Factors Associated with Hypoparathyroidism and Vocal Cord Paralysis
                    Following Thyroid Surgery: A Multicenter Cross-Sectional Analysis of 3,365
                    Cases

Carmen Kirchner; Sarah Krieg; Matthias Schott; Andreas Krieg; Karel Kostev

doi:10.1055/a-2731-0631

Hormone and Metabolic Research, Table of Contents

Horm Metab Res
DOI: 10.1055/a-2731-0631

Original Article: Endocrine Care

Factors Associated with Hypoparathyroidism and Vocal Cord Paralysis Following Thyroid Surgery: A Multicenter Cross-Sectional Analysis of 3,365 Cases

Authors

Carmen Kirchner

¹Department of General and Visceral Surgery, Thoracic Surgery and Proctology, University Hospital Herford, Medical Campus OWL, Ruhr University Bochum, Herford, Germany
Sarah Krieg

²University Clinic for People with Neurodevelopmental Disorders, Mara Hospital, Medical School and University Medical Center OWL, Bielefeld University, Bielefeld, Germany
Matthias Schott

³Division for Specific Endocrinology, Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
Andreas Krieg‡

¹Department of General and Visceral Surgery, Thoracic Surgery and Proctology, University Hospital Herford, Medical Campus OWL, Ruhr University Bochum, Herford, Germany
Karel Kostev‡

⁴Epidemiology, IQVIA, Frankfurt, Germany

Abstract

Postoperative hypocalcemia caused by hypoparathyroidism and vocal cord paralysis remain common complications following thyroid surgery. Sex and metabolic comorbidities may influence their occurrence. We conducted a multicenter cross-sectional analysis using anonymized data from 3,365 patients (1,517 hemithyroidectomies and 1,848 thyroidectomies) treated at 27 German hospitals between 2019 and 2024. Primary outcomes were postprocedural hypoparathyroidism and vocal cord paralysis, identified via ICD-10 codes. Associations with age, sex, obesity, diabetes, thyroid pathology, and surgical extent were analyzed using multivariable logistic regression. Postoperative hypoparathyroidism was more frequent after thyroidectomy (3.6%) than hemithyroidectomy (0.3%). Female sex was positively associated with postoperative hypoparathyroidism (odds ratio: 2.30; 95% confidence interval: 1.11–4.77), while obesity was inversely associated with postoperative hypoparathyroidism (odds ratio: 0.15; 95% confidence interval: 0.04–0.63). Vocal cord paralysis was observed in 1.7% of hemithyroidectomy and 1.0% of thyroidectomy cases. Factors significantly or tendentially associated with vocal cord paralysis included malignant neoplasm (odds ratio: 4.00; 95% confidence interval: 1.37–11.64), diffuse goiter (odds ratio: 4.94; 95 % confidence interval: 0.86–28.37), parathyroidectomy (odds ratio: 3.47; 95% confidence: 1.04–11.59), and diabetes mellitus (odds ratio: 3.09; 95% confidence: 0.98–9.74). Individual risk profiling and intraoperative neuromonitoring are critical to improving outcomes after thyroid surgery.

Keywords

thyroid surgery - hypocalcemia - vocal cord paralysis - hypoparathyroidism

Full Text

References

References
1 Chen Z, Zhao Q, Du J. et al. Risk factors for postoperative hypocalcaemia after thyroidectomy: A systematic review and meta-analysis. J Int Med Res 2021; 49: 300060521996911
2 Torabi SJ, Avery JM, Salehi PP. et al. Risk factors and effects of hypocalcemia prior to discharge following thyroidectomy. Am J Otolaryngol 2020; 41: 102420
3 Sheahan P, O’Connor A, Murphy MS. Risk factors for recurrent laryngeal nerve neuropraxia postthyroidectomy. Otolaryngol Head Neck Surg 2012; 146: 900-905
4 Głód M, Marciniak D, Kaliszewski K. et al. Analysis of risk factors for phonation disorders after thyroid surgery. Biomedicines 2022; 10: 2280
5 Bergamaschi R, Becouarn G, Ronceray J. et al. Morbidity of thyroid surgery. Am J Surg 1998; 176: 71-75
6 Han Y, Zhao Y, Kou J. et al. The risk factors for postoperative temporary vocal cord paralysis after thyroid cancer surgery: an observational retrospective cohort study. Int J Surg 2024; 110: 4821-4829
7 Lorenz K, Schneider R, Elwerr M. Thyroid carcinoma: do we need to treat men and women differently?. Visc Med 2020; 36: 10-14
8 Xu S, Chen G, Peng W. et al. Oestrogen action on thyroid progenitor cells: relevant for the pathogenesis of thyroid nodules?. J Endocrinol 2013; 218: 125-133
9 Butz F, Müller-Debus CF, Mogl MT. Gender medicine: endocrine and neuroendocrine diseases : Implications for surgery and perioperative management. Chirurgie (Heidelb) 2024; 95: 736-741
10 Zhang F, Li Y, Yu X. et al. The relationship and gender disparity between thyroid nodules and metabolic syndrome components based on a recent nationwide cross-sectional study and meta-analysis. Front Endocrinol 2021; 12: 736972
11 Rezzonico J, Rezzonico M, Pusiol E. et al. Introducing the thyroid gland as another victim of the insulin resistance syndrome. Thyroid 2008; 18: 461-464
12 Demetriou E, Fokou M, Frangos S. et al. Thyroid nodules and obesity. Life (Basel) 2023; 13: 1292
13 Nguyen DN, Kim JH, Kim MK. Association of metabolic health and central obesity with the risk of thyroid cancer: data from the korean genome and epidemiology study. Cancer Epidemiol Biomarkers Prev 2022; 31: 543-553
14 Păduraru DN, Ion D, Carsote M. et al. Post-thyroidectomy hypocalcemia – risk factors and management. Chirurgia (Bucur) 2019; 114: 564-570
15 Haddadin SW, Mahasna AM, Abumekhleb IA. et al. Comparison of recurrent laryngeal nerve insult incidence post thyroidectomy for benign and malignant lesions. Med Arch 2023; 77: 213-217
16 Stopa M, Barczyński M. Prognostic value of intraoperative neural monitoring of the recurrent laryngeal nerve in thyroid surgery. Langenbecks Arch Surg 2017; 402: 957-964
17 Schneider R, Machens A, Sekulla C. et al. Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy. Br J Surg 2021; 108: 566-573
18 Geron Y, Benbassat C, Shteinshneider M. et al. Long-term outcome after hemithyroidectomy for papillary thyroid cancer: a comparative study and review of the literature. Cancers (Basel) 2018; 11: 26
19 Gut L, Bernet S, Huembelin M. et al. Sex-specific differences in outcomes following thyroidectomy: a population-based cohort study. Eur Thyroid J 2021; 10: 476-485
20 Gray WK, Aspinall S, Tolley N. et al. The volume and outcome relationship for thyroidectomy in England. Langenbecks Arch Surg 2021; 406: 1999-2010
21 Melot C, Deniziaut G, Menegaux F. et al. Incidental parathyroidectomy during total thyroidectomy and functional parathyroid preservation: a retrospective cohort study. BMC Surg 2023; 23: 269
22 Kazaure HS, Zambeli-Ljepovic A, Oyekunle T. et al. Severe hypocalcemia after thyroidectomy: an analysis of 7366 patients. Ann Surg 2021; 274: e1014-e1021
23 Ning K, Yu Y, Zheng X. et al. Risk factors of transient and permanent hypoparathyroidism after thyroidectomy: a systematic review and meta-analysis. Int J Surg 2024; 110: 5047-5062
24 Dufour DR, Wilkerson SY. Factors related to parathyroid weight in normal persons. Arch Pathol Lab Med 1983; 107: 167-172
25 Dekker A, Dunsford HA, Geyer SJ. The normal parathyroid gland at autopsy: the significance of stromal fat in adult patients. J Pathol 1979; 128: 127-132
26 Wierzbicka A, Oczkowicz M. Sex differences in vitamin D metabolism, serum levels and action. Br J Nutr 2022; 128: 2115-2130
27 Al Qubaisi M, Haigh PI. Hypocalcemia after Total Thyroidectomy in Graves Disease. Perm J 2019; 23: 18-188
28 Remer LF, Linhares SM, Scola WH. et al. Transient hypocalcemia after total thyroidectomy: the obesity paradox at work?. J Surg Res 2022; 278: 93-99
29 Li J, Yin Y, Lu L. et al. Body mass index and post-thyroidectomy hypocalcemia: a protective effect of overweight through non-surgical mechanisms-a propensity score-matched study. BMC Surg 2025; 25: 146
30 Soelling SJ, Mahvi DA, Liu JB. et al. Impact of obesity on risk of hypocalcemia after total thyroidectomy: targeted national surgical quality improvement program analysis of 16,277 patients. J Surg Res 2023; 291: 250-259
31 Fields T, Ramonell K, Fazendin J. et al. The obesity paradox in thyroid surgery: is higher BMI protective against hypoparathyroidism?. Am Surg 2024; 90: 9-14
32 Czerwińska E, Marcinowska-Suchowierska E, Walicka M. et al. The influence of bariatric surgery on calcium homeostasis and biochemical markers of bone turnover in patients with morbid obesity. Endokrynol Pol 2007; 58: 130-138
33 He Y, Perry B, Bi M. et al. Allosteric regulation of the calcium-sensing receptor in obese individuals. Int J Mol Med 2013; 32: 511-518
34 Llewelyn J, Tomlinson D, Thomas P. et al. Diabetic Neuropathies in Peripheral Neuropathy Philadelphia: Elsevier Saunders; 2005. pp. 1951-1991
35 Dyck PJ, Kratz K, Karnes J. et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology 1993; 43: 817-817
36 Ozemir IA, Ozyalvac F, Yildiz G. et al. Importance of latency and amplitude values of recurrent laryngeal nerve during thyroidectomy in diabetic patients. Int J Surg 2016; 35: 172-178
37 Schneider R, Randolph GW, Dionigi G. et al. International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal. Laryngoscope 2018; 128 Suppl 3: S1-S17