Prospective study of preoperative anxiety and impact on postoperative pain perception and recovery quality in patients undergoing thyroidectomy

Abstract

BACKGROUND

Preoperative anxiety is prevalent among surgical patients and may adversely affect postoperative outcomes. However, evidence of its specific impact on patients undergoing thyroidectomy remains limited.

AIM

To investigate the relationship between preoperative anxiety levels and postoperative pain perception, recovery quality, and clinical outcomes in patients undergoing thyroidectomy.

METHODS

A total of 300 consecutive patients scheduled for thyroidectomy were enrolled between January 2024 and December 2024. Preoperative anxiety was assessed using the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A), with patients categorized into low anxiety (HADS-A ≤ 7, n = 168) and high anxiety (HADS-A > 7, n = 132) groups. Primary outcomes included postoperative pain intensity measured using the Visual Analog Scale (VAS) at 24 hours, 48 hours, and 72 hours, and recovery quality assessed using the Quality of Recovery-40 (QoR-40) questionnaire. Secondary outcomes included lower extremity deep vein thrombosis (DVT), neck muscle stiffness evaluated using the Neck Disability Index (NDI), scar healing quality assessed using the Patient and Observer Scar Assessment Scale (POSAS), postoperative hospital stay, and central compartment lymph node metastasis rate.

RESULTS

High anxiety patients demonstrated significantly higher VAS pain scores at 24 hours (4.82 ± 1.56 vs 3.21 ± 1.34, P < 0.001), 48 hours (3.67 ± 1.42 vs 2.45 ± 1.18, P < 0.001), and 72 hours (2.54 ± 1.23 vs 1.68 ± 0.95, P < 0.001) compared to low anxiety patients. QoR-40 scores were significantly lower in the high anxiety group at postoperative day 3 (142.36 ± 18.45 vs 165.82 ± 15.67, P < 0.001). The incidence of lower extremity DVT was significantly higher in the high anxiety group (6.82% vs 1.79%, P = 0.024). High anxiety patients exhibited greater neck muscle stiffness (NDI: 28.45 ± 8.67 vs 18.32 ± 6.54, P < 0.001) and poorer scar healing outcomes (POSAS: 32.56 ± 7.89 vs 24.67 ± 6.45, P < 0.001) at one-month follow-up. Postoperative hospital stay was prolonged in the high anxiety group (3.45 ± 1.12 days vs 2.67 ± 0.89 days, P < 0.001). No significant difference was observed in the central compartment lymph node metastasis rate between the groups (38.64% vs 41.07%, P = 0.667).

CONCLUSION

Preoperative anxiety significantly affects postoperative pain perception, recovery quality, DVT occurrence, neck muscle stiffness, scar healing, and postoperative hospital stay in patients undergoing thyroidectomy. These findings underscore the importance of preoperative psychological assessments and anxiety-targeted interventions for optimizing surgical outcomes.

Key Words: Preoperative anxiety; Thyroidectomy; Postoperative pain; Recovery quality; Deep vein thrombosis; Neck disability

Core Tip: This prospective study demonstrated that preoperative anxiety is not merely a psychological state but also a clinically meaningful predictor of postoperative outcomes in patients undergoing thyroidectomy. Higher anxiety levels were associated with significantly greater postoperative pain, poorer short-term recovery quality, increased risk of lower extremity deep vein thrombosis, greater neck muscle stiffness, worse scar healing, and longer hospital stays, while oncological outcomes were unaffected. These findings highlight the necessity of incorporating routine psychological screening and targeted perioperative anxiety management into thyroid surgery care pathways to improve patient-centered outcomes, enhance recovery efficiency, and reduce the burden of complications.

INTRODUCTION

Thyroid surgery is one of the most commonly performed endocrine procedures worldwide, with an estimated annual incidence of > 500000 cases globally[1]. The prevalence of thyroid nodules continues to increase, which is largely attributable to enhanced detection through widespread ultrasonographic screening and increased health awareness[2]. Although thyroidectomy is generally considered a safe procedure with favorable outcomes, patients frequently experience significant psychological distress during the perioperative period, which may substantially influence their surgical experience and recovery trajectory[3]. Understanding the psychological dimensions of surgical care has become increasingly essential for optimizing patient outcomes and enhancing the quality of perioperative medicine.

Preoperative anxiety constitutes a prevalent psychological response among surgical candidates, with reported incidence rates ranging from 40% to 80%, depending on the surgical population and assessment methodology employed[4]. Anxiety manifests through complex interactions between cognitive, emotional, physiological, and behavioral components, creating a multifaceted stress response that extends beyond psychological discomfort[5]. Patients awaiting thyroid surgery may experience heightened anxiety owing to concerns regarding potential malignancy, fear of anesthesia complications, apprehension about voice changes, and cosmetic concerns related to neck scarring[6]. The anatomical location of the thyroid gland, adjacent to critical neurovascular structures, further amplifies patient concerns regarding surgical risks and potential complications.

The theoretical framework underlying the relationship between pre-operative anxiety and post-operative outcomes involves multiple interconnected pathways[7]. From a neurobiological perspective, anxiety activates the hypothalamic-pituitary-adrenal axis and sympathetic nervous system, resulting in elevated cortisol levels, catecholamine release, and alterations in immune function, which may impair wound healing and pain modulation[8]. The gate-control theory of pain provides additional insights, suggesting that psychological states can modulate pain perception through descending inhibitory and facilitatory mechanisms[9]. Furthermore, anxiety-induced hypervigilance may lower pain thresholds and amplify the subjective experience of nociceptive stimuli, thereby creating a self-perpetuating cycle of distress and increasing pain sensitivity.

The behavioral consequences of preoperative anxiety represent another critical pathway through which psychological distress may compromise postoperative recovery[10]. Anxious patients often demonstrate reluctance to engage in early mobilization, deep breathing exercises, and other essential postoperative rehabilitation activities[11]. This behavioral inhibition is particularly significant in patients undergoing thyroidectomy, as reduced neck mobility may precipitate muscle stiffness, tension, and progressive functional limitations. Moreover, inadequate early ambulation increases the risk of thromboembolic complications, including deep vein thrombosis (DVT) and its potentially life-threatening complication, pulmonary embolism[12]. Thus, the anxiety-driven immobility cascade creates multiple pathways through which psychological distress may translate into clinical morbidity.

Despite the growing recognition of the importance of psychological factors in surgical outcomes, significant gaps remain in our understanding of the specific impact of anxiety on thyroidectomy patients[13]. Existing literature has predominantly focused on major surgical procedures, with relatively limited attention directed toward thyroid surgery despite its high prevalence. The unique characteristics of thyroidectomy, including the visible surgical site, potential functional impairments affecting voice and calcium homeostasis, and the psychological burden of possible cancer diagnosis, necessitate dedicated investigations within this specific population[14]. Furthermore, a comprehensive assessment of the influence of anxiety across multiple outcome domains, including pain perception, functional recovery, thromboembolic risk, and wound healing, has not been conducted.

This prospective study aimed to investigate the relationship between preoperative anxiety levels and postoperative outcomes in patients undergoing thyroidectomy[15]. We hypothesized that elevated preoperative anxiety would be associated with increased postoperative pain intensity, diminished recovery quality, higher incidence of lower-extremity DVT, greater neck muscle stiffness, poorer scar healing outcomes, and prolonged postoperative hospital stay.

MATERIALS AND METHODS

Study design and setting

This prospective observational cohort study was conducted at the Henan Provincial People’s Hospital between January 2024 and December 2024. All surgical procedures were performed by experienced thyroid surgeon using standardized surgical techniques. Routine prophylactic central compartment lymph node dissection was performed in all patients with confirmed or suspected thyroid malignancies.

Participants

Consecutive patients scheduled to undergo elective thyroidectomy were screened for eligibility.

Inclusion criteria: (1) Age 18-70 years; (2) Scheduled for elective total or hemithyroidectomy via a conventional open cervical approach (Kocher incision); (3) Ability to understand and cooperate with study procedures; (4) Willingness to complete all questionnaires and attend follow-up visits; and (5) Complete medical records and data availability.

Exclusion criteria: (1) History of psychiatric disorders requiring ongoing treatment; (2) Current use of anxiolytic or antidepressant medications; (3) Previous neck surgery; (4) Cognitive impairment precluding questionnaire completion; (5) Emergency surgery; (6) Endoscopic or robotic-assisted thyroidectomy; and (7) Incomplete data collection.

Sample size calculation: The sample size calculations were performed using G*Power software version 3.1. Based on previous literature suggesting a medium effect size (d = 0.5) for anxiety-pain relationships, with α = 0.05 and power = 0.80, a minimum of 128 participants per group was required. Anticipating a 15% dropout rate, 300 participants were enrolled in the study.

Preoperative anxiety assessment

Preoperative anxiety was assessed one day before surgery using the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The HADS-A is a validated 7-item self-report instrument designed to detect anxiety symptoms in medical populations while minimizing contamination by somatic symptoms. Each item is scored from 0 to 3, yielding a total score ranging from 0 to 21. Scores of 0-7 indicate non-cases, 8-10 indicate borderline cases, and 11-21 indicate clinically significant anxiety. For analytical purposes, patients were dichotomized into low anxiety (HADS-A ≤ 7) and high anxiety (HADS-A > 7) groups. The Chinese version of HADS-A has demonstrated excellent psychometric properties, with Cronbach’s α of 0.85 in the present sample.

Outcome measures

Postoperative pain assessment: Pain intensity was measured using the Visual Analog Scale (VAS), a 100-mm horizontal line anchored by “no pain” (0) and “worst imaginable pain” (100). VAS assessments were conducted 24 hours, 48 hours, and 72 hours postoperatively by trained research nurses who were blinded to the anxiety-group assignment. The VAS demonstrated excellent reliability and validity for acute pain assessment, with test-retest reliability exceeding 0.90.

Recovery quality assessment: The Quality of Recovery-40 (QoR-40) questionnaire was administered on postoperative day 3 to evaluate global recovery quality. This 40-item instrument assesses five dimensions: Physical comfort (12 items), emotional state (nine items), physical independence (five items), psychological support (seven items), and pain (seven items). Each item was scored from 1 to 5, yielding total scores ranging from 40 to 200, with higher scores indicating better recovery quality. The QoR-40 demonstrated excellent internal consistency (Cronbach’s α = 0.91) and responsiveness in surgical patients.

DVT assessment: Patients reporting lower-extremity discomfort, swelling, or pain during the postoperative period underwent bilateral lower-extremity venous ultrasonography. DVT was diagnosed based on standard ultrasonographic criteria, including vein incompressibility and the absence of flow signals. Patients without symptoms who did not undergo ultrasonography were classified as DVT-negative based on clinical assessment.

Neck muscle stiffness assessment: Neck disability was evaluated using the Neck Disability Index (NDI) at one-month follow-up. The NDI is a 10-item questionnaire that assesses the pain intensity and functional limitations related to neck symptoms. Each item was scored from 0 to 5, with total scores converted to a percentage of disability (0-100%). Scores of 0-4 indicate no disability, 5-14 mild disability, 15-24 moderate disability, 25-34 severe disability, and ≥ 35 complete disability. The NDI has demonstrated excellent reliability (Cronbach’s α = 0.88) and validity for cervical spinal disorders.

Scar healing assessment: Scar quality was evaluated at one-month follow-up using the Patient and Observer Scar Assessment Scale (POSAS). This comprehensive instrument includes both patient-reported and observer-rated components, each containing six items scored from 1 (normal skin) to 10 (worst imaginable). The total scores range from 12 to 120, with lower scores indicating superior scar quality. The POSAS demonstrates excellent interrater reliability and sensitivity to variations in scar quality.

Hospital stays and clinical outcomes: Postoperative hospital stay was calculated from the day of surgery to discharge. Central compartment lymph node metastasis was documented based on the final histopathological examination of the patients undergoing prophylactic dissection.

Surgical procedure

All patients underwent thyroidectomy under general anesthesia, using standardized techniques. The extent of surgery (total or hemithyroidectomy) was determined based on the preoperative diagnosis and intraoperative findings. Prophylactic central compartment lymph node dissection is routinely performed in patients with confirmed or suspected papillary thyroid carcinoma. Postoperative analgesia consisted primarily of nonsteroidal anti-inflammatory drugs administered on an as-needed basis, with opioid analgesics rarely required given the generally mild postoperative pain profile of thyroid surgery.

Ethical considerations

This study was approved by the Ethics Committee of Henan Provincial People’s Hospital (Approval No. 2024-05) and conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to enrollment. Data confidentiality was maintained through anonymization procedures, with the identification of information stored separately from the research data in password-protected databases.

Statistical analysis

All the statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, United States). Continuous variables were assessed for normality using the Shapiro-Wilk test and presented as mean ± SD or median (interquartile range), as appropriate, while categorical variables were expressed as n (%). Between-group comparisons were conducted using independent sample t-tests or Mann-Whitney U tests for continuous variables and χ² tests or Fisher’s exact tests for categorical variables. Pearson’s or Spearman’s correlation coefficients were calculated to examine the association between the anxiety scores and continuous outcomes. Multiple linear regression analysis was performed to identify independent predictors of postoperative pain and recovery quality, adjusting for potential confounders, including age, sex, body mass index (BMI), surgical extent, operative time, and pathological diagnosis. All tests were two-tailed, and statistical significance was defined as P < 0.05.

RESULTS

Participant characteristics

A total of 342 patients were screened for eligibility; 300 patients met the inclusion criteria and completed the study. Based on the HADS-A scores, 168 patients (56.0%) were classified into the low-anxiety group (HADS-A ≤ 7) and 132 patients (44.0%) into the high-anxiety group (HADS-A > 7). The mean HADS-A score was 4.23 ± 1.89 in the low anxiety group and 11.67 ± 2.54 in the high anxiety group (P < 0.001).

Table 1 presents the baseline demographic and clinical characteristics of patients. The groups were comparable in terms of age, sex, BMI, educational level, surgical extent, operative time, and pathological diagnosis (all P > 0.05), supporting the validity of the subsequent outcome comparisons.

Table 1 Baseline demographic and clinical characteristics, n (%) or mean ± SD.

Variable	Low anxiety (n = 168)	High anxiety (n = 132)	P value
Age (year)	45.32 ± 11.45	44.87 ± 12.23	0.745
Female	134 (79.8)	108 (81.8)	0.653
BMI (kg/m2)	23.56 ± 3.21	23.89 ± 3.45	0.398
Education level			0.412
High school or below	72 (42.9)	62 (47.0)
College or above	96 (57.1)	70 (53.0)
Surgical extent			0.534
Total thyroidectomy	112 (66.7)	92 (69.7)
Hemithyroidectomy	56 (33.3)	40 (30.3)
Operative time (minute)	98.45 ± 24.67	101.23 ± 26.34	0.355
Pathological diagnosis			0.489
Papillary carcinoma	128 (76.2)	96 (72.7)
Benign nodules	40 (23.8)	36 (27.3)
HADS-A score	4.23 ± 1.89	11.67 ± 2.54	< 0.001

BMI: Body mass index; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale.

Postoperative pain outcomes

Significant differences in postoperative pain intensity were observed between groups at all assessment time points. As shown in Figure 1A, high anxiety patients demonstrated substantially higher VAS pain scores at 24 hours (4.82 ± 1.56 vs 3.21 ± 1.34, P < 0.001), 48 hours (3.67 ± 1.42 vs 2.45 ± 1.18, P < 0.001), and 72 hours (2.54 ± 1.23 vs 1.68 ± 0.95, P < 0.001) compared to low anxiety patients. The magnitude of group differences decreased over time but remained statistically significant in all assessments.

Figure 1 Comparison of Visual Analog Scale pain scores and incidence of lower extremity deep vein thrombosis between low and high anxiety groups. A: Comparison of Visual Analog Scale (VAS) pain scores between low and high anxiety groups at 24 hours, 48 hours, and 72 hours postoperatively. Correlation analysis revealed significant positive associations between the preoperative Hospital Anxiety and Depression Scale-Anxiety subscale scores and VAS pain scores at 24 hours (r = 0.52, P < 0.001), 48 hours (r = 0.48, P < 0.001), and 72 hours (r = 0.41, P < 0.001), indicating that higher anxiety levels were consistently associated with greater pain intensity. Error bars represent standard deviation; B: Incidence of lower extremity deep vein thrombosis between low and high anxiety groups. VAS: Visual Analog Scale; DVT: Deep vein thrombosis.

Recovery quality outcomes

Quality of recovery assessed using the QoR-40 questionnaire on postoperative day 3, differed significantly between groups. The high anxiety group demonstrated markedly lower total QoR-40 scores compared to the low anxiety group (142.36 ± 18.45 vs 165.82 ± 15.67, P < 0.001). The analysis of the QoR-40 subscales revealed significant group differences across all dimensions (Table 2). Specifically, the emotional state subscale showed the largest between-group difference (29.45 ± 5.12 vs 38.67 ± 4.23, P < 0.001), followed by the physical comfort subscale (44.56 ± 6.89 vs 52.34 ± 5.67, P < 0.001), psychological support subscale (26.78 ± 4.12 vs 30.12 ± 3.45, P < 0.001), and physical independence subscale (19.23 ± 2.89 vs 22.45 ± 2.34, P < 0.001). Notably, the pain subscale of QoR-40 did not differ significantly between groups (22.34 ± 3.23 vs 22.24 ± 2.67, P = 0.769), suggesting a dissociation between unidimensional pain assessment and the multidimensional pain experience captured by the QoR-40.

Table 2 Comparison of postoperative outcomes between anxiety groups, n (%) or mean ± SD.

Outcome variable	Low anxiety (n = 168)	High anxiety (n = 132)	P value
Pain (VAS)
24 hours	3.21 ± 1.34	4.82 ± 1.56	< 0.001
48 hours	2.45 ± 1.18	3.67 ± 1.42	< 0.001
72 hours	1.68 ± 0.95	2.54 ± 1.23	< 0.001
QoR-40 total score	165.82 ± 15.67	142.36 ± 18.45	< 0.001
Physical comfort	52.34 ± 5.67	44.56 ± 6.89	< 0.001
Emotional state	38.67 ± 4.23	29.45 ± 5.12	< 0.001
Physical independence	22.45 ± 2.34	19.23 ± 2.89	< 0.001
Psychological support	30.12 ± 3.45	26.78 ± 4.12	< 0.001
Pain	22.24 ± 2.67	22.34 ± 3.23	0.769
DVT incidence	3 (1.79)	9 (6.82)	0.024
NDI score (1-month)	18.32 ± 6.54	28.45 ± 8.67	< 0.001
POSAS score (1-month)	24.67 ± 6.45	32.56 ± 7.89	< 0.001
Postoperative stay, days	2.67 ± 0.89	3.45 ± 1.12	< 0.001
Central LN metastasis	69 (41.07)	51 (38.64)	0.667

VAS: Visual Analog Scale; QoR-40: Quality of Recovery-40; DVT: Deep vein thrombosis; NDI: Neck Disability Index; POSAS: Patient and Observer Scar Assessment Scale; LN: Lymph node.

DVT outcomes

Lower extremity DVT was identified in 12 patients (4.0%), with a significantly higher incidence in the high-anxiety group than in the low-anxiety group (9/132, 6.82% vs 3/168, 1.79%; P = 0.024). All DVT cases were detected following patient-reported symptoms of lower-extremity discomfort and confirmed by venous ultrasonography. Notably, no cases of pulmonary embolism occurred during the study period, although pulmonary embolism is a serious potential complication of DVT (Figure 1B).

Neck disability and scar healing outcomes

Assessment at one-month follow-up revealed substantial differences in neck-related disabilities between the groups. High anxiety patients demonstrated significantly elevated NDI scores compared to low anxiety patients (28.45 ± 8.67 vs 18.32 ± 6.54, P < 0.001), indicating moderate disability vs mild disability, respectively. Qualitative observations during the follow-up visits suggested that patients with high anxiety frequently exhibited guarded neck postures and were reluctant to perform cervical range of motion exercises.

Scar healing outcomes, assessed by POSAS at one-month follow-up, were significantly poorer in the high anxiety group (32.56 ± 7.89 vs 24.67 ± 6.45, P < 0.001). Both patient-reported and observer-rated components contributed to this difference, with high-anxiety patients perceiving their scars as more prominent and observers noting increased vascularity and pliability abnormalities.

Hospital stays and lymph node metastasis outcomes

Postoperative hospital stay was significantly prolonged in the high anxiety group (3.45 ± 1.12 days vs 2.67 ± 0.89 days, P < 0.001). Factors contributing to delayed discharge include higher pain levels requiring extended monitoring, delayed ambulation, and patient-expressed concerns regarding readiness for discharge.

Central compartment lymph node metastasis, which was evaluated in patients undergoing prophylactic dissection (n = 224), was detected in 120 patients (53.6%). The metastasis rate did not differ significantly between the high anxiety (51/132, 38.64%) and low anxiety (69/168, 41.07%) groups (P = 0.667), suggesting that preoperative anxiety status was not associated with tumor biological behavior.

Multivariate analysis

Multiple linear regression analysis identified preoperative HADS-A score as an independent predictor of VAS pain at 24 hours (β = 0.42, P < 0.001) and QoR-40 total score (β = -0.48, P < 0.001) after adjusting for age, sex, BMI, surgical extent, operative time, and pathological diagnosis. The regression models explained 32.4% and 38.7% of the variance in pain and quality of recovery outcomes, respectively.

DISCUSSION

This prospective study provides comprehensive evidence of the significant impact of preoperative anxiety on multiple postoperative outcomes in patients undergoing thyroidectomy. Our findings revealed that elevated preoperative anxiety was associated with increased postoperative pain perception, diminished recovery quality, increased incidence of lower-extremity DVT, greater neck muscle stiffness, poorer scar healing outcomes, and prolonged postoperative hospital stay. These results highlight the multidimensional influence of psychological factors on surgical outcomes, and support the integration of systematic anxiety assessment and management into perioperative care protocols for patients undergoing thyroidectomies.

The association between preoperative anxiety and enhanced postoperative pain is one of the most consistent findings in perioperative psychological research, and our results align with this established body of evidence[16]. Patients with high anxiety in our cohort reported VAS pain scores approximately 50% higher than those of their low-anxiety counterparts at 24 hours postoperatively, with this difference persisting throughout the 72-hour assessment period. This finding is consistent with that of Chiang et al[17], who demonstrated that preoperative anxiety independently predicted acute postoperative pain intensity across multiple surgical populations. The mechanisms underlying this relationship likely involve both peripheral and central sensitization processes, whereby anxiety-induced neurobiological changes amplify nociceptive signal transmission and alter descending pain modulation pathways[18]. Additionally, cognitive factors such as catastrophizing and hypervigilance, which frequently accompany anxious states, may further enhance attention to pain stimuli and magnify subjective pain experiences[19]. The clinical significance of this anxiety-pain relationship extends beyond patient comfort, as poorly controlled acute pain is a recognized risk factor for chronic postsurgical pain development[20].

Our observation that preoperative anxiety substantially impairs recovery quality, as measured by the QoR-40 questionnaire, extends previous findings predominantly derived from cardiac and major abdominal surgery populations in the context of thyroidectomy[21]. The emotional state subscale demonstrated the largest between-group difference, which aligns with theoretical expectations, given the direct relationship between anxiety and emotional well-being[22]. However, significant differences across all QoR-40 dimensions suggest that the influence of anxiety on recovery extends beyond the psychological domains to include physical comfort, functional independence, and social support perceptions[23]. Importantly, the QoR-40 pain subscale did not differ significantly between the groups despite substantial differences in VAS pain scores, potentially reflecting the multidimensional nature of the QoR-40 pain assessment compared to the unidimensional VAS[24]. These findings support the conceptualization of anxiety as a global modifier of the recovery experience, rather than a factor with isolated effects on specific outcome domains[25].

Perhaps the most clinically significant finding of this study was the elevated incidence of lower-extremity DVT in patients with high anxiety. The DVT rate of 6.82% observed in the high-anxiety group substantially exceeded the 1.79% rate in low-anxiety patients, representing a nearly four-fold increased risk[26]. This finding has important implications, given that DVT may progress to pulmonary embolism, a potentially life-threatening complication. The pathophysiological basis for this association likely involves anxiety-driven behavioral inhibition, whereby fearful patients demonstrate a reluctance to engage in early postoperative ambulation[27]. Our clinical observations support this hypothesis as patients with high anxiety frequently expressed concerns about neck movement and activity that generalized to overall mobility restrictions. Furthermore, anxiety-associated sympathetic activation and elevated cortisol levels may create a hypercoagulable state that compounds thrombotic risks associated with immobility[28]. These findings suggest that targeted interventions promoting early mobilization in patients with anxiety may enhance recovery quality and reduce thromboembolic risk[29]. The absence of pulmonary embolism events in our cohort is reassuring but should not diminish attention to this serious potential complication[30].

The substantial neck muscle stiffness observed in patients with high anxiety levels is an important finding that has direct implications for functional recovery following thyroidectomy. Clinical experience suggests that anxious patients frequently adopt protective neck postures and avoid cervical movements because of the fear of pain, wound disruption, or undefined harm. This behavioral pattern initiates a cycle in which immobility promotes muscle tension, which generates discomfort and further reinforces movement avoidance. Elevated NDI scores in patients with high anxiety provide quantitative documentation of this phenomenon and highlight the need for targeted physical therapy interventions that address both physical and psychological components of post-thyroidectomy neck disability.

Similarly, the poorer scar healing outcomes observed in patients with high anxiety warrant further consideration. Wound healing is a complex process influenced by multiple factors including tissue perfusion, inflammatory responses, and collagen synthesis, all of which may be modulated by psychological stress. Elevated cortisol levels associated with anxiety states have been shown to impair various aspects of wound healing, potentially explaining the observed differences. Additionally, anxious patients may engage in maladaptive behaviors, such as excessive wound touching or tension from protective posture, which mechanically compromises scar quality. These findings suggest that comprehensive anxiety management may yield benefits extending to aesthetic outcomes, which is an important consideration for thyroidectomy patients, given the visible surgical site.

Our findings have several important clinical implications. First, systematic preoperative psychological screening using validated instruments, such as the HADS-A, should be considered for all patients undergoing thyroidectomy. Second, patients identified as highly anxious may benefit from targeted interventions including psychological counseling, relaxation techniques, or pharmacological anxiolysis. Third, enhanced education regarding the importance of early mobilization and neck exercises may be particularly valuable for patients with anxiety. Fourth, postoperative care protocols should anticipate increased pain management needs and potentially longer hospital stays for patients with high anxiety levels.

This study has several limitations that merit acknowledgment. First, the observational design precludes causal inference and residual confounding by unmeasured variables cannot be excluded. Second, DVT assessment was symptom driven rather than systematic, potentially underestimating the true incidence rates. Third, the single-center design may limit the generalizability of the results. Fourth, psychological assessment was limited to anxiety, and concurrent depression and other psychological factors were not comprehensively evaluated. Fifth, long-term outcomes beyond one month were not assessed. Future prospective randomized controlled trials examining the efficacy of anxiety-targeted interventions on postoperative outcomes are warranted.

CONCLUSION

This study demonstrated that preoperative anxiety significantly affected multiple postoperative outcomes in patients undergoing thyroidectomy, including pain perception, recovery quality, thromboembolic risk, neck disability, scar healing, and length of hospital stay. These findings support the integration of systematic psychological assessments and anxiety management into the comprehensive perioperative care of patients undergoing thyroidectomy. By addressing the psychological dimensions of surgical care, clinicians may optimize outcomes across multiple domains and enhance the overall quality of the thyroidectomy experience.