Thyroidectomy: A detailed guide on what to expect

Preparing to undergo surgery to remove some or all of the thyroid gland can be daunting but with expert care and modern techniques, patients can look forward to a smooth and speedy recovery following a thyroidectomy. In this informative and detailed guide to the procedure, renowned consultant ENT surgeon Professor Neil Tolley expertly explains when a thyroidectomy may be required and the implications of surgery. He also offers reassurance on what to expect and how he ensures swift recovery for his patients following treatment.

What is a thyroidectomy?

Thyroidectomy is the surgical removal of part (usually one half) or all of the thyroid gland. The thyroid is a very important gland found at the base of the neck which regulates our metabolic rates. If it is underactive, the body processes tend to slow down and if it is overactive, they tend to speed up. For good health, it’s very important to have normal thyroid function.

When is a thyroidectomy necessary?

A thyroidectomy is typically performed for one of three main reasons: a multinodular goitre, an overactive thyroid and thyroid cancer.

Multinodular goitre

A thyroidectomy may be required if the thyroid develops benign (non-cancerous) growths or nodules which cause the thyroid to enlarge and form what is sometimes called a goitre (another term for a big thyroid). The development of these nodules is the most common cause of a large thyroid and this is known as a multinodular goitre.

A multinodular goitre can produce symptoms in terms of a lump or swelling in the neck and this can cause patients a lot of cosmetic concerns about how the area appears. Additionally, if the thyroid is very large, it can also lead to swallowing problems, compressive symptoms and a feeling of tightness around the windpipe and therefore requires removal. In some patients, the thyroid can slip down into the chest which can also lead to quite significant problems with breathing. Multinodular goitres can often affect elderly patients who may also present with heart problems such as atrial fibrillation.

Overactive thyroid

If the thyroid is overactive, the gland may also need to be removed. This is referred to as thyrotoxicosis or hyperthyroidism and has three principal causes. One such cause is an autonomous nodule, where one solitary nodule produces too much thyroid hormone and surgery is often the best way of treating this as opposed to an alternative form of therapy.

There can also be overactivity in the gland in general which is associated with lots of nodules within the thyroid. This is referred to as Plummer's disease.

Finally, Graves' disease can also cause overactivity in the thyroid. Patients suffering from this autoimmune condition can experience a global increase in thyroid hormone production when the white cells of the body stimulate the thyroid glands which results in excessive hormone production and overactivity in the gland. Surgery is just one way of treating thyrotoxicosis due to Graves' disease.

The final reason for removing the thyroid gland is the presence of cancer, which usually causes a painless lump in the area. Patients can also present with lymph node metastasis (cancer which has spread from elsewhere) as the most form of thyroid cancer is papillary thyroid cancer, which has a tendency to spread to the lymph nodes. These forms of cancer are more common in women than men and have a very good prognosis.

By and large, treatment for thyroid cancer is always surgical and in some cases, a removal of just part or half of the thyroid may be required. In other cases, however, removing the entire gland as well as the lymph nodes that drain it may be necessary but this is determined according to the patient’s individual prognosis.

Are there any non-surgical alternatives to a thyroidectomy?

Not everyone with thyroid condition requires surgery, but it is the primary choice in treating patients with thyroid cancer. In terms of thyrotoxic goitres or the overactive thyroid, there are alternative medical treatments and many of the associated conditions, such as Graves’ disease, may burn themselves out over time.

If the goitre is small, treatment with radioactive iodine may offer an alternative to surgery. There are advantages and disadvantage to both surgery and alternative approaches to treatment and usually the decision comes down to patient preference and social circumstances. Due to the side effects of treatment with radioactive iodine, a period of isolation is required and as patients with Graves’ disease are very often young women, some of whom have families, this can be very inconvenient. However, there are also advantages to radioactive iodine treatment as well as disadvantages much like surgery so a shared decision process between the patient and consultant is the best approach to choosing how to go forward.

Is a thyroidectomy risky?

All surgical procedures have a small risk of complications. With thyroid surgery, there's a small risk of bleeding and around one per cent of patients will have to return to theatre because of bleeding. Infection rates average at less than two per cent following thyroid surgery, which is lower than in procedures on other areas of the body because the neck has very good blood supply.

Complications which are specific to a thyroidectomy depend on how much of the thyroid is being removed. If just half is being removed, this is known as hemithyroidectomy. Following a hemithyroidectomy, eighty per cent of patients won't have any problems with thyroid hormone replacement, but twenty per cent may become low in terms of hormone levels. We assess this by checking how the thyroid is functioning six weeks after surgery. We have two parathyroid levels on each side which are very important in controlling and regulating blood calcium. If only half of the thyroid is removed, the patient will not have any problems with calcium control following the surgery. This is also the case after one-sided surgery and also only one of the nerves of the voice box is involved which minimises any risk of damage.

A total thyroidectomy brings the calcium glands into the equation and around twenty per cent of patients may temporarily require vitamin D and calcium support to keep their calcium in the normal range and only five per cent may need this more permanently. In rare cases, damage to one of the nerves to the voice box may or may not affect the voice. Around a third of patients that have a problem with the nerve to the larynx after thyroid surgery do not have any voice symptoms at all, but some do, and that may require further treatment. In the long term, however, most of these injuries, caused by traction or stretching of the nerve during surgery, resolve themselves.

How long does it take to recover from a thyroidectomy?

Generally speaking, thyroidectomy is not a painful operation and in my practice, I don’t prescribe strong pain killers for my patients following the surgery. In most cases, patients can take normal paracetamol for twenty four to forty hours after surgery to manage any discomfort

To aid recovery, I use dissolvable sutures and glue the skin so the patient can shower without fear of getting the area wet. This means there is also no need for any dressings or for the patient to clean or care for the incision which makes recovery at home smoother and more convenient.

I also don’t use a drain, which is a plastic tube put underneath the skin as this leads to more scarring. It's also very uncomfortable for the patients and there is very good evidence that drains aren’t of any benefit. Nonetheless, many thyroid surgeons continue to use drains and it is a question of surgeon preference.

In terms of return to work, I would say most patients undergoing a hemithyroidectomy need one week to recover and can then also return to the gym or to physical activities. After a total thyroidectomy, patients may take a little bit longer to recover, depending on their calcium levels but certainly all patients will be back to normal activities after a two week period.

If you are seeking treatment for a thyroid related disorder, don’t hesitate to visit Professor Tolley’s Top Doctors profile where you can learn more about him and book a consultation.