Thyroid Surgery Patient Information

Anh Q. Truong, MD

Bellevue ENT

1231 116th Avenue NE, Suite 915

Bellevue, WA 98004

Phone: (425) 454 - 3938

What are the indications for thyroid surgery (thyroidectomy)?

Typically, surgery such as a thyroid lobectomy or total thyroidectomy is recommended in patients diagnosed with thyroid cancer or in patients with high clinical suspicion for thyroid cancer. In addition, thyroid surgery is also indicated in patients with large thyroid nodule (> 4 cm), non-diagnostic thyroid nodule with high-risk features, poorly controlled hyperthyroidism (e.g. Grave’s disease), and enlarged goiter causing compressive symptoms or cosmetic deformity. However, other factors such as the patient’s co-morbidities, age, and goal of care may guide the decision between observation and surgery. Patients with thyroid cancer who are at high risk for regional metastasis to lymph nodes in the neck or have evidence of nodal metastasis will usually need a concurrent neck dissection (removal of lymph nodes).

Figure 1. Common indications for thyroid surgery include thyroid cancer (left) and thyroid goiter (right).

What is thyroid surgery (thyroidectomy)?

The decision to proceed with a thyroid lobectomy (removal of half the thyroid gland) or total thyroidectomy (complete removal of the thyroid gland) is based on the underlying pathology and goal of care. The approaches to the surgeries are the same.

A horizontal skin incision is made at the midline of the neck over the thyroid gland. The thyroid gland is identified under the muscles in the neck. The gland is then carefully separated from the underlying structures in the neck. The parathyroid glands (responsible for calcium regulation) and the recurrent laryngeal nerves (responsible for voice and breathing function) are often identified and preserved. Often, the recurrent laryngeal nerve is monitored (neuro-monitoring) to aid in the surgery while reducing the risk of injury to the nerve.

Figure 2. Illustration of skin incision and removal of the thyroid gland. Source: uptodate.com

The lymph nodes may be removed (central neck dissection) at the same time if there is evidence of cancer spreading to the nodes or if the risk of nodal metastasis is high. This is performed by removing fatty and lymphatic tissue in the area over the trachea, between the recurrent laryngeal nerves.

Figure 3. Central neck nodes are removed after removal of the thyroid gland. Source: uptodate.com

What should I expect before thyroid surgery?

• If you have a diagnosis of thyroid cancer and anticipate treatment with radioactive iodine after surgery, then the use of iodine contrast (often with a CT scan) should be avoided for 1-2 months before surgery to avoid interference with post-operative treatment.
• If you have a history of hyperthyroidism (e.g. Grave’s disease), then a saturated solution of potassium iodide may be prescribed by your endocrinologist prior to surgery to minimize the risk of bleeding.
• DO NOT TAKE THE FOLLOWING MEDICATIONS FOR AT LEAST 14 DAYS PRIOR TO SURGERY: NSAIDs products including aspirin, ibuprofen (Motrin/Advil), and naproxen (Aleve). Over the counter products including vitamin E (multivitamin is OK), gingko biloba, garlic (tablets), ginseng, and St. John's wort. These medications can thin the blood and create excessive bleeding. Tylenol is safe and may be taken any time up to the day of surgery.
• You must inform your surgeon if you have any underlying medical problems including heart problems, lung problems, or bleeding disorders prior to surgery. In addition, inform your surgeon and anesthesiologist if you are taking Coumadin, Plavix, ACE inhibitor blood pressure medications such as lisinopril or enalapril, and SGLT2 Inhibitor diabetes medications such as empagliflozin or canagliflozin.
• While our office will make every attempt to keep your primary care physician informed before and after your surgery, it is important that you personally inform him/her that you are planning to have thyroid surgery. If you have underlying medical conditions, your primary care physician may help to clear you medically for your thyroid surgery. Most of the necessary pre-operative testing will be performed at Bellevue ENT during your preoperative visit. This takes place approximately 1 week prior to your surgery if needed.
• Due to the frequently changing operating room schedule, the surgery center will usually call you one business day before your surgery date to inform you of your surgery time. You are usually expected to arrive two hours prior to your surgery to check in.

What should I expect during thyroid surgery?

Your surgical team will include your surgeon, a surgical assistant, an anesthesiologist, a scrub nurse, a circulating nurse, and additional supporting staff dedicated to ensuring that your surgery is safe. Thyroid surgery is performed under general anesthesia and will usually last about 2-3 hours; however, the duration will vary depending on your underlying pathology. Blood loss from thyroid surgery is usually minimal. Your surgeon may choose to monitor the recurrent laryngeal nerve during the surgery by using a special intubation tube. At the end of the surgery, the incision is usually closed using sutures and a temporary drain may be placed to remove excess fluid until it is removed the next day.

Figure 4. Neuromonitoring during thyroid surgery. Source: Butterworth et. al. Morgan & Mikhail's Clinical Anesthesiology, 5th Ed

What should I expect after thyroid surgery?

• After your surgery, you will spend approximately 1-2 hours in the recovery area. Approximately 1 hour after you arrive in the recovery area, a family member or friend should be able to visit with you. If the entire thyroid gland is removed (total thyroidectomy), you will usually be admitted to the hospital overnight for observation. If only half of the thyroid gland is removed (hemithyroidectomy or thyroid lobectomy), then you may be discharged home.
• If a drain is placed, it is usually removed the next day once the fluid discharge is low. You may shower and gently wash the wound two days after surgery. If there is a dressing or tape in place, it will be removed by your surgeon one week later.
• You will have return visits to the Bellevue ENT clinic at approximately 1 and 4 weeks after surgery. At your first post-operative visit, the ENT surgeon will examine the wound and remove any dressing if needed. You will also follow up with your endocrinologist about 3-4 weeks after surgery and will obtain thyroid blood test at that time. Please write down any questions you may have so that we can answer them at your appointment.
• Typically, you may resume a regular diet. Your endocrinologist may place you on a short-term low-iodine diet if post-operative radioactive iodine treatment is anticipated.
• You should plan on taking one week off from work and ideally have a half-day planned for your first day back.
• Please see the post-operative instructions for additional details.

What are the risks of thyroid surgery (thyroidectomy)?

As with any surgical procedure, a thyroidectomy has associated risks. With meticulous planning and appropriate precautions, complications from thyroid surgery are very rare. Although the chance of a complication occurring is very small, it is important that you understand the potential complications and ask your surgeon about any concerns you may have. These risks may include:

• Bleeding: Bleeding during surgery is usually minimal. If bleeding occurs after surgery, it may develop a blood clot and form a hematoma. In severe cases, this can compromise the airway and swallow function. Fortunately, this is extremely rare and can be avoided if appropriately monitored and managed.
• Hypoparathyroidism: The four parathyroid glands are usually located behind the thyroid gland. If all four glands are injured or removed, the patient will develop hypoparathyroidism, resulting in low calcium level. Should this rare complication occur and does not recover, then the patient may need to take calcium and vitamin D supplements to maintain normal blood calcium level.
• Recurrent Laryngeal Nerve Injury: The recurrent laryngeal nerve runs behind each thyroid lobe. It is usually identified during surgery and preserved. It is also typically monitored using neuromonitoring. If the nerve is injured, recovery is low and patients may develop a hoarse voice or difficulty breathing. Fortunately, the risk of injury is extremely rare and can be avoided if the appropriate precautions are taken.
• Other risks: Other uncommon risks of surgery include scarring at the incision line; local or distant recurrence of thyroid cancer; difficulty swallowing; and voice change.

What restrictions will I have during the postoperative recovery period?

• You should not lift more than 15 lbs for 4 weeks after surgery. You may resume light exercise such as jogging one week after surgery. Do not engage in any strenuous activities.
• You should not fly for at least one week after surgery. Please see the post-operative instructions for additional details.

Your surgeon is committed to providing you with the highest level of care in a comfortable and caring environment. We want you to have all of your questions answered and provide you with a complete understanding of your condition and treatment plan related your thyroid surgery. Please feel free to ask questions about any aspect of your care. Learn more about thyroid nodule, thyroid cancer, and post-operative care after thyroid surgery.