Thyroid surgery

While endocrinologists and family doctors look after the medical aspects of thyroid problems, ENT surgeons manage thyroid problems requiring excision of the gland (thyroidectomy).

Thyroidectomy is done for a variety of conditions including:

1.   Thyroid cancer

2.   Some thyroid nodules where the FNA (fine needle aspiration) is uncertain

3.   Large thyroids (goiter)

4.   Some overactive thyroid glands (Graves, autonomous hot nodule, Plummer’s)

Common thyroid investigations include:

1.   Blood tests: TSH, fT4, Calcium level, PTH level, Vit D level

2.   Ultrasound scan

3.   FNA (fine needle aspiration)

4.   CT scan-in selected situations

Total thyroidectomy is the name given to the operation where the whole thyroid gland is removed. Afterwards the patient will need to take thyroid medication once a day every day for the rest of their life. The patient will also need to have occasional blood tests to monitor the thyroid hormone status. Initially this is done every month but very quickly it can usually required every 6 to 12 months. Total thyroidectomy is sometimes complicated by injury to the parathyroid glands. The parathyroid glands are very small-each about the size of a grain of rice. If the parathyroid glands or their blood supply are injured the patient will need to take calcium and sometimes rocaltriol tablets.

Hemithyroidectomy is the name given to the operation where only half the thyroid gland is removed. The patient will not need to take thyroid medication and the patient will not require calcium medication afterwards.

All thyroid surgery involves operating very close to the recurrent laryngeal nerve. This nerve innervates the muscles that move the vocal cord. Injury to one recurrent laryngeal nerve results in hoarseness. Fortunately the chance of injury to the recurrent laryngeal nerve is very small, about 1%.

The superior laryngeal nerve lies close to the upper part of the thyroid gland. If this nerve is injured the singing voice is affected. Usually the incision heals very nicely. Less than 1% of patients will get a keloid scar. A keloid scar is an unsightly raised scar.

Parathyroid surgery

Hyperparathyroidism is a condition where one or more parathyroid glands make too much parathyroid hormone resulting in an elevated calcium level in the blood. The condition may cause the following:

1.   Kidney stones

2.   Osteoporosis-as the calcium is leached out of the bones

3.   Fractures

4.   Abdominal pain-from constipation, indigestion or pancreatitis

5.   Depression

6.   Fatigue, lethargy

7.   Altered mentation

8.   Without symptoms

Patients with symptomatic hyperparathyroidism should undergo surgery. There is some debate regarding asymptomatic hyperparathyroidism and which patients benefit from surgery. Fortunately there are guidelines discussing which patients are likely to benefit.

Hyperparathyroidism may be:

1.   Primary (PHP): not caused by any underlying medical condition

2.   Secondary to underlying kidney disease.

About 85% of the time in PHP one gland is involved. This one gland has a benign tumour which secretes parathyroid hormone (PTH). About 15% of the time all four parathyroid glands are involved-a condition called parathyroid hyperplasia.

Secondary hyperparathyroidism seen in kidney disease is associated involves all four glands-parathyroid hyperplasia. 

Parathyroidectomy is the name given to the operation where one or more parathyroid glands are removed. The operation is usually highly successful. Potential complications are similar to those for thyroid surgery and include the risk of injury to the recurrent laryngeal nerve resulting in hoarseness. Sometimes, not very commonly, the operation fails to cure the condition and sometimes the calcium level can be too low after surgery.

Thyroidectomy

What is thyroidectomy?

Thyroidectomy is surgery to remove all or part of the thyroid gland.

Thyroidectomy is usually used to treat or explore an overactive thyroid gland, benign nodules or suspicion of cancerous cells in the thyroid gland. Your surgeon will discuss with you the reason for recommending surgery, including the risks and benefits and whether all or just part of your thyroid needs to be removed.

If you have any questions or concerns please ask your surgeon.

What does the thyroid gland do?

The thyroid gland located in the neck (in front of the trachea), produces a chemical substance (a hormone) called thyroxine. This hormone circulates around the body in the blood and controls the speed at which the body's chemical processes work. The normal thyroid has considerable spare capacity for making thyroxine and so normally removal of as much as half of the gland can be undertaken without any need to give thyroxine replacement in the form of daily tablets after the operation. If, however, the whole thyroid has been removed you will need to take thyroxine for the rest of your life.

Very close to the thyroid glands are four tiny glands called parathyroid glands, each not much bigger than a grain of rice. These produce a hormone which controls the level of calcium in your body. The parathyroid glands are normally left in place when the thyroid gland is operated on but their function may be affected by the operation on the thyroid.

What does surgery involve?

Thyroidectomy is an operation in which the surgeon removes all or part of the thyroid gland. Access to the thyroid requires that the surgeon makes an incision in the neck. This is made a couple of finger breadths above the top of the breastbone. It is made in a skin crease or following the 'grain' of the skin. This is called a "collar incision". Most thyroidectomy incisions heal to produce a discreet scar. At the end of the operation the surgeon may consider it appropriate to leave a small 'drain' in the neck. This is a small tube used to drain fluid or blood from a wound. This will normally be removed on the first or second day after surgery. In some thyroid operations it is necessary to remove some of the lymph glands from the neck. The absence of these glands does not normally produce any problems; if your surgeon expects to remove lymph glands he/she will have discussed this with you.

How long will I be in hospital?

The operation is done under a general anaesthetic (you will be asleep during the surgery) and can take a couple hours. You may be kept in for an overnight stay afterwards and most people then go home the next day.

Risks and possible complications

Most thyroid operations are straightforward and associated with few problems. However, all operations carry risks which include post-operative infections (e.g. in the wound or chest), bleeding in the wound and miscellaneous problems due to the anaesthesia but these are very rare.

Bleeding

Bleeding in the wound can be a serious problem if it occurs but the chance of a significant bleed needing you to return to the operating theatre within a day or two after your operation is small (less than 2%).

Scarring

The scar may become relatively thick for a few months after the operation before fading to a thin line. Very rarely, some patients develop a thick exaggerated scar (called a keloid scar) but this is uncommon.

Voice change

It is virtually impossible to operate on the neck without producing some change in the voice; fortunately, this is not normally detectable. A specific problem related to thyroid surgery is injury to one or both of the recurrent laryngeal nerves. These nerves pass close to the thyroid gland and control movement of the vocal cords. Injury to these nerves causes hoarseness and weakness of the voice. The nerve may not work properly after thyroid surgery due to bruising of the nerve but if this should occur it recovers over a few weeks or months. Rarely, the nerve may be permanently injured and the function will not recover. The external laryngeal nerve may also be injured and this results in a weakness in the voice although the sound of the voice is unchanged. Difficulty may be found in reaching the high notes when singing, the voice may tire more easily, and the power of the shout be reduced. Careful surgery reduces the risk of permanent accidental injury to a very low level but cannot absolutely eliminate it. Injury to both recurrent laryngeal nerves is extremely rare but is a serious problem and may require a tracheostomy (tube placed through the neck into the windpipe). 

Low blood calcium levels

Patients undergoing surgery to the thyroid gland are at risk of developing a low calcium level if the four tiny parathyroid glands which control the level of calcium in the blood stop working after the operation. It is normally possible to identify and preserve some if not all of these glands and so avoid a long term problem. Unfortunately, even when the glands have been found and kept they may not function. If this happens then you will need to take extra calcium and/or vitamin D on a permanent basis. The risk of you needing long term medication because of a low calcium level is small (about 2%). It is quite common to require calcium and/or vitamin D tablets for a few weeks or months after the operation. 

Loss of thyroid function

If you require removal of the entire thyroid gland, then you will require lifelong replacement of thyroxine. Fortunately, this is a straightforward once-a-day regimen with little requirement for adjusting dosage. If most, but not all, of the thyroid gland is removed then in the early weeks after the operation the remaining thyroid may not produce enough thyroxine and you may require replacement tablets temporarily until the retained thyroid produces enough hormone itself. This will be monitored.

Swallowing difficulty

Usually swallowing is improved following thyroid surgery, especially for large goitres (big thyroid glands/nodules within the gland) or those which have extended down into the chest but occasionally some mild difficulty may develop or be persistent. Similarly, if you are experiencing any difficulty with your breathing before the operation, this may also be eased.

Eye problems

If you have trouble with your eyes as a consequence of an overactive thyroid gland then there is a slight risk of this worsening after the operation. It is important to emphasise that the potential risks and complications mentioned above are unusual but we believe it is essential to tell you about these rather than have you develop a complication without having been forewarned. This is intended as a guide only.  Please do not hesitate to discuss your concerns with your surgeon.