Thyroid Frequently Asked Questions

What is the thyroid gland?

The thyroid is a butterfly shaped gland that sits low in your neck along the front of the trachea (windpipe). It has two lobes, left and right, and is connected by a band of tissue, called the isthmus. It is responsible for secreting thyroid hormones, which act throughout the body to influence metabolism, growth and development, and body temperature. It is located near several important structures including the superior and recurrent laryngeal nerves (which control the vocal cords) and the parathyroid glands (which regulate the body’s calcium levels).

What is thyroid disease?

Thyroid disease encompasses a large variety of problems with the thyroid. The thyroid can be become underactive (hypothyroid) or overactive (hyperthyroid) for many different reasons. Blood tests are usually the first step in diagnosing thyroid disease. The thyroid can also become enlarged (goiter) or develop nodules (growths within the thyroid). Based on physical exam and blood tests your doctor can determine if other studies are needed such as ultrasound, thyroid scan, or biopsy and the appropriate treatment.

What does the thyroid do?

The thyroid gland uses iodine to produce thyroid hormones — primarily thyroxine (T4) and triiodothyronine (T3). T4 gets converted into T3 (a more active form) in the blood. Thyroid hormones regulate our metabolic rate and affect weight and energy level. The thyroid also produces calcitonin, which contributes to calcium balance. Thyroid hormone production is regulated by a feedback system involving the pituitary gland (a small gland at the base of the brain).

Why do people get thyroid nodules?

A thyroid nodule is a growth within the thyroid gland, which may or may not be felt by physical exam. Some nodules are only found incidentally on imaging of the thyroid. Thyroid nodules are very common and by age 60 almost one-half of all people will have a thyroid nodule. Fortunately most of these nodules are benign and do not cause any symptoms. We do not know why most thyroid nodules occur, although some conditions, such as Hashimoto’s thyroiditis (inflammation of the thyroid), a family history, radiation exposure, and iodine deficiency (rare in the United States), may increase the frequency of nodules.

What should I do if I have a thyroid nodule?

If you feel a thyroid nodule, your doctor will initially start the evaluation by a physical exam and laboratory tests to check if your thyroid function is normal. The next step is usually a thyroid ultrasound. Thyroid ultrasound can help determine the size of the nodule, whether it is solid or fluid filled (cystic), whether there are any other non-palpable nodules, and if there are any suspicious features. Based on the ultrasound and your thyroid function studies it will be decided whether you need a biopsy, known as a fine needle aspiration.

What is a fine needle aspiration biopsy of a thyroid nodule?

If you feel a thyroid nodule, your doctor will initially start the evaluation by a physical exam and laboratory tests to check if your thyroid function is normal. The next step is usually a thyroid ultrasound. Thyroid ultrasound can give us significant information on the nature of thyroid nodules, but frequently a biopsy of the thyroid cells is necessary.

This can often be done in the doctor’s office with a very small needle under ultrasound guidance or by a radiologist. It does not require any special preparation and you can return to work and regular activity the same day. Usually 2-4 samples must be taken to give the best chance of finding normal or abnormal cells. These cells are reviewed under the microscope by a pathologist and your doctor will then review the results with you.

What are the different types of thyroid cancer?

Papillary thyroid cancer (PTC) is the most common type of thyroid cancer making up to 80-90% of all thyroid cancer cases, while Follicular and Hürthle cell cancers represent the second most common. PTC can sometimes spread to the lymph nodes of the neck and those can be surgically removed along with the thyroid.

Follicular or Hurthle cell cancers are more difficult to diagnose on fine needle aspiration (FNA) biopsy compared to PTC and are more likely to spread to the lungs or bones.

Medullary thyroid cancer (MTC) accounts for 3 to 10% of all thyroid cancers and grows from specialized thyroid cells called parafollicular or C-cells that make a hormone called calcitonin. Those with MTC require a total thyroidectomy and central neck dissection, which involves removing the lymph nodes behind the thyroid gland.

Anaplastic thyroid cancer is a rare, but very aggressive cancer, representing only 1-2% of all thyroid cancers and usually occurs in older patients.

What are the symptoms of thyroid cancer?

Most patients with thyroid cancer do not have any symptoms. Typically, patients present with a thyroid nodule that is found to be cancer on further evaluation. As with all thyroid disease, a thorough history is important, such as a family history of thyroid cancer, personal history of radiation exposure, or enlarged lymph nodes. Your physician will review with you any symptoms such as pain, swelling in the neck, difficulty with swallowing, shortness of breath, difficulty with breathing or changes in your voice. If the nodule is large, it may cause symptoms such as difficulty swallowing, choking sensations, or a large mass in the neck. Rarely, the cancer can grow into the nerves (i.e. the recurrent laryngeal nerves) that control the voicebox and cause hoarseness.

What is the treatment for papillary thyroid cancer?

If you have a diagnosis of papillary thyroid cancer (PTC) of the thyroid, surgery (either a thyroid lobectomy or total thyroidectomy with or without a lymph node dissection) is almost always recommended as the first step. For “older” patients with very small (less than 1 cm) cancers limited to one side of the thyroid and without lymph node involvement, active surveillance may be a reasonable option. some surgeons may only remove one half of the thyroid by performing a thyroid lobectomy.

For patients with intermediate and high risk tumors, radioactive iodine ablation (RAI) is given postoperatively after a total thyroidectomy  – it is not recommended for smaller and intrathyroidal cancers.. After total thyroidectomy, patients need to take thyroid hormone replacement pills for the rest of their life. Thyroid cancer can come back and therefore you will need long-term follow up after your initial treatment.

What is the treatment for follicular thyroid cancer?

The best treatment for invasive, un-encapsulated Follicular and Hürthle cell cancers is a total thyroidectomy (i.e. removal of the whole thyroid); however, most patients diagnosed with this type of cancer will initially present with a Follicular or Hürthle cell neoplasm on their thyroid biopsy. Therefore, most patients are initially treated with a thyroid lobectomy to remove the nodule to make a pathological diagnosis which cannot be made on fine needle aspiration (FNA) biopsy. Once a patient is diagnosed with Follicular or Hürthle cell cancer, he or she usually needs to have the rest of the thyroid removed in an operation called a completion thyroidectomy. If it is a minimally invasive or encapsulated form of follicular/Hurthle cancer, a lobectomy is usually adequate.

After thyroidectomy, patients need to take thyroid hormone replacement pills for the rest of their life. Follicular cell cancers can spread through the blood and thus can spread to the lungs or bones. Some Hürthle cell cancers will spread to lymph nodes in the neck, which may be felt pre-operatively on examination or seen on ultrasound and can be biopsied by FNA if they look suspicious; these can be removed at the same time as the thyroidectomy. Radioactive iodine ablation (RAI) may be given for follicular cell carcinomas.

What is the treatment for medullary thyroid cancer?

The best treatment for medullary thyroid cancer (MTC) is surgery to completely remove all disease including the entire thyroid gland, the central neck lymph nodes (located behind the thyroid gland) and all lateral lymph node metastases (located on the side of the neck near the jugular vein and carotid artery).

The extent of disease can be estimated in most patients based on their calcitonin and CEA levels, which are tumor markers for MTC. After surgery, blood levels for calcitonin and CEA should be monitored routinely, usually every 6 months to a year. If calcitonin and CEA levels rise above the initial post-operative level, a neck ultrasound and computed tomography (CT) scan, should be performed to look for recurrent disease. If there is recurrent disease, then another operation may be needed.

Radioactive iodine ablation does not work for MTC; external beam radiation or chemotherapy is reserved for patients with very advanced or severe disease. Clinical trials with targeted therapy are also available for patients with more advanced disease.

What is a goiter?

“Goiter” is a term for abnormal enlargement of the thyroid gland. The gland can be generally enlarged or have multiple growths (nodules) leading to enlargement of the whole thyroid gland. A goiter can be associated with an overactive gland, an underactive gland, or a normal thyroid gland.

Does a goiter always require surgery?

The natural history of a benign goiter is usually slow enlargement or growth of its nodules. Therefore, observation can be safe. A goiter is treated if there is a suspicion of the nodules harboring cancer, if the goiter is growing quickly or hormonally overactive, or if the goiter’s large size is causing compressive symptoms, such as hoarseness, difficulty swallowing, or difficulty breathing.

What is a multinodular goiter?

Multinodular goiter is enlargement of the thyroid due to the growth of multiple nodules. The number and sizes of the nodules vary amongst individuals. There are two forms of multinodular goiter: 1) nontoxic multinodular goiter and 2) toxic multinodular goiter. If the goiter makes normal amounts of thyroid hormone, it is known as a nontoxic multinodular goiter. If the goiter makes inappropriately high amounts of thyroid hormone, it is known as a toxic multinodular goiter.

What are thyroid nodules?

A thyroid nodule is a growth within the thyroid gland. Thyroid nodules are extremely common, and nodules large enough to be felt can be seen in 5 to 10% of women and 1 to 5% of men. If imaging is performed of your thyroid, smaller nodules that cannot be felt can be found in over 60% of patients. The risk of a thyroid nodule being cancer is about 5-10%; therefore, further evaluation is recommended if the nodule is >1 cm in size or there are other concerning features.

What is the difference between a thyroid nodule and a goiter?

A thyroid nodule is a growth within the thyroid gland. Thyroid nodules are extremely common, and nodules large enough to be felt can be seen in 5 to 10% of women and 1 to 5% of men. A goiter is an enlargement of the thyroid gland and may be due to general enlargement of the gland or enlargement due to the presence of multiple nodules.

Why is iodine important for the thyroid gland?

The thyroid gland uses iodine from the diet to make thyroid hormone. Thyroid hormone is stored in the thyroid gland and released into the bloodstream as needed by the body to help control the body’s metabolism. Iodine deficiency can lead to enlargement of the thyroid or goiter.

What does the tightness in my throat have to do with my thyroid?

If thyroid enlargement occurs very slowly, one may not notice the slow increase in size or have any symptoms. However, some patients may complain of a feeling of fullness in the neck, a choking sensation, difficulty swallowing large pills or chunky foods, a sense of pressure on the neck, or worsening snoring, especially when the thyroid grows beneath the breastbone (i.e. substernal goiter). These compressive symptoms can be due to enlargement of the thyroid or due to inflammation in the thyroid and are often an indication to remove the thyroid.

Should I take iodine for my goiter?

Iodine deficiency as a cause of goiter is rare in North America and most of Europe, largely due to the amount of iodized salt in our diets. However, even in areas of iodine deficiency most patients do not develop goiters. The Recommended Dietary Allowance (RDA) for iodine in adult men and women is 150 μg per day, and one teaspoon of iodized salt contains approximately 400 μg iodine. Taking too much iodine can also worsen underlying thyroid disease and is not recommended.

What is Graves’ Disease?

Graves’ Disease is an autoimmune disorder where the body makes antibodies which attack the thyroid, resulting in overproduction of thyroid hormone. As a result, the patient becomes hyperthyroid (overactive thyroid).

Additional tests that your physician may order include: a radioactive iodine uptake scan, thyroid function blood tests, and blood tests for antibodies which act on the thyroid causing hormone production or release.

In addition to over activity of the thyroid gland, patients may also have symptoms of bulging eyes and/or swelling of the fronts of the lower legs with associated thickening of the skin.

What should I do if I’ve been diagnosed with Graves’ disease?

If you have just been diagnosed with Graves’ Disease, the first step is getting your thyroid function under control. This is generally done with anti-thyroid medications which block the production of the excess thyroid hormone. Additional medications, called beta blockers, can also be given to control many of your symptoms of hyperthyroidism – racing heart beat (palpitations), tremor, and anxiety. To determine what will be the best long term treatment for you, we recommend you contact either an endocrinologist or a surgeon specializing in endocrine diseases.

Is surgery a safe option for Graves’ disease?

Surgery is a safe and effective treatment option for Graves’ Disease. The surgical management of Graves’ Disease consists of a total thyroidectomy, or removal of the entire thyroid gland, or a subtotal thyroidectomy (removal of most of the gland). The risks of surgery include voice hoarseness and problems with low calcium, but with an experienced surgeon the risks of these complications are very low (1-2%).

What is the treatment for Graves’ disease?

There are three main treatment options for Graves’ Disease. Medical management consists of giving anti-thyroid medications, which block the production and release of the thyroid hormone. Surgical management consists of the surgical removal of the entire thyroid by a total thyroidectomy. Patients will then go on thyroid hormone replacement for the rest of their lives. The third treatment option is radioactive iodine ablation of the thyroid gland. The radioactive iodine treatment kills the functional thyroid cells, resulting in a hypothyroid state three to six months after the treatment.

Surgical management and radioactive iodine ablation are equally safe and effective for long term control of Graves’ Disease. However, certain patients are better managed with one versus the other. Discuss both options with your doctor to find out which one is best for you.

Who should consider having surgery for Graves’ disease?

Surgery for Graves’ Disease involves the removal of the entire thyroid gland by a total thyroidectomy. The surgery can be done very safely, and results in a quick and permanent resolution of hyperthyroidism. It is equally effective and safe as radioactive iodine ablation. For some patient populations it may be their best option, including those with thyroid enlargement and compressive symptoms, suspicious nodules (or growths), patients needing rapid control of their disease, patients with significant eye problems, or women who are pregnant or nursing.

Do thyroid problems cause weight gain?

There is a complex relationship between thyroid function, metabolism, and body weight. Hypothyroidism, or an underactive thyroid, is associated with decreased metabolism, and you may experience modest weight gain (5-10 lbs) as a result. Most of this weight gain is due to excess salt and fluid retention.

If you have an underactive thyroid and are placed on thyroid hormone replacement, your ability to gain or lose weight should be the same as those without thyroid problems. Many factors may contribute to weight gain, and treatment of an underactive thyroid does not necessarily result in weight loss.

How can I tell if my thyroid is working properly?

Both an underactive and overactive thyroid gland can cause symptoms. If you are experiencing symptoms such as fatigue, depression or anxiety, changes in sleep, changes in weight, intolerance to hot or cold temperature, hair loss, dry skin, muscles aches or tremors, or menstrual irregularities, you may have a thyroid problem. Additionally, symptoms of thyroid enlargement such as a swelling in the neck, hoarse voice, or increased discomfort wearing neckties or turtlenecks, should prompt a thyroid investigation. Ask your doctor to test your thyroid function if you are experiencing any of these symptoms.

How can thyroid problems affect my sleep?

Both an underactive and an overactive thyroid can affect your sleep habits. Hypothyroidism, or underactive thyroid, can cause fatigue, lack of energy, and excessive daytime sleepiness. Hyperthyroidism, or overactive thyroid, can cause anxiety, rapid heart rate, and insomnia. You may have difficulty falling asleep, or wake up often in the middle of the night. Sleep disturbances, left untreated, can lead to fatigue, decreased productivity, and mood changes. If you have a thyroid problem and are experiencing sleep disturbances, make sure to discuss your symptoms with your doctor.

Can a thyroid problem cause night sweats?

Night sweats are hot flashes that occur at night, associated with excess sweating that may soak nightclothes and bedsheets. Night sweats can be associated with both underactive or overactive thyroid function. However, there are numerous potential causes of night sweats, such as menopause, low blood sugar, certain drugs, or other medical conditions. Tell your doctors if you are experiencing night sweats and they can evaluate for possible causes.

What causes hyperthyroidism?

Hyperthyroidism, or overactive thyroid, can be caused by a number of conditions affecting the thyroid. Common causes of hyperthyroidism include Graves disease, toxic nodule, toxic multinodular goiter, thyroiditis, excess TSH secretion, taking excess thyroid hormone, or excess iodine intake.

Graves disease is an autoimmune disorder characterized by generalized overactivity of the thyroid gland. It is more common in women and may be hereditary. Alternatively, the overactivity may be centered in areas of overgrowth, called nodules. When there is one or more overfunctioning nodules, this is called a toxic nodule or toxic multinodular goiter. Thyroiditis, or inflammation of the thyroid, may be associated with both hyper and hypothyroidism. Thyroiditis may occur following a viral infection or after pregnancy. Rarely, excess TSH secretion from the pituitary gland in the brain may cause hyperthyroidism. Excess iodine intake is also rare, and may be due to specific drugs, such as amiodarone.

How is hypothyroidism diagnosed?

Hypothyroidism, or an underactive thyroid, is diagnosed based on a careful history and physical exam. An underactive thyroid can cause fatigue, depression, daytime sleepiness, cold intolerance, weight gain, water retention, thinning hair, dry skin, constipation, difficulty concentrating. The diagnosis is proven by laboratory testing. Your TSH (thyroid stimulating hormone), which is the brain’s signal to the thyroid to make thyroid hormone, is elevated. The normal range for TSH is 0.5-4.5 mIU/L. Your circulating thyroid hormone levels (free T4 or T3) are usually low.

What is Hashimoto’s disease?

Autoimmune thyroiditis is also known as Hashimoto’s thyroiditis or chronic lymphocytic thyroiditis, and is the most common cause of hypothyroidism. The majority of patients with Hashimoto’s have antibodies to thyroid peroxidase (TPO). These antibodies cause destruction of thyroid cells that leads to fewer cells making thyroid hormone. Most patients with Hashimoto’s disease will ultimately require thyroid hormone supplementation. In addition to causing an underactive thyroid, sometimes patients can get enlargement or swelling of their thyroid which can cause pain and pressure in their neck which can lead to difficulty swallowing.

Risk factors for Hashimoto’s thyroiditis include female gender, personal or family history of other autoimmune disease.

What causes hypothyroidism?

Primary hypothyroidism is caused by an underlying disease of the thyroid.

The most common causes of primary hypothyroidism are autoimmune thyroiditis (i.e. Hashimoto’s thyroiditis or lymphocytic thyroiditis), surgical removal of the thyroid (i.e. thyroidectomy), radioactive iodine treatment, or certain medications such as Lithium, Amiodarone.

Secondary hypothyroidism is a much less common problem. It is caused by diseases that affect the pituitary gland’s ability to make and release TSH (which regulates thyroid hormone production). Specific problems include pituitary tumors, postpartum pituitary necrosis (Sheehan’s syndrome — an uncommon problem where all or part of the pituitary dies after childbirth), trauma, or tumors that grow into the pituitary gland.

What are the symptoms of hypothyroidism?

Symptoms of hypothyroidism may include fatigue, depression, daytime sleepiness, cold intolerance, weight gain, water retention, thinning hair, dry skin, constipation, and difficulty concentrating.

Hypothyroidism can range from mild forms that are asymptomatic, and found only via blood tests, to severe hypothyroidism, that is associated with significant symptoms along with abnormal lab results.

What is the treatment for hypothyroidism?

The treatment of hypothyroidism includes replacing the body’s natural thyroid hormone with a pill form of thyroid hormone. Thyroid hormone replacement is typically a form of T4 (also known as levothyroxine); it is long lasting and only needs to be taken once a day. During treatment, the patient’s TSH level must be monitored to ensure that the correct dose is given. The starting dose is based on the patient’s weight and is usually about 1.6 mcg/kg although some patients require significantly more or less than that dose.

There are several situations where the dose may need to be adjusted. For example, in elderly patients, thyroid hormone replacement should be started at a lower dose due to the risks of heart problems and increased bone loss. In patients with thyroid cancer, the dose is adjusted to suppress TSH below normal levels.

What are symptoms of hyperthyroidism?

Hyperthyroidism symptoms include anxiety, insomnia, tremors, palpitations, weight loss, muscle weakness, heat intolerance, excessive sweating, and menstrual changes. The number, degree, and severity of these symptoms can provide some clue as to the severity of hyperthyroidism.

How do I keep my thyroid healthy?

A well balanced diet should include all the minerals needed to help support the function of the thyroid. Deficiencies in some minerals can contribute to thyroid issues (see below), but excess supplementation of these minerals is not recommended.

  • Iodine: Iodine is needed for the production of thyroid hormone. Generally, there is ample iodine in the diet, mostly in iodized salt. Iodine deficiency is very rare in the United States and excessive supplementation with iodine can actual worsen some thyroid problems.
  • Iron: You also need sufficient iron levels to make thyroid hormone and to help it get into other cells in the body. Insufficient iron levels alter and reduces the conversion of T4 to T3, besides binding T3.
  • Trace Minerals: Zinc, selenium and chromium help you convert inactive T4 to active T3.

When should I get tested for thyroid dysfunction?

The thyroid gland is an important organ that secretes a hormone (thyroid hormone), which controls the body’s metabolism. Thyroid hormone affects many bodily functions including heart contractility, gastrointestinal motility, and bone mineralization/turnover, among others. These functions are increased in patients who have hyperthyroidism, and decreased in patients with hypothyroidism. Symptoms of hyperthyroidism include palpitations, insomnia, or weight loss, while hypothyroid patients may have fatigue, weight gain, dry skin, or constipation. If you have any of these symptoms, you should go to your healthcare provider for a thorough history and physical exam. Your provider will use information gained from such an evaluation to determine if testing is right for you.

What does it mean when lab results show an elevated TSH level?

Thyroid stimulating hormone (TSH), also known as thyrotropin, is produced by the pituitary gland in the brain and causes the thyroid to make thyroid hormone. When there is not enough thyroid hormone in the body, the pituitary makes more TSH, which tells the thyroid to make and release more thyroid hormone. Therefore, when patients have elevated TSH levels, it means they are hypothyroid and have an underactive thyroid.

Can I have thyroid disease if my thyroid function tests are normal?

It is possible to have thyroid problems despite having normal thyroid function tests. If blood test results show that the thyroid is functioning within normal ranges, patients with symptoms should talk to their doctors to rule out other problems of the thyroid including, autoimmune disorders, thyroid nodules, or thyroid cancer. Further work-up will likely involve checking for antibodies in the blood, ultrasound evaluation of the thyroid, and biopsy of any suspicious thyroid nodules.

Why are thyroid function tests not always reliable?

The TSH level is the best initial test for determining thyroid function. Other tests of thyroid function include free T4, and free T3. Each of these tests has a reference range of what’s considered to be “normal”, and these ranges are not the same at every testing center. Therefore, a lab value may be reported as normal at one facility, and abnormal at a different facility. Additionally, test results can be affected by stress, medications, or other medical illnesses that a patient has and results can vary when checked at different times or different labs.

Should I take medicine if I have borderline thyroid function test results?

When thyroid function tests are borderline, deciding to take thyroid medication can be a difficult decision. Most endocrine specialists recommend waiting at least three months to repeat a borderline abnormal test. However, if a patient is very symptomatic, he or she may be started on medication. The decision to start a medication is one made by both doctor and patient, after a thorough evaluation of the patient’s clinical picture and the risks and benefits of medical treatment.

What are the treatment for an underactive thyroid?

Hypothyroidism, or an underactive thyroid, is treated with thyroid medication. Levothyroxine (Synthroid, Levoxyl, Levothroid, etc), a synthetic thyroid hormone, is most commonly used. Levothyroxine is T4 which is the long-acting storage form of thyroid hormone. This medication replaces the hormone from your thyroid.

Can I drink alcohol while taking levothyroxine?

While various foods and medications affect the absorption of levothyroxine, alcohol has no significant interaction with this medication. Consuming alcohol on a regular basis could lead to liver disease and is not recommended. Because levothyroxine is broken down by the liver, it is possible that alcohol-induced liver dysfunction could change the metabolism of levothyroxine.

Should I take Cytomel if I have hypothyroidism?

Hypothyroidism, or an underactive thyroid, is treated with thyroid hormone medications that replace T4. In the body, T4 is converted to T3, which is the active form of thyroid hormone. Cytomel (Liothyronine) is a man-made hormone that replaces the body’s natural thyroid hormone (T3). Because of its rapid and less predictable absorption from the intestinal tract, it is generally not used as the primary medication to treat hypothyroidism. Cytomel is sometimes used in combination with levothyroxine. Cytomel can also be used to lessen symptom duration if you need to come off of your levothyroxine as part of your thyroid cancer surveillance or treatment.

What are natural treatments for hypothyroidism?

Alternative treatments for hypothyroidism include “natural” medication in the form of desiccated animal thyroid (Armour), usually obtained from pigs. Both T3 and T4 are contained in Armour. It also contains a chemical binder. This medication is available only by prescription and many physicians do not support its use for treating hypothyroidism.

What foods and medications can interact with thyroid medication?

There are numerous foods and medications that interact with levothyroxine. These foods and medications do not need to be avoided completely, but should not be ingested within 4 hours of taking levothyroxine. Some of these foods and medications include iron, calcium, multivitamins, soy, phenytoin, some estrogen products, and some cholesterol-lowering medications. These substances can alter the absorption of thyroid hormone. If you are taking these medications, please talk to your physician or pharmacists about possible interactions.

How can I find an experienced thyroid surgeon?

Research has shown that experienced surgeons who specialize in thyroid operations have superior surgical outcomes and less frequent complications compared to providers who only rarely perform thyroid surgery. Ask your primary care physician or endocrinologist to refer you to an experienced thyroid surgery specialist. When speaking with your surgeon, it is acceptable and appropriate to ask them how many thyroid operations they do in a year (high volume surgeons perform >50 thyroid operations per year). Members of the American Association of Endocrine Surgeons (AAES) have clinical and research expertise in thyroid surgery.

How long does thyroid surgery take?

Most thyroid operations take from one to five hours for the surgeon to perform. There is additional preparation and recovery time before and after the actual operation. When a patient has had previous neck surgery, there is often scar tissue which makes the procedure time longer. Thyroid operations that involve removal of lymph nodes (neck dissection) also take longer. Ask your thyroid surgeon for an estimate about how long your particular procedure is likely to take. Descriptions of the main types of thyroid operations can be found in the links, below.

What type of anesthesia will I need for my thyroid surgery?

Most thyroid operations are performed under general anesthesia, which means you will be totally asleep during the procedure and a plastic tube will be placed in your airway (trachea) to help you breathe.

However, some thyroid operations are performed under “monitored anesthesia care” with a “cervical block”. This means the anesthesiologist will administer sedation medication through an IV (catheter in a vein) to make you relaxed, and the surgeon will inject numbing local anesthetic medication into the skin around your neck. Some surgeons routinely perform thyroid surgery in this way, while other thyroid surgeons prefer to use general anesthesia unless it is too risky (for example, if the patient has severe heart or lung disease). Ask your thyroid surgeon what kind of anesthesia will be used for your operation.

Will I have pain after my thyroid surgery?

Most patients prefer to use some pain medication for a few days after thyroid surgery. There is pain at the neck incision, and many patients have a sore throat due to the plastic endotracheal breathing tube that is needed for general anesthesia. Your surgeon may give you a prescription for a pain-killer that combines acetaminophen with a narcotic (hydrocodone, oxycodone, or codeine). If your pain is mild, you may stop taking the stronger pain medication and just use acetaminophen (Tylenol) or another over-the-counter medication. Be sure to ask your surgeon if it is safe to use aspirin or non-steroidal anti-inflammatory (NSAID) medications such as ibuprofen, because these drugs can increase the risk of post-surgical bleeding. Always tell your surgeon and anesthesiologist if you have any drug allergies or history of problems (such as nausea and vomiting) with a particular pain medication.

Will I need a drain after my thyroid surgery?

Drains are flexible and hollow plastic tubes that the surgeon leaves in the patient’s neck to allow drainage of blood, lymph, and other body fluids after thyroid surgery. Drains are not necessary for most thyroid operations. Thyroid surgeons place drains when there is a high likelihood of body fluid accumulation after an operation; for example, if an extensive neck dissection (lymph node removal) was performed or if the patient is on an anticoagulant (blood thinner) for some other medical condition. Ask your surgeon if a drain is likely to be placed at the end of your thyroid operation.

What medicines will I have to take at home after thyroid surgery?

Generally, most patients are sent home with pain medication and calcium supplementation. You may also require thyroid hormone. Please follow the instructions your surgeon sends home with you in regards to your home medications.

Tylenol is safe in most cases but unless otherwise instructed, you should avoid NSAIDS such as aspirin, ibuprofen, or naproxen for 36-48 hours after your surgery as these medications can increase the risk of bleeding.

Whether or not you need other medications will depend on why your thyroid was removed and how much was removed.

What happens to the thyroid tissue that’s removed?

Your thyroid gland and any other specimen is sent to the pathology laboratory where it is examined under the microscope to obtain a final diagnosis. Sometimes, this is performed during the operation, and is called a frozen section examination. More typically, careful analysis and special testing of the thyroid tissue takes several days, and the final results should generally be available to you at the time of your follow-up visit.

Will I have any restrictions after my thyroid surgery?

You should not drive or drink alcohol while taking narcotic pain medications. You should also not drive until your neck has comfortable, full range of motion.

You should not soak or scrub your incision for the first week or two after surgery, although you may shower and pat the area dry gently.

Generally, walking, stairs, and lifting objects are all fine after thyroid surgery. Most people return to work or routine activities within 1-2 weeks of surgery.

Will my thyroid surgery leave a scar?

Yes. The standard scar from thyroid surgery is generally about 2 inches long and is located in the front of the neck. Most surgeons try to hide the scar in a skin crease. Practice does vary, so ask your surgeon where your scar will likely be and how large it will be.

Will I have stitches that need to be removed after my thyroid surgery?

Most surgeons use dissolvable stitches under the skin that do not require removal. Other surgeons may use glue in place of sutures.

You may have steri-strips (tape strips), skin adhesive, or a dressing which needs to be removed at home. Please follow the instructions your surgeon sends home with you.

After thyroid surgery, how should I care for the incision site?

Although your scar is small on the outside, many tissue layers are divided to reach the thyroid gland. The layers are generally stitched back together at the end of the surgery. The normal healing process can cause temporary swelling or stiffness under the skin. Most swelling develops within the first two weeks after surgery and may last several months as the healing process evolves. When your surgeon recommends, massaging the swollen area daily can thin the scar tissue, help it flatten and heal nearly invisibly.

Sometimes fluid accumulates in the empty space created by surgery leading to swelling, this is more common in patients with very large thyroids and when lymph nodes are removed as well. This type of swelling develops slowly and peaks about 5-7 days after surgery and usually begins to resolve after that. While some swelling is expected, marked swelling is more concerning. If the area under the scar suddenly increases in size, bulges out impressively, or causes difficulty breathing, speaking, swallowing, or lying flat, you should contact your surgeon immediately.

Will I have to take thyroid hormone after my thyroid surgery?

After a partial thyroidectomy or thyroid lobectomy, about 30% of patients require some amount of thyroid hormone. To determine if you need long term thyroid hormone replacement, your doctor will check your thyroid hormone levels approximately 6-8 weeks after surgery.

If you had your entire thyroid removed, or a total thyroidectomy, you will need thyroid hormone replacement for the rest of your life. In most cases, this will be started immediately after thyroid surgery. Your doctor will check your thyroid hormone levels about 6-8 weeks after starting the medication to ensure the dose started is right for you.

If you have thyroid cancer then you will receive special instructions based on your specific situation from your surgeon and/or endocrinologist.

What are the most important complications that can happen during or after thyroid surgery?

Surgery to remove the thyroid gland is well tolerated and has low complication rates when performed by an experienced thyroid surgeon. Complications unique to thyroid surgery include bleeding within the neck causing difficulty breathing, seroma (simple fluid) formation under the incision, and infection of the incision. Infrequent but serious complications associated with thyroid surgery also include temporary or permanent voice changes and temporary or permanent low blood calcium levels.

Will I lose my voice after thyroid surgery?

There are two sets of nerves near the thyroid gland that help control the voice, the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve. Damage to a recurrent laryngeal nerve can cause you to have some hoarseness of the voice. For some patients this is a mild voice change, for others it can be more pronounced. The chance that one of the recurrent laryngeal nerves will be permanently damaged is about 0.5-2% depending on the experience of the surgeon.

Temporary voice changes, such as mild hoarseness, voice tiring, and weakness are more common and can happen in 10=20% of patients. If the external branch of the superior laryngeal nerve is injured it may cause a problem in making high-pitched noises (i.e. high notes when singing) or yelling or projecting the voice to a large room.

What are the signs of low calcium levels in the blood after thyroid surgery?

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 first week or two of recovery following total thyroidectomy (removal of the whole thyroid) you may be sent home with instructions to take supplemental calcium and/or vitamin D. If you have symptoms that you think are related to low calcium, it is best to take some calcium and see if your symptoms resolve. If you have questions or your symptoms don’t resolve, you should contact your surgeon. A blood calcium level may be drawn by your surgeon during your postoperative visit, and the calcium will be cut back as appropriate.