Goiters (from the Latin guttur, throat), defined as an enlargement of the thyroid, have been recognized since 2700 B.C. even though the thyroid gland was not documented as such until the Renaissance period. In 1619 A.C, Hieronymus Fabricius ab Aquapendente recognized that goiters arose from the thyroid gland [1] . The thyroid gland is a midline structure located in the anterior neck. The thyroid functions as an endocrine gland and is responsible for producing thyroid hormone and calcitonin, thus contributing to the regulation of metabolism, growth, and serum concentrations of electrolytes such as calcium [2,3].  The thyroid gland is divided into two lobes that are connected by the isthmus, which crosses the midline of the upper trachea at the second and third tracheal rings. In its anatomic position, the thyroid gland lies posterior to the sternothyroid and sternohyoid muscles, wrapping around the cricoid cartilage and tracheal rings. It is located inferior to the laryngeal thyroid cartilage, typically corresponding to the vertebral levels C5-T1[3-6]. The thyroid attaches to the trachea via a consolidation of connective tissue, referred to as the lateral suspensory ligament or Berry’s ligament. This ligament connects each of the thyroid lobes to the trachea. The thyroid gland, along with the esophagus, pharynx, and trachea, is found within the visceral compartment of the neck which is bound by pretracheal fascia[7-9]. The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery, and the inferior thyroid artery, a branch of the thyrocervical trunk, and sometimes by an anatomical variant the thyroid ima artery, The superior thyroid artery splits into anterior and posterior branches supplying the thyroid, and the inferior thyroid artery splits into superior and inferior branches [10,11]. The superior and inferior thyroid arteries join behind the outer part of the thyroid lobes [12]. The venous blood is drained via superior and middle thyroid veins, which drain to the internal jugular vein, and via the inferior thyroid veins. The inferior thyroid veins originate in a network of veins and drain into the left and right brachiocephalic veins. Both arteries and veins form a plexus between the two layers of the capsule of the thyroid gland [13,14]. Thyroidectomy is a common general surgery procedure classified as a clean, class 1 operation, typically involving a small surgical incision [15]. Modern thyroid surgery, as it is practiced today, traces its origins back to the 1860s in Vienna with the pioneering work of the Billroth school. This type of surgery is considered clean because it is performed without bacterial contamination during the operation. Postoperative wound infections are rare in thyroidectomy cases due to its clean nature [16-18]. There are several types of thyroid surgeries, each with a distinct approach and purpose. Lobectomy involves the removal of only one of the two lobes of the thyroid, allowing the remaining lobe to retain some or all of its function. Subtotal thyroidectomy removes most of the thyroid gland but leaves behind a small portion of tissue to preserve partial thyroid function [18,19]. However, many individuals who undergo this surgery develop hypothyroidism, requiring daily hormone supplements. Total thyroidectomy, on the other hand, removes the entire thyroid gland and surrounding thyroid tissue. This surgery is appropriate when nodules, swelling, inflammation, or cancer affects the entire thyroid gland [20,21]. A wound is any damage to the integrity of biological tissues, including skin, mucous membranes, or organ tissues. Wounds may result from various types of trauma, and it is essential to clean and dress them properly to prevent infection and further injury[22]. The Centers for Disease Control and Prevention (CDC) has classified wounds into four categories based on their cleanliness and condition. Thanks to modern sterilization techniques and advanced operating rooms, postoperative infections are relatively uncommon in clean surgeries like thyroidectomy, with reported surgical site infection (SSI) rates ranging from 0.09% to 2.9% [23,24]. International guidelines do not routinely recommend antibiotic prophylaxis for thyroid surgery because unnecessary antibiotic use can lead to pathogen resistance, superinfections, potential toxicity, increased healthcare costs, and prolonged hospital stays. Recent guidelines from the American Association of Endocrine Surgeons (AAES) suggest that antibiotic prophylaxis is not necessary for most cases of standard transcervical thyroid surgery in adults. However, the guidelines from the American Thyroid Association do not mention antibiotic use at all [25,26]. Despite these guidelines, antibiotics are commonly used in clinical practice, with significant regional variations. An international survey revealed that 8.8% of European surgeons, 27.9% of American surgeons, and 58.3% of Asian surgeons routinely administer antibiotic prophylaxis for thyroid surgery. This discrepancy between clinical guidelines and actual practice suggests the need for more robust evidence regarding the efficacy of antibiotics in thyroid surgery to guide their appropriate use and minimize the risk of antibiotic resistance [27,28]. In light of this issue, we conducted a systematic review of the latest research to determine whether antibiotic prophylaxis impacts the incidence of postoperative SSI in thyroid surgery [29-32]. The purpose of this study was to evaluate whether prophylactic antibiotics are necessary in clean thyroid surgery, to explore ways to reduce the cost and potential adverse effects of antibiotic use, and to identify any risk factors that may contribute to surgical site infections (SSI).

The 112 patients participants in this interventional clinical trial comparison study, who had thyroidectomy surgery, were of both sexes. The patients classified in to two groups each one with 56 patients. first one with prophylactic antibiotic, second group without antibiotic. Third generation cephalosporin(ceftriaxone 1g) one dose within one hour before surgery (before making inscion) was used. Following the completion of an extensive clinical history and examination, each of the chosen patients signed an informed consent form. This study has been approved by the scientific council of Iraqi Board of General Surgery. Ninety-nine females and thirteen males, admitted to Tikrit emergency Hospital from Dec. 2021 to Dec. 2022. Patients were aged above 15 years. Comparisons were made between the two groups in terms of age, gender, operating time, and chronic illness.

Statistics 

The study performed by laptop window 7 version by using Microsoft word and Microsoft excel applications 2010, it performed in Tikrit Emergency hospital ,Dec. 2022. an interventional clinical trial comparative study was used.

112 patients were included in this study who were hospitalized at the Tikrit Emergency Hospital (TEH) for thyroidectomy surgery. Of these, only 1 (0.89%) male diabetic patient aged 50 years presented 3 days post-operation with seroma but without pain or hyperthermia. The patient was treated with local wound care only, and no antibiotics were used. This case is marked by a red star in the tables and figures.

The patients in this study were classified into two groups (A and B), each consisting of 56 patients. Group A received prophylactic antibiotics (A.B.), and Group B did not. The only patient who developed seroma was in Group A.

Table 1:   Hospitalized at the Tikrit Emergency Hospital (TEH) for thyroidectomy surgery according to gender 

The male-to-female ratio in Group A was 1:10.2, while in Group B it was 1:6.

Table 2: Patient Ages

The mean age of patients in Group A was 33±1, while in Group B it was 36±1. The only patient with seroma was 50 years old.

Figure 1 : The distribution of patients ages: showing the patients ages, their percentages, and the mean age in both groups.

Table 3: Time of Surgery

The only patient who developed seroma was in Group A and had a surgery duration of 100 minutes.

Figure 2: time of surgery: showing the range of operation time in both group A and B.

Table 4: Chronic Disease Distribution

Thyroid surgery is classified as a clean procedure and is being connected to a low incidence of wound infections [33]. Systemic prophylactic antibiotic treatment is not generally advised by international standards, but it is used often in some countries and infrequently in others [34].  An audit carried out by the British Association of Endocrine Surgery (BAES) in England and Ireland showed that 9% of patients received routine antibiotic prophylaxis, 16% in selected cases and 75% did not receive it [35].In an Taiwan retrospective study carried out by Rosato on 14.394 patients, it was  Evidenced that 50% of surgeons use antibiotic prophylaxis, 17% antibiotic therapy and 33% neither prophylaxis nor therapy [34]. The Scottish Intercollegiate Guidelines network (SIGN) does not advocate antibiotic prophylaxis for benign pathologies regarding it an opportunity to be reserved for selected cases of Malignancies [36].  The BAES and the Royal College of Physicians Thyroid Cancer do not list antibiotic prophylaxis amongst the recommendations to follow for thyroidectomy [37,38]. Antibiotic prophylaxis does not ward off the development of infective complications of the surgical wound [33].  The occurrence of severe cervical infections after thyroid surgery is an extremely rare event with an extremely high inherent mortality rate; however the occurrence of these infections, often cellulites with fulminating Streptococcal sepsis cannot be avoided with antibiotic Prophylaxis [35]. According to our interventional clinical trial comparison study in TEH, data collected, and the result of only 1 (0.89%) diabetic male patient of 50 years with long operation time (100 minutes) presented 5 days post operation with only seroma , our study agreed with this postulate that considering prophylactic antibiotics is not necessary in clean thyroid surgery.  SSI occur more frequently in men than in women [39-41], and this agree with our study because Despite low number of male patient in my thesis, the only 1 seroma patient was male.  Increasing age independently predicted an increased risk of SSI until age 65 years. At ages >/=65 years, increasing age independently predicted a decreased risk of SSI [42], so our result was accepted as the only 1 patient presented post OP. with seroma was 50 years(<65 years).  There is significant association between diabetes and SSI that was consistent across multiple types of surgeries and after controlling for BMI(43). This is agree with our result as the patient with seroma had diabetes mellitus.  There is great association between extended operative time and SSI typically remained statistically significant . This is agree with our result that the only patient with seroma was with long operation time(100 minutes). 

A preventive antibacterial medication for incision infection may not be necessary as thyroidectomy surgery is class 1(clean surgery), and is carried out under strict sterility and hemostasis conditions. However, surgeons must be aware that adverse effect may result from antibiotic using. 

1. Regularly taking antibiotics before thyroidectomy surgery might not be needed. expensive and have serious side effects. 

2. high risk patients(male gender, elderly patient, chronic disease, long operation time) should be thought about using antibiotics in patients undergoing clean thyroidectomy surgery.

The authors declare that they have no conflict of interest

 No funding sources

The study was approved by the Kirkuk  Health Directorate, Iraq.

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