A thyroidectomy is the removal of all or part of your thyroid gland.

The thyroid gland is a butterfly-shaped gland in the front of the neck. It consists of two lobes and a connecting part called the isthmus. The thyroid gland produces hormones that regulate the body’s metabolic rate, thus controlling heart, muscle, digestive function, brain development, and bone maintenance.

There are three main reasons why it would be necessary to operate on the thyroid gland. These are:

  • Gross enlargement, leading to difficulties in swallowing, difficulty breathing or pain if there is bleeding into a cyst within the thyroid. Sometimes the decision to operate can be solely due to a poor cosmetic appearance because of the enlarged gland.
  • A hyperfunctioning gland (abnormally increased function) that cannot be controlled by medication or radioactive iodine.
  • Suspicion of cancer or established cancer of the thyroid gland.

There are some other, very rare, indications for surgery.

For the more common indications, removal of one lobe of the thyroid gland with the isthmus or removal of the entire thyroid gland is usually recommended. In some cancer operations, lymph nodes in the neck may also be removed. In a thyroidectomy, an incision is placed in the front of the neck and the neck muscles are either retracted or divided. The thyroid lobe, or the entire thyroid, is then removed. After the operation, in most cases, a drain is generally placed in the neck that is removed soon after the operation.

The short-term consequence of having one’s thyroid removed is that for approximately three weeks, it is recommended that patients avoid strenuous activity to allow the wounds to heal. Initially, should patients find swallowing difficult immediately after the operation, soft foods such as yoghurt, mashed potatoes, apple sauce, etc. are recommended. Long-term – the reality of having one’s thyroid removed is that your body can no longer make the thyroid hormone. Consequently, without medication, patients will develop symptoms associated with an underactive thyroid (hypothyroidism). These symptoms can include dry skin, weight gain and fatigue. Only 1 out of every 8 patients undergoing a lobectomy (where only a single thyroid lobe is removed) will require thyroid hormone replacement.

It is important to note that thyroid surgery can have complications. Next to the general complications of postoperative bleeding and infection (which are rare), there are others that, whilst rarely life-threatening, can be especially bothersome.

This is due to the special anatomy of the thyroid gland and its location in the neck. It is in close proximity to important nerves and blood vessels as well as the parathyroids (two pairs of small, oval-shaped glands located next to the two thyroid gland lobes in the neck), which are important in calcium metabolism.

Two nerves on each side can be injured in thyroid operations – the recurrent laryngeal nerve (branch of the Vagus nerve that supplies motor function and sensation to the larynx) and the external branch of the superior laryngeal nerve (involved in the pitch of one’s speech and protecting your airway from food and drink when you swallow).

The recurrent laryngeal nerve runs in very close proximity to the back of the thyroid gland and supplies the vocal cords. It is a small nerve, about one millimetre in diameter, has a variable anatomy and needs to be handled delicately as it is easily injured. Injury to the nerve manifests itself by hoarseness due to the vocal cord on the injured side becoming paralysed. This can be improved by speech therapy or by specialised treatments such as silicone injections into the affected cord.

If both recurrent laryngeal nerves are injured, the paralysed vocal cords are then positioned very close together and the airway is obstructed. An emergency tracheotomy (cutting a hole into the trachea under the larynx so that the patient can breathe) then needs to be performed.

The superior laryngeal nerve lies in proximity to the upper part of the thyroid lobe on each side. It is seen only in about 25% of the cases in the operative field (otherwise not usually visible).  Similar to the recurrent laryngeal nerve, it is very small and can easily be injured but an injury is less likely. An injury can also be bothersome as the tension of the vocal cord on the affected side is lost. The voice becomes tired easily, a problem for singers or in professions that depend on a lot of talking.

Nerve injuries are significantly lower in the hands of experienced thyroid surgeons and also reduced with the use of intra-operative nerve monitoring.

A further complication of a total thyroidectomy or repeat surgery on the thyroid gland is injury to the parathyroid glands. These are four small glands that are located in close proximity to the posterior thyroid capsule (the thyroid gland is covered by a thin fibrous capsule, which has an inner and an outer layer) as well as the recurrent laryngeal nerve. They share the blood supply with the thyroid gland. Due to their small size (3 x 5 mm diameter, 50 mg weight) and their camouflage (only a trained eye can distinguish between the thyroid tissue and the lymph nodes in the area) they are easily injured during a thyroidectomy either directly or by injury to their blood supply.

If parathyroid glands are injured, calcium levels can drop to critical levels and patients develop severe cramps that are relieved with calcium supplementation.

Surgeons who have a special interest in thyroid and parathyroid health, and consequently do higher volumes of such surgery, have a much lower rate of complications[1].

Endoscopic (keyhole) surgical approaches have been described for thyroid surgery, but currently, these are not favoured as only a few patients qualify. Access from the oral cavity or the armpit is also cumbersome with much more extensive dissection and consequent scarring along the access routes. In addition, operation times are much longer and complications more frequent. Therefore, these techniques are currently experimental.

Traditional thyroidectomies and parathyroidectomies can leave a very visible scar in the middle of the neck. But advancements in endocrine surgery (surgery focused on the endocrine glands including the thyroid) are allowing surgeons to provide a much-improved aesthetic outcome.

In summary, surgery for thyroid disease is an essential part of thyroid health. However, the results, as proven in many aspects of health care, are much better in the hands of specialised, high-volume centres with experienced surgeons.

Liang TJ, Liu SI, Mok KT, Shi HY. Associations of Volume and Thyroidectomy Outcomes: A Nationwide Study with Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg. 2016;155(1):65‐75. doi:10.1177/0194599816634627