Total Thyroidectomy From A Patient’s Perspective

Abstract

Dear Editor,

Thyroidectomy is a common surgical procedure performed by us otolaryngologists on our patients. Quite often, we make our post-operative rounds on them, not knowing that the patient may have a lot of concerns regarding his or her operation that we somehow take lightly or worse, do not take seriously. I would like to share with other Ear Nose Throat (ENT) surgeons how it was to be a patient who underwent total thyroidectomy.

My journey began in the mid- 1990s with an incidental finding of thyroid nodules when I underwent a Magnetic Resonance Imaging (MRI) of the cervical spine. It was then when I started medical suppression and yearly thyroid ultrasound examinations. However as the years passed, the nodules became more numerous involving both lobes and enlarging. It was last July when ultrasonography revealed that 2 of the nodules were solid and large. I then underwent ultrasound guided Fine Needle Aspiration Biopsy of the thyroid nodules for which the result was Bethesda 1 (the biopsy was non-conclusive). It was unanimously decided by the endocrinologist and my ENT surgeons, Dr. Alfredo Pontejos Jr. and Dr. Arsensio Cabungcal, that I would undergo total thyroidectomy.

I had myself admitted at the Manila Doctors Hospital (MDH) on September 18, 2017 and underwent the surgical procedure on September 19, 2017. Pre-operatively, I told the ENT chief resident, Dr. Catherine Oseña my special “bilins”: 1) that I had a cervical spine problem so I could not hyperextend the neck; 2) that I was allergic to Penicillin; 3) that I had ceased antiplatelets (Clopidogrel, Aspirin) and fish oil omega for one week; 4) I had allergies to some non-steroidal anti-inflammatory drugs (NSAIDs); 5) if possible the suturing be subcuticular so that there wouldn’t be any need to remove any stitches post-op; and 6) the superior thyroid artery be ligated 2 times and the end of the stump sealed by harmonic scalpel.  I had some anxieties regarding the surgery: losing my voice, undergoing tracheostomy for bilateral abductor paralysis since both thyroid lobes would be removed, having a malignant histopathologic result and hypocalcemia.

            DAY 0: “This is it”, I said to myself, when the nurse fetched me from my room at 6:00 AM to be brought to the operating room (O.R.) for my 7:00 AM schedule. At the O.R., everybody who saw me greeted me with phrases such as “Ikaw pala ang pasyente, kaya mo yan,” “Good luck” and “God bless.” Here I saw one of my surgeons, Dr. Cabungcal enter the OR suite. It was then when I saw my anesthesiologists, Dr. Ariel La Rosa and Dr. Greg Macasaet. The last memory I had pre-op was that of Dr. La Rosa inserting an intravenous (I.V.) line in my right wrist and that was the last thing I remembered.

            I woke up, already in the Post-Anesthesia Care Unit (PACU) or Recovery Room (RR) when I felt severe pain in my neck (surgical area). I also wanted to fix the pillow at the back of my head, but I did not want to cause any strain on my anterior neck. It was also here when I was very happy to hear my own voice. It was then I said that the surgeons preserved my voice.  “Whataguys!” I said to my self, “Thank God.” It was very painful then, I remember the PACU nurse injecting something thru my I.V. line. I felt the medication run thru the I.V. line towards my arm and throughout my body and this made me sleep again (later I found out that it was nalbuphine). I recognize seeing my wife Lil, my son Vinci and the ENT resident, Dr. Dindo Retreta at the PACU. The medication I was given made me sleep again. I woke up again and heard that I was being wheeled out of the PACU to be brought to my room. I only learned later that I slept about an hour after the nalbuphine was given.

            In my hospital room, the pain in the neck was really painful (9/10) and I had difficulty expelling the phlegm from my trachea. Each time I swallowed my saliva, I could feel my trachea move up with accompanying pain. When the resident-on-duty (ROD) visited, I was given N-acetylcysteine effervescent tablet BID (Ed: bis in die; twice a day) that was very helpful as it made my expectoration easier.  I could feel the pressure dressing over my neck, which was now stiff due to dried blood.

            I had my first meal at around 4:00 PM. I remember it was a tuna sandwich and cold water which I drank using a straw from the hospital plastic cup. Every bite and swallow was painful in the neck and throat. I could not detect whether the pain was coming from the throat or from the surgical site. My antibiotic was given I.V. and so was the pain reliever parecoxib, paracetamol and tranexamic acid. I still did not resume the blood thinners to prevent any post-op bleeding.

            I tried to get up after dinner to walk around but warm serosnguinous fluid came out of the drain soaking my hospital gown. I then had the nurse call the ENT ROD to change my thyroid dressing.  In a few minutes, a new fluffy gauze pressure dressing was applied by the ROD and my hospital gown was replaced. I had a good sleep with some pain still at the surgical site and throat.

            DAY 1: The day started with Holy Communion in my room, a good breakfast and my usual morning breakfast pills (thyroxine, nevibolol and folic acid). The residents came and changed the dressing. The resident “milked” the neck trying to see if there was any accumulated blood or serum at the surgical site. This was the most painful of the whole surgical experience (10/10), and it was good news that there was no hematoma in the operative site. They then mobilized the drain by a few centimeters. The dressing was still replaced with less fluffy dressing. I have allergic rhinitis, and the act of sneezing caused recurrent pain in the surgical site, so I asked for an antihistamine tablet. My neck and throat were still painful on Day 1 (8/10) but relieved every time the I.V. analgesic was given. In the afternoon, I had a sponge bath given by the nurse on duty with me lying in bed. I still had throat phlegm but thanks to the acetylcysteine effervescent tablet it was easier to expectorate. Every time the ROD made rounds, he checked for hypocalcemia-- fortunately I did not have it.

            DAY 2: The day again started with Holy Communion and breakfast in my hospital room.  My main attending surgeon, Dr. Pontejos made his rounds late morning and he changed the dressing and removed the drain. I was here that I realized that the superior and inferior flaps including the incision were all numb. There was no pain on drain removal as well as on tying of the standby suture to close the drain site. They were all numb. At this point, I realized that in all our patients, this removal of the drain and the tying the standby suture were painless.  After a bath in the mid-afternoon before discharge, I was then feeling better but the pain was still there (7/10). On the way home, I bought some sterile gauze, plaster, mupirocin ointment and hydrogen peroxide (H2O2) for my neck wound dressing at home.

            DAY 3. The pain was less (5/10), and I did not have to take any analgesic from hereon. Bathing became a problem, but I devised a way to bathe that I adopted for the following days. In the shower, I first shampooed by hair with my head and face facing down with my wife holding the telephone shower and focusing it where it was needed.  After this I dried my head and hair with a clean towel then bathed the rest of the body in standing position with the telephone shower targeting the area needing to be rinsed. I did this method of bathing for a week until I decided that I could now bathe without my head looking down. I was at rest at home for 2 weeks.

            DAY 6:  It was one of the best days of my life when the chief resident told me that the histopathologic result was multinodular goiter and no malignancy.  Yehey! Thanks to God! God is really good!

            To summarize some of the things I want to share with other thyroid surgeons:

• I didn’t realize that the post-op pain was really painful, so I can now understand my patients if they experience pain post-operatively.
• It was difficult to expel throat phlegm and the N-acetylcysteine effervescent tablet was a big help in liquefying the phlegm.
• The whole area is numb (superior and inferior flaps), thus the removal of the drain and sutures would not cause any pain on the patient.
• The “milking” of the site was painful and this procedure should be gently done.
• If the patient has nasal allergy, cover the patient with an antihistamine to prevent sneezing and unnecessary pain.
• Teach your patient the way I bathed and order a sponge bath on Day 1 and 2.

I hope this sharing of experience will benefit all your patients who will undergo the same procedure- thyroidectomy.

I would like to thank my surgeons (Dr. Alfredo Pontejos Jr. and Dr. Arsenio Cabungcal), the anesthesiologists (Dr. Ariel La Rosa and Dr. Greg Macasaet), the surgical assistants (MDH ORL residents – Drs. Catehrine Elise Oseña and Dindo Retreta), my endocrinologist Dr. Robert Mirasol and my Cardiologist Dr. Rogelio Tangco, for the excellent job, well done.

I would like to thank my family-- Lil my wife, Vinci, Ericka, Raymond for their love and support and for taking care of me.

I would like to thank the MDH ORL Residents for taking care of me and for a job well done as well. I would also like to thank all the nursing staff at the MDH tower 1 and the OR, PACU nurses for taking care of me as well.

Sincerely yours,

Cesar V. Villafuerte Jr. MD, MHA