Thyroid & General Surgery

Thyroid and General Surgery

The thyroid is a gland located in the front of the neck. It is about 5 cm-long, shaped like a butterfly or the map of Australia. It is made up of two halves or lobes that sit on each side of the windpipe cupping Adam’s apple. Behind the thyroid are 4 small glands called the parathyroid.

The thyroid is one of the glands that make up the endocrine system. The thyroid makes and releases hormones responsible for controlling your metabolism—the way the body uses energy—and affects nearly every organ in the body.

The thyroid gland makes two hormones, triiodothyronine (T3) and thyroxin (T4). These hormones are made from iodine absorbed from our diet. The parathyroid glands secrete parathyroid hormone (PTH) which is part of the system that are responsible for controlling calcium in our body.

Thyroid hormones affect metabolism, brain development, breathing, heart and nervous system functions, body temperature, muscle strength, skin dryness, menstrual cycles, weight, and cholesterol levels. 

Thyroid hormone production and release is regulated by thyroid-stimulating hormone (TSH), which is made by the pituitary gland.

Located in the brain, the pituitary gland is the “master gland” of the endocrine system.

Thyroid disease is very common and highly treatable.

Thyroid disease can be grouped under 4 broad headings, although these almost always overlap.

1. Functional – abnormal production of thyroid hormones.

Generally treated with medications and sometimes with surgery.

 2. Goitre/nodules – thyroid enlargement.

Monitored for changes over time or treated by surgery.

3. Malignant – cancer of the thyroid.

Treated with surgery.

 4. Inflammatory/infective

Treated with medications, occasionally with surgery.

Tests routinely used to investigate the thyroid gland include:

Thyroid gland removal can be recommended for various reasons.

A person is most likely to undergo thyroid removal surgery if:

• The thyroid is overactive (hyperthyroidism) and medications have not managed to control it, or are causing undesired side effects. E.g. Graves’ disease 
• Fine needle biopsy (FNA) of thyroid nodule confirms the presence of a thyroid cancer
• If the FNA of a suspicious nodule is suggestive but not diagnostic of thyroid cancer or has concerning features. Thyroid nodules are usually benign (80% benign, 20 % malignant).
• Whole gland or nodule is enlarged, pushing on adjacent structures and causing bothersome or dangerous symptoms, such as difficulty breathing, changes to the voice, trouble swallowing. E.g. multinodular goitre or dominant nodule in multinodular goitre
• Growth of the thyroid into the chest cavity below
• Presence of a thyroglossal duct cyst – a congenital abnormality
• Cosmetic – i.e. nodule or goitre causing visible disfigurement of the neck

There are various types of thyroid operations including:

• Total thyroidectomy – removal of the whole thyroid
• Hemithyroidectomy – removal of half the thyroid
• Excision of thyroid nodule – removal of a lump from the thyroid – not done very often these days
• Isthmectomy – removal of the bridge of thyroid tissue linking the two thyroid lobes
• Central and or lateral neck dissection – this is when the lymph nodes in the neck are removed as part of thyroid cancer surgery.
• Excision of thyroglossal duct cyst.

 After total thyroidectomy, you can lead a perfectly normal life, however, you’ll need to take thyroxine tablets every day, for the rest of your life. If less than a total thyroidectomy is performed, you will generally not need to take thyroxine although around 15% of people still require some thyroxine supplementation after just a hemithyroidectomy.

Thyroid surgery is performed under a general anaesthetic and usually lasts about 1.5 -3 hours (depending on the size of the gland). An incision is made in the front of the neck, about 2 finger breaths above the collarbone. The overlying muscles are pushed aside or divided to expose the thyroid gland.

Half or the whole gland is removed. Great care is taken not to injure the nerves which control the vocal cords (laryngeal nerves) and every attempt is made to preserve the parathyroid glands which control the body’s calcium levels.

Blood tests to check the calcium levels and parathyroid hormone (PTH) are done a few hours after surgery to determine if you will need to take calcium supplements.

Sometimes the parathyroid glands may need to be transplanted into a nearby muscle to preserve their function. The muscles are then put together and the skin is closed with absorbable sutures.

A soft drain is usually inserted into the neck to drain away any excess fluid or blood that gathers in the space where the thyroid once was. It is usually removed the day after surgery.

Most patients stay in hospital overnight and are discharged the next day.

Most people stay overnight in hospital can return home the day after thyroid removal surgery, limiting strenuous physical activities or sports for two weeks, after surgery.

 Most patients report a discomfort on the neck rather than pain. Sometimes a sore throat for a few days. Over-the-counter pain relievers, such as paracetamol or ibuprofen are often all that is needed to reduce the pain.

After surgery, the doctor may need to monitor your thyroid hormone and calcium levels to check for hypothyroidism or hypoparathyroidism.

You should notify your doctor if you experience hoarseness in your voice or difficulty breathing.

Also alert your doctor if there is sudden swelling in your neck after you have gone home as this may be a sign of a delayed haemorrhage

Most surgery nowadays is safe however any operation has general risks including reactions to the anaesthetic, chest infections, blood clots, heart and circulation problems, and wound infection.

There are specific risks associated with thyroid surgery as follows:

• Post-operative bleeding may cause swelling in the throat and difficulty breathing due to pressure on the windpipe. It is usually fixed by a further operation to remove the blood clot.
• Injury to the laryngeal nerves may cause hoarseness of the voice. This is usually temporary but may be permanent in up to 1 to 2% of cases. If temporary, it may improve with speech therapy or further surgery to the vocal cords. If you are a singer or public speaker, any surgery to the thyroid may cause subtle long-term changes to your performing voice.
• If a total thyroidectomy is performed, injury to the parathyroid glands may cause the calcium level in the blood to drop. It is treated with calcium and vitamin D tablets and usually comes good in a few weeks, although up to 1 to 2% of cases will need lifelong calcium supplements.
• A keloid, or overgrowth of scar tissue, may form in any surgical scar. It will result in a tender, pink raised scar but may able to be treated with silicone gel tape or steroid injections.