This case involves a fifty-four-year-old female who experienced cold intolerance, weight gain, depression, constipation, dry skin, brittle hair, and decreased heart rate. Her thyroid gland was found to be enlarged on physical examination. Laboratory blood work revealed that her thyroid hormone levels were low and thyroid antibodies were elevated. Biopsy of the thyroid gland diagnosed the patient with Hashimoto’s thyroiditis, an autoimmune hypothyroid condition. It was also found that her thyroiditis contained extensive inflammation requiring a thyroidectomy. After surgery, the woman experienced difficulties speaking and had hoarseness in her voice. Examination of the vocal cords with fiberoptic laryngoscopy indicated that her left vocal cord was paralyzed. The patient established care with a different physician who commented that she most likely sustained nerve injury as a result of the thyroidectomy. Surgical exploration showed that her left recurrent laryngeal nerve was cut. She required surgical repair of the injury six months later. She regained a normal voice but developed difficulties eating which never resolved.
Question(s) For Expert Witness
- 1. Did this surgeon practice the standard of care when surgically treating Hashimoto’s thyroiditis, and what should have been done to prevent hoarseness from occurring in this patient?
Expert Witness Response
Hashimoto’s thyroiditis is an autoimmune condition of the thyroid gland. Autoantibodies are formed against the thyroid gland causing local inflammation. Diagnosis can be made with a combination of laboratory work and biopsy. On lab work, thyroid hormone levels will be decreased and there will be elevated levels of anti-thyroid antibodies. These antibodies include anti-microsomal, anti-thyroglobulin, and anti-thyroid peroxidase antibodies. Thyroid biopsy will reveal lymphocytic infiltration and fibrosis. Long-standing inflammation can cause the thyroid gland to enlarge. It is likely that this surgeon transected the left recurrent laryngeal nerve during the thyroidectomy. When performing this surgery, it is very important to know the exact location of this nerve. The nerve can be identified using a nerve monitoring device. The recurrent laryngeal nerve is responsible for innervating muscles of the larynx, which then controls the movement of the vocal cords. Unilateral injury to this nerve causes hoarseness of the voice, which was observed in this patient. Sometimes a unilateral injury will heal over time and hoarseness will resolve. If it does not resolve in six months, the patient can undergo medialization and re-innervation surgery. If the injury was bilateral, the patient would have developed significant respiratory distress after extubation. If this occurs, the patient will require a tracheostomy.