Thyroidectomy
A thyroidectomy is removing the thyroid gland.
There are a number of operations that involve taking part of or all of the thyroid gland:
- A total thyroidectomy means removing the whole gland.
- A thyroid lobectomy or hemithyroidectomy is removing one half of the thyroid.
- A sub-total thyroidectomy is a historical procedure that involves removing the front of a thyroid lobe or of both thyroid lobes.
If your surgery is for a thyroid cancer, you may also require removal of lymph nodes from the middle of the neck (central neck dissection) or from the side of the neck (lateral neck dissection)
Why Do I Need To Have My Thyroid Removed?
You may require thyroid surgery if the thyroid gland:
- Causes pressure symptoms (such as difficulty swallowing or breathing)
- Is overactive (produces too much thyroid hormone)
- Has suspicious or cancerous nodules
- Has enlarged down into the chest (retrosternal goitre)
OR
- Is unsightly (for cosmetic purposes)
Understanding the surgery and its risks requires some understanding of where the thyroid gland lies and what structures lie in close proximity.
The thyroid sits in front of the larynx (or voice box) on the so called “thyroid cartilage” of the larynx. This is the solid structure you can feel in the middle of your neck where the “Adam’s apple” is. The “Adam’s apple” is actually part of the thyroid cartilage called the thyroid notch.
The larynx continues down into the trachea (windpipe) which goes into the chest to the lungs. Behind the trachea is the oesophagus which carries food from the mouth to the stomach.
Between the trachea and the oesophagus, a very important nerve runs towards the larynx. It is called the recurrent laryngeal nerve (RLN). It innervates the muscles that move the vocal cords. This nerve is at risk as the thyroid sits on top of it and attaches to the larynx exactly where the nerve goes into it.
Another nerve at risk is one that lies behind the top of the thyroid. It is called the external branch of the superior laryngeal nerve (EBSLN). This is important for shouting or producing a high note when singing. It is at risk when removing the top part of the thyroid by dividing its blood vessels.
Behind the thyroid lie four “parathyroid” glands – two on each side. Their name means: “next to the thyroid”. Although they are located very close to the thyroid gland, their function is completely separate from the thyroid and they should be preserved during a thyroidectomy. You only need one of the four to be functioning to have normal parathyroid function. Their job is to increase the level of calcium in the body. Their blood supply is fragile and dependant on the thyroid blood vessels and their position is variable around the thyroid gland.
At the end of the thyroid surgery, their appearance is assessed. If it looks like they have been damaged or lost their blood supply, we remove them from the neck, cut them up into very small pieces and inject them into one of the neck muscles. They usually start working again within a month. This is called an autotransplant.
A thyroidectomy is performed under a general anaesthetic.
A pair of fine needles connected to electrodes are placed just under the skin of your upper arm. These are connected to a machine used to monitor the laryngeal nerves during your operation.
An incision is made over the front of the lower part of the neck along a skin crease if possible. The incision is usually 5-7cm long but may be longer for larger thyroid goitres.
The thyroid gland is removed by dividing its blood vessels taking care to preserve the parathyroid glands and prevent injury to the nerves. This may involve the placement of metal clips inside the neck to seal some of the blood vessels. These are titanium clips and they do not set off metal detectors (eg. at airport security). They are also MRI-safe.
You may have a drain to collect blood / fluid after the operation.
The incision is closed with dissolving sutures and dressed with Steristrips which are waterproof
Surgical procedural risks can be divided into anaesthetic and surgical risks.
Anaesthetic risks are usually discussed with the patient by the anaesthetic team.
Surgical risks specific to thyroid surgery include:
- Nerve injury – The risk of permanent damage to the recurrent laryngeal nerve (RLN) is less than 1%. The risk of temporary paralysis is about 7% with full recovery by 6 months. Injury to one of the nerves may result in a weak husky voice. Injury to the RLN nerve on both sides is thankfully extremely rare (1 in 10,000) but results in closure of both vocal cords. This may require a tube to be put into the trachea through a hole in the neck (tracheostomy) at least as a temporary measure.
- Reduced parathyroid function – As described above, you only need one of these parathyroid glands to be functioning normally for normal overall parathyroid function.
- Removing one half of the thyroid will therefore not affect overall parathyroid function. The parathyroid glands are still preserved during a thyroid lobectomy in case you require a thyroidectomy in the future.
- When removing the entire thyroid gland, the risk of temporary drop in parathyroid function is about 20%. However, the risk of permanent drop in function is 1%.
- A drop in parathyroid function causes a drop in your blood calcium levels which may manifest as tingling around the lips, in the fingers or toes. You should report these symptoms to your nurse as soon as possible or to your doctor if you notice these after discharge. A drop in calcium is a medical emergency that may result in serious cardiac arrhythmias if left untreated.
- Your parathyroid function is checked after surgery with a blood test. If there is a drop in function, you will be started on calcium tablets and calcitriol which is a special form of vitamin D. You will require frequent blood tests until your parathyroid function returns to normal.
- If you continue to have a drop in your parathyroid function more than six months after surgery, this drop is likely to be permanent and you will need to be on calcium and calcitriol indefinitely.
- Bleeding – Bleeding post thyroidectomy is unlikely but is a serious complication as it can affect the airway. The risk is highest in the first 12 hours which is why you are admitted to hospital after your surgery. If you have any neck swelling or difficulty breathing, you should report this to your nurse immediately.
- A post-operative bleed may occur even one week after surgery. You should avoid straining / shouting / lifting for the first week to reduce this risk.
- If experience neck swelling or difficulty breathing after discharge, you should call an ambulance or go to the nearest emergency department as soon as possible.
- Infection – the risk of infection post thyroidectomy is very small.
Before surgery
Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.
You will be contacted by the hospital the day before your procedure to let you know what time to come in. This is usually 1-2 hours before your procedure to allow for the hospital check-in procedures.
If your surgery is for an overactive gland, a blood test of your thyroid function may be required one week before surgery to ensure you are safe to have an anaesthetic.
You may require a vocal cord check before surgery. If this is the case, it will be organized some time before surgery. It involves doing a nasoendoscopy where a thin flexible tube with a camera is inserted into the nose to inspect the vocal cords to ensure they are working normally. This is especially important if you have had thyroid surgery in the past.
After surgery
Take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).
Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.
Stronger pain killers such as opioid anaelgesics (Endone, Codeine) should be taken sparingly as they can cause constipation which results in more straining.
Once you are awake from the anaesthetic, you can have a normal diet as tolerated. You start with sips of water, clear fluids, then to a diet.
Following a total thyroidectomy, you will be started on Thyroxine. This is the same hormone that your thyroid makes. You will be on it indefinitely and will require a blood test in 6 weeks to adjust the dose required to give you normal thyroid function.
Following a thyroid lobectomy, 20% of patients may require Thyroxine. You will not be started on this straight away but will have a blood test in six weeks. If your thyroid function is reduced, you will be started on Thyroxine.
- As described above, you may have reduced parathyroid function with a low calcium
- You may experience tingling around the lips, tips of your fingers or toes. If you experience this at home:
- You should take 3 Caltrate tablets as soon as possible (can be found in any pharmacy over the counter)
- Go to the emergency department or your local doctor as soon as possible.
- Contact our office or after-hours emergency number.
- You may require calcium and calcitriol tablets if your parathyroid function is reduced to prevent a low calcium level (see above).
If you have a drain, this is usually removed on the first day after surgery before you go home.
Your wound is dressed with Steristrips only.
These are waterproof so you can shower but cannot swim or have a bath for 2 weeks or until after your follow up wound review.
Keep the Steristrips on for 1-2 weeks.
You should avoid straining for 1 week as this can increase the chance of post-operative bleeding.
Following a thyroid lobectomy, you are admitted overnight and can usually go home the next day. There is no need for any blood tests.
Following a total thyroidectomy, you are admitted overnight. You will have a blood test of your parathyroid function. If this is normal, you can go home the next day. If it is not, you may need to stay in for an extra day to recheck your parathyroid and calcium levels.
You will be seen 1-2 weeks after surgery for a wound check and to discuss your pathology results.
The appointment is usually made for you before leaving the hospital.