Thyroid Surgery

Surgery of the thyroid may be needed for a number of reasons:

• Thyroid cancer – confirmed or suspected by biopsy
  
• Goitre – enlarged thyroid or thyroid nodule that is causing difficulty breathing or swallowing or an unsightly mass.
  
• Hyperthyroidism - goitre or nodule that is causing symptoms through the production of too much thyroid hormone

Cancer
Thyroid cancer usually presents as a painless lump in the thyroid or in the lymph nodes in the neck. There a few different types of thyroid cancer and each is treated slightly differently.

Goitre
A goitre is an enlarged thyroid. It may be visible or symptomatic or both. Symptoms may include difficulty swallowing or breathing, or a feeling of facial fullness or even faintness upon raising your arms in the air. The most common cause of goitre in Australia is Multinodular Goitre (MNG). This is not thyroid cancer.

Hyperthyroidism
When the thyroid produces too much thyroid hormone, the body’s metabolic rate is increased. People with overactive thyroids may experience restlessness, increased anxiety, sweating, difficulty sleeping, rapid heart rate, increased appetite, weight loss, hair loss, diarrhoea and an intolerance for hot weather.

Staring eyes (exophthalmos) which is often seen in hyperthyroidism, is associated with a particular thyroid disease called Graves' Disease.

Blood tests – These can indicate whether the thyroid is producing too much or too little thyroid hormone.

Radiology – An ultrasound can be used to find nodules and characterise a goitre. A CT scan is useful to define the full extent of a goitre.

Biopsy – Any nodules that are suspicious on ultrasound should be biopsied with a needle. Biopsy is often done using ultrasound guidance and then interpreted by a pathologist.

The decision to operate often depends on the results of these investigations.

There are three types of thyroid surgery:

• Total thyroidectomy – complete removal of the thyroid.
  
• Hemi-thyroidectomy – removal of half of the thyroid. This is also known as thyroid lobectomy.
  
• Isthmusectomy – removal of the bridge of thyroid tissue that joins the two lobes together.

The extent of surgery depends on the diagnosis and the extent of disease. A large cancer or goitre may necessitate a total thyroidectomy. A small cancer or goitre only involving part of the thyroid gland may require a hemithyroidectomy or isthmusectomy. A hemithyroidectomy confirming a suspected cancer may be followed by a completion thyroidectomy where the rest of the thyroid is removed at a second operation.

Complications of thyroid surgery are uncommon. The most well recognised are:

1. Post-operative bleeding – this happens in the hours after surgery and usually requires a trip back to the operating theatre
   
2. Recurrent laryngeal nerve injury – The right and left recurrent laryngeal nerves run beneath the thyroid on each side of the windpipe. They provide muscle supply to the voice-box. Damage to one of these nerves leads to hoarseness of the voice. Damage to both of them is exceedingly rare but may cause breathing problems.
   
3. Damage or removal of the parathyroid glands – There are usually four parathyroid glands that sit behind the thyroid (two on the right and two on the left). They produce parathyroid hormone which helps our body to regulate calcium levels in the blood. If one to three of these are damaged or removed, calcium levels can drop. This is usually temporary, but medications are required to maintain calcium levels until recovery occurs. This can take up to three months. Rarely, recovery does not occur, and the medications are required lifelong. The chance of parathyroid damage depends on the indication for surgery. It is more common in patients with very large goitres, extensive cancers or those undergoing redo thyroid surgery.

If you have a total thyroidectomy or completion thyroidectomy, you will need lifelong thyroid hormone replacement. If you have a hemi-thyroidectomy, there is a 10% chance that you will require thyroid hormone supplementation. The dose of thyroid hormone that you require is roughly estimated by your weight but is individual, can take time to determine and may depend on the results of periodic blood tests.

If your parathyroid glands are not functioning in the post-operative period, you will require calcium and vitamin D supplementation. Most people only need these medications temporarily and they can be ceased once the parathyroid glands start functioning again.

Prior to your operation you may need to attend a Preadmissions Clinic. Your fitness for surgery will be assessed, tests may be ordered and referrals to other specialists arranged if required.

You cannot eat for 6 hours prior to your operation. You may sip water for up to 2 hours prior to your operation. Fasting decreases the risk of vomiting and aspiration during induction of anaesthesia. Aspiration can cause pneumonia and a prolonged stay in hospital.

Thyroid surgery is almost always done under general anaesthesia. You will be asleep during the whole procedure. The anaesthetist will discuss the anaesthetic with you prior to your operation. They will see you in the pre-operative area and accompany you to the operating theatre.

Following general anaesthesia, you are positioned on the operating table, your neck is marked, and local anaesthetic is injected to decrease post-operative pain. An incision is made across the lower part of the neck. The thyroid is removed one lobe at a time. Care is taken to identify and preserve the recurrent laryngeal nerves and parathyroid glands. At the end of the operation, the skin is closed with absorbable sutures and dressed with transparent lilac coloured glue and a transparent dressing. The whole operation takes 1.5-2 hours.

Following the operation, you will wake up in the recovery area. You will feel a little disoriented and may feel a little nauseous. The staff in recovery are equipped to help you. Immediate post-operative pain is usually minimal. Once you are awake and oriented, you will be taken to a ward bed. After a few hours, and once the nurses are satisfied that it is safe, you can get out of bed.

Most patients who have a hemi-thyroidectomy can go home on the day of their surgery. Most patients who have a total or completion thyroidectomy will spend one night in hospital. You will have one blood test in the recovery area and another one the morning after surgery (if you stay the night). This is to check your parathyroid hormone and calcium level.

If you have no remaining thyroid or your remaining thyroid isn’t functional, you will commence thyroid hormone replacement therapy the morning after your operation. Most patients will also require calcium supplementation, and a few will require Vitamin D tablets temporarily.

Please do not drive yourself home from the hospital but rather arrange a family member or friend to come and pick you up.

There are no dietary restrictions or special dietary supplements that are required after thyroid surgery. You may eat whatever you choose. Paracetamol is usually all that is required for pain relief. You may bathe and shower. The wound is waterproof and can get wet.

You should avoid strenuous physical activity for two weeks after your operation. It increases the risk of post-operative bleeding which could result in an emergency trip back to the operating theatre. Once this period has passed and you feel that you have recovered, you may return to your normal physical activities.

There is no specific law covering surgery and driving. It is not advisable to drive immediately after surgery. In general, in order to return to driving, you must:

1. Have a valid drivers’ licence
   
2. Be able to control your vehicle during an emergency
   
3. Be able to testify in court as to your capacity to drive

Your car insurer may not cover you following an accident if:

1. You have had recent surgery (‘recent’ is not clearly defined)
   
2. You are taking pain or sedative medications that may impair your concentration or judgement

Aim to return to driving when:

1. You are pain free
   
2. You have full range of motion
   
3. You are not taking strong pain medications or sedatives
   
4. Your reaction time is not compromised

If you are in doubt, do not drive. Call your insurer for advice.

  - Driving Safety and Medicines PDF
NSW Government fact sheet

Post-operative swelling around the wound is normal and usually resolves within a month or so. No specific wound management is needed in the first two weeks while the dressings are on. After this, gentle scar massage is advisable for 10 minutes two or three time a day for 6 months. You may use whatever moisturising lotion you like (e.g. sorbolene, bio-oil etc.) but creams with Vitamin E should be avoided for the first post-operative month. Alternatively, you can keep the scar covered with a silicon strip for 12 hours a day for 6 months. These strips are available from the chemist but are quite costly.

Initially the scar will be pink. Over 6-12 months, the scar will fade until it becomes pale.

Post-operative complications are uncommon but do occur:

Short-term

1. Bleeding – post-operative bleeding can be an emergency and usually requires a trip back to the operating theatre
   
2. Infection – wound infection is rare but is usually treatable with a course of oral antibiotics

Long-term

1. Recurrent laryngeal nerve palsy – this complicates 1-2% of thyroid surgery and is usually temporary. Rarely, it can be permanent. The result of dysfunction of one or the other recurrent laryngeal nerve is one-sided vocal cord paralysis and a hoarse voice. If both nerves are damaged, airway compromise and difficulty breathing can result. This is exceedingly rare.
   
2. Hypoparathyroidism – damage or removal of one or more of the parathyroid glands results in a temporary disturbance in calcium metabolism. If all four glands are removed or damaged, this disturbance can be permanent. This is a very rare occurrence but necessitates lifelong dependence on calcium and vitamin D supplementation.
   
3. Hyertrophic scar and keloid – this usually occurs in patients who have a known predisposition. A number of intra- and post-operative strategies can be implemented to minimize this problem. Operative scar revision is occasionally required.

A follow-up appointment should be arranged in rooms, 4-6 weeks after surgery for a post-operative check-up. At this appointment, your wounds will be assessed, blood tests checked, and any further investigations and management arranged.

Please call to arrange a convenient time. Prior to attending, please have a blood test for thyroid and parathyroid function. A request form will be supplied to you prior to your discharge from hospital.

If you have any questions, please do not hesitate to contact us.

Ph: 02 8307 0977
Fax: 02 8088 7420
Email: info@drgideonsandler.com

Please refer to the following resources for more information:

1. 2015 Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer
   American Thyroid Association
   
2. 2016 Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
   American Thyroid Association
   
3. 2015 Revised Guidelines for the Management of Medullary Thyroid Carcinoma
   American Thyroid Association
   
4. 2012 Guidelines for Management of Patients with Anaplastic Thyroid Cancer
   American Thyroid Association
   
5. 2015 Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer
   American Thyroid Association