Complications from Thyroid Surgery

Surgery to remove the thyroid gland is well tolerated and has low complication rates when performed by an experienced thyroid surgeon. In general, thyroid surgery is very safe and has a low risk of major complications. Your surgeon will discuss the risks of your specific thyroid operation with you in detail, and you will have a chance to ask questions. We encourage you to ask your surgeon about any concern you may have about thyroid surgery, their level of experience, and your expected follow-up treatment.

There are risks, benefits and alternatives to any treatment offered. General risks of surgery include bleeding, infection, and complications related to the patient’s other health problems (such as heart disease, respiratory problems like asthma or COPD, etc.).

Bleeding in the neck — occurs only in about 1/300 thyroid operations. The amount of bleeding is usually small, but even small amounts of blood can compress the windpipe and cause difficulty breathing. In that case, it may be necessary to perform an urgent operation to drain the blood and relieve the pressure. Needing a blood transfusion is very rare for thyroid surgery.

Seroma — is a fluid collection under the incision which feels like fullness or swelling. This is very common and will get better over the course of a few weeks. If it is large, it may be drained by the surgeon.

Infection — occurs in about 1/2000 thyroid operations, and the routine use of antibiotics to prevent infection is not necessary. In general, the neck is a clean area that usually does not get infected. However, if a postoperative infection does develop, drainage of the infected fluid and/or antibiotics may be necessary.

Voice change — is a known complication after thyroid surgery. There are two sets of nerves near the thyroid gland that help control the voice. These are the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve. Damage to a recurrent laryngeal nerve can cause you “to lose your voice”. The chance that one of the recurrent laryngeal nerves will be permanently damaged is about 0.5-2-3% depending a surgeon experience and volume. A more subtle change in vocal function may be noticeable if you are a professional voice singer or public speaker.

Temporary voice changes, such as mild hoarseness, voice fatigue and weakness are more common and can happen in up to 10-20% of patients. This is often a temporary problem and may occur because one or more of the nerves are irritated either by moving them out of the way during the operation or because of the inflammation that develops after surgery (a normal and expected response). Although the voice usually improves in the first few weeks after surgery, changes may last up to 6 – 12 months after surgery at which point no further improvement would be expected.

If both recurrent laryngeal nerves are damaged, the vocal cords may close and not allow air to pass from the mouth and nose into the lungs. In this case, a tracheostomy tube may need to be placed to allow passage of air into the lungs. This is extremely rare.

If the external branch of the superior laryngeal nerve is injured and not functioning properly, the vocal cord may move normally. However, it may cause a problem in making high-pitched noises or yelling. These changes are slightly more common, but may be so subtle that they are difficult to notice.

If any of these voice changes last for more than 6 months after the operation, they are likely to be permanent. An otolaryngologist/Ear, Nose, & Throat (ENT) doctor or vocal specialist can be very helpful in determining the specific problem and can perform different procedures to reposition the vocal cord to improve voice quality (vocal cord medialization).

Hypoparathyroidism resulting in low calcium levels — or low blood levels of calcium can occur if the parathyroids are injured or removed. The parathyroid glands control the calcium level in your bloodstream. They are four small delicate glands about the size of a grain of rice located near, or attached to, the thyroid gland, two on each side. Occasionally, a parathyroid gland may be within the thyroid gland. If the blood supply to a parathyroid gland is inadequate after the thyroid is removed, the parathyroid gland may need to be transfered (autotransplanted) to a nearby muscle. The blood supply to the muscle should eventually grow into the parathyroid cells and allow the gland to function again. This takes 6-12 weeks to occur. Only one parathyroid gland is needed to function for the entire body. The symptoms of low blood calcium level include a tingling or “pins and needles” feeling, usually around the mouth and in the fingertips. Severely decreased calcium can cause spasm or “locking up” of the muscles. The chance that all four parathyroid glands would not be able to function permanently is about 0.5 – 2-3% depending on surgeon experience and type of surgery. If this happens, the patient will need to take supplemental calcium for the rest of their life. Again, there is variability in the severity and time course of this complication.

In general, the parathyroid glands may not function well right after surgery. Therefore, the first week or two of recovery following total thyroidectomy, you may be sent home with instructions to take supplemental calcium and/or vitamin D. The specific instructions will be determined by your surgeon. A blood calcium level may be drawn during your postoperative visit, and you will be “weaned” off the calcium as appropriate. Up to 20% of patients will have low calcium levels temporarily. Within a few weeks after surgery, the calcium levels usually return to normal. If calcium and parathyroid hormone levels have not returned to normal after 3-6 months, this is usually a permanent condition. This may occur in 2-3% of patients.

Temporary hypoparathyroidism is common enough that your surgeon may advise you to take substantial extra calcium doses for the first few weeks postoperatively, to maintain your calcium levels and prevent symptoms. Your calcium levels should normalize within the first few weeks of your operation and your calcium supplements will therefore decrease as well. Your surgeon will guide you with specific instructions during this time. Please communicate with your surgeon or other members of your care team if you are experiencing these symptoms. Most often, they can be managed at home with simple adjustments of calcium supplements. If the symptoms get worse, you may need to be seen urgently to supplement your calcium levels. After recovery, if you are a woman over the age of 50 years, you and your surgeon may choose to lower your calcium supplements down to a smaller dose instead of stopping altogether (to help prevent osteoporosis). Most other patients will likely be weaned completely off of calcium supplements.