Thyroid surgery

The thyroid is a small gland at the front of the neck, just above the collarbone. It has a shape a bit like a butterfly. It produces hormones (chemicals that are released into the blood) which we need to help the body function normally. 
 
The thyroid is close to two important structures in your neck: 

• the nerves which control your voice lie on each side of the thyroid. They also help with swallowing and breathing.
• the parathyroid glands, which are four tiny glands about the size of a grain of rice. There are two at each side of the neck. They sit behind the thyroid and are attached to it. They produce a hormone (parathyroid hormone) which controls the level of calcium in your blood.

Image of the thyroid used with the kind permission of Macmillan Cancer Support

Surgery is the usual treatment for thyroid conditions such as:

• Thyroid nodules or cysts: these develop when part of the gland grows abnormally and sticks out. Nodules are solid and cysts contain fluid. Sometimes surgery is the only way to definitely diagnose the type of nodule or cyst. 
• Thyroid goitre: this is when part of or the whole thyroid gland is enlarged. Not all patients with a goitre will need an operation. We usually advise or offer surgery if the goitre affects your breathing and swallowing (by pressing on your windpipe or gullet (oesophagus)), if it causes discomfort, or if its appearance is a cause of concern. 
• Graves' disease: this is a condition in which the body’s immune system makes antibodies (proteins that usually help protect us when unwanted substances enter the body) which make the thyroid gland produce too much hormone. This then interferes with the function of other organs of the body.
• Thyroid cancer: there are a number of different cancers that affect the thyroid gland. Treatment will depend on the type of cancer. Patients who need surgery for thyroid cancer can find out more on the thyroid cancer page.

During surgery, we aim to cut out a part or all of the thyroid to remove the abnormal tissue which is causing the problem. Depending on the problem you have, your doctor may recommend different types of medical or surgical treatment.

Types of thyroid surgery 

• A total thyroidectomy is an operation to remove the whole thyroid gland.
• A hemithyroidectomy is an operation to remove half of your thyroid gland. 
• A completion thyroidectomy is a second operation which is sometimes needed after a hemithyroidectomy. The operation removes all of the remaining thyroid gland. 

It may also be necessary to remove small structures called lymph nodes which surround the thyroid. If this is the case your doctor will explain why before your operation.

These operations are done under general anaesthetic which means you will be asleep during the procedure. 

As with any operation, there are risks associated with thyroid surgery. These include: 

• Scarring: Some patients develop thick scars where the cut has been made, but this is very rare. Although the scar usually fades with time, most patients will be left with a visible thin line. 
   
• Neck pain, swelling or stiffness: the area around the cut may be sore and swollen for a few days. This is part of the healing process, and we will give you medication to help your pain and reduce the swelling while you are in hospital. Please tell us if you are in pain so we can help as soon as possible. These symptoms should self-resolve within a week but if they persist or are too uncomfortable, please contact us (see Section 14 below for contact details). The physiotherapist on the ward can also teach you some exercises to help you recover. Please ask if this would be helpful. 
   
• Bleeding: this is a rare complication that can cause neck discomfort, bruising and swelling. In more severe cases it can make breathing difficult. Very rarely, patients may need to go back to the operating theatre to deal with the cause of the bleeding.
   
• Infection: this is an uncommon complication which can occur around four to seven days after the operation. An infection can usually be treated with antibiotics.
   
• Nerve injury: there are fragile nerves which run very close to the thyroid. During the operation the surgeon will use a nerve monitor to find their location and check they are working. This will help us to avoid damage where possible. If the nerves are bruised however they may not work properly after surgery. This results in voice changes and sometimes swallowing and breathing difficulties. Most patients who develop these problems recover and return to normal in the following days or weeks.
  
  If the voice problems continue, we can refer you to a Speech and Language Therapist who can examine your voice box and teach you exercises to help restore your voice. Around 30 per cent (one in every three) of patients will have some type of voice change, but most recover fully. However, one per cent (one in every hundred) of all patients have permanent changes. If important nerves are permanently damaged a patient may need to have a feeding tube and tracheostomy (breathing tube) for the rest of their life. While this is very serious, it is also extremely rare. 
   
• Hypoparathyroidism: this is a condition that causes low levels of calcium (an essential mineral) in the blood. It occurs when all four parathyroid glands are affected after a total thyroidectomy. If you are having a hemithyroidectomy, this does not happen to you as at least two parathyroid glands will continue to work normally. During thyroid surgery the surgeon will always try to identify the parathyroid glands and preserve them. However as they are very small and attached to the back of the thyroid gland it is possible that they will be removed during the surgery.
  
  In any thyroid operation, the parathyroid glands will be put under stress and may not work properly afterwards: this too may cause low calcium levels in your blood. Symptoms of low calcium in the blood include tingling in your fingers and toes, numbness around the mouth or cramps in your muscles. To prevent these symptoms, you will have a blood test the day after a total thyroidectomy or a completion thyroidectomy to check parathyroid hormone and calcium levels. This will help us to tell if you need calcium and vitamin D supplements. You may need to take this medication for a few weeks and come to the hospital for regular blood tests. 
  
  About 25 per cent (one in four) of patients will have low calcium blood levels after a total thyroidectomy or completion thyroidectomy. For most patients this is temporary and gets better in the weeks and months after your surgery. However, there is a one to five per cent (one in one hundred to one in twenty) chance that this will be not get better. If this happens you will need to take calcium and vitamin D supplements for life. Very rarely, if the calcium level is very low and the symptoms get worse, you may need to come to hospital for intravenous supplements, where they are given through a thin flexible tube (cannula) into the bloodstream.
   
• The need for thyroxine replacement therapy: after a total or completion thyroidectomy all patients will need to take levothyroxine tablets every day. This is to replace the hormone which was made by the thyroid before it was removed. Most patients who have a hemithyroidectomy do not need levothyroxine immediately, but 30 per cent (one in three) of patients will need to take it in the future. You will have a blood test four to six weeks after a hemithyroidectomy to check the thyroid function and start this medication if it is low.

The risks associated with general anaesthetic will be discussed with you when you come for your pre-assessment appointment before the operation. You will also see an anaesthetist on the day of your operation.

What alternatives are available?

For most patients surgery is the treatment of choice. There are alternative treatments available, but they are not suitable for all patients and all conditions. We will discuss alternatives if we think they will be of benefit to you.  
 
In cases of thyroid cancer and large thyroid goitres, not having surgery could lead to worsening your condition. Patients who have Graves’ disease can sometimes be treated with medication to control the thyroid function. It can also sometimes be treated with a special type of radiotherapy (radioactive iodine). An endocrinologist (a doctor who specialises in hormone conditions) will be able to give you further advice on these treatments. Radiofrequency ablation is a newer treatment that can sometimes be used to treat large thyroid nodules. Because this treatment is new however, there is limited evidence about how effective it is. Your doctor will inform you if it may be an option for you.  

Before your operation, we will organise a pre-assessment appointment. We will ask you for details of your medical history and carry out any tests we need to make sure you are fit for the anaesthetic and the operation. Staff in the pre-assessment clinic will tell you how to prepare for your operation, when to stop eating and drinking, and the admission process. You might be advised to stop taking certain medications, such as blood thinners or thyroid tablets. 

You will be admitted to hospital on the day of your operation. You will meet a member of the anaesthetic team and a member of the surgical team before the operation. They will again explain the risks and benefits of the procedure, answer any questions you may have, and will obtain your consent. The nursing team will do some safety checks before we go ahead with the surgery. 

Asking for your consent 

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please speak with a senior member of staff again.

Sometimes, we may also ask you for consent to participate on research projects. If this is the case, we will discuss this with you in detail beforehand. 

Thyroid surgery is performed under general anaesthesia. Your will be asleep and you will not feel any pain during the procedure. Surgery usually takes one to three hours. 

The surgeon will make a five to seven centimetre cut (‘incision’) in your neck. They will remove all or part of your thyroid gland as discussed with you beforehand, while where possible preserving other important structures such as blood vessels and nerves. The surgeon will close the wound with stitches and glue and cover it with a dressing. In some cases, a thin flexible drainage tube may be placed under the skin to prevent build up of fluid under the wound. This is connected to a small plastic bottle. The drainage tube is not painful.

 After the operation you will wake up in the Recovery Area. You will have a covering on your neck wound and an intravenous drip (fluid given through a thin plastic tube (‘cannula’) into your blood stream), through which we can also give you painkillers or any other medication you may need. A recovery nurse will look after you until you are ready to go to the ward.

Once you are awake, we will ask you to sip some water: when you are able to swallow safely, we will allow you to eat and drink. A member of the surgical team will review you every day while you are in hospital after the operation. 

If you are having a total thyroidectomy or a completion thyroidectomy, you will need blood tests early the next morning to check the function of the parathyroid glands. You may need to stay in hospital longer for calcium supplements, if the results show this is needed. 

If you have a drainage tube inserted at the operation it is likely that you will be in hospital for a few extra days. The tube will be removed on the ward by a nurse once the fluid stops draining. You can have a shower after surgery, but we would recommend you wait until the scar heals before you take a bath. 

Most people are discharged one to two days after their operation. You will need someone to drive you home and provide support for the first few days.  

Medication

We will advise you to take over the counter medication to help you manage any discomfort or pain. It is a good idea to have a supply at home before you come in for your operation. 
If all of your thyroid gland was removed (after a total thyroidectomy or completion thyroidectomy), you will require lifelong levothyroxine. This is a straightforward tablet you take once each day with little need for adjusting the dosage over time. It is very important that you continue to take this tablet every morning before you eat, ideally half an hour before breakfast. 

If you miss your thyroxine tablet one day, you will feel no difference, but if you miss it for several days, you will gradually feel more tired. Not taking the medication can cause a serious medical condition.
Some patients may also require Vitamin D supplements and calcium tablets. Your doctor will let you know if you need to take these. 

Exercise and going back to work

You should rest for two or three days when you get home. It is normal to feel tired for a few weeks after surgery. You can move your neck gently and regularly to prevent stiffness and improve healing. The medical team will provide instructions on specific exercises should you develop stiffness around your neck. 

We advise you to avoid strenuous activities such as heavy lifting or vigorous exercise for two weeks after the operation. Also avoid swimming for at least two weeks and contact sports for one month. We usually advise patients to take one or two weeks off work, but this can vary, depending on the type of work you do. You should be able to resume most of your normal activities a week after surgery. 

Wound care

You may notice some bruising, swelling and numbness around your wound, which is normal and will subside in a few days. Keep your wound clean and dry. Avoid touching or scratching your scar. Avoid wearing tight clothing or jewellery around your neck. Avoid moisturisers until you are reviewed in clinic. 

You may shower from the day after the operation, but we advise you not to have a bath for at least two weeks. You can remove the wound covering over three to four days after the operation. You will have glue and dissolvable stitches which do not need to be removed. The glue will peel off over the next few days. Your scar will fade over time and become less noticeable. 
 
If you have any concerns about your wound or medication, please contact the surgical team. 

Driving

Avoid driving until you are comfortable turning your head and have stopped taking pain killers that might affect your alertness. Check with your insurance company, as they may have specific rules about driving after surgery. 

Travelling

Please discuss with your medical team if you are planning to travel after surgery. We normally recommend that you remain in your local area until we review you in clinic three to four weeks after surgery. This is to ensure you are fit and we can provide you with medication or further advice should you need it. This will also allow us to address any possible urgent problems in the meantime.

Other symptoms

You may experience some voice changes or swallowing difficulty after surgery. This should gradually resolve but it may persist for up to six months. If you are still experiencing problems six months after surgery, we will organise further tests and treatment by a specialist.

Urgent problems

If you have an urgent problem please come to the Emergency Department at University College Hospital.
Please seek urgent medical advice if you develop:

• redness around the surgical wound
• a fever 
• more swelling in your neck after you have gone home
• tingling or pins and needles in your fingers or toes, which does not go away after you have taken calcium supplements.
   

We will give you an appointment to review you in the outpatients clinic three to four weeks after the operation. It is important that you come to the hospital two or three days before this appointment for a blood test to check your thyroid function. If you had a total or completion thyroidectomy, we will also check your parathyroid hormone and calcium levels.

When you come to clinic we will check your wound, voice and general recovery. We will review the blood test results and we will advise you on what medication you need to take. A pathologist will look at the thyroid tissue which was removed. If needed, we will discuss the findings in a multidisciplinary team meeting. We will inform you of the results and we will also tell you if you need any further treatment or follow-up.

Further information

The British Association of Endocrine and Thyroid Surgeons (BAETS) provides some information on their website about surgery.
www.baets.org.uk/patients 
 
The British Thyroid Foundation is a charity which supports people with thyroid disorders and their families. 
www.btf-thyroid.org
 
UCLH cannot accept responsibility for information provided by other organisations.

Contacts 

Pathway Co-ordinator (Monday to Friday 09:00–17:00)
Direct line: 020 3447 9460 / 07890 945 294 
Switchboard: 08451 555 000 / 020 3456 7890 ext. 79460
E-mail: uclh.endocrinesurgery@nhs.net 
Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London NW1 2BU.