Preoperative Information
The thyroid gland may be removed for a variety of reasons, including thyroid cancer, thyroid nodules that are suspicious for cancer, compressive symptoms due to an enlarged thyroid gland, and hyperthyroidism that is difficult to control with medication. We typically remove either half of the thyroid gland (hemithyroidectomy) or the entire thyroid gland (total thyroidectomy). It is generally not possible to remove individual nodules because they are inside the thyroid gland. In cases of confirmed thyroid cancer, we may also remove lymph nodes surrounding the thyroid gland. This will provide your endocrinologist with more staging information (i.e., if the cancer has spread from the thyroid gland to lymph nodes around the gland) and may help prevent local recurrence of the disease.
In the hands of an experienced endocrine surgeon, thyroid surgery is not a dangerous operation, and complications are quite rare. However, as with any surgical procedure, there are risks that every patient should be aware of.
Bleeding
Except in very rare cases, there will be minimal blood loss during your thyroid operation. This generally amounts to less than 10 milliliters (1/3 ounce) of blood. Nevertheless, you will be asked to sign a consent giving permission for a blood transfusion in the event of an emergency. We recommend that you sign this consent, unless you have strong religious objections to blood transfusion (e.g., Jehovah’s Witnesses).
Infection
Infection of the neck wound after thyroid surgery is also an extremely rare event. The neck has a remarkable ability to heal after surgery. Unless you are immunosuppressed, antibiotics may not be necessary during or after your operation. In most cases, they are simply not necessary and carry risks that are generally greater than the risk of infection.
Hypocalcemia
Hypocalcemia, or low calcium levels, after total thyroidectomy is a fairly common, but almost always temporary, condition. This occurs because the parathyroid glands often do not function normally immediately after thyroid surgery. The parathyroid glands are four small glands near the thyroid gland (para = near). They produce a hormone called parathyroid hormone (PTH) that controls calcium levels in the blood stream. The parathyroid glands share small blood vessels with the thyroid gland. And, during the process of removing the thyroid gland, many of these small blood vessels must be tied off. The end result is often a drop in the level of PTH for several weeks after surgery, leading to a temporary drop in the calcium level. Furthermore, the parathyroid glands can be difficult to see, and one or more of them may be inadvertently removed with the thyroid gland. The good news is that our bodies have evolved to have a certain amount of redundancy. Being born with four parathyroid glands, it is extremely rare to lose all them during thyroid surgery. And, all we need to maintain a normal calcium level is one good parathyroid gland. Your surgeon will try to identify and preserve as many of the parathyroid glands as possible. If a parathyroid gland is found on the surface of the thyroid gland as it’s being removed, the surgeon will re-implant it in the neck muscles, where it will eventually recruit new blood vessels and begin to function again.
In order to prevent symptoms of hypocalcemia in the postoperative period, we will give you instructions to take a calcium supplement for two weeks after surgery. The easiest way to do this is by taking Tums. We recommend that you chew 2 tablets of Tums Ultra 1000 twice each day for two weeks (i.e., 2 tablets in the morning and 2 tablets in the evening for 14 days). In certain cases, your surgeon may also add a special form of vitamin D to this regimen.
Nerve Injury
The complication that often worries patients the most is the possibility of changes to the voice, or hoarseness, after surgery. The problem stems not from damage to the vocal cords themselves but from damage to the nerves that control the vocal cords. These nerves are called the recurrent laryngeal nerves, and there is one on either side of the trachea — one for the left vocal cord and one for the right. During thyroidectomy, the surgeon must identify these nerves and leave them intact. The incidence of nerve injury quoted in the medical literature is usually ~1%. That means that one patient out of 100 may experience a nerve injury with some resultant hoarseness. But, it is thought that this number is generally even lower when the operation is performed by an experienced endocrine surgeon. We do everything possible to avoid these types of injuries. But, it is important to keep in mind that nerve injuries can still occasionally happen in even the most experienced hands.
In the unlikely event of injury to one of the recurrent laryngeal nerves, patients may be referred to a vocal cord specialist, who can diagnose the problem and offer treatment options. With appropriate treatment, we can almost always get the voice back to normal.
You may also read about the possibility of injury to both recurrent laryngeal nerves. This type of injury is an exceedingly rare event. It can lead to more severe hoarseness and shortness of breath. Patients with bilateral nerve injuries often require a temporary tracheostomy to protect the airway until treatment can be initiated.
Preoperative Evaluation
Prior to surgery, you will need some type of evaluation to be sure that it is safe for you to undergo general anesthesia. This evaluation may be performed by your primary care physician or by a dedicated preoperative anesthesia clinic at the hospital. At the University of Miami, many of our patients are seen in the UHealth Preoperative Assessment Center (UPAC) prior to their surgery.