Uncovering a rare but critical complication following thyroid surgery: an audit across the UK and Ireland

Is Prophylactic Antibiotic Therapy Needed in Thyroidectomy?

Antibiotics have been traditionally prescribed for any open head and neck surgery. With classification of wound and wound contamination and various published guidelines the practice is still widely prevalent. Thyroidectomy being a clean surgery does not warrant the use of antibiotics at all. We performed an interventional prospective study to see the occurrence of wound infection in patients who received antibiotic prophylaxis as compared to those who did not. A total of 71 patients were recruited in the study who were randomly divided into two groups, one received antibiotic prophylaxis and other did not. Both the groups did not show any marked change in the incidence of wound infection hence highlighting the unnecessary use of prophylactic antibiotics in thyroid surgeries.

Simple Prediction Score for Developing Surgical Site Infection after Clean Neck Operation

Background: Clean neck operations (thyroidectomies, parathyroidectomies, and lymph node resection) are among the most common procedures performed in the United States. Surgical site infections (SSIs) after clean neck operations are rare, but the consequences are devastating and often life-threatening. The aim of this study was to develop a score that will identify patients at high risk for developing a SSI after a clean neck procedure. Materials and Methods: Patients with either thyroidectomies, parathyroidectomies, or lymph node resection of the neck were identified from the 2016 and 2017 databases of the American College of Surgeons National Surgical Quality Improvement Program and were used for this analysis. Our primary goal was to build a scoring system with which we will be able to identify patients at high risk for SSI after a clean neck operation. Results: Of a total of 99,877 patients, 72,719 patients had a thyroidectomy, 22,043 patients had parathyroidectomy, and 5,115 patients had lymph node resection of the neck. Multivariable logistic regression identified the following independent risk factors associated with post-operative SSI: male gender (adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.03-1.51), diabetes mellitus (aOR, 1.34; 95% CI, 1.07-1.67), smoking (aOR, 1.66; 95% CI, 1.36-2.04), pre-operative steroid use (aOR, 1.75; 95% CI, 1.21-2.53), cancer diagnosis (aOR, 1.44; 95% CI, 1.17-1.77), radical lymphadenectomies (aOR, 2.94; 95% CI, 2.16-4), and total operative time ≥198 minutes (aOR, 2.25; 95% CI, 1.82-2.78). Afterward, we developed a prognostic score for calculating the odds of having post-operative SSI. One point was allotted for each of the aforementioned factors, except lymphadenectomies where two points were allotted, and operative time was excluded. Our score was associated with a stepwise higher risk of post-operative SSI after a clean neck operation. Conclusions: Pre-operative and intra-operative factors can predict which patients undergoing a clean neck surgery may develop SSI. Our prognostic score may help guide surgeons identify patients at high-risk for SSI after clean neck surgery and these patients might benefit from prophylactic use of antibiotic agents.

Effect of Antibiotic Prophylaxis on Surgical Site Infection in Thyroid and Parathyroid Surgery: A Systematic Review and Meta-Analysis

Thyroid and parathyroid surgery are considered clean procedures, with an incidence of surgical site infection (SSI) after thyroidectomy ranging from 0.09% to 2.9%. International guidelines do not recommend routine antibiotic prophylaxis (AP), while AP seems to be employed commonly in clinical practice. The purpose of this systematic review is analyzing whether the postoperative SSI rate in thyroid and parathyroid surgery is altered by the practice of AP. We searched Pubmed, Scopus, the Cochrane Library, and Web of Science (WOS) for studies comparing AP to no preoperative antibiotics up to October 2021. Data on the SSI rate was evaluated and summarized as relative risks (RR) with 95% confidence intervals (95% CI). Risk of bias of studies were assessed with standard methods. Nine studies (4 RCTs and 5 nRCTs), including 8710 participants, were eligible for quantitative analysis. A meta-analysis showed that the SSI rate was not significantly different between AP and no preoperative antibiotics (SSI rate: 0.6% in AP vs. 2.4% in control group; RR 0.69, 0.43-1.10 95% CI, p = 0.13, I2 = 0%). A sensitivity analysis and subgroup analysis on RCTs were consistent with the main findings. Evidence of low quality supports that AP in thyroid and parathyroid surgery produce similar SSI rates as to the absence of perioperative antibiotics.

Rare case of postoperative mediastinitis following thyroidectomy

Descending necrotizing mediastinitis (DNM) is a life-threatening complication secondary to oropharyngeal abscesses, cervical esophageal perforation, or neck infections spreading along the fascial planes into the mediastinum. Post-thyroidectomy surgical site infection is a highly unusual complication that is typically localized around the incision, but may be propagated into the mediastinum, causing DNM. We encountered a case of this rare complication after thyroidectomy. The patient was a 33-year-old woman who was admitted to our center for left hemithyroidectomy. The surgery was performed without any intraoperative events. However, she later developed fever, hypotension, and tachycardia. Imaging revealed deep neck emphysema and focal pneumomediastinum with infiltration in the anterior neck and mediastinum with abscess formation. Additional imaging at 7 days postoperatively revealed reduced fluid collection deep in the neck with minimal changes in fluid collection in the mediastinum. Esophageal perforation was excluded via an esophagogram, which lead to the conclusion that the infection may have been caused by open thyroidectomy. The patient was treated with prompt medical and surgical intervention. After treatment, she was discharged from the hospital with no further complications. We present our case report as well as a literature review of the diagnosis and treatment of this disease.

Antibiotic Prophylaxis in Clean Head and Neck Surgery: An Observational Retrospective Single-Centre Study

INTRODUCTION

Surgical site infection (SSI) is a common complication in surgery. In head and neck surgeries, different rates are reported in the indexed literature. Nowadays, this indiscriminate use of antibiotics is associated with increased cost and risks for patients. Antimicrobial misuse has also contributed to the development of antibiotic-resistant bacteria.

PATIENTS AND METHODS

A total of 204 patients were included in this observational retrospective cohort study. The primary outcome of this study was to describe the rate of SSI. Wound infection was considered as SSI and was defined as any cellulitis or pus drainage requiring treatment with antibiotics.

RESULTS

Of all, 127 were included in group A (not antibiotic) and 77 in group B (antibiotic prophylaxis); 109 (53.5%) patients were male, and 97 (47.5%) were female. Four (3.14%) patients developed SSI in group A and 3 (3,89%) developed SSI in group B, being not statistically significant (P = .592). In group A, 2 patients suffered SSI after a submandibular gland resection (SGR), 1 patient after a parotid gland resection (PGR), and another one after a branchial cleft cyst resection. In group B, 1 patient suffered SSI after an SGR and 2 after a PGR. On univariate and multivariate analyses, we did not find any variable associated with the development of SSI.

CONCLUSION

According to our results, the prophylactic antibiotic in clean, benign head and neck surgery is not necessary. Nevertheless, physicians and surgeons should be aware that severe or even fatal SSIs might be developed, and it needs to be explained to our patient before any surgery.

Antibiotic prophylaxis for clean neck surgery

The frequency of surgical site infections (SSIs) after clean neck surgery is low and antibiotic prophylaxis is not recommended. This retrospective study investigated the effect of perioperative prophylactic antimicrobial therapy on the development of infections. A total of 807 consecutive patients undergoing clean neck surgery were included in the study. Antimicrobial prophylaxis with intravenous cefuroxime was administered in 518 cases. Although patients who received prophylaxis had a lower rate of SSIs than those who did not receive antibiotics, this was not statistically significant (0.4% vs 1.4% respectively, p=0.19). Older age was the only variable associated with the development of SSIs (p=0.014).

[Streptococcal mediastinitis after thyroidectomy. A literature review]

INTRODUCTION

Surgical site infections after thyroid surgery are mostly superficial and can be well treated. Streptococcal mediastinitis in contrast is a rare but life-threatening complication.

CASE REPORT

A 57-year-old female patient experienced septic fever, increase of inflammation parameters and erythema 2 days after thyroid surgery for Graves' disease. This process was triggered by a three-compartment infection by group A Streptococcus (GAS) with involvement of the mediastinum. Therapy over 6 weeks including seven wound revisions with the patient under general anesthesia, pathogen-adapted antibiotic treatment and cervical negative pressure treatment managed to control the infection. A total of 21 cases have been published on this phenomenon, 11 of which had a fatal outcome.

CONCLUSION

High fever and surgical site erythema in the early postoperative period after thyroid surgery can be signs of a GAS infection, which might lead to necrotizing, descending, life-threatening mediastinitis. Early diagnosis with support of computed tomography (CT) scans, immediate therapy including wound opening, lavage, intravenous antibiotic treatment with penicillin and clindamycin are vital. If treatment resistance occurs, cervical negative pressure treatment should be considered.

Morphological Changes Induced by Bipolar Radiofrequency Ablation in Thyroid Nodules - a Preclinical Ex Vivo Investigation

Introduction: Recently, radiofrequency ablation (RFA) has been increasingly used for the treatment of thyroid nodules. However, immediate morphological changes associated with bipolar devices are poorly shown. Aims: To present the results of analysis of gross and microscopic alterations in human thyroid tissue induced by RFA delivered through the application of the original patented device. Materials and methods: In total, there were 37 surgically removed thyroid glands in females aged 32-67 at presentation: 16 nodules were follicular adenoma (labelled as 'parenchymal' solid benign nodules) and adenomatous colloid goitre was represented by 21 cases. The thyroid gland was routinely processed and the nodules were sliced into two parts - one was a subject for histological routine processing according to the principles that universally apply in surgical pathology, the other one was used for the RFA procedure. Results: No significant difference in size reduction between parenchymal and colloid nodules was revealed (p>0.1, t-test) straight after the treatment. In addition, RFA equally effectively induced necrosis in follicular adenoma and adenomatous colloid goitre (p>0.1, analysis of variance test). As expected, tumour size correlated with size reduction (the smaller the size of the nodule, the greater percentage of the nodule volume that was ablated): r=-0.48 (p<0.0001). Conclusion: The results make it possible to move from ex vivo experiments to clinical practice.

A secure retraction technique for exposing the internal mammary vessels

Taghizadeh R, Stevenson S, Williams N. A secure retraction technique for exposing the internal mammary vessels. Ann R Coll Surg Engl 2013; 95: 533 doi 10.1308/003588413X13781990150491h

Streptococcal toxic shock syndrome following total thyroidectomy

Hung JA, Rajeev P. Streptococcal toxic shock syndrome following total thyroidectomy. Ann R Coll Surg Engl 2013; 95: 457–460 doi 10.1308/003588413X13629960048118

Severe group a streptococcus surgical site infection after thyroid lobectomy

BACKGROUND

Thyroidectomy is rarely complicated by a surgical site infection (SSI). Despite its low incidence, post-thyroidectomy SSI is especially concerning because of its proximity to vital head and neck structures and the very real potential for airway compromise and death. Severe SSIs frequently are caused by Group A Streptococcus (GAS) because of its potential for developing into necrotizing fascitis. No description of the surgical approach to a necrotizing soft-tissue infection after thyroid resection is available in the current literature.

METHODS

Case report and review of the pertinent English-language literature.

RESULTS

A 47-year-old male underwent a right thyroid lobectomy and isthmusectomy for a follicular neoplasm. On post-operative day 2, the patient presented to the emergency department with persistent pain, rapid onset of swelling, and airway compromise shown on computed tomography scan. Emergency incision and drainage revealed a severe soft tissue infection. Because of subsequent worsening erythema and soft-tissue swelling, the patient had to be re-explored. The infection, later identified as caused by GAS, might have been transmitted from the patient's daughter.

CONCLUSION

To our knowledge, this is the first case reported of exposure to a family member with GAS pharyngitis. Successful treatment requires an appropriately high level of suspicion followed by emergent operative debridement and systemic antibiotics.

Antibiotic prophylaxis in thyroid surgery: a preliminary multicentric Italian experience

Post-operatory wound infections are a very uncommon finding after thyroidectomy. For these reasons international guidelines do not routinely recommend systemic antibiotic prophylaxis. The benefits of this antibiotic prophylaxis is not supported by clinical evidence in the literature. We have conducted a multicentric randomized double-blind trial on 500 patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The 500 patients enrolled in the study (mean age 47 years) were randomized in two subgroups of 250 patients. 250 patients were treated with standard antibiotic prophylaxis with sulbactam/ampicillin 1 fl (3 gr.) 30 min before surgery. No antibiotic prophylaxis was instituted in the remainder 250 patients. Our RCT showed that prophylactic antibiotic treatment is not beneficial in patients younger than eighty years old, with no concomitant metabolic, infective and hematologic disease, with no cardiac valvulopathies, not under steroidal or immunosuppressive treatment, and not severely obese. Our study should be regarded only as a preliminary RCT, and should be followed by a study in which a larger number of patients should be enrolled so that statistically significant data can be obtained.