Search tips
Search criteria 


Logo of annrcseLink to Publisher's site
Ann R Coll Surg Engl. 2017 January; 99(1): 60–62.
Published online 2017 January. doi:  10.1308/rcsann.2016.0270
PMCID: PMC5392799

Patterns, timing and consequences of post-thyroidectomy haemorrhage



Post-thyroidectomy bleeding is a low frequency but potentially life threatening event that is very difficult to predict. Given the increasing drive towards thyroidectomy with same day discharge, this study was conducted with the aim of identifying patterns, timing and consequences of post-thyroidectomy bleeding to assess the feasibility of day-case thyroidectomy.


All patients who underwent a thyroidectomy between 2008 and 2015 at our institution were identified. Patterns, timing and consequences in all those who developed post-thyroidectomy bleeding were studied.


Of the 805 patients included in the study, 14 required re-exploration for bleeding; 7 (50%) of these within 8 hours of surgery, 6 (43%) between 18 and 30 hours, and 1 (7%) at 49 hours. Just under half (43%) of those with post-thyroidectomy bleeding had thyrotoxicosis.


A significant number of postoperative haemorrhages occurred beyond the immediate postoperative period. Same day discharge after thyroidectomy cannot therefore be recommended as a routine practice.

Keywords: Thyroidectomy, Bleeding, Postoperative, Pattern

Post-thyroidectomy haemorrhage can be a life threatening complication of thyroid surgery. It has a reported incidence of 0.1–2.1%.13 While a variety of factors (eg postoperative hypertension, use of anticoagulants and extent of dissection) have been implicated in increasing the risk of post-thyroidectomy haemorrhage, it is generally considered a low frequency stochastic event, which is difficult to predict.47 Bleeding deep to the strap muscles is associated with a higher risk of life threatening airway swelling and obstruction, and the risk of post-thyroidectomy haemorrhage is highest in the early hours following surgery.8 For these reasons, patients traditionally remained in hospital for 72 hours or longer after thyroidectomy. There is an increasing drive towards delivering efficient and cost effective care, and reducing the length of hospital stay is one of the main areas for improvement.

Many centres (especially in the US) perform day-case thyroidectomy and have reported good outcomes and safe care.921 In the UK, the British Association of Day Surgery included thyroidectomy as a potential day-case procedure in 2001 but the 2011 consensus statement of the British Association of Endocrine and Thyroid Surgeons (BAETS) was more cautious, recommending that thyroidectomy should be a ‘day-and-stay’ procedure with a minimum length of stay of 23 hours.22 This study examined the pattern and timing of post-thyroidectomy haemorrhage in a large interdisciplinary district hospital to identify potential risk factors for this complication as well as the extent to which its impact on preventing short stay thyroid surgery may be mitigated.


All patients who underwent thyroidectomy by general and ear, nose and throat surgeons at Barking, Havering and Redbridge University Hospitals NHS Trust between 2008 and 2015 were studied retrospectively. Information about age, sex, ASA (American Society of Anesthesiologists) grade, indication for surgery, nature of surgery, bleeding risks, use of a Harmonic® scalpel (Ethicon, Somerville, NJ, US), duration of the procedure and occurrence of post-thyroidectomy haemorrhage was obtained from patient records. For those patients who had post-thyroidectomy haemorrhage, the location of the bleeding in relation to strap muscles, whether bleeding was from an identified vessel or whether it was a general ooze and whether there was any difficulty in tracheal intubation or any airway related complication at the time of neck re-exploration were recorded. The time interval from the end of the primary procedure to re-exploration was recorded. The relationship between duration of primary surgery and time to neck exploration was ascertained using simple correlation. Statistical analysis was performed with MedCalc® (MedCalc Software, Mariakerke, Belgium).


Over the study period, 805 patients underwent thyroidectomy. The mean age at surgery was 52 years (standard deviation [SD]: 13 years) and 80% of patients were female. There were 449 total thyroidectomies, 59 completion thyroidectomies and 297 hemithyroidectomies. Surgical drains were inserted in all patients. Seventeen patients required a return to theatre. The reason was post-thyroidectomy haemorrhage in 14 cases and in 3 cases, it was to drain a neck abscess.

Post-thyroidectomy haemorrhage patients

The incidence of this complication in our series was 1.7%. There were four male and ten female patients, and the mean age of patients requiring treatment for post-thyroidectomy haemorrhage was 57 years (SD: 17 years). The sex and age distribution was not significantly different from the overall patient population.

There were no unexpected events during any of the procedures except for division of sternohyoid muscle in one patient to facilitate access. The indication for surgery was multinodular goitre (n=7, including 3 toxic multinodular goitres), toxic thyroid nodule (n=3), Hashimoto’s thyroiditis (n=2), Graves’ disease (n=1) and completion thyroidectomy for papillary thyroid cancer (n=1). Four patients had ASA grade 1, nine patients had ASA grade 2 and one patient had ASA grade 3. Only one patient had been taking aspirin and this was stopped ten days before surgery. A Harmonic® scalpel had been used in eight patients. There were eight total thyroidectomies and six hemithyroidectomies. All but one of the procedures were performed by high volume thyroid surgeons and the one operation that was undertaken by a senior trainee was performed under direct supervision of a consultant.

Pattern and timing of re-exploration for haemorrhage

There were three temporal bleeding patterns. Half of the cases occurred within eight hours of surgery. None of these patients had a surge in blood pressure in the immediate postoperative period. A second bleeding cluster of six cases occurred between 18 and 30 hours, and one patient bled at 49 hours (Fig 1). The three cases of bleeding beyond 24 hours occurred in patients who were treated for thyrotoxicosis and the nature of the bleeding was superficial ooze in all of these patients.

Figure 1
Relationship between operative duration and time interval from thyroidectomy to re-exploration for bleeding

Emergency intervention

There were eight cases of potentially dangerous bleeding deep to the strap muscles. In three of these patients, the wound needed to be opened on the ward to manage an expanding haematoma and avert acute airway obstruction. In one of these cases, significant intubation difficulty was encountered owing to acute pharyngolaryngeal oedema but no long-term harm resulted. The source of bleeding was arterial in one patient and venous in two patients. In the remaining six cases, bleeding was superficial to the strap muscles (Fig 2). There were no deaths or permanent harm resulting from post-thyroidectomy haemorrhage in this series.

Figure 2
Sites of post-thyroidectomy bleeding


Post-thyroidectomy bleeding is a potentially life threatening complication. Early detection, proactive airway management, haematoma evacuation and control of bleeding points are crucial to prevent escalation into death or permanent injury due to airway obstruction. The incidence of post-thyroidectomy bleeding in our series was 1.7%, which is in line with published reports.13 Half of the haemorrhages occurred within 8 hours of surgery and the majority occurred within the first 24 hours of surgery. These findings are in comfortable alignment with the BAETS recommendations to consider thyroidectomy a 23-hour procedure.22 Based on the observation that a significant number of haemorrhages occur beyond the immediate postoperative period, we have reservations about routine day-case thyroidectomy although it may be feasible in selected cases.

A number of studies have attempted to identify predictors for post-thyroidectomy haemorrhage. Revision thyroidectomies were noted to be associated with a higher risk of bleeding, and data from the Swedish thyroidectomy registry suggest that male sex and older age are risk factors for this complication.2 These findings were echoed in a study by Promberger et al, who identified male sex, older age, extent of resection, bilateral procedures, recurrent disease and surgeon experience as risk factors for post-thyroidectomy haemorrhage.23 Lee et al noted that nine of their ten cases of post-thyroidectomy haemorrhage occurred in patients with papillary thyroid cancer.24

On the other hand, a study by Burkey et al5 and subsequent works2,4 have suggested that post-thyroidectomy haemorrhage is a low frequency stochastic event that cannot be reliably predicted using preoperative and surgical variables. This observation is in keeping with our findings. There were no significant differences in age, sex, pathology or extent of surgery between patients who did and those who did not have post-thyroidectomy bleeding. All patients who bled beyond 24 hours had surgery for thyrotoxicosis and their operations took longer than 1.5 hours although given the small numbers (n=3), the credence of this finding is somewhat limited.

A surgical bed in the UK costs in the region of £350–£430 per day22 and day-case thyroidectomy would bring significant savings. However, in addition to the incalculable human cost associated with death or major injury following surgery, from a financial perspective, one excess death or major injury following day-case thyroidectomy would eliminate the monetary benefit from almost 1,000 saved bed days.22 Given the incidence, unpredictability, timing and potential consequences associated with post-thyroidectomy bleeding, our findings support the BAETS consensus statement that achieving a safe outcome requires patients to be monitored for at least 24 hours following thyroidectomy.


Post-thyroidectomy bleeding cannot be predicted using preoperative or surgical variables and the majority of these cases occur within 24 hours of surgery. We cannot recommend routine day-case thyroidectomy with same day discharge. Conversely, day surgery with an overnight stay and at least 24 hours of postoperative observation in the hospital is a practical option.


1. Lang BH, Yih PC, Lo CY A review of risk factors and timing for postoperative hematoma after thyroidectomy: is outpatient thyroidectomy really safe? World J Surg 2012; : 2,497–2,502. [PMC free article] [PubMed]
2. Bergenfelz A, Jansson S, Kristoffersson A et al. Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg 2008; : 667–673. [PubMed]
3. Shandilya M, Kieran S, Walshe P, Timon C Cervical haematoma after thyroid surgery: management and prevention. Ir Med J 2006; : 266–268. [PubMed]
4. Leyre P, Desurmont T, Lacoste L et al. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch Surg 2008; : 733–737. [PubMed]
5. Burkey SH, van Heerden JA, Thompson GB et al. Reexploration for symptomatic hematomas after cervical exploration. Surgery 2001; : 914–920. [PubMed]
6. Reeve T, Thompson NW Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg 2000; : 971–975. [PubMed]
7. Shaha AR, Jaffe BM Practical management of post-thyroidectomy hematoma. J Surg Oncol 1994; : 235–238. [PubMed]
8. Mirnezami R, Sahai A, Symes A, Jeddy T Day-case and short-stay surgery: the future for thyroidectomy? Int J Clin Pract 2007; : 1,216–1,222. [PubMed]
9. Mazeh H, Khan Q, Schneider DF et al. Same-day thyroidectomy program: eligibility and safety evaluation. Surgery 2012; : 1,133–1,141.
10. Hessman C, Fields J, Schuman E Outpatient thyroidectomy: is it a safe and reasonable option? Am J Surg 2011; : 565–568. [PubMed]
11. Houlton JJ, Pechter W, Steward DL PACU PTH facilitates safe outpatient total thyroidectomy. Otolaryngol Head Neck Surg 2011; : 43–47. [PubMed]
12. Tuggle CT, Roman S, Udelsman R, Sosa JA Same-day thyroidectomy: a review of practice patterns and outcomes for 1,168 procedures in New York State. Ann Surg Oncol 2011; : 1,035–1,040. [PubMed]
13. Seybt MW, Terris DJ Outpatient thyroidectomy: experience in over 200 patients. Laryngoscope 2010; : 959–963. [PubMed]
14. Snyder SK, Hamid KS, Roberson CR et al. Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J Am Coll Surg 2010; : 575–584. [PubMed]
15. Inabnet WB, Shifrin A, Ahmed L, Sinha P Safety of same day discharge in patients undergoing sutureless thyroidectomy: a comparison of local and general anesthesia. Thyroid 2008; : 57–61. [PubMed]
16. Terris DJ, Moister B, Seybt MW et al. Outpatient thyroid surgery is safe and desirable. Otolaryngol Head Neck Surg 2007; : 556–559. [PubMed]
17. Snyder SK, Roberson CR, Cummings CC, Rajab MH Local anesthesia with monitored anesthesia care vs generalized anesthesia in thyroidecotomy: a randomized study. Arch Surg 2006; : 167–173. [PubMed]
18. Spanknebel K, Chabot JA, DiGiorgi M et al. Thyroidectomy using monitored local or conventional general anesthesia: an analysis of outpatient surgery, outcome and cost in 1,194 consecutive cases. World J Surg 2006; : 813–824. [PubMed]
19. McHenry CR.  Same-day thyroid surgery: an analysis of safety, cost savings, and outcome. Am Surg 1997; : 586–589. [PubMed]
20. Mowschenson PM, Hodin RA Outpatient thyroid and parathyroid surgery: a prospective study of feasibility, safety, and costs. Surgery 1995; : 1,051–1,053. [PubMed]
21. Steckler RM. Outpatient thyroidectomy: a feasibility study. Am J Surg 1986; : 417–419. [PubMed]
22. Doran HE, England J, Palazzo F Questionable safety of thyroid surgery with same day discharge. Ann R Coll Surg Engl 2012; : 543–547. [PMC free article] [PubMed]
23. Promberger R, Ott J, Kober F et al. Risk factors for postoperative bleeding after thyroid surgery. Br J Surg 2012; : 373–379. [PubMed]
24. Lee HS, Lee BJ, Kim SW et al. Patterns of post-thyroidectomy hemorrhage. Clin Exp Otorhinolaryngol 2009; : 72–77. [PMC free article] [PubMed]

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England