Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

Thyroid and Parathyroid Surgery

The thyroid gland manufactures hormones which regulate bodily functions; the parathyroid glands are small endocrine glands, lying immediately posterior to the upper and lateral parts of the thyroid gland and these produce parathyroid hormone which regulates the balance of calcium in the body.

The thyroid gland lies anteriorly in the lower part of the neck and the four parathyroid glands, around the size of a pea each, lie immediately behind the upper and lower lateral parts of the thyroid gland.

Thyroid problems tend to include:

  1. Hyperthyroidism – overproduction of thyroid hormone
  2. Hypothyroidism – underproduction of thyroid hormone
  3. Benign (non-cancerous) thyroid diseases with normal thyroid hormone production (euthyroid), such as a diffusely enlarged thyroid gland (goitre) or a multi-nodular goitre
  4. Malignancy thyroid disease

Development of a parathyroid adenoma involves a benign tumour occurring in a parathyroid gland resulting in overproduction of parathyroid hormone, pathologically increasing calcium level in the blood (hypercalcaemia).  Hypercalcaemia can be associated with the development of renal calculi, bone pain, osteoporosis, pathological fractures, constipation, pancreatitis, gastric ulceration, fatigue, and depression.  Hypocalcaemia results from underproduction of parathormone from the parathyroid glands.  This can be manifest as tetany and can occur as a complication of thyroid or parathyroid surgery.

Investigations of a thyroid gland can include ultrasound, possibly with fine needle aspiration and cytology to assess THY status – which gives an indication of risk of malignant disease – and Thyroid function tests (blood tests), radio iodine scan and possibly CT or MRI imaging.

Investigations for parathyroid disease include serum calcium levels and ultrasound to assess the location of an abnormal parathyroid gland. A specialised scan may help to localise abnormal parathyroid glands and CT and MRI imaging are also likely to be required.

Indications for Thyroid and Parathyroid Surgery

Indications for thyroid surgery include suspected or proven thyroid malignancy, enlargement producing either unacceptable cosmetic appearances, difficulties with breathing or swallowing and also failure of other forms of medical treatment to control thyroid gland activity.  Most thyroid swellings are benign and most thyroid diseases are managed medically.

Hyperparathyroidism relates to hyperfunction of the parathyroid glands, with excessive parathormone causing hypercalcaemia (abnormally high calcium levels in the blood).  Parathyroidectomy is performed to treat hyperparathyroidism when other non-operative methods have failed to control this.

Thyroidectomy

Thyroidectomy involves removal of all or part of the thyroid gland under general anaesthetic; hemi-thyroidectomy relates to removal of one thyroid lobe whilst total thyroidectomy describes removal of the entire thyroid gland.

An incision is made in the lower neck.  Careful anatomical dissection is necessary to avoid injury to the parathyroid glands and the recurrent laryngeal nerves.  These latter nerves supply motor and sensory function to the larynx; hence voice and breathing problems can be a complication of thyroid surgery.

The blood supply to the portion of the thyroid gland to be removed is ligated and then all or part of the gland is removed, preserving parathyroids as necessary or possible.  The extent of removal of thyroid gland tissues depend on the type of thyroid disease being treated.  A drain (a soft plastic tube which permits exit of fluid from the operative area) may be sited before the incision is closed.  The incision is usually closed with sutures, sometimes clips and a dressing may cover the incision and drain.

A frozen section may, occasionally, be used in theatre as a rapid type of pathological analysis to assist in planning both the extent of surgical dissection and extent of removal of thyroid tissue necessary.

Parathyroidectomy

Parathyroidectomy is performed after initial thyroid approach, as described in thyroidectomy.

A use of pre-operative test before parathyroidectomy involves infusion of methylene blue into the blood to help locate the glands at the time of surgery – the parathyroid glands concentrate this dye, to produce blue staining.

The closure of a parathyroidectomy procedure is similar to the technique described for thyroidectomy.

Complications of Thyroid Surgery

1.         Haemorrhage.  The risk of bleeding is small and in many cases is minimal.  However, in some cases a return to the operating theatre may be necessary to stop bleeding and – quite rarely – a blood transfusion may be required.

2.         Infection. A small risk of infection is associated with any surgical procedure.

3.         Damage to the recurrent laryngeal nerve.  These nerves lie very close to the thyroid gland and supply the vocal cords, as part of their motor, and sensory supply to the larynx.  Any degree of bruising, stretching or direct trauma to the recurrent laryngeal nerve can produce weakness of a vocal cord, resulting in a weak voice and, occasionally, breathing problems or even stridor.  Certainly, in the case of bilateral recurrent laryngeal nerve trauma, there is a significant risk of major breathing difficulties and this can necessitate a tracheostomy.  This is a surgical procedure to create an artificial opening through the neck into the trachea to bypass the obstruction of closed, immobile, vocal cords and is a very rare complication of thyroid surgery.

4.         Scar.  The incision of the approach is typically placed in a skin crease and unusually heals extremely well with a very good cosmetic result and minimal scarring.  Rarely, a thick scar or keloid, can develop and is likely to have some degree of numbness, or altered sensation, in the skin of the neck.

5.         Thyroid hormone (Thyroxine) replacement therapy.  Following thyroid surgery it may be necessary to take life-long thyroid medication to replace thyroid hormones if there is deficiency.  This can depend on the pathology being treated and the extent of surgery, and is managed by serum thyroid function tests.

6.         Calcium replacement therapy.  Approximately 1% of patients may develop hypocalcaemia, low levels of serum calcium, after complete removal of both thyroid lobes.  Calcium levels are regulated by parathormone produced from the thyroid glands and these can be removed, or devascularised, during thyroid surgery.  Calcium levels are monitored post-operatively and in the event of early hypocalcaemia intravenous correction may be required.

7.         Further thyroid surgery.  Depending on the results of the histology from a primary procedure there is occasionally the need to return to the thyroid gland for further surgery.  In the case of removal of one lobe of the thyroid, should the histological analysis indicate malignancy, there is often need to reoperate remove the remainder of the thyroid gland.

Complications of Parathyroidectomy

Complications 1 – 6, as described in thyroid surgery, apply to this procedure.

Furthermore, the following supplementary comments apply to points 5 and 6:

5.         Whilst this can also be mandatory following thyroid surgery (in the event of inadvertent loss of function of the parathyroid glands) in the case of complete parathyroidectomy there will be need for medication to control calcium levels in the blood.  As mentioned for thyroid surgery, close monitoring of serum calcium levels is necessary and occasionally early post-operative intravenous correction may be required.  Depending on the results of surgery calcium supplementation, or replacement therapy, may be needed life-long in the case of complete removal of all parathyroid glands.  Precise calcium levels will depend on the extent of functioning parathyroid gland tissue which remains following surgery.

6.         Further surgery.  Should elevated calcium levels in the blood fail to drop after surgery a further procedure may be required to locate and remove any remaining parathyroid gland tissue which may either have been spared, or which defied identification, at the original surgery.

Following thyroid surgery:

The drain is typically removed after around 24 hours and it is common to have a degree of discomfort, aggravated by swallowing, which should normally resolve over 2 – 3 days.  Discharge home normally occurs 2 – 3 days after surgery, with suture removal around 7 days after surgery.  The level of serum calcium will be monitored and, as described above, replacement therapy may be required.  Symptoms of low blood calcium can include numbness and tingling of the lips, arms or feet, twitching of facial muscles and spasms or severe cramps in long-limbed muscles.  Similarly, Thyroxine levels will be monitored and replacement therapy may be required, as also described above.

Further follow up is likely to be required and this, and the precise management, would depend on the indication of the surgery, the final histological result of the tissue removed, and the progress of the case post-operatively.

In the case of thyroid cancer, treatment with radio-active Iodine may be used to destroy any residual potentially malignant cells.

Two weeks off work or school should be expected and tanning should be discouraged for 6 months after surgery.

Following parathyroid surgery:

The above expectations following thyroid surgery apply.  In addition, longer term follow up with an Endocrinologist is likely to be necessary for monitoring and management of blood calcium levels.  As described above, symptoms of low blood calcium can include numbness and tingling of the lips, arms or feet, twitching of facial muscles and spasms or severe cramps in long-limbed muscles.  Furthermore, clinical examination can indicate signs such as Chvostek’s sign (low threshold of facial twitching on tapping over the trunk of the facial nerve) or Trousseau’s sign (spasm and twitching of forearm muscle with compression).