Details
You will be asleep for the operation. The incision is made in a curve in the skin low in the neck. The operation will usually last 2-3 hours. A cosmetic, plastic surgical closure is performed.
- The extent of operation depends on your particular case:
- There can be removal of only one lobe of the thyroid. This is call a lobectomy (also known as a hemithyroidectomy).
- Removal of one lobe plus the majority of the opposite lobe is called a subtotal thyroidectomy and is done for hyperthyroidism.
- A near total thyroidectomy is functionally the same as a total thyroidectomy and is performed for cancer.
- The parathyroid glands are preserved and not purposely removed. On occasion it is necessary to autotransplant a parathyroid gland into a neck muscle. These glands function well after a few weeks of recovery.
Some of the following tests may be done depending on your particular case.
- Thyroid Function Tests: A blood test to see how your thyroid functions. Your level of thyroid stimulating hormone (TSH) is checked.
- Ultrasound: Harmless sound waves are aimed at the thyroid gland. This is a painless and convenient way to get a picture of the thyroid. It is often used to guide a biopsy.
- Biopsy: The best way to determine if a nodule is cancer is to do a fine needle aspiration biopsy (FNA) of the nodule. The skin is prepared and numbed and a needle is inserted into the nodule. Cells from the nodule are removed and examined.
- Cytology: The FNA biopsy specimen is read by the cytopathologist. Thyroid cytology is classified into one of six categories according to the risk of cancer.
- After review of the microscopic slides, thyroid nodules can be classified into one of six different categories according to the Bethesda Classification:
- A benign (noncancerous) result is found in 60-70% of biopsies.
- A definite cancer is found in about 5% of biopsies.
- Ten percent of nodules may be suspicious for cancer. The final risk of cancer in the group is approximately 75%, but 25% of these nodules will prove to be benign. Thyroid removal is necessary to make a definitive diagnosis.
- About 20% of nodules are classified as suspicious for a follicular neoplasm. These neoplasms can be benign (75%) or they can be malignant in approximately 25% of cases. These nodules may be reevaluated with a second fine-needle aspiration (FNA) biopsy for molecular testing or may need to be removed by surgery to make a definitive diagnosis.
- Atypical cells of undetermined significance or follicular cells of undetermined significance is the result in 10-15% of cases. This category is associated with a 5-30% risk of cancer. As with follicular neoplasms, these nodules may be reevaluated by molecular testing, repeat FNA biopsy in 3-4 months, or surgical removal for definitive diagnosis.
- Inadequate biopsies, from which no diagnosis can be made, are rare. These nodules need repeat biopsy.
- After review of the microscopic slides, thyroid nodules can be classified into one of six different categories according to the Bethesda Classification:
- Molecular Testing: At the University of Colorado Hospital, doctors in our Thyroid Tumor Program have developed two types of molecular tests to reduce unnecessary operations and decrease the chance that a patient with thyroid cancer will need a second operation.
- The best way to determine if a thyroid nodule is cancerous is to do a fine needle aspiration biopsy (FNA) of the nodule. The FNA biopsy specimen is read by the cytopathologist.
- The results of the biopsy are classified int. Two of these categories, in particular, can be problematic:
- About 20% of nodules are classified as suspicious for a follicular neoplasm (SFN). These neoplasms can be either benign (75% of cases) or malignant (25% of cases).
- About 10-15% of nodules are classified as atypical cells of undetermined significance (ACUS) or follicular lesion of undetermined significance (FLUS). This category is associated with a 5-30% risk of cancer.
- Until 2011, patients with these indeterminate results from thyroid nodule biopsies either had to undergo diagnostic surgery to make a definitive diagnosis or were monitored closely. With an average risk of cancer at about 20%, many patients underwent unnecessary diagnostic operations. On the other hand, the rate of cancer in these indeterminate nodules was unacceptably high to simply monitor in most patients. Many doctors and patients felt stuck.
- At the University of Colorado Hospital, doctors in our Thyroid Tumor Program have been working hard to develop and bring two types of molecular tests into clinical use to reduce unnecessary operations and decrease the chance that a patient with thyroid cancer in an indeterminate thyroid nodule will need a second operation.
- Genomic Test
- The first test is a ‘genomic’ test called the Afirma® Gene Expression classifier (Veracyte, Inc.). This test uses a pattern of RNA expression from a needle biopsy to distinguish benign nodules which do not need surgery from suspicious nodules that need surgery.
- We typically use this test on patients with indeterminate biopsies in the atypical (AUS/FLUS) or neoplasm (FN/SFN) categories.
- A benign Afirma result has a 95% accuracy rate and allows us to safely avoid a diagnostic operation. These nodules are monitored for growth or other changes.
- A suspicious result is associated with a 40-50% risk of thyroid malignancy, which means a thyroidectomy will be necessary.
- Since implementing use of this test, we have reduced the number of unnecessary thyroid surgeries by 50%.
- Genetic Test
- The second test is a ‘genetic’ test that looks for mutations in several genes know to be altered in thyroid cancer. This test is marketed by different laboratories, with the most commonly used test being miRInform® (Asuragen Corp). If the test is positive, we can be fairly certain that a patent with an indeterminate biopsy has a thyroid cancer.
- We generally use this test for patients who have indeterminate nodules and are likely to opt for diagnostic surgery for various reasons (e.g., suspicious features on ultrasound, large nodules, or patient preference). The test results help guide the type of surgery. If the mutation test is negative, it may be worth considering removing only half of the thyroid, preserving the other half. If the mutation test is positive, we recommend removing the entire thyroid
- Thyroid Uptake and Scan: A small amount of radioactive iodine solution is ingested. The radioactive material is taken up by the thyroid, allowing a scanner to take pictures of the thyroid. This test also determines if the thyroid is overactive, normal, or underactive. It is most commonly used in evaluation of patients with hyperthyroidism.
Two of the most common complications of thyroidectomy are as follows:
- Hoarseness: The nerves to the vocal cords run under the thyroid gland on either side of the neck. Injury to the nerve causes hoarseness. Only 1% of the time is the hoarseness permanent. There can be a temporary nerve injury in up to 5% of patients. Twenty-five percent of patients will have mild and temporary hoarseness due to swelling and operating around the voice box that is not related to a nerve injury. This form of voice dysfunction will improve over several weeks.
- Another possible complication is a low blood calcium due to hypoparathyroidism. Approximately 25% of patients experience a temporary low calcium after surgery. Low calcium can cause a feeling of numbness or “pins and needles.” Low calcium can also lead to muscle spasms. We will check the calcium levels in the blood after surgery, and if necessary, we will treat you with calcium supplements and vitamin D after surgery to keep the calcium levels normal. However, only 5% patients will need to take calcium and Vitamin D supplements on a long-term basis due to hypoparathyroidism. Calcium problems do not occur after a hemithyroidectomy.
Preparing for Your Operation
- You will be contacted by the pre-operative call center prior to your surgery to confirm the time and date of your surgery. If you do not hear from them by the business day before your surgery, please call them at 720-848-6070 between 2 and 4 p.m.
- Do not eat or drink anything for 6 hours before the operation.
- Shower or bathe as usual on the morning of the operation.
Medications
- Do not take aspirin, ibuprofen, or other non-steroidal anti-inflammatory drugs for 7 days before the operation.
- Stop herbal medications and supplements 2 weeks before surgery.
- Blood thinners such as Coumadin (warfarin), Pradaxa (Dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), Lovenox (enoxaparin),Fragmin (dalteparin), and Plavix (clopidogrel) need to be stopped a few days to a week prior to surgery. It is important to discuss with your surgeon exactly when these medications should be stopped.
- Stop ACE/ARBS medications 24 hours before surgery. These include any medication that ends with -pril or –sartan (e.g., Acupril, Losartan, Prinivil, Lisinopril)
- Do NOT stop inhalers and other lung medications.
- Do NOT stop beta blockers (metoprolol, atenolol, etc.)
- Discuss diabetes medications with your doctor or Pre-Procedure Services.
- Stop ADHD drugs one day before surgery.
- Stop cholesterol/lipid meds one day before surgery.
- Other medications such as antacid medications and medications for depression or anxiety are generally OK to take on day of surgery; discuss with your surgeon if you have questions.
When You Arrive
- When you arrive at the hospital, the first step will be registration. Then you will go to the pre-operative area, where a nurse will guide you through a series of safeguards and preparations for surgery.
- Next you will meet the surgical team, which includes anesthesia professionals, nursing staff, surgical residents, and your surgeon.
- You will be given general anesthesia, so you will be asleep during the procedure.
- The duration of the operation depends on the type and extent of the resection. Two to three hours is typical.
- Your surgeon will contact your family as soon as your operation is completed.
If you have questions before your surgery, please call 303-724-2724.
Postoperative Care
- Your surgeon will contact your family as soon as your operation is completed.
- You will wake up in a recovery room. When your blood pressure, pulse, and breathing are normal, you will be taken to a regular hospital room.
- Patients that have a hemithyroidectomy are often allowed to go home on the day of surgery.
- You may have a drain coming out of your neck, but this is only done 15-20% of the time. This is necessary if you have a very large goiter or mass to drain off fluid that may accumulate in the neck. We will track how much fluid comes out of the drain. We may be able to remove the drain before you are discharged from the hospital. If you are sent home with the drain still in, the nurses will teach you how to care for the drain. We will bring you back to the clinic to remove the drain when the drainage is low enough.
- Pain can be controlled with pain medication.
- Swallowing may be a little difficult. This swallowing difficulty will resolve with time. You will be started on a liquid diet and advanced to a regular diet as tolerated.
- Dry mouth and mild hoarseness are common. (Ice chips and lip balm are helpful.)
- Your blood calcium level will be monitored after surgery.
- If necessary you will be started on a calcium supplement (calcium carbonate or calcium citrate). You may also need Vitamin D to help absorb the calcium.
- If you have had a near-total or total thyroidectomy, you will be started on thyroid hormone. You cannot live without thyroid hormone and will need to take this every day for the rest of your life. Many people have heard that taking thyroid hormone changes your weight, energy and mood. However, if you are on the right dose and your thyroid functions tests are at target, you should stay at your baseline.
- You should be able to go home the next day. On occasion, a patient may need to stay longer in the hospital if the calcium level needs to be monitored for a longer time.
- Typically it is OK to shower the day after surgery. However, do not submerge your incision under water for 10 days.
Home Care Following a Thyroidectomy
- You may have a mild temperature of less than 100 degrees F. for a day or so. This is normal.
- You will have some swelling and mild bruising in the neck and possibly in the upper chest.
- You may have a little difficulty swallowing which will resolve over time. You can eat regular food.
- For mild pain, take over-the-counter pain relievers. Take the prescribed pain medication if it is needed. Some prescription pain medications contain acetaminophen. You should not take more than 3,000 mg of acetaminophen per day.
- Take thyroid hormone medication as instructed by your health care provider. See this guide for detailed information: Thyroid Hormone Replacement (PDF)
- You may take a shower 24 hours after surgery. Do not bathe or swim for 10 days.
- You may remove the dressing 2-3 days after surgery and leave the incision open to air.
- It is normal to feel tired for several days. If you do not have discomfort, feel free to resume your regular activity.
- You may resume driving when you can turn your head and no longer need prescription pain medications.
- You may return to work when you feel ready (energy has returned and no prescriptive pain meds). Most patients need 1-2 weeks off from work.
- If necessary you will be sent home on calcium and Vitamin D.
- If you have difficulty with bowel movements, you may take any laxative (such as milk of magnesia or MiraLAX).
When to Call the Doctor
Call your healthcare provider if you have any of the following symptoms:
- A fever higher than 101 degrees F.
- Pain not controlled with pain medications.
- Symptoms of a low calcium that are not improving or are getting worse despite taking calcium.
For medical emergencies, dial 911 or go to closest emergency department.
Follow-up Appointments
- You should have a follow up appointment with your surgeon in 2-3 weeks. If you do not already have an appointment, please call 303-724-2728 to schedule one.
- If you have been started on thyroid hormone, you will need to get your TSH level checked in 6-8 weeks. Your primary care provider or endocrinologist can do this for you if you call them for an appointment.
- Your pathology will not be available for 5-7 days. The pathology determines if there is anything concerning (like cancer) about your thyroid tissue and/or lymph nodes that were removed. Your surgeon will go over the pathology results with you. If you have not made a follow up appointment or have not heard anything regarding your pathology in 10 days, please call the clinic as above.
- If you have an endocrinologist, schedule a postoperative appointment for 4-8 weeks after surgery.
- If you have been given a diagnosis of thyroid cancer and do not have an endocrinologist, please call 720-848-2650 and ask to speak to the Thyroid Tumor Coordinator about how to make an appointment. For most cases, it is okay for you to be seen 4-8 weeks after surgery. If your case is more urgent, your surgeon will contact endocrinology to obtain an appointment more quickly.
Scar Management
Scarring is a part of every surgery and is very important to many patients for a variety of reasons: Scars may be painful, itchy or unsightly. Below is a list of common topical agents that are available over-the-counter for scarring.
Most incisions will heal to a thin, cosmetically acceptable scar without using any of the agents described below. However, if you would like to use a topical agent to improve healing and the cosmetic appearance of your scar, we recommend a silicone-based product. See below for additional details.
If you're short on time, you can skip to the summary.
Silicone
Silicones are synthetic polymers that can be a liquid, gel, or rubber.
Findings
Several studies illustrate that treatment of hypertrophic and keloid scars with silicone gel improves the appearance and bulk of the scars, especially in patients with burns. The superiority of one form of silicone gel dressing over another is not clear. Although both silicone gel sheeting and silicone gels improved scars, studies indicate no significant difference between the two forms.
Silicone dressings are believed to decrease scars via wound hydration, increased static charge, and modulation of growth factors.
Materials other than silicones (i.e., polyurethane) have shown to be equally effective in the treatment of hypertrophic scars. Both silicone and non-silicone gel dressings have been effective in reducing scar size, induration, and symptoms, but no significant differences have been noted between treatment with silicone and treatment with non-silicone gel dressings.
Bottom Line: There is good evidence showing the efficacy and safety of topical silicone for the treatment of hypertrophic and keloid scars. Silicone gel may improve the thickness, color, and texture of scars, especially thick ones. Although early treatment is ideal, silicone gel sheeting may still be beneficial for older scars.
Patients who wish to use silicone gel for scar management should apply it to the scar for 8 to 24 hours per day. It may take several months to see improvement.
Vitamin E
Vitamin E preparations are probably the most popular for use in improving the cosmetic appearance of scars.
Belief Basis
Early studies showed that vitamin E, applied topically, penetrates deep into the dermis and subcutaneous tissue, which is likely what led to the idea that vitamin E may improve wound healing when applied topically. When the skin is injured, free oxygen radicals are released in the inflammatory phase and may affect healing. In theory, Vitamin E could reduce free radicals by its antioxidant activity, thus enhancing wound healing.
Findings
Research on the effects of vitamin E on skin healing is sparse. Studies have shown that topically applied vitamin E provides no more effect than other emollient-type ointments, and hydration appears to be its only beneficial effect. Interestingly, topical vitamin E may actually cause more harm than good, possibly worsening a scar's appearance and causing contact dermatitis, contact urticaria, and erythema multiform-like reactions in some patients. A recent report from Widegrow has highlighted the skin irritation and reduced tensile strength caused by vitamin E. Use of vitamin E later on in the scar's maturity (4 to 6 weeks and later) may flatten the scar because of its hydrative capabilities, but it may result in a stretched and weakened scar because of its decreased strength effect on the scar; and if used too early, wound separation can occur.
Bottom Line: Although many patients believe vitamin E speeds wound healing and improves the look of a scar, current research evidence does not support this idea. In fact, studies report adverse effects with use of vitamin E.
We discourage patients from using topical vitamin E on healing wounds and scars.
Onion Extract
Another popular and heavily marketed over-the-counter scar treatment consists of onion extract in a topical gel, which has been marketed as a product to improve scar appearance and texture (Mederma, Merz Pharmaceuticals).
Theories
The mechanism of onion extract seems to reside in its antihistamine properties. The theory behind this is that a compound that blocks histamine release may decrease collagen production by fibro-blasts, resulting in reduced scar volume and normalization of the scar maturation process. The cosmetic result is a decrease in scar redness and hypertrophy.
Findings
Wounds treated with Mederma did show significantly better improvement of collagen organization. However, a prospective, double-blind study of Caucasian males demonstrated that the effects of topical onion extract on cosmetic appearance, erythema, and hypertrophy of scars in new surgical scars were equivalent to those of petroleum emollient.
Bottom Line: Products containing onion extract (i.e., Mederma) do not improve scar symptoms and have not shown any benefit over petroleum emollients. Applying this product to scars will probably not cause any harm, but will also probably not improve them.
Honey
Honey has been used as a dressing for wounds and burns for centuries.
Theories
Honey' effects on wound healing are theorized to be from its antibacterial activity in addition to its hydrating properties.
Findings
A review of 22 clinical trials involving more than 2,000 patients concluded that honey rapidly clears existing wound infections and protects against further infection, reduces swelling, minimizes scarring, removes infected and dead tissue, and speeds
healing by stimulating new tissue growth.
Bottom Line: More well-designed, double-blind controlled trials in humans are needed, but preliminary studies are promising regarding honey and its wound-healing and scar-improvement properties.
Applying honey to a healing wound or existing scar has not been shown to be harmful and may speed healing and improve scar appearance.
What works? The bottom line
To summarize, silicone gel has the most data behind it as an efficacious topical, over-the-counter treatment option for scars, and is an option for patients who want something they can buy themselves. Also, there is probably not any harm, and possibly some benefit, to rubbing honey onto healing wounds and scars.
Further controlled studies involving human subjects are needed for topical, natural preparations for scars, so in the meantime, we recommend that patients not waste time or money on other “natural” products that claim to improve the look of scars.
Sample Products: Silicone-Based Scar Therapy
We do not endorse any particular silicone gel over another; the products below are simply examples of brands that are available over the counter at the time of this posting.
Cica-Care gel sheeting (Smith and Nephew
Mepiform (Molnlycke Health Care)
This information is provided by the Department of Surgery at the University of Colorado School of Medicine. It is not intended to replace the medical advice of your doctor or healthcare provider. Please consult your healthcare provider for advice about a specific medical condition.