THYROIDECTOMY This infrmatin aims t help yu understand the peratin, what is invlved and sme cmmn cmplicatins that may ccur. It may help answer sme f yur questins and help yu think f ther questins that yu may want t ask yur cancer care team; it is nt intended t replace advice r discussin between yu and yur cancer care team. AN OVERVIEW TO THYROIDECTOMY The thyrid is lcated belw the vice bx arund the windpipe (trachea). It is shaped like a butterfly with tw lbes laying either side f the windpipe (see picture belw). The thyrid gland makes thyrid hrmnes that circulate arund the bdy in the bld and cntrl the speed at the cells in the bdy wrk. T much f these hrmnes (hyperthyridism), r t little (hypthyridism) can make yu unwell. Thyridectmy is the remval f the whle f, r part f the thyrid gland. If the whle thyrid gland is remved, thyrid hrmne tablets are required t replace the thyrid s natural functin after the peratin. 1
Next t the thyrid gland are tw imprtant structures that the surgen needs t prtect (see picture abve): The glands that cntrl level f calcium in the bld, called the parathyrid glands The nerves t the vice bx, called the recurrent laryngeal nerves. Many surgens will check whether these nerves are wrking nrmally befre the peratin by lking at the vice bx. This can be dne with a mirrr r a telescpe, called nasendscpy (see belw). 2
WHY IS A THYROIDECTOMY NEEDED A thyridectmy is dne t treat thyrid cnditins such as cancer, ndules r enlargement f the thyrid (gitre) that are nt cancerus, r an veractive thyrid. Visit the Beynd Five website t view further infrmatin n thyrid cancer. The amunt f thyrid t be remved depends n the reasn fr the peratin. This may be part f the thyrid (partial); half (hemithyridectmy); r all f the thyrid (ttal thyridectmy). Usually fr thyrid cancer, the whle thyrid is remved. This is because thyrid cancers ften need additinal treatment called radiactive idine, which is nly effective if the thyrid gland is cmpletely remved. Hwever, nt all thyrid cancers need t be treated with radiactive idine r ttal thyridectmy. Smetimes the lymph ndes in the neck may need t be remved and this is called a neck dissectin. If there are n signs f cancer having spread t the lymph ndes, then usually just the lymph ndes near the thyrid are remved. This is called a paratracheal r central cmpartment dissectin. Yu may want t dwnlad further infrmatin n neck dissectin, which is available n the Beynd Five website. Tissue remved frm the thyridectmy will be examined in detail by a specialist pathlgist, under a micrscpe t lk fr cancer cells and assess whether additinal treatment may be needed. Thrugh this examinatin, the cancer can be accurately staged. Further infrmatin abut staging f cancer is available n the Beynd Five website. 3
HOW TO PREPARE FOR THE OPERATION Befre the peratin: Yu will need t fast (have nthing t eat r drink) fr 6 hurs befre yur peratin (unless advised differently by yur surgen r anaesthetist) because thyridectmy is perfrmed under a general anaesthetic (yu will be asleep and will nt remember what happens during the peratin). Yur surgen will explain the details f yur peratin. Be sure t bring up any questins r cncerns, and share yur needs and wishes with yur cancer care team (see bx). Yu shuld speak t yur dctr abut hw t manage aspects f yur lifestyle, such as smking, drinking alchl and chrnic cnditins (e.g. diabetes and besity) that may increase the risk f cmplicatins. Pssible questins that yu may want t ask yur cancer care team Hw lng will it take befre I can eat again? Hw lng will the incisin be? Will my vice be affected? Will I need t take thyrid hrmne medicatin (thyrxine)? Hw will I knw if I am taking the right dse f thyrid hrmne? Where shuld I stre the medicatin? Will I need t take calcium medicatin after the surgery? What bld tests will I need after the surgery? Will I need ther treatment, such as radiactive idine? Can I fall pregnant and are there any special precautins? Additinal questins are listed at the end f this factsheet. If yu take bld thinning medicatin fr a heart cnditin r bld clts (such as Warfarin, Plavix, Aspirin r Pradaxa), make sure yur surgen is aware. Sme f these medicatins need t be stpped mre than a week befre the peratin. Smetimes a shrt-acting bld thinner (such as Clexane) is used befre and after the surgery. Talk t yur surgen, endcrinlgist and cancer care team abut any likely side effects t expect fllwing the peratin. Yu may find it useful t talk t a dietitian, speech pathlgist r specialist head and neck nurse abut these issues. Visit the Beynd Five website fr further infrmatin n health prfessinals wh may be part f yur cancer care team 4
WHAT TO EXPECT DURING THE OPERATION During thyridectmy, an incisin (cut) abut 6 cm lng will be made in the frnt f the neck, in ne f the natural skin creases, where pssible. Yur surgen will carefully remve yur thyrid away frm the laryngeal nerves and parathyrid glands. Sme surgens use a nerve mnitr attached t the breathing tube during surgery. This can be very useful in difficult peratins, such as when there is scaring frm previus thyrid surgery. In sme circumstances, the surgery may be dne endscpically (using a small vide camera), thrugh small cuts elsewhere in the neck r chest. It culd als be dne with the assistance f a rbt, but these ptins are nt very cmmn in Australia. WHAT TO EXPECT AFTER THE OPERATION After the peratin, nce yu are fully awake, yu will be mved t a bed in the hspital. Yu will have surgical drains cming frm the site f the surgery t allw bld r lymphatic fluid t escape and prevent swelling. These will usually be remved befre yu g hme but it may be pssible t g hme with the drains if yu are ready. Sme surgens may use an ice pack n the wund t reduce swelling Yur anaesthetist and surgical team will give yu medicine t help cntrl any pain and nausea after the peratin. Sme strnger pain medicatins may als be charted but yu will need t ask the nurse fr these as needed. Yu may want t dwnlad infrmatin abut pain management, which is available n the Beynd Five website. Yu shuld be able t eat and drink but sft fd is usually recmmended. 5
If nly a part f the thyrid is remved, further bld tests may nt be necessary, hwever, if the whle thyrid is remved, bld tests will be needed t check the level f calcium and parathyrid hrmne. Sme surgens prescribe calcium medicatin fr all patients and thers wait t see what the bld tests shw befre deciding whether calcium is needed. If calcium levels drp, yu may ntice tingling in the lips, fingers and/r tes r cramping in the hands and feet. Infrm the nurse r dctr if yu ntice any f these symptms. This usually takes 24 48 hurs t ccur. Thyrxine, a thyrid medicatin, will be prescribed t patients wh have had all f the thyrid gland remved, and it may be started the day after the peratin. It is imprtant t take the medicatin withut fd, milk r ther tablets. Often the easiest time t take thyrxine is an hur befre breakfast with a sip f water. Mst patients stay in hspital fr abut 1 2 days after thyrid surgery. POSSIBLE RISKS OF THYROIDECTOMY All peratins carry sme risks such as bld clts, wund infectins, bleeding, chest infectin, adverse reactins t anaesthetic, and ther cmplicatins. These risks will be explained by yur cancer specialist and anaesthetist. Yur dctr will explain details f the peratin, general risks and side effects f the peratin, they may recmmend: stpping bld thinners (e.g. aspirin) befre surgery t reduce the risk f bleeding a bld thinner (called heparin) may be injected befre and after surgery t reduce the risk f bld clts antibitics t reduce t risk f wund infectin early mbilisatin t reduce the risk f bld clts and chest infectin special stckings t reduce the risk f bld clts. 6
Thyridectmy is a very safe peratin but there are sme specific risks that yu shuld knw abut: Change in vice and speaking: There are tw nerves t the vice bx n each side f the windpipe (trachea). The nerves that make the vcal crds pen and clse are called the recurrent laryngeal nerves. The nerves that tighten the vcal crds are called the external laryngeal nerves (these are nt as imprtant, but if they stp wrking it may cause difficulty in singing high ntes r prjecting the vice). During thyrid surgery, nerves are carefully separated frm the thyrid gland. If ne f the recurrent laryngeal nerves is injured, the vice may sund very breathy and weak. The chance f this is lw (Up t 2 peple in 100 peple). If bth recurrent nerves are injured it may be difficult t breath and, in extremely rare situatins, a trachestmy may be required. Yu may want t dwnlad infrmatin n trachestmy, which is available n the Beynd Five website. Lw calcium: The parathyrid glands cntrl calcium levels in the bld. They are very clse t the thyrid and share the same bld supply. During thyridectmy the parathyrid glands need t be separated frm the thyrid withut affecting their bld supply. This may be difficult and the parathyrid gland has t be implanted int a neck muscle where it will grw a new bld supply. Smetimes the parathyrid glands are within the thyrid and are remved at the time f the surgery. It is quite cmmn fr the parathyrid hrmne levels t drp after a ttal thyridectmy (abut 20%) but usually this will recver ver a perid f weeks. If this happens, calcium and vitamin D medicatin may need t be taken until the levels recvers (dn t take this at the same time as the thyrid hrmne medicatin). Bleeding: Usually very little bleeding ccurs during thyrid surgery. Hwever, bleeding after the peratin may be dangerus given the thyrid sits next t the wind-pipe. If this ccurs, there may be sme breathing difficulties and yu will be taken back t the perating rm. This is quite rare. 7
SIDE EFFECTS AND THEIR MANAGEMENT As with all peratins, there is a chance that thyridectmy may lead t a number f side effects. Yu may nt experience all f the side effects. Speak with yur dctr if yu have any questins r cncerns abut treatment side effects. Side effects cmmn fr all peratins may include: Nausea: General anaesthetic may cause nausea. This will settle dwn sn after the peratin and can be treated with medicatins. Sre thrat: Yur thrat may be sre initially because f the breathing tube placed during the peratin. Pain management: Pain is a cmmn side effect f the peratin. Yur anaesthetist will give yu pain medicine during the peratin t keep yu cmfrtable when yu wake up, and yu may cntinue n pain medicines t ensure pain is under cntrl. Ensure yu take pain relief medicatins as prescribed by yur dctr and speak t yu cancer care team if the pain is nt under cntrl, gets wrse f if the medicatin causes any side effects. Yu may want t dwnlad further infrmatin abut pain management, which is available n the Beynd Five website. Pssible side effects f thyridectmy include: Scar: There will be a scar acrss the neck. This may be red fr a few mnths, befre fading t a thin line. It is pssible that the scar may becme red and thickened (kelid scar). If yu tend t scar badly, let yur surgen knw t help reduce the risk f this happening. Changes in vice and speaking: Many patients may ntice that their vice fatigues easily fr a few mnths after thyridectmy, even if the nerves are wrking well. Thyrid hrmne replacement: Daily thyrid hrmne tablets need t be taken fr thse wh are having a ttal thyridectmy. This helps replace the thyrid s natural functin fr the rest f yur life. Occasinal bld tests will be needed t check that yu re n the right dse. 8
OTHER TREATMENT(S) Additinal treatment(s) depend n the nature and extent f the cancer Head and neck cancers ften require treatment with mre than ne frm f therapy t reduce the risk f the cancer recurring. Many patients need radiactive idine therapy after the peratin. Yur cancer care team will be able t discuss the likelihd f needing further treatment befre yur peratin. BEFORE GOING HOME Any particular instructins fr wund care r medicatins will be prvided t yu befre yu g hme. Yu may want t dwnlad further infrmatin abut wund care n the Beynd Five website. Yur dctr may prescribe pain medicatins t help relieve pain fllwing the peratin. Ensure yu take the pain relief medicatins as prescribed by yur dctr and speak t yur cancer care team if the pain is nt under cntrl, gets wrse r if the medicatin causes any side effects. Yu may want t dwnlad further infrmatin abut pain management, which is available n the Beynd Five website. If yu have had a ttal thyridectmy, make sure yu have a supply f thyrid hrmne medicatin. Yu will be assessed by the team invlved in yur care befre yu g hme and fllw-up will be arranged with yur surgen and GP. If yu were cmmenced n calcium medicatin, make sure yu knw when t have yur next bld test t check the calcium level and wh yu shuld cntact t get the result. DO NOT RELY ON YOUR SURGEON TO CALL YOU. Be sure yu knw wh t call if there is a prblem. Usually calling the surgen r their team directly is best, but yu can als g t yur GP r call the hspital where yu had surgery. 9
Care f the wund Each surgen will clse the wund in their wn way. Often the wund will have sutures under the skin that cannt be seen. These will disslve ver time and they d nt need t be remved. Avid wearing any tight r restrictive clthing arund the neck fr a few weeks after the peratin. There may be a small sticky dressing (called a steri-strip ) ver the wund when yu are discharged frm hspital. Yur dctr will have specific instructins regarding when the dressing shuld be remved and whether yu can get the wund wet. There may be a waterprf glue dressing (Dermabnd) ver the wund fllwing the peratin. This is a temprary cver t keep the wund clean; it can be peeled ff after a week r s. At yur first pstperative check, the surgen will discuss what yu can apply t the wund t help avid a nticeable scar. Activities Fr the first few days after arriving hme frm hspital, it is imprtant t rest and nt d any activities that invlve mving the neck a lt. If pssible, take ne r tw weeks ff wrk depending n hw labur-intensive wrk may be. D nt d any heavy lifting, strenuus exercise r cntact sprts fr a mnth after the peratin, althugh it is k t g fr walks as sn as yu feel up t it. If yu have small children it is recmmended that yu d nt lift them fr 1 2 weeks. Yu can drive after a week r as sn as yu feel cmfrtable with the range f mvement in yur neck, but yu must nt drive if yu feel that yur ability is impaired. 10
Thyrxine Thyrxine is the main hrmne prduced by the thyrid. After a ttal thyridectmy (all f the thyrid remved) yu are n lnger able t prduce thyrxine and a supplement f thyrxine is needed fr the rest f yur life. If nly half f the thyrid was remved (hemithyridectmy), the thyrid is still able t prduce thyrxine and a supplement may nt be required. The cmmn brand names fr thyrxine are Orxine and Eutrxsig As there are different strengths f thyrxine tablets available (50, 75, 100 and 200 micrgrams), it is helpful t knw the thyrxine dse rather than number f tablets (e.g. 100 mcg per day x 7 days per week rather than 1 tablet per day). Smetimes it can take sme time t get the thyrxine dse crrect. Thyrxine shuld be: Taken ONE r TWO HOURS befre fd r drink It may be easiest t take it in the mrning, as sn as yu wake up befre yu begin yur mrning rutine. It is very imprtant that thyrxine is nt taken with fd. Fr thse wh are als taking calcium, d nt take the tw medicatins at the same time f the day (have the calcium with r after fd). Stred in the fridge having it ut fr a day is fine if yu are travelling, but refrigerate it as sn as pssible. Make sure yu always have enugh tablets and if yu are running ut either call the surgen s rms, endcrinlgist r see yur GP t get a new prescriptin. 11
Symptms t watch fr after discharge frm hspital Significant swelling: There may be sme mild swelling after the peratin. This is nrmal and may last fr sme weeks. Hwever, if this becmes very nticeable and painful, cntact the surgen, yur family dctr r the hspital. Difficulty breathing r swallwing: Yu shuld be able t breathe nrmally after yur surgery. If yu are having difficulty yu must cntact yur surgen, GP r g t the hspital emergency department. Discharge frm the wund: If the wund becmes red, ht and starts t discharge yu may have an infectin and shuld cntact the surgen r yur family dctr, as yu may need antibitics. Fever: If yu develp a fever cntact yur surgen r yur family dctr. FOLLOW-UP CARE The surgen will discuss what t apply t the wund t help avid a nticeable scar. Different surgens may have different recmmendatins and it may take 12 mnths (r lnger) fr the wund t cmpletely settle dwn depending n yur age and skin-type. If the tumur remved is benign (nt cancer) then nly ne r tw visits may be needed. Hwever, if there is thyrid cancer then yu will need lng-term fllw-up with yur surgen, endcrinlgist, r bth. Smetimes the diagnsis f thyrid cancer has been made prir t the peratin, based n a needle bipsy, s yu are prepared fr this result. Hwever smetimes (abut 1 in 10 patients underging thyridectmy) an unexpected cancer may be fund. Shuld this happen, yur treatment plan may change. Other referrals may be arranged as needed with ther health prfessinals t assist yu with any ther difficulties r supprtive care. Any additinal treatments that yu may need are planned after discharge. This enables time fr yu t recver frm the initial peratin, get results f the pathlgy that examined the tissue remved at the peratin, and make the arrangements fr any additinal treatment r next steps. 12
Regular bld tests: Are cnducted t make sure the thyrxine dse is apprpriate. Yur surgen r endcrinlgist will give yu bld test request frms. Usually the first thyrid functin test is dne 6 weeks after the peratin because it may take ne r tw mnths fr the levels t stabilise. The fllwing are signs f an incrrect dse; ask yur dctr fr a bld test t check yur thyrid hrmne level if yu are experiencing these: Signs f t little thyrxine: Fatigue/lethargy Pr exercise tlerance Hair lss Dry skin Weight gain Impaired memry Cld intlerance Cnstipatin Signs f t much thyrxine: Shakes (tremr) Palpitatins (heart racing) Increased appetite and thirst Weight lss Intlerance t heat Fatigue/muscle weakness Difficulty sleeping Osteprsis (lng-term) 13
Radiactive idine Sme patients with thyrid cancer may need radiactive idine ablatin (RAI; idine that is radiactive t help kill any remaining thyrid cells in the bdy). This invlves admissin t hspital where a tablet cntaining radiactive idine is taken. RAI des nt wrk straight away, it takes many mnths t have any effect. High levels f thyrid stimulating hrmne (TSH) are required during RAI t help stimulate the thyrid cells that remain. This can be achieved either by: withdrawal (stpping thyrid hrmne medicatin) 4 6 weeks prir t RAI; r synthetic TSH (Thyrgen ) given as an injectin fr tw days befre RAI. After RAI a whle bdy scan will be used t lk fr any thyrid cells remaining and t make sure the cancer has nt spread t ther parts f the bdy. The scan may als shw nrmal thyrid cells (where the thyrid was remved; very cmmn) r salivary glands (cmmn). Onging surveillance Fllwing a diagnsis f thyrid cancer, mst patients are mnitred fr several years depending n their individual cancer. Mnitring may include regular bld tests, ultrasund and specialist visits (fr example, surgen and/r endcrinlgist). The specialist may check the lymph ndes in the neck using ultrasund (either at the surgery r having ne dne prir the appintment). Thyrid cancer may be tested by a marker in the bld called thyrglbulin. If this marker is lw, it suggests there is n recurrence f cancer; but if thyrglbulin increases, further tests may be needed. Sme patients need repeat whle bdy scans r treatments with radiactive idine based n these results. Fr further infrmatin abut the peratin fr cancer and what t expect, yu can als refer t Understanding Surgery: a guide fr peple with cancer, their families and friends. 14
QUESTIONS TO ASK YOUR DOCTOR What type f cancer d I have? Where is it lcated? What lifestyle changes (diet, exercise) d yu recmmend I make? What are the chances that the surgery will cure the cancer? What will happen if I dn't have the surgery? Will I need thyrid hrmne replacement therapy? When will I be able t get back t wrk? What are the pssible side effects f treatment? Hw can they be prevented r managed? Will I have a scar? Hw lng will I have t stay in hspital fr? Hw much will the peratin cst? Will my health insurance cver it? Will I be able t lead a nrmal life? When will I get the pathlgy results? What fllw-up tests will I need after the peratin? Am I suitable fr any clinical trials? If I wanted t get a secnd pinin, can yu prvide all my medical details? 15
Yu may want t write specific questins here t ask yur dctr r cancer care team Beynd Five disclaimer: Yu acknwledge and accept that the infrmatin in this factsheet is fr general infrmatin purpses nly. It is nt intended, nr shuld it be relied n, as medical r legal advice, r as a substitute fr cnsultatin with a physician r ther licensed healthcare prvider. Yu agree that if yu have individual healthcare-related questins yu shuld cntact yur dctr prmptly and shuld nt disregard prfessinal medical advice, r delay seeking it, because f infrmatin cntained here. Yu als agree that Beynd Five is nt liable fr any injury r damage t persns r prperty (hwsever caused, including by negligence) arising ut f r related t any use f Beynd Five s patient educatin materials, r fr any errrs r missins. Last updated: 17 Octber 2016 16