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Thyroidectomy

General Background

The thyroid gland is located in the anterior part of the neck is responsible for the secretion of thyroid hormone, an important hormone involved in the regulation of your body's metabolism. The gland consists of two lobes with an interconnecting middle portion known as the isthmus. Both benign and malignant (cancerous) tumors can affect the gland. Other inflammatory or autoimmune diseases, such as Grave’s Disease or Hashimoto's Thyroiditis, can also affect the gland. Tumors of the thyroid gland are prevalent, and though the majority of thyroid tumors are benign, the incidence of thyroid malignancy is increasing in the U.S. It is important to have any suspected thyroid masses be carefully examined by an otolaryngologist. Benign and malignant thyroid tumors respond well to surgical treatments when found early. Thyroid cancers, when found early, are managed quite well with surgery, and cure rate is often well above 95 percent. Signs the warrant an appointment with an otolaryngologist include a growing mass in the neck, painful neck masses, voice changes, swallowing difficulties, referred pain to the ears, and shortness of breath. Often your surgeon will have performed a needle biopsy of a suspected tumor in the gland. If the biopsy shows a malignant lesion or a lesion highly suspected to be malignant, or if the gland has a disease process that has not responded to medical treatment, such as Grave’s Disease, the removal of the entire thyroid gland may be necessary. If the results of the needle biopsy are indeterminate, the removal of the lobe containing the lesion as well as the isthmus may be necessary.

The Procedure

This procedure is performed under general anesthesia administered by our MD Anesthesiologist and takes approximately one to two hours for a hemithyroidectomy and two to three hours for a total thyroidectomy. A horizontal incision is made in the neck, typically in a natural skin crease to minimize the appearance of any scar after surgery. The gland is carefully dissected away from surrounding important structures, and once removed, the deeper layers of the wound and the skin are then sutured closed. Occasionally a small drain is placed in the wound- this drain is typically removed in one to two days after surgery.

After spending several hours in the recovery area, you will be discharged home. Pain associated with the procedure is typically mild. Most patients often state the worst sensation after surgery is a sore throat, which is caused by the breathing tube placed in the airway during surgery. This sensation usually resolves after several days. If a drain has been placed during surgery, you will return to the office the next day to have it removed. If the entire thyroid gland is removed, blood calcium levels will be checked once or twice after surgery to ensure that they remain stable. Approximately one week after surgery, the skin sutures are removed. Thyroid hormone supplementation is started after surgery when the entire gland is removed. Depending on the type of tumor removed, post-operative radioactive iodine therapy may be needed as well.

Risks of Surgery

There are several risks associated with thyroid surgery. One of the important structures located near the thyroid gland is the recurrent laryngeal nerve. There is a nerve on both the right and left sides, and each is responsible for the movement of the vocal fold in the larynx, or voice box, on that specific side. Damage to the nerve during surgery can cause decreased movement or paralysis of vocal fold on that side, which can result in hoarseness or loss of voice. The risk of this complication is approximately 2%.

When injury does occur to the nerve, the resulting hoarseness is usually temporary and gradually resolves over time. On the occasions that the voice does not improve, adjunctive procedures can be performed to improve the quality of the voice. Another risk is hypocalcemia, or low blood calcium levels, secondary to injury to the parathyroid glands. This risk is associated only with a total thyroidectomy or a completion of a previous partial thyroidectomy, not with a hemithyroidectomy. The parathyroid glands are small glands located adjacent to the thyroid gland, and they secrete a hormone responsible for the regulation of the body's calcium levels. There are typically four glands in total, two on each side. During the dissection of the thyroid gland, the blood supply to the parathyroids may become disrupted. This can result in a post-operative decrease in parathyroid hormone levels, which can lead to low calcium levels. Low calcium levels can cause fatigue, muscle tightness and cramping, and in severe cases, EKG changes and seizures. Fortunately the rate of permanent hypoparathyroidism (low parathyroid hormone) is very low.

After surgery, your blood calcium levels will be checked to monitor for any signs of hypoparathyroidism. You may be started on oral calcium and Vitamin D (a vitamin also involved in calcium regulation) supplementation after surgery in cases of temporary hypoparathyroidism. The risk of temporary hypoparathyroidism is 10-20%, while the risk of permanent hypoparathyroidism is less than 1%. Once the parathyroid glands have returned to normal function, you will be weaned off the calcium and Vitamin D. In cases of permanent hypoparathyroidism, you would need to remain on daily calcium and Vitamin D supplementation. The risk of bleeding after surgery is very low, typically less than 1 percent. If any sudden swelling associated with pain or difficulty breathing is noted, immediate evaluation is required. This risk is minimized by the avoidance of any heavy lifting, strenuous activity, straining, or the use of blood-thinning products such as aspirin or NSAIDS for two weeks after surgery. Tumor recurrence, though extremely rare, is a possible complication that may necessitate further surgery in the future. Infection after surgery is a rare complication and is managed by oral antibiotics. Scarring from the surgery is very minimal; often the scar is so well hidden in skin creases that they are virtually unnoticeable. If you have prior history of keloids or hypertrophic scars, however, you may be at risk for larger-than-normal scar formation.