Revised 2024

Your guide to thyroid surgery

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Content overview

Why do I need surgery?

What can I expect before the operation?

What happens during the operation?

What can I expect after surgery?

Can the operation affect my voice?

Can the operation affect my parathyroids?

What will my scar look like?

What follow-up care will I have after the surgery?

Some important points

Why do I need surgery?

Surgery should be considered as treatment for several disorders of the thyroid gland. These may include one of the following:

• Large thyroid or multinodular goitre or single nodule (a goitre is an enlarged thyroid gland) which is causing breathing obstructions or swallowing difficulties
• Solitary nodule or nodule within a multinodular goitre that is classified as 'indeterminate' on a cytology report (e.g. Thy3a, Thy3f or Thy4)
• Thyroid cancer
• Recurrent or uncontrolled Graves’ disease (hyperthyroidism) especially where it affects people with thyroid eye disease
• Recurrent thyroid cyst

It is important that your surgeon who gives you advice and who performs your surgery is experienced and regularly performs thyroid operations. Do not hesitate to ask the surgeon any questions that are on your mind, such as the number of thyroid operations they perform each year, about any possible complications (including their own complication rates), as well as any alternatives to surgery that might be available to you. It is very important that you are involved in the decisions about your treatment. In order to give your informed consent before surgery you must be given information about all of the risks and benefits of the treatment in a format that you understand. 

If you are being considered for surgery you should also have thyroid function blood tests as part of the assessment before surgery.  

What can I expect before the operation?

Once you decide to have surgery you will have a pre-operative assessment. You will be given blood tests which will include checking your thyroid function, calcium levels and maybe thyroid peroxidase antibodies (TPO) antibody status, vitamin D level, parathyroid hormone level and kidney function. You may also have a chest x-ray, CT scan and/or an electrocardiogram (ECG). Your vocal cords are likely to be checked prior to surgery. 

If you have had a previous thyroid surgery, you should have a further vocal cord check which will help your surgeon make the decision as to the specific surgery you now require. 

Your hospital team will explain how long you can expect to stay in hospital (usually one to two days) and what to take into hospital with you.

What happens during the operation?

The operation is performed under a general anaesthetic. Thyroid operations are usually straightforward when performed by an experienced surgeon. The main types of thyroid surgery are:

• total thyroidectomy (removing all of the thyroid gland)
• lobectomy or hemithyroidectomy (removing half of the thyroid gland)
• near-total thyroidectomy (removing most of the thyroid gland but leaving a little tissue on one side)
• occasionally, isthmusectomy (removal of the central part of the thyroid gland) 
• removal of thyroglossal tract cyst
• in some cases lymph nodes near the thyroid are also removed, either centrally or centrally and laterally (a neck dissection)

The incision is usually made through a lower crease in your neck. Many structures pass through the neck and during the operation the surgeon will take care to identify the various arteries, veins and nerves. Special attention is paid to the nerves that supply your voice box, as well as the blood supply to the parathyroid glands which control your calcium metabolism. Some surgeons will use intraoperative nerve monitoring (either intermittent or continuous) to help them track the local nerve/s and preserve the function of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve.   

The thyroid gland has a very rich blood supply, and to avoid bleeding, the arteries are carefully tied or sealed off before removing the gland. After the part of the thyroid that needs to be removed has been taken out, the wound is closed together with the skin. This can be done with stitches (sutures), clips, staples, strips of sticky tape (steristrips) or glue. Some stitches need to be removed, others are absorable (soluble) and do not need to be removed. Each surgeon will have their own preferences. Small drainage tubes are sometimes placed in the neck to drain away any extra fluid for the first 24-48 hours.

What can I expect after surgery?

After surgery you may feel a little uncomfortable and your neck can be quite sore, but this should not last for long. If there are no complications you may be ready to go home on the day of surgery (usually only if you have had a hemithyroidectomy / isthmusectomy / removal of thyroglossal tract cyst). However, in many thyroid surgery cases it will be the next day. Someone who has had a total thyroidectomy is almost always requested to stay in hospital at least one night.  Some people will have to stay in extra days due to the extent of the operation or because their calcium levels are low and need to be stabilised.

If there is significant bleeding within the wound you will need to be taken back to the operating theatre, but this is extremely rare and usually happens within the first 12 hours.

It is normal to feel tired following surgery and it may take up to a month before you feel you have your energy levels back. However, the recovery process varies between individuals and how you are affected will depend in part on the operation you have had.   

Can the operation affect my voice?

Your voice may sound a little hoarse after surgery, but this is usually temporary. If the main nerve to the voice box (the recurrent laryngeal nerve) is damaged then your voice may sound husky or breathy, and may be slightly weaker than before. Usually this recovers within six months. When the damage is just on one side, the other vocal cord often compensates and the voice is often normal or near normal. Permanent problems arise in approximately one to two per cent of cases. If you have on-going problems with your voice there are operations available to help. You should ask to be referred to a speech therapy unit and you may need to see a surgeon who specialises in laryngeal surgery. A small operation can be performed to help correct the problem with the vocal cords.

If you have voice problems after the operation you should be offered a post operative vocal cord assessment to try and work out the reason.   

Professional singers, public speakers, teachers and others who deal with young children may notice that it is harder to project their voice after surgery, and sometimes the voice may appear to ’wobble’. This is because another nerve (the external branch of the superior laryngeal nerve) that supplies one small muscle in the voice box has been affected by the surgery. This is also uncommon but happens in about six cases in every 100, but usually recovers within six months of surgery or your other vocal muscles compensate for that small muscle that does not work very well. If there is temporary or permanent damage to the nerve then speech therapy and a referral to a specialist voice unit can help.

If you use your voice professionally it is important that you discuss this fully with your surgeon before the surgery.

Can the operation affect my parathyroids?

The parathyroids are four small glands the size of a small pea that are next to, or occasionally within, the thyroid. They control the balance of calcium levels in your body. Your surgeon will make every effort to preserve these, but even in the best of hands their blood supply may be affected as a result of thyroid surgery so that they may stop working. In addition, one or more parathyroids may be unavoidably removed. If the surgeon notices this during the operation, and it is safe to do so, they can reimplant pieces of a parathyroid that has lost its blood supply.

Loss of one or more parathyroids, or disruption to the parathyroids’ blood supply, due to surgery can result in hypoparathyroidism (or low blood calcium levels) which may be temporary or permanent. Fortunately, you do not need all four parathyroids, but sometimes it takes days, weeks, or even months after the operation for the remaining parathyroids to be able to completely control the balance of your calcium levels. This is because the parathyroids often get part of their blood supply from the thyroid and have to adjust to a slightly different blood supply after the surgery.

If you experience a tingling sensation in your hands, fingers or around your mouth after surgery you must alert the medical staff since this may be a sign that your calcium levels have dropped, usually as a result of a decreased blood supply or damage to one or more parathyroids.

If you have had a total thyroidectomy, you will usually have your blood tested to check your calcium levels either on the evening after your surgery, or the next morning. If it is too low, it may be checked later. This is the most common cause of delayed discharge from the hospital. Over 40% of patients are discharged home with some calcium and/or vitamin D tablets. The majority of patients will not need to continue taking these once levels return to normal. The parathyroid glands often recover their function within six to eight weeks. Following a total thyroidectomy about up to ten per cent of patients may have permanent hypoparathyroidism and will need to take calcium and/or vitamin D for life. Lymph node surgery for thyroid cancer increases these risks.

What will my scar look like?

Once the scar heals it is usually hardly visible. In some people, though, it can become tender, red and thickened. This is called a hypertrophic or keloid scar. Keloids are more common in young people especially those with red hair and those from Africa or the West Indies. However, although they are rare, they can arise in all races in an unpredictable way. Silicone tape, steroid tape and injections can be used to decrease the elevation/thickening. Laser treatment can sometimes help. If you have had problems with previous scars, discuss this with your surgeon.

What follow-up care will I have after surgery?

You will be given a date for a follow-up appointment to check on how you are, and your doctor will arrange for blood tests to check your thyroid function about six to eight weeks after the surgery.

If you have a total thyroidectomy your body will no longer be able to produce the hormones that the thyroid normally produces and you will need to take levothyroxine tablets for the rest of your life. Levothyroxine tablets are the main treatment for hypothyroidism (where the thyroid is unable to produce enough hormones for the body’s needs) and contain the hormone thyroxine that your thyroid would have produced. The thyroid mostly produces thyroxine (T4) along with a small amount of triiodothyronine (T3) and also calcitonin. The body converts the inactive hormone T4 into the active hormone T3. T3 helps to regulate the body’s metabolism, heart and digestive function, brain function and muscle control. You will be given levothyroxine tablets to start, usually immediately or very soon after surgery. It may be necessary to adjust the dose of your medication over the following months in order to find the most appropriate dose for your body, and, if so, it may take a while to fully recover.

If you have a lobectomy or hemithyroidectomy you may develop hypothyroidism (underactive thyroid) which affects approximately 10-15% of patients. If the amount of gland left is unable to maintain normal thyroid function, you will need to take a small amount of levothyroxine to top up the thyroxine produced by the remaining thyroid gland.

If you have had more extensive neck surgery to remove some of your lymph nodes you may be referred to a physiotherapist.

Some important points….

• Thyroid surgery should be performed by an experienced thyroid surgeon
• You will be asked for your informed consent. You should be able to ask any questions you have about the surgery and feel that your questions have been answered in a way that you understand before you give your consent. 
• Alert medical staff immediately if you have any tingling in your hands, fingers or face after surgery. You may need calcium supplements.
• The scar usually settles and becomes a white line which is hardly visible after approximately six months to a year. Your scar will often be at its most noticeable at 6 - 8 weeks after the surgery.  
• After thyroid surgery you should have a thyroid function blood test approximately once in the 3 months after your surgery. 
• If you notice any symptoms of hypothyroidism such as lethargy, weight gain, or mood changes, you should see your doctor and ask for a thyroid function blood test.
• If you need to start taking levothyroxine tablets following surgery, it can take several months to find the correct dose for your body’s needs. 
• The main complications of thyroid surgery are voice problems and low calcium. These are usually temporary but in a small number of cases may be permanent.
• Alternatives to thyroid surgery for hyperthyroidism are antithyroid drug therapy or radioactive iodine treatment.

Thyroid problems often run in families and if family members are unwell they should be encouraged to discuss with their own GP whether thyroid testing is warranted.

If you have questions or concerns about your thyroid disorder, you should talk to your doctor or specialist as they will be best placed to advise you. You may also contact the British Thyroid Foundation for further information and support, or if you have any comments about the information contained in this leaflet.

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The British Thyroid Foundation

www.btf-thyroid.org
The British Thyroid Foundation is a registered charity: England and Wales No 1006391, Scotland SC046037T

Endorsed by:

The British Thyroid Association - medical professionals encouraging the highest standards in patient care and research
www.british-thyroid-association.org

The British Association of Endocrine and Thyroid Surgeons - the representative body of British surgeons who have a specialist interest in surgery of the endocrine glands (thyroid, parathyroid and adrenal)
www.baets.org.uk

First issued: 2008
Revised: 2011, 2015, 2018, 2024
Our literature is reviewed every two years and revised if necessary.
© 2024 BRITISH THYROID FOUNDATION

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