Surgery on the thyroid & Parathyroid Gland
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

1. Which diseases of the thyroid may require surgery?

There are a variety of diseases affecting the thyroid gland, including hypo- or hyperfunction, development of nodules, tumours etc. While some of them may be treated medically, others require partial or total removal of the thyroid or parathyroid gland.

.   Multinodular goitre. Surgery is recommended because of the presence of an enlargement of the thyroid gland which may cause pressure symptoms or cosmetic embarrassment. The aim of the operation [subtotal thyroidectomy] is to reduce the size of the thyroid gland by removing a sizable part of it [80-90%, leaving 2-3gr of tissue]. The small thyroid remnant reduces the risk of long-term hormone replacement treatment. Further to this, the risk of damage to the tissues surrounding the thyroid [although small] is reduced.

.  Solitary cold thyroid nodules [lump]. As the risk  of this lump being a tumour is considerable [20%], it is safer to remove the total lobe of the gland [total thyroid lobectomy]. If a biopsy was performed and is certainly a cancer, then the surgeon may have to proceed to removal of both thyroid lobs [total thyroidectomy].

.   Hyperthyroidism [overactive thyroid]. The gland is producing too much hormone and this causes a variety of symptoms [palpitations, sweating, intolerance to heat, irritability, weight loss, fatigue, tremor]. Although medications may often be able to control the over-functioning gland, if they have failed or are causing side-effects, surgery is the best option. The aim is to reduce the size of the gland by removing a large size of it [subtotal thyroidectomy] so that the thyroid remnant will produce only the amount of hormone necessary for your well being. 

.   Hyperparathyroidism. On the sides of the thyroid there are 4 small glands producing hormones controlling the metabolism of calcium. They are called parathyroids. When they are overactive, the level of blood calcium becomes higher than normal. This high calcium level may cause many potential problems and symptoms [stones, bones, moans and abdominal groans], such as kidney stones, kidney impairment, bone pains, abdominal pain, excessive thirst, frequency in passing water, constipation, psychiatric symptoms, fatigue and weakness. In order to prevent future damage from the high calcium levels removal of the responsible gland is essential [parathyroidectomy]. Most commonly only one of the parathyroid glands is enlarged, but occasionally all 4 may be hyperplastic. The cause of enlargement is almost always benign.

Surgery is extremely successful in almost all cases.

·     Subtotal thyroidectomy for multinodular goitre is successful in 99-100% of cases; for overactive thyroid in 95% of cases.

·     The results of total thyroidectomy depend on the type of tumour removed. However, even if it was a cancer, 20 year survival is 40-90%. The papillary carcinoma [the most common, 80%] has the best prognosis.

·     The results of parathyroidectomy are also excellent, especially when only one of the 4 glands is enlarged. The overall risk of serious complications [nerve injury and hypoparathyroidism] is 1-2%.

You will be taken into the anaesthetic room and from there to theatres. You will be put to sleep as the operation is always done under general anaesthetic.

The thyroid gland is situated into the lower half of the front of the neck. It has a shape like a butterfly with two lobes [the wings] on either side of the trachea [the windpipe] and a small portion that connects them [isthmus] in front of the trachea. Closely attached to the thyroid are the parathyroid glands, two on each side, and the recurrent laryngeal nerves which pass up from the chest to enter the voice box [larynx] and innervate the muscles that control the vocal cords [voice production].

An incision is made at lower neck [transverse, along the crease lines], 2cm above the notch. The length depends on the size of the thyroid, the site of the lump and your built.

4. After the operation

.  You will be allowed to eat and drink what you want

.  The drain will be removed within 24 hours.

.  Blood tests to check your thyroid hormone levels and the blood calcium will be performed on the second day. If surgery was performed for hyperparathyroidism, the calcium levels usually return to normal within 48 hours.

.  Quite often [especially after subtotal or total thyroidectomy] you will be advised to start thyroid hormone tablets. This is because either the remaining thyroid tissue will be unable to produce the necessary hormone or because we wish to suppress the remaining thyroid tissue to reduce the risk of thyroid growing again. If you are put on thyroxine, this may be for life.

.  You will usually go home the second day after surgery

.  The surgeon will see you again in his outpatient clinic in 6 weeks from surgery.

5. Problems that may follow thyroid surgery.

.   It is common to get a sore throat [due to the breathing tube], but this usually settles in a few days.

.    Bruising in the skin may occur, but it will settle in a couple of days.

.    Bleeding is rare, and only rarely it will be necessary to reopen the wound to control the bleeding.

.   Infection of the wound is extremely uncommon. If it happens, antibiotics are usually successful.

.  Damage to the laryngeal nerves may occur, and in most instances it causes only temporary symptoms, i.e. a weak, hoarse and croacky voice. However, in 1% of cases the voice weakness is permanent, which may important in some professions [e.g. singers, speakers]

.   Hypoparathyroidism [low calcium levels].  The parathyroid glands may cease to function due to handling or reduced blood supply after surgery. This is usually temporary. Permanent loss of the parathyroid function is rare [1%] and in this circumstance calcium and vitamin D will be needed to bring the blood calcium levels back to normal.

.  Hypothyroidism [underactive thyroid]. Hypo-active thyroid may be a result of total thyroidectomy [for cancer] where no thyroid tissue is left behind, or subtotal thyroidectomy, where the tissue left is either not enough or is not functioning well. In these cases supplementary thyroxine hormone will be needed [100mcg/day]. As years pass by, the number of patients becoming underactive rises [25%] and this is usually identified by symptoms and blood tests. Treatment is simple with thyroxine tablets.

.   Overactive thyroid. If surgery was performed for overactive thyroid, it may fail in 3-4%, and the gland will continue to produce excessive hormone. In this case, the treatment of choice is radioactive iodine treatment.

.   Failure of the operation to cure the high calcium levels [if surgery was undertaken for hyperparathyroidism]. This is because the overactive gland is in an inaccessible or abnormal position. If this happens, then sophisticated tests will be needed to find out where the glands are located and further surgery may be required. Fortunately, this problem is uncommon.

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.