Clinical Indicators: Thyroidectomy

1. History (one or more required)
   1. Thyroid mass
   2. Family history of thyroid disease
   3. History and/or symptoms of hyper or hypothyroidism
   4. History of radiation to the neck
   5. History of accidental exposure to radiation
   6. History of medullary carcinoma in the family with positive RET oncogene or stimulation test for calcitonin
   7. A neck mass with histologic findings of metastatic thyroid tumor
2. Related Symptoms
   1. Hoarseness
   2. Dyspnea, stridor
   3. Dysphagia
3. Physical Examination (required)
   1. Complete physical examination of the head and neck with emphasis on inspection and palpation of the thyroid gland and neck.
   2. Indirect mirror or fiberoptic flexible laryngoscopy
4. Tests (one or more required)
   1. Fine needle aspiration biopsy
   2. Thyroid nuclear scan
   3. Ultrasonography
   4. Ultrasonography-guided fine needle biopsy
   5. CT scan of neck and chest
   6. MRI of neck and chest
5. Tests (required)
   1. Pre-operative tests as required by institutional guidelines
   2. Thyroid function tests (T3,T4, TSH)
6. Tests (optional)
   1. Serum calcium, phosphorous, albumin
   2. Chest radiograph
   3. Airway films (for suspected tracheal compression/deviation)
   4. Flow-volume studies (for suspected tracheal compression/deviation; retrosternal goiter)
   5. For suspected or proven medullary carcinoma:
      1. Calcitonin level
      2. RET oncogene
      3. Stimulation tests for calcitonin
      4. Alkaline phosphatase
      5. Urine catecholamines
      6. Imaging studies of the abdomen

Postoperative Observations

1. Immediate respiratory distress – notify surgeon; remove dressing. Surgeon to consider:
   1. Vocal cord paralysis
   2. Hematoma
   3. Tracheomalacia
   4. Hypocalcemia
2. Bleeding – check for expanding hematoma; notify surgeon
3. Hypocalcemia – symptoms and signs: tetany; circumoral paraesthesia/dysesthesia; carpopedal spasm; Chvostek’s sign; mental status changes.

Notify surgeon; obtain blood sample for calcium and albumin levels; prepare IV calcium gluconate or calcium chloride.

Outcome Review

1. One Week
   1. Vocal cord function – hoarseness? aspiration? respiratory distress?
   2. Calcium level – normal levels?
   3. Wound infection?
   4. Pathology report – compare with pre-operative diagnosis
   5. Need for thyroid hormone replacement/suppression therapy
2. Beyond One Month
   1. If thyroid cancer – total body scan done? Ablative radioactive iodine indicated?
   2. Thyroid hormone replacement/suppression given?
   3. Calcium levels – normal?
   4. TSH levels?
   5. Vocal cord paralysis?, vocal cord paresis?, hoarseness?, aspirations?
   6. Keloid/hypertrophic scar formation?
3. Beyond One Year
   1. Vocal cord paralysis?, dysphonia?, hoarseness?, aspirations?, rehabilitative procedure
      indicated?
   2. If cancer – follow-up includes:
      1. Physical examination
      2. Chest radiographs
      3. Periodic thyroid scan
      4. Thyroglobulin level
      5. Ultrasonography
   3. If benign – follow-up includes:
      1. Physical examination – recurrent neck mass?
      2. Symptoms or signs of hyper or hypothyroidism – adjust medication
      3. Thyroid function tests

Associated ICD-10-CM Diagnostic Codes (Representative, but not all-inclusive codes)

• C73 Malignant neoplasm of thyroid gland
• C78.30 Secondary malignant neoplasm of unspecified respiratory organ
• C78.39 Secondary malignant neoplasm of other respiratory organs
• C79.82 Secondary malignant neoplasm of genital organs
• C79.89 Secondary malignant neoplasm of other specified sites
• C79.9 Secondary malignant neoplasm of unspecified site
• D09.3 Carcinoma in situ of thyroid and other endocrine glands
• D09.8 Carcinoma in situ of other specified sites
• D34 Benign neoplasm of thyroid gland
• D43.0 Neoplasm of uncertain behavior of brain, supratentorial
• D43.1 Neoplasm of uncertain behavior of brain, infratentorial
• D43.2 Neoplasm of uncertain behavior of brain, unspecified
• D43.4 Neoplasm of uncertain behavior of spinal cord
• D48.7 Neoplasm of uncertain behavior of other specified sites
• E01.0 Iodine-deficiency related diffuse (endemic) goiter
• E01.1 Iodine-deficiency related multinodular (endemic) goiter
• E01.2 Iodine-deficiency related (endemic) goiter, unspecified
• E01.8 Other iodine-deficiency related thyroid disorders and allied conditions
• E02.9 Hypoparathyroidism, unspecified
• E03.2 Hypothyroidism due to medicaments and other exogenous substances
• E03.8 Other specified hypothyroidism
• E03.9 Hypothyroidism, unspecified
• E04.0 Nontoxic diffuse goiter
• E04.1 Nontoxic single thyroid nodule
• E04.2 Nontoxic multinodular goiter
• E04.8 Other specified nontoxic goiter
• E04.9 Nontoxic goiter, unspecified
• E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
• E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
• E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm
• E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm
• E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm
• E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm
• E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm
• E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm
• E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm
• E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm
• E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm
• E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm
• E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
• E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm
• E06.3 Autoimmune thyroiditis
• E06.5 Other chronic thyroiditis
• E20.0 Idiopathic hypoparathyroidism
• E20.8 Other hypoparathyroidism
• E83.51 Hypocalcemia
• E89.0 Postprocedural hypothyroidism
• E89.2 Postprocedural hypoparathyroidism
• J22 Unspecified acute lower respiratory infection
• J38.00 Paralysis of vocal cords and larynx, unspecified
• J38.01 Paralysis of vocal cords and larynx, unilateral
• J38.02 Paralysis of vocal cords and larynx, bilateral
• J39.8 Other specified diseases of upper respiratory tract
• J98.09 Other diseases of bronchus, not elsewhere classified
• J98.8 Other specified respiratory disorders
• K22.8 Other specified diseases of esophagus
• K23 Disorders of esophagus in diseases classified elsewhere
• R06.1 Stridor
• R13.0 Aphagia
• R13.10 Dysphagia, unspecified
• R13.11 Dysphagia, oral phase
• R13.12 Dysphagia, oropharyngeal phase
• R13.13 Dysphagia, pharyngeal phase
• R13.14 Dysphagia, pharyngoesophageal phase
• R13.19 Other dysphagia

Additional Information

Assistant Surgeon — Varies
Supply Charges — N
Prior Approval — N/A
Anesthesia Code(s) — 00160

Patient Information

Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed. The most common indications for thyroidectomy include a large mass in the thyroid gland, difficulties with breathing related to a thyroid mass, difficulties with swallowing, suspected or proven cancer of the thyroid gland and hyperthyroidism (overproduction of the thyroid hormone). Your physician will discuss the need for thyroidectomy based on your history, the results of a physical examination and tests. The most common tests to determine whether a thyroidectomy is necessary include a fine needle aspiration biopsy, thyroid scan, ultrasound, x-rays and/or CT scan, and assessment of thyroid hormone levels.

The procedure is usually done under general anesthesia. The extent of surgery (removal of one or both lobes) may sometimes be determined in the course of surgery after microscopic examination of tissue removed during the surgery.

After surgery it is very common to have difficulties and/or pain with swallowing. This pain is usually resolves within 24 to 72 hours although . Bleeding or infection are also possible short term complications. Although rare in thyroid surgery,some patients may develop a thick scar or keloid. Two complications specific to thyroid surgery are hypocalcemia and vocal cord weakness or paralysis. Hypocalcemia, or low blood levels of calcium, may occur after complete removal of both thyroid lobes. This condition is caused by injury to four tiny glands called parathyroid glands, which are located within or very close to the thyroid gland. Hypocalcemia is usually temporary, but sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcemia is fortunately rare. Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the thyroid gland. Temporary hoarseness may result. Again, this is uncommon, usually temporary complication. Permanent vocal cord paralysis is rare. Depending on the final histologic (microscopic examination) diagnosis of the gland removed, continuous follow-up by your endocrinologist and/or surgeon may be indicated.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery.