Thyroidectomy is a common procedure used to treat thyroid nodules, thyroid cancer, and hyperthyroidism, among other entities [12]. It is recommended for benign conditions such as symptomatic large goiters and for the treatment of malignant disease of the thyroid gland [3]. Although there has been a growing trend towards performing thyroidectomy, even in an outpatient setting, it has potential complications that have to be taken into account [45].

The most frequent postoperative complications are hypocalcemia, seroma, wound infection, recurrent laryngeal nerve injury, and hematoma [67]. Post-thyroidectomy hematoma is a relatively uncommon but feared complication of surgery [8]. As the thyroid gland is highly vascularized, postoperative bleeding leading to neck hematoma can result in rapid airway compression or obstruction, which may be life-threatening [9]. It may presented as hoarseness, dysphagia, and difficulty in breathing, which could progress to airway obstruction, becoming a suffocating neck hematoma (SNH) [10]. SNH is a rare but potentially fatal surgical complication, becoming one of the most severe and feared complications of thyroidectomies for head and neck surgeons [11].

It was classically believed that various perioperative factors, such as the presence of goiter or Graves disease, might be more prone to the generation of SNH [10]. In an effort to reduce its incidence, many surgeons opt for the selective use of surgical drains in these patients, which would allow for hematoma evacuation, preventing patient asphyxiation. However, there are no prospective randomized studies demonstrating the benefit of this strategy. Therefore, the use of drains in thyroidectomies remains controversial [12].

Our primary outcome is to analyze the utility of drainage for SNH after thyroidectomies. Secondly, we aim to identify perioperative factors that might be associated with SNH in our series.

A total of 1,334 surgeries were recorded during the study period, of which 1,032 (77.4%) were TT and 302 (22.6%) were HT. Of these, 197 patients (14.7%) required central neck dissection. Regarding the indications of surgery, 570 surgeries (42.7%) were performed due to thyroid nodules, 416 (31.1%) due to multinodular goiter, 250 (18.7%) due to goiters bigger than 3 cm, and 98 (7.3%) due to Graves disease (Table 1).

Only 338 patients (25.3%) had drains placed, out of which 268 (79.2%) were TT and 70 (20.8%) were HT (P = 0.300). Total complication rate was 10.7% (143/1,334), of which 139 patients (10.4%) had minor Clavien-Dindo surgical complications (I/II) [15] (Table 2). Only 4 patients (0.3%) presented SNH, all of them from the drain group, and all of whom required surgical reintervention (Table 3).

It was observed that only the presence of a drain was significantly associated with SNH (P = 0.004) and with reoperations (P = 0.004). No other perioperative factors were found to be statistically significantly related to SNH in our series (Table 1).

SNH is one of the most severe and feared complications of thyroidectomies [11]. To reduce its incidence, many surgeons opt for the use of surgical drains, although there are no randomized prospective studies showing the benefit of this strategy. Published meta-analyses state that there is no sufficient evidence to recommend routine drainage in thyroid surgery [16]. In this way, the use of drains remains controversial [1217].

Our results have shown how surgical drains after thyroidectomies could not prevent SNH or reoperations, since the use of drainage in our series was statistically significantly associated with the presence of SNH and with reoperations; therefore, showing no clear utility of drain placement after thyroidectomy.

Regarding the indications for thyroidectomy, in our series, patients who developed SNH underwent thyroidectomy for Graves disease, goiter greater than 3 cm, multinodular goiter, and thyroid nodule with the requirement for central neck dissection. When we analyzed these factors as potential risk factors for suffocating hematoma, none of them was statistically significant, as more than 99% of patients undergoing thyroidectomy for these indications had no complications such as SNH. No other demographic or perioperative variables were found to be statistically significantly related to SNH in our series.

Finally, although our study did not evaluate other uses of drainage, taking into account our results that show drainage does not prevent suffocating hematoma or its reoperations, combined with meta-analyses already published that show no statistically significant differences for the generation of seroma or other complications between patients with and without drainage, drains after thyroidectomies have shown no clear benefit [12].

The strength of our study lies in the fact that it was conducted at a high-volume center for thyroidectomies, using a refined surgical technique performed by only 2 head and neck surgeons with more than 30 years of experience, which explains our low incidence of SNH and other postoperative complications. As limitations, we believe that our results regarding drains could be related to their selective use.

In our series, the placement of drains after thyroidectomies did not prevent the development of SNH or its reoperations. No other perioperative variables were found to be statistically significantly associated with SNH. The selective use of drains after thyroidectomies has shown no clear benefit in our retrospective series. Randomized prospective studies are needed to confirm these trends.