Predictors of Postoperative Hypocalcemia, Recurrent Laryngeal Nerve Injury, and Hospital Stay Following Total Thyroidectomy with Central Neck Dissection

Abstract

Background: Total thyroidectomy with central neck dissection is an established treatment for thyroid malignancies with central compartment involvement; however, postoperative hypocalcemia, recurrent laryngeal nerve injury, and prolonged hospital stay remain important causes of morbidity.

Objective: To identify predictors of postoperative hypocalcemia, recurrent laryngeal nerve injury, and prolonged hospital stay among patients undergoing total thyroidectomy with central neck dissection.

Methodology: This retrospective cohort study was conducted at Department of ENT, Bolan Medical Complex Hospital, Quetta from 1^st October 2025 to 31^st March 2026 and 210 patients undergoing total thyroidectomy with unilateral or bilateral central neck dissection for thyroid malignancies were included.

Results: The mean age of patients was 46.8±12.9 years, and 154 (73.3%) were female. Postoperative hypocalcemia occurred in 64 patients, while recurrent laryngeal nerve injury was observed in 18 patients. Patients with hypocalcemia had longer operative times (176.4±41.2 vs. 145.0±32.4 minutes; p<0.001), fewer preserved parathyroid glands (2.4±0.7 vs. 3.4±0.6; p<0.001), and more frequent bilateral central neck dissection (64.1% vs. 34.2%; p<0.001). Recurrent laryngeal nerve injury was associated with larger tumor size (4.1±1.8 vs. 2.7±1.3 cm; p<0.001), extrathyroidal extension (61.1% vs. 24.5%; p=0.001), longer operative time (201.7±44.6 vs. 150.2±35.3 minutes; p<0.001), and lower use of intraoperative nerve monitoring (38.9% vs. 68.8%; p=0.012). Preservation of fewer than three parathyroid glands (AOR=4.28, p<0.001), bilateral central neck dissection (AOR=2.74, p=0.004), and operative time >180 minutes (AOR=2.21, p=0.028) independently predicted hypocalcemia. Tumor size >3 cm (AOR=3.65, p=0.013), extrathyroidal extension (AOR=3.17, p=0.026), and absence of nerve monitoring (AOR=2.86, p=0.041) independently predicted RLN injury.

Conclusion: Postoperative complications following total thyroidectomy with central neck dissection are influenced by both disease-related and operative factors. Careful preservation of parathyroid glands, selective use of bilateral central neck dissection, routine intraoperative nerve monitoring, and strategies to reduce operative duration may help minimize postoperative morbidity and shorten hospital stay.