Thyroidectomy: types of thyroid surgery, risks and recovery

The British Thyroid Foundation (BTF) lists several reasons for considering surgery: a large thyroid, multinodular goitre or single nodule causing breathing or swallowing difficulties; a nodule classed as indeterminate on a cytology report (for example Thy3a, Thy3f or Thy4); thyroid cancer; recurrent or uncontrolled Graves disease, especially where thyroid eye disease is present; and a recurrent thyroid cyst.

The NHS thyroid cancer page notes that surgery is the most common treatment for thyroid cancer. The BTF emphasises that your surgeon should be experienced and regularly perform thyroid operations, and encourages you to ask about the number of operations they perform each year, their own complication rates and alternatives to surgery. Thyroid function blood tests should be part of the assessment before any operation.

The BTF describes the main operations. The choice depends on the condition, whether one or both sides of the gland are affected, and, in cancer, the stage.

The BTF says you will have a pre-operative assessment with blood tests that include thyroid function and calcium levels, and perhaps thyroid peroxidase antibodies, vitamin D, parathyroid hormone and kidney function. You may also have a chest X-ray, CT scan and/or an ECG. Your vocal cords are likely to be checked before surgery, and if you have had previous thyroid surgery a further check helps the surgeon plan the operation.

Your hospital team will explain how long to expect to stay (usually one to two days) and what to take in. Informed consent requires information on all risks and benefits in a form you understand, so use the appointment to ask about voice, calcium, scarring and the likely need for tablets.

The incision is usually made through a lower crease in the neck. The BTF explains that the surgeon takes care to identify arteries, veins and nerves, paying special attention to the nerves that supply the voice box and the blood supply to the parathyroid glands, which control calcium. Some surgeons use intraoperative nerve monitoring to help track and preserve nerve function.

Because the thyroid has a rich blood supply, the arteries are carefully tied or sealed before the gland is removed. The wound is closed with stitches, clips, staples, steristrips or glue, and small drainage tubes are sometimes placed in the neck for the first 24 to 48 hours.

The BTF says your neck may be sore for a short time. You may go home on the day of surgery only after a hemithyroidectomy, isthmusectomy or removal of a thyroglossal cyst, and often the next day; after total thyroidectomy you will almost always stay at least one night. Some people stay longer because of the extent of the operation or low calcium that needs stabilising. Significant bleeding needing a return to theatre is extremely rare and usually in the first 12 hours.

Tiredness is normal, and it may take up to a month to feel your energy has returned, though recovery varies between individuals.

On the voice, the BTF says it may sound a little hoarse after surgery, usually temporarily. If the recurrent laryngeal nerve is damaged, it may sound husky, breathy or weaker, usually recovering within six months, with permanent problems in approximately one to two per cent of cases. Damage to the external branch of the superior laryngeal nerve, in about six cases in every 100, can make it harder to project the voice, and usually recovers within six months. Singers, teachers and others who use their voice professionally should discuss this fully beforehand, and speech therapy and specialist voice units can help.

The parathyroids, four pea-sized glands that control calcium, may stop working temporarily or permanently, or be unavoidably removed. The BTF says tingling in the hands, fingers or around the mouth after surgery is a sign calcium may be low and should be reported to staff. Over 40% of patients go home with calcium and/or vitamin D tablets, most do not need them long term, and function often recovers in six to eight weeks, but up to ten per cent may have permanent hypoparathyroidism after total thyroidectomy. Lymph node surgery for cancer increases these risks.

Scars usually become barely visible but can become red, tender and thickened (hypertrophic or keloid), and silicone tape, steroid tape or injections, or laser, can help. Discuss any history of difficult scars.

The BTF says you will have a follow-up appointment and blood tests of thyroid function about six to eight weeks after surgery. After a total thyroidectomy you will need levothyroxine for life, usually started immediately or very soon after the operation, with dose adjustments over following months. After a lobectomy or hemithyroidectomy, hypothyroidism affects approximately 10-15% of patients, and if the remaining gland cannot maintain normal function you will need a small amount of levothyroxine.

The NHS notes that after thyroid cancer surgery hormone tablets also help stop the cancer coming back; your specialist will explain the aim of your own dose.

NHS thyroid surgery is carried out by ear, nose and throat or endocrine surgeons, with cancer cases discussed in a multidisciplinary team. Waiting times differ between trusts.

Private thyroid surgery is available and can be quicker. Whichever route, the BTF's advice stands: choose a surgeon experienced in thyroid operations, ask about their volumes and complication rates, and make sure calcium monitoring and levothyroxine follow-up are arranged before discharge.