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Thyroidectomy

Instructions for Patients following Thyroidectomy

  1. Wound care. If your wound is covered by surgical tapes, leave these tapes alone until directed by your physician to remove them. If your wound has exposed stitches, then follow these instructions: Wash your hands. Clean the wound with hydrogen peroxide and apply antibiotic ointment twice daily. Polysporin and Neosporin ointments, which are available over the counter, are appropriate to use.
  2. Medications. Take your medications as prescribed by your physician. Acetaminophen (Tylenol or Extra-Strength Tylenol) might be sufficient for pain relief. Avoid any medications that contain aspirin or ibuprofen. Do not drive or make important decisions while taking narcotic pain medications. If you need refills for medications, please call during regular office hours.
  3. Diet. Eat a well-balanced, healthy diet. There are no particular restrictions.
  4. Activity level. Avoid any strenuous activity for at least two weeks after your surgery. This means you should limit lifting anything more than about ten pounds following your surgery.
  5. Showering and bathing. It is permissible to shower and bathe following your surgery. Avoid getting the wound soaking wet.
  6. Follow-up appointment. You should call our office to set up a postoperative visit for one week following your surgery.

Thyroid Gland Anatomy

The thyroid gland is located over the trachea (windpipe) just below the larynx (voice box), and it has two lobes that extend along each side of the trachea. The central portion of the gland is called the isthmus. The function of the thyroid gland is discussed on another web page. Patients who have total thyroidectomy will need to be on hormone replacement therapy, meaning taking a tablet daily, for the rest of their lives. Patients who have partial removal of the gland usually do not require daily thyroid hormone replacement, but this can vary depending on the underlying thyroid disease.

The parathyroid glands are located alongside the lobes of the thyroid. There are usually two parathyroid glands on each side of the neck. The parathyroid glands regulate calcium levels in the blood. Without the any of the parathyroid glands, calcium levels can drop to dangerously low levels. Surgery around the thyroid gland requires identification and preservation of as many of these glands as possible. Sometimes, this very disection around the parathyroid glands can disturb their blood supply and temporarily affect their functioning. Occasionally, tumors of the thyroid invade and destroy these glands, making their preservation impossible. In such circumstance, if one gland can be positively identified, then it can be implanted (autotransplant) and it will begin functioning several weeks after surgery. In the meanwhile, calcium replacement and Vitamin D are given to maintain normal parathyroid hormone levels.

The nerves that control the vocal folds are located near the thyroid gland. On each side of the neck, there is a superior laryngeal nerve and an inferior (more commonly called recurrent) laryngeal nerve. Each nerve controls its own set of muscles and provides sensation to its own part of the larynx. The superior laryngeal nerve has two branches: an external branch that controls the cricothyroid muscle, and an internal branch that gives sensation to the larynx above the vocal folds. The cricothyroid muscles repositions the thyroid cartilage over the cricoid cartilage. This action tenses the true vocal folds, allowing the voice to reach higher notes. Damage to this nerve eliminates the ability to reach the high notes.

The recurrent laryngeal nerve controls the other muscles of the larynx and provides sensation to the rest of the larynx. Its most important functions are to open the true vocal folds allowing unrestrained respirations and to close the vocal folds producing a normal voice, cough, and swallow. Damage to one recurrent laryngeal nerve produces a breathy, low-volume voice and poor cough reflex. It might also produce difficulty with swallowing so that one’s food or drink might go down the trachea (also called aspiration). Damage to both recurrent laryngeal nerves prevents adequate opening of the true vocal folds, and results in shortness of breath. Voice quality might, however, be relatively normal with bilateral recurrent laryngeal nerve paralysis. Sometimes the respiratory difficulty from bilateral recurrent laryngeal nerve injury might be so severe as to require tracheostomy.

Risks of Surgery

  1. Vocal fold weakness or paralysis, due to damage to one or more of the nerves that control vocal fold movement
  2. Low calcium levels, due to damage or loss of the parathyroid glands
  3. Hematoma formation
  4. Infection
  5. Hypothyroidism, need for daily thyroid hormone replacement

Surgical Procedures

Thyroid Lobectomy and Isthmusectomy

Thyroidectomy is performed under a general anesthetic. The patient is positioned in such a way that the neck is extended slightly. Prophylactic antibiotics are given just prior to starting the procedure.

After the patient is draped in sterile towels and drapes, an incision is planned, usually about two fingerbreaths above the bony notch at the base of the neck. This incision is carried down through the soft tissues of the neck until the strap muscles that cover the thyroid are found. These strap muscles are separated and spread apart to expose the thyroid gland. The inferior part of the diseased gland is then mobilized. The recurrent laryngeal nerve and parathyroid glands are identified and preserved. The superior part of the gland is followed closely to avoid injury to the superior laryngeal nerve. The diseased thyroid lobe is then removed, usually by dividing the isthmus (isthmusectomy), and leaving the normal lobe alone.

The surgical specimen is usually sent for a rapid or frozen section pathologic diagnosis. If the frozen section reveals a benign disease process, then a surgical drain is placed to prevent accumulation of blood or fluid in the surgical bed. The wound is then closed in layers with sutures.

If the frozen section pathologic diagnosis discloses a malignancy, then the remaining gland is usually removed (see total thyroidectomy). Sometimes the frozen section cannot definitely find evidence of malignancy. In this circumstance, one must wait for the final pathologic diagnosis (usually 3 – 5 business days). If a malignancy is found on the final pathologic diagnosis, then a completion thyroidectomy is scheduled for the near future (usually within a week or two of the original surgery date).

Total Thyroidectomy

This procedure is begun in the same fashion as described in Total Thyroid Lobectomy and Isthmusectomy. However, the isthmus is usually not divided, and both lobes of the thyroid are mobilized. Each recurrent laryngeal nerve is identified and preserved. The parathyroid glands are identified and preserved. The entire gland is removed.

In cases of aggressive malignancy, the recurrent laryngeal nerve, superior laryngeal nerve, or parathyroid gland cannot be separated from the tumor. In these cases, the nerve or parathyroid gland has to be sacrificed in order to remove the tumor completely. If at least one of the parathyroid glands can be identified, then it can be implanted into one of the strap muscles (autotransplantation).

The surgical specimen is usually sent for a rapid or frozen section pathologic diagnosis. Once the gland is removed, a surgical drain is placed to prevent accumulation of blood or fluid in the surgical bed. The wound is then closed in layers with sutures.

Completion Thyroidectomy

This procedure is begun in the same fashion as described in Total Thyroid Lobectomy and Isthmusectomy. The remaining lobe of the thyroid is mobilized. The recurrent laryngeal nerve is identified and preserved. The parathyroid glands are identified and preserved. The remaining gland is removed.

In cases of aggressive malignancy, the recurrent laryngeal nerve, superior laryngeal nerve, or parathyroid gland cannot be separated from the tumor. In these cases, the nerve or parathyroid gland has to be sacrificed in order to remove the tumor completely. If at least one of the parathyroid glands can be identified, then it can be implanted into one of the strap muscles (autotransplantation).

A frozen section is not necessarily performed, since the diagnosis has already been determined. The surgical specimen will be examined and a pathology report will be issued within 3 to 5 business days.

Once the gland is removed, a surgical drain is placed to prevent accumulation of blood or fluid in the surgical bed. The wound is then closed in layers with sutures.

Post-Operative Course

The patient is kept in hospital for at least one day. Prophylactic antibiotics are continued for the first day. The patient is observed for the potential problems of hematoma formation and hypoclacemia.

Accumulation of blood (hematoma) in the operative bed can occur in the first 24 hours. When this occurs, the accumulated fluid can displace the trachea and make breathing difficult. This hematoma needs to be drained and the bleeding site controlled.

During the post-operative hospitalization, calcium levels are checked. In cases of total thyroidectomy, when all of the parathyroid glands have been disturbed, checking calcium levels is very important. Calcium levels can drop to levels that produce symptoms such as tingling around the mouth or fingertips. Replacement of calcium and vitamin D are given to restore the calcium level to normal. Patients with low calcium are observed until the calcium level stabilizes. If just one of the parathyroid glands has been preserved (or sometimes autotransplanted), then calcium levels will stabilize in time.

Patients that have had total thyroidectomy for benign disease are started on thyroid hormone replacement. Patients that have had total thyroidectomy for malignant disease are not started on thyroid hormone replacement, until a thyroid survey has been performed (usually within the first 6 weeks after surgery).

Most patients have some discomfort with swallowing for the first few days, and this is normal. When the recurrent laryngeal nerve is sacrificed, patients will have more difficulty with swallowing and a weaker than normal voice. Many patients notice improvement in swallowing and voice with speech therapy. Sometimes a surgical procedure to move the vocal fold toward the opposite fold can be performed to improve the voice and eliminate aspiration.

The duration of hospitalization is usually dictated by either the amount and duration of drainage through the surgical drain or the occurrence of one of the complications listed above. If the postoperative course is uncomplicated, then this drain is removed, and patients are generally able to go home.

Outpatient Course

Patients are seen about one week after surgery. Stitches, if present, are removed. An evaluation of vocal fold movement is usually conducted.

For patients with benign disease, thyroid replacement hormone is continued and TSH levels are checked periodically until an appropriate level of hormone replacement has been reached. These patients are generally followed in consultation with endocrinologists.

For patients with malignant disease, thyroid hormone replacement is delayed until a thyroid survey can be obtained. This nuclear thyroid scan looks for any sign of residual or metastatic thyroid disease. Patients are then treated with ablative doses of radioactive iodine. These patients are generally followed in consultation with endocrinologists and/or oncologists. Periodic examinations and blood tests are performed to find any recurrence of the cancer.