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A thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland.
Surgeons often perform a thyroidectomy when a patient has thyroid cancer or some other condition of
the thyroid gland (such as hyperthyroidism). Other indications for surgery include cosmetic (very
enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing). One of
the complications of "thyroidectomy" is voice change and patients are strongly advised to only be
operated on by surgeons who protect the voice by using electronic nerve monitoring. Most
thyroidectomies are now performed by minimally invasive surgery using a cut in the neck of no more
than 2.5 cms(1 inch).
The thyroid produces several hormones, such as thyroxine (T4), triiodothyronine (T3) and calcitonin.
After the removal of a thyroid patients usually take prescribed oral synthetic thyroid hormones to
prevent the most serious manifestations of the resultant hypothyroidism.
Less extreme variants of thyroidectomy include:
• "hemithyroidectomy" (or "unilateral lobectomy") -- removing only half of the thyroid
• "isthmectomy" -- removing the band of tissue (or isthmus) connecting the two lobes of the
thyroid
A "thyroidectomy" should not be confused with a "thyroidotomy" ("thyrotomy"), which is a cutting
into (-otomy) the thyroid, not a removal (-ectomy) of it. A thyroidotomy can be performed to get access
for a median laryngotomy, or to perform a biopsy. (Although technically a biopsy involves removing
some tissue, it is more frequently categorized as an -otomy than an -ectomy because the volume of
tissue removed is minuscule.)

INDICATIONS

• Malignancy (see Thyroid neoplasm)

• Cosmetic reasons
• Goiter which is untreatable by medical methods
• Severe hyperthyroidism refractory to conservative treatment
• Orbitopathy in Graves' disease
• Removal and evaluation of a thyroid nodule whose FNAC results are unclear
TYPES
1. Hemithyroidectomy - entire isthmus is removed along with 1 lobe. Done in beningn diseases of
only 1 lobe.
2. Subtotal thyroidectomy - done in toxic thyroid. primary or secondary and also for toxic MNG
3. Partial thyroidectomy - removal of gland in front of trachea after mobilisation.It is done in
nontoxic MNG. role is controversial.
4. Near total thyroidectomy - Both lobes except the lower pole which is very close to recurrent
laryngeal nerve and parathyroid is removed. In papillary carcinoma thyroid.
5. Total thyroidectomy- Entire gland is removed. done in case of follicular carcinoma of thyroid,
medullary ca of thyroid.
6. Hartley Dunhill operation- removal of 1 entire lateral lobe with isthmus and partial/subtotal
removal of opposite lateral lobe. it is done in non toxic MNG.
Main steps of Thyroidectomy:
1. Exposure - horizontal neck incision, +/- raising of flaps, +/- division of strap muscles
 2. Identification of essential structures - Recurrent and ext. branch of superior laryngeal nerve,
parathyroid glands
3. Devascularization
• Superior thyroid artery
• Inferior thyroid artery while protecting the supply to the parathyroids
• Thyroid ima if present
4. Resection
5. Exploration of other pathology - e.g. contralateral lobe, lymph nodes
6. Closure

COMPLICATIONS
1. Hypothyroidism/Thyroid insufficiency in up to 50% of patients after ten years
2. Thyrotoxic crisis/Thyroid storm
3. Laryngeal nerve injury in about 1% of patients, in particular the recurrent laryngeal nerve:
Unilateral damage results in a hoarse voice. Bilateral damage presents as laryngeal obstruction
on removal of the tracheal tube and is a surgical emergency: an emergency tracheostomy must
be performed. Recurrent Laryngeal nerve injury may occur during the ligature of the inferior
thyroid artery.
4. Hypoparathyroidism temporary (transient) in many patients, but permanent in about 1-4% of
patients
5. Anesthetic complications
6. Infection
7. Stitch granuloma
8. Haemorrhage/Hematoma
• This may compress the airway, becoming life-threatening. A suture removal kit should
be kept at the bedside throughout the postoperative hospital stay.
9. Surgical scar/keloid

INDICATIONS FOR THYROIDECTOMY

Thyroidectomy is usually performed for the following reasons:
1. As therapy for some individuals with thyrotoxicosis; those with Graves’ disease; and others
with a hot nodule or toxic nodular goiter.
2. To establish a definitive diagnosis of a mass within the thyroid gland, especially when cytologic
analysis after fine needle aspiration (FNA) is either non-diagnostic or equivocal.
3. To treat benign and malignant thyroid tumors.
4. To alleviate pressure symptoms or respiratory difficulties associated with a benign or malignant
process.
5. To remove an unsightly goiter (Figure 9).
6. To remove large substernal goiters, especially when they cause respiratory difficulties.
 Thyroid Surgery (Thyroidectomy) Indications:
Thyroid surgery is a common operation, but one which needs to be taken seriously because of the
potential complications which may occur. Commonly, this surgery is done because of suspected
cancer. Patient risk factors, appearance on ultrasound examination or needle biopsy results may
cause your surgeon to recommend surgical removal of the thyroid. If there is a vocal cord
paralysis or rapid growth of a solid mass also indicates a cancer. Unfortunately, one of the forms
of thyroid cancer, follicular carcinoma, can appear benign on needle biopsy and may also be read
as benign on frozen section during surgery. See Evaluation of Thyroid Nodule Page
From 1973 to 2002 the incidence of thyroid cancer has increase 2.4 times to 8.7 cases per 100,000
per year. The increase was entirely due to an increase in papillary carcinoma. The mortality from
thyroid cancer has stayed unchanged at 0.5 patients per 100,000 per year. View Article (JAMA
2006)
If the thyroid becomes so large that it compresses the trachea or esophagus surgical removal is
indicated. A thyroid cyst that recurs after a single or repeated needle drainage is also an
indication for removal. Rarely, a thyroiditis will cause scaring in the neck which also compresses
the airway. The thyroid must also be removed in this case. However, cases of thyroiditis have an
increased complication rate due to bleeding and scaring.

Thyroid Surgery (Thyroidectomy) Technique:

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Thyroid Surgery (Thyroidectomy) Care After Surgery:

Depending upon the working environment, patients can expect to be off of work for one to three
weeks. Stitches are removed in five to seven days. If removed at five days, steri-strips are usually
applied to the incision. After 24 hours the incision can be gently washed. Antibiotic ointment
should be applied to the wound twice a day. The wound must be kept clean.
Depending upon the diagnosis, thyroid medication may be given. If only a single thyroid lobe is
removed for benign disease, and the opposite lobe is normal, then thyroid replacement is often not
started. If thyroiditis is present, then thyroid replacement should be started.

If a total thyroidectomy is performed, thyroid replacement is mandatory. If the thyroid was

removed because of cancer, then thyroid suppressive dosages should be considered. In cases of
thyroid nodules, goiter and thyroiditis, mild thyroid suppression is controversial because of the
possible risk of osteoporosis. If the patient is placed on thyroid suppression, a bone scan for
osteoporosis and supplemental calcium and vitamin D should be prescribed.

If I-131 therapy is planned after a total thyroidectomy, Cytomel (liothyronine sodium), should be
considered to shorten the time of hypothyroidism before the treatment. Cytomel contains
synthetic T3, a thyroid hormone with a short half life. Thus, the patient is taken off of it for a
shorter time before I-131 therapy, than if the patient was prescribed a T4 replacement.

In all patients who receive thyroid replacement or suppression, TSH and Free-T4 should be
routinely monitored. If hypoparathyroidism is suspected, calcium levels will also need to be
measured.
Thyroid Surgery (Thyroidectomy) Complications:
1) Paralysis of the Recurrent Laryngeal Nerve (RLN) is the most common complication after
thyroid surgery. It can occur in approximately 2% of patients. If one lobe of the thyroid is removed
only one RLN will be placed at risk. Injury can result in a weak, breathy voice. However, in some
patients compensation will occur and a strong raspy voice results. In cases of a weak voice,
augmentation of the vocal cords may improve the voice.
If a total thyroidectomy is performed, both RLNs are at risk. If both RLNs are injured, the patient
will have a poor airway and may require a tracheotomy. There is no satisfactory treatment for
this complication and the patient must decide between a strong voice and a good airway, both are
not possible.
The picture to the right shows the
appearance of the operative field after
the thyroid gland is removed. Note the
left recurrent laryngeal nerve. This
nerve runs next to the undersurface of
the thyroid and between the trachea
and esophagus. The recurrent
laryngeal nerve controls the
movement of the left true vocal cord.
This nerve can be damaged during
surgery, which will result in a weak,
breathy voice.

Mouse Over Picture to identify

nerve.
Click on picture to enlarge.
Chindo and Chheda reported
(Archives of Otolaryngology May 2007) that the incidence of vocal cord paralysis is between
2.09% in monitored patients to 2.96% in unmonitored patients. There was not a statistical
difference between the two groups.
2) Hypoparathyroidism: There are four small glands next to the thyroid which control calcium
metabolism. These location of these glands are variable and they can mimic lymph nodes and
globs of fat. Two of these glands are located on each side. If a total thyroidectomy is performed
(both the right and left thyroid lobes are removed) these glands may be inadvertently removed. If
all four are removed the patient's calcium will drop over a matter of hours and cramps, tetany and
cardiac arrest will develop. Treatment is to give intravenous calcium. After stabilization, the
patient is discharged home on oral Vitamin D and calcium. It must be stressed that these glands
are hard to identify and one or two are often removed during surgery. Repeated frozen section
may be required to identify the glands. If they can be identified after removal, they can be
implanted into the local muscles where they will grow and calcium metabolism will return to
normal after their function returns.
3) Bleeding: Because of the vascularity, bleeding can occur after the operation which can cause
airway obstruction. If this occurs, the surgical wound must be opened immediately to relieve the
pressure on the trachea.

http://www.entusa.com/thyroidectomy.htm
http://en.wikipedia.org/wiki/Thyroidectomy