Assaf Harofeh Hospital and 17.4,
plication rates to those of the ST procedure and the sug-
19.2, and 19 days, respectively, for the Ivanovo Medical
gested lower pathologic recurrence rate.9,10 NT evolved as a
Academy Hospital. The differences in lengths of hospital-
compromise between TT and ST operations,11 but it had no
ization between the two medical centers reflect hospital
significant effect on the rate of complications. When feasi-
policy.
ble, however, TT was nevertheless replaced by partial op-
Conservative postoperative treatment was sufficient in
erations with the intention of avoiding injuries of laryngeal
2984 cases, while reoperation was required for the remain-
nerves and accidental excision of parathyroid glands as well
ing 486 patients who suffered recurrence of benign disease
as postoperative hypothyroidism (TT by definition causes
hypothyroidism).
While hypothyroidism after ST is not at all rare and almost
Table 2
inevitable after NT, an HT approach might be considered
Distribution of the three types of partial
thyroidectomies
“safer” in terms of postoperative hypothyroidism in cases of
unilateral disease. A recent study, however, set the overall
Near- incidence of post-HT hypothyroidism at 27% and noted that
Medical center Hemi- Subtotal total the majority of cases developed within the first 6 to 12 months
after surgery.12 Risk factors for the development of hypothy-
Assaf Harofeh
roidism included pathologic diagnosis (Hashimoto thyroiditis
(Israel) 457 516 364
Ivanovo Academy and MNG) as well as a high-normal serum thyrotropin level. In
(Russia) 594 1022 517 our study, the incidence of 28% hypothyroidism after HT
Total 1051 1538 881 versus 87% after ST and 100% after NT is clearly significant
and a decisive advantage; the surgical decision, however, is
100 Otolaryngology–Head and Neck Surgery, Vol 138, No 1, January 2008

Table 3
Type and percentage of hypothyroidism after hemi-, subtotal, and near-total thyroidectomies carried out in the
two medical centers*

Hemi-total Subtotal Near-total

Type Israeli Russian (mean) Israeli Russian (mean) Israeli Russian (mean)

Temporary 45 47 (46) 92 94 (93) 100 100 (100)

Permanent 25 31 (28) 83 90 (87) 100 100 (100)
Temporary, a serum thyrotropin level ⬎ 6.0 mIU/L that persisted for at least 8 weeks after surgery; Permanent, a serum
thyrotropin level ⬎ 6.0 mIU/L that persisted at 6 months and more after surgery.
*P ⬍ 0.01 (␹2 test)

usually made on grounds of nodule location, ie, unilateral or FINANCIAL DISCLOSURE

bilateral location of the nodules.
Technically speaking, hypothyroidism is not a postsur- None.
gical complication but an expected outcome of the removal
of a significant portion (or all) of the thyroid gland. The
subsequent functional role of the remaining thyroid tissue
has been addressed by only a few reports. Koyuncu et al13
reported that L-thyroxin was not required in 36.6% of cases REFERENCES
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Michael Vaiman, main idea, editing; Andrey Nagibin, main idea, editing; 14. Ozbas S, Kocak S, Aydintug S, et al. Comparison of the complications
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