Older patients undergoing thyroidectomy had higher rates of recurrent laryngeal nerve injury, hematoma, and mortality at last follow-up compared with younger patients, but absolute differences were small, according to a systematic review and meta-analysis published in JAMA Otolaryngology–Head & Neck Surgery.
The analysis included 11 cohort studies and 427,886 patients undergoing thyroidectomy, including 104,232 patients aged 65 years or older. Researchers searched Ovid MEDLINE, CINAHL, Ovid Embase, and the Cochrane Library from inception through May 29, 2025.
Among patients aged 65 years or older, recurrent laryngeal nerve (RLN) injury occurred in 2% compared with 1% of younger patients. Hematoma occurred in 2% vs 1%, and mortality at last follow-up was 0.3% vs 0.01%. Rates of hypocalcemia and wound complications were similar between age groups, as was operative time. Older patients had a slightly longer hospital stay, but researchers described the difference as clinically insignificant.
Why Older Patients May Face Greater Risk
The researchers pointed to several age-related physiological changes that may contribute to the elevated complication rates. The thyroid gland tends to descend toward the sternal notch with advancing age, and cervical spine mobility declines by approximately 5 degrees per decade—both of which can limit surgical exposure and visualization of the operative field and potentially increase the risk of RLN injury.
When nerve injury does occur in older patients, recovery may also be less complete. Peripheral nerve regeneration diminishes with age due to reduced interactions between Schwann cells and regenerating axons, which may help explain higher rates of permanent injury in this group.
Frailty may also play a role. Defined as a decline in physiological reserves across multiple systems, frailty has been shown in prior research to independently predict endocrine-related complications in thyroidectomy. Older patients are also more likely to have vitamin D deficiency, a biochemical predictor of hypocalcemia, meaning even minor intraoperative injury to the parathyroid glands could result in permanent dysfunction. Similarly, higher rates of bleeding disorders and anticoagulant use among older patients likely contribute to increased hematoma risk.
Subgroup Findings
In subgroup analyses, permanent RLN injury was more common among older patients, while transient injury rates were similar between groups. Among patients who underwent total thyroidectomy, RLN injury rates did not differ by age.
In studies using an age threshold of 75 years, overall RLN injury and permanent hypocalcemia were higher among older patients, while transient RLN injury, overall hypocalcemia, and hematoma were similar.
Clinical Implications
The researchers suggested several strategies to help mitigate risk in older patients, including more inferior surgical incisions to account for gland descent, use of intraoperative nerve monitoring, incorporation of frailty indices into preoperative assessment, prophylactic calcium and vitamin D supplementation, greater use of parathyroid localization techniques, and closer postoperative monitoring. Referral to high-volume surgeons was also encouraged.
Limitations
All included studies were observational, most were single-center, and several potential confounders—including frailty, comorbidity burden, anticoagulant use, disease severity, surgeon experience, and surgical complexity—were inconsistently reported. Definitions of hypocalcemia and the time threshold used to classify complications as permanent also varied across studies.
“Thyroidectomy is safe in older patients, with low overall complication rates and only small absolute increases in RLN injury, hematoma, and mortality,” wrote lead researcher Ahmed Ghani, of University College Dublin, and colleagues. “Future investigations should target strategies to further optimize outcomes for the older population.”
The researchers reported no conflicts of interest.