Total thyroidectomy

Total thyroidectomy is the removal of the entire thyroid gland.

There may be one or more factors that are important in any one patient. Every patient will react to their own illness in a different way so we use this list as a guide to making the decision about whether surgery is necessary and how much surgery is needed.

What are the complications that can happen with any operation?

When patients undergo surgery there is a risk of having a heart attack or stroke, of developing kidney or lung failure. Generally these conditions are more likely if there is already evidence of a pre-existing illness, which is why your past history is noted in detail. If you have forgotten some part of the history, you can ring Dr Yeung’s rooms to fill in any gaps.

We take precautions with any major operation to minimise the risk of blood clots forming in the legs and pelvic veins. If these travel to the lungs they can occasionally be life threatening. You must make sure that if you or your family have a blood clot history, or if you have had leg immobilisation prior to surgery to let Dr Yeung know. All operations carry a risk of infection. The risk of infection is greater if you need to stay longer, have a long complex procedure, or have a depressed immune system, or other medical problems like diabetes.

Complications specific to thyroid surgery

Voice Complications

The larynx (the organ for speaking) lies just above the thyroid and there are nerves (recurrent laryngeal nerve) to make the vocal cords move for speech, to avoid food going “down the wrong way” and for coughing which run very close to the thyroid from above and below. It is important to avoid injury to these nerves during thyroid surgery. We may check the vocal cord function before or after your operation with a flexible telescope through the nose (nasendoscopy).

During surgery, Dr Yeung uses a nerve monitoring device – this allows her to confirm that the recurrent laryngeal nerve has been identified and is working during the operation. Temporary hoarseness affects about 10% of patients but is due to nerve damage in only half. Wound swelling, and vocal cord bruising from the anaesthetic tube are other causes. The external branch of the superior laryngeal nerve is another nerve encountered during thyroid surgery. It is responsible for voice pitch and projection. This nerve is usually identified and preserved during surgery. It may also be confirmed with the use of the nerve monitoring device. Permanent paralysis of one recurrent laryngeal nerve is uncommon (about 0.5%) and the nerve may take up to 2 years to recover. Often the other vocal cord can be strengthened to do the work for both sides. Very rarely (mostly with advanced thyroid cancer) both nerves do not work and a tracheostomy (breathing tube in the neck) is necessary, in some cases permanently.

It is unusual for thyroid patients not to be able to use their voice at the same level as before. Voice weakness and voice fatigue (losing the voice after prolonged speaking) are common symptoms that usually improve over six months. This can be due to the upper nerve of the larynx being damaged, and this may affect up to 30% of patients but is usually mild. We recommend using the voice as much as is comfortable as the larynx muscles, like muscles in the arms and legs, recover better if they are being exercised. This exercise is not always popular with other family members! If your work involves a lot of speaking we may recommend “light voice duties” to help with recovery.

Thyroid Hormone Replacement

When the whole thyroid is removed, replacement of thyroid hormone (a chemical made in the thyroid and released into the blood stream) is necessary to remain healthy. This hormone is given in the form of thyroxine which is a tablet form of the same chemical that is called T4 in the blood test that you may have had recently. This hormone is needed to maintain important metabolic (a bit like the accelerator pedal in a car) function. Usually 100 to 150 mcg (ug or micrograms) per day is enough. We usually test this with a blood test 6 weeks after surgery and 6 – 12 monthly afterwards. The level is usually easy to maintain and the dose needed may gradually get less as you grow older.

The prescription is inexpensive and the tablets come in blister packs. We give various combinations of 50, 100, and 200 mcg tablets. The dose lasts a few days in the blood stream so missing a dose and catching up occasionally is not a problem. Most people get in to a routine of taking the tablet on getting up in the morning. Thyroxine is absorbed through the intestine and the absorption can be affected by binding to calcium in calcium tablets and vitamin supplements containing calcium. Milk and soy products have large amounts of calcium which can have this effect.

We advise taking thyroxine on an empty stomach half to one hour before any of these products are consumed. You should not adjust the dose according to how you feel as the effect of changing the dose is delayed. If you are forgetful, the chemist has a dispenser with the days of the week marked on it, so you can set out your weeks’ medication and take it regularly.

Parathyroid glands

The parathyroid glands are located on both sides of the neck, so an operation on one thyroid lobe usually puts only half these glands at risk. As a result, the problems described below are rarely experienced, unless you have already had one thyroid lobe removed, or we need to remove both thyroid lobes. Behind the thyroid there are four tiny glands only 5mm in length. These glands have the same blood supply as the thyroid, and even with very careful surgery, they can be injured.

If this happens then the important parathyroid hormone (PTH) may fall, leading to low levels of calcium in the blood. As calcium is an important mineral for bones, muscles and nerves, a fall in calcium can lead to a loss of bone substance or osteoporosis, although this is a long term complication. More immediately low calcium can cause numbness, cramps, and pins & needle symptoms. These are easily fixed by giving calcium either in tablet form, and to bring the level up if very low, a potent form of Vitamin D, Calcitriol. About 25% of patients have some form of fall in calcium after surgery to remove both lobes of the thyroid (total thyroidectomy). Patients who have had previous thyroid surgery or Graves’ disease are more susceptible. About 1 in 50 patients need long term calcium and Rocaltrol replacement, but are usually otherwise healthy.

There may be an increased risk of developing cataracts, so an eye check and measurement of bone strength may be needed. Vitamin D is not used in pregnancy and calcium tablets are large so not always popular with patients who have trouble with tablets. Chewable and dissolvable forms are available. Several serves of dairy food or calcium enriched food may substitute for some calcium tablets.

If we are worried about the health of one or more parathyroid glands we may implant them into the sternomastoid muscle (the large diagonal muscle on the front of the neck). Here they develop a new blood supply like a skin graft and work well after 6 weeks. If there is a temporary problem, this is usually better within 2-3 weeks but sometimes takes 6-12 months to settle. Hypoparathyroidism (lack of parathyroid function) does not usually interfere with normal daily living or work.

Wound Healing

We pay particular attention to the wound from thyroid surgery. Just like every patient is different, every scar is also different. If your neck is long and thin and the thyroid is small, then the scar is usually about 4-6 cm above the collar line. We will make the scar longer to suit the conditions we find and so that surgery can be performed safely with good vision.

Some people are prone to form a red, raised up (hypertrophic) scar. This is seen more in young people with pigmented skin. The scar usually gets better with time but may take 6 to 18 months. If a scar is particularly hypertrophic (and these can sometimes be itchy as well), we may ask a plastic surgeon to advise regarding treatment, but we usually wait 12 months before referring.

Unsatisfactory scars affect perhaps 3% of patients. Some patients have numbness in the skin above the scar. In men this can be a problem with shaving. The numbness settles after about 6 months. Some patients experience a feeling of tightness in the neck. This symptom settles in most cases over 2 weeks but may take up to 6 months to subside. There may be a feeling of difficulty swallowing during that time and sometimes pain and an irritating cough.

Patients who have a low thyroid hormone level are more prone to neck swelling and tightness and correction of the low level with thyroid hormone may help. Rarely these symptoms can be persistent, but usually not severely disabling.

Bleeding

Bleeding is an uncommon complication after thyroid surgery. Even a small amount of blood collecting around the throat (haematoma) can cause swelling and breathing problems. For this reason, we watch thyroid patients closely after their surgery to look for any signs of swelling. Occasionally patients may develop a haematoma in the wound and will need to have this evacuated in the operating room. This risk is less than 1% of all neck operations. We take particular steps during the operation and at the end to minimise the risk of bleeding.

It is important to stop aspirin, arthritis medicines and anti-platelet drugs (eg. clopidogrel) at least 7 days before surgery. Warfarin treatment needs special arrangements. New blood thinning medications (eg. Dabigatran, Rivaroxaban, Xarelto) are becoming more popular and must also be stopped prior to surgery. There are also some herbal medicines (particularly gingko biloba, fish oil) that can interfere with blood clotting.

If you are unsure, show Dr Yeung the details of any dietary supplement or natural remedies you are using. We use a variety of techniques to secure blood vessels that run to the thyroid. These include advanced heat sealing devices, surgical ties and small titanium clips. The heat sealing devices are used as much as possible as they form a secure seal on the blood vessels and do not leave any residual material. Surgical ties that are used will commonly dissolve after weeks to months. Small titanium clips are used to secure very small arteries close to the nerves and parathyroid glands without “collateral” damage to these important structures. The clips are inert, do not rust and do not set off metal detectors, and do not move or heat up in strong magnetic fields used in Magnetic Resonance Imaging (MRI).

Sometimes patients have neck X-rays after thyroid surgery and are alarmed when the report notes “surgical clips are seen in the neck” and think that instruments have been left there by mistake! These clips are used in most branches of surgery and do not produce adverse health problems.

Getting back to normal activities

Most patients recover quickly from their thyroid operation and are well enough to leave hospital on the first day after surgery. We advise taking it easy at home for about 10-14 days after thyroidectomy. Some patients who feel unable to relax, or run their own business return to work after about 5 days.

Occasionally the recovery time may be longer, for example if the voice is recovering, and we take this into consideration when providing a medical certificate. As the neck muscles may be stiff, it is important not to drive until you can turn your head comfortably to have full vision of the inside lane and when reversing. Heavy housework should be avoided for 2 weeks, and really heavy manual work and heavy lifting above shoulder height avoided for 6 weeks.

Contact sport should be avoided for 6 weeks but exercise to maintain fitness such as walking, running and cycling may be started after 7-10 days. Recommencing sexual relations is best guided by individual patient comfort levels and common sense.