Thyroid surgery is growing in prevalence due to the increase in thyroid disease and cancer. In the United States alone, roughly 20 million people have thyroid disease and as many as 60% have undiagnosed thyroid disease. More than 12% of the United States population will develop some form of thyroid disease, including thyroid cancer, during their lifetime.

Undiagnosed and untreated thyroid disease can lead to numerous symptoms or even severe disease (heart disease, irregular heartbeat, vision changes, and more). Many people with thyroid disease need thyroid removal for treatment (i.e., thyroid cancer). Most important in the diagnosis, work-up, and thyroid surgery for thyroid disease is an expert team with an abundance of experience. Thyroid surgery for treatment and cure of thyroid disease should only be done by well- trained, high- volume surgeons.

Here are the Top 4 Reasons for Thyroid Surgery:

#1 Reason for Thyroid Surgery:  Thyroid Cancer

#2 Reason for Thyroid Surgery: Thyroid Nodules

#3 Reason for Thyroid Surgery: Thyroid Goiter

#4 Reason for Thyroid Surgery: Autoimmune Thyroid Disease.

Let’s take a more detailed look at all four of these diseases of the thyroid gland that call for thyroid gland removal.

Reasons for thyroid surgery #1 Thyroid Cancer

Thyroid surgery for thyroid cancer is frequently not different than surgery for non-cancerous disease. Thyroid removal (or thyroidectomy) for thyroid cancer, however, is the most critical and important component of the cure. Many cancerous thyroid nodules can be treated by removal of half the thyroid along with the lymph nodes that are located behind and around the thyroid. Numerous studies have shown that up to 30% of thyroid cancers have spread to lymph nodes at the time of diagnosis and surgery. Expert evaluation and complete removal of all cancer with the first surgery are extremely important to avoid complications and leaving cancer behind.

In other instances, total thyroidectomy is needed to treat cancers that are large, located in both halves of the thyroid, or when thyroid cancer has spread to lymph nodes in the neck. Again, removal of the lymph nodes behind and around the thyroid in the middle of the neck at a minimum is important to ensure the cancer is completely cured. Complete thyroid removal is even riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands (calcium control glands) as well as all the nerves to the voice box to potential damage. Thus, total thyroid removal should only be done by high-volume, experienced surgeons at busy centers such as ours. For more information about thyroid surgery for cancer, visit our extensive thyroid cancer website at and check out our blog on thyroid removal for thyroid cancer. 

Reasons for thyroid surgery #2 Thyroid Nodules

Thyroid nodules are growths that occur in the thyroid gland forming a lump or bump within the otherwise smooth thyroid surface. Thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. Most are benign, but some are cancerous. When people hear they have a thyroid nodule, they worry if thyroid surgery will be required to remove their thyroid nodule. We have written a very informative section on Thyroid Cancer Surgery at our website. Almost all thyroid nodules which are malignant or highly suspicious of malignancy are treated with surgery. Thyroid removal is also very frequently needed for nodules that have atypical or suspicious cells on biopsy. As noted above, thyroid surgery is the mainstay of curing thyroid cancer.

Thyroid nodules that are benign on biopsy may be observed. This is provided that the nodule is not overactive/toxic (causing hyperthyroidism), large (4 cm or greater; or >1.5 inches) or progressing in size, symptomatic, part of a goiter that is extending into the chest cavity, or pushing the windpipe (tracheal) or swallowing tube (esophagus). If one or more of those characteristics are present, then thyroid surgery for treatment is necessary. In cases where thyroid surgery is not needed, the duration of observation is somewhat arbitrary. Observation usually implies repeating thyroid blood tests, ultrasound, and physical examination in approximately 12-18 months (an ultrasound every 3 or 6 months is not indicated for benign nodules). Of note, large nodules can harbor cancer (10.4%- 22% of the time) that is not diagnosed with FNA biopsy (or needle biopsy) preoperatively. That is to say that needle biopsies are not perfect, particularly as the nodules get larger.

To learn more about thyroid nodules, check out our blog post on the top 5 worries about thyroid nodules. 

Reasons for thyroid surgery #3 Thyroid Goiter

A goiter just means “big or enlarged thyroid”, and a multinodular goiter means that the thyroid has more than one nodule, along with being large. The nodules themselves are not the goiter, but in fact the whole thyroid containing the nodules is the enlarged goiter or multinodular goiter. Thyroid goiters almost always require thyroid surgery.

A substernal goiter is when the thyroid has abnormally enlarged over time and grown below the collar bone and into your chest.  This is not something that occurs over the course of several weeks or months. The enlargement usually occurs over the course of years.  The most common cause of substernal goiters is long standing multinodular goiters that have grown over many, many years into the chest cavity. The incidence of substernal goiters among patients with multinodular goiters is reported to range from approximately 5-15%.

The most common symptom or complaint of a multinodular goiter is the unsightly cosmetic appearance of a large lump in the neck or the symptoms produced by the actual size of the goiter. Symptoms related to the size of the goiter may include a sense of a lump in the throat, difficulty swallowing, difficulty breathing and even in extreme cases, voice changes and even a completely hoarse voice. Substernal goiters may not produce a lump in the neck, however, because they may not grow outward.  The substernal goiter may actually grow inwards toward the back portion of your neck and down into the chest area.

Thyroid goiters very often need thyroid removal for treatment. Sometimes, half of the thyroid can be removed, and other times, a total thyroidectomy (complete thyroid removal) is needed. There are many indications for thyroid surgery in these cases. The first indication is the sheer size of the goiter causing a visible mass in the neck.  A second major reason is that the goiter may be producing symptoms of difficulty breathing or swallowing. In some scenarios, the goiter could be producing excessive hormone and be “toxic” to your body.  Finally, multinodular goiters can also harbor a thyroid cancer and need removal to cure the malignancy.

One important consideration is that even though a substernal goiter may extend extensively below the sternum (collar bone) and go well into the chest, these can almost routinely be removed through an incision in the lower neck right above your collar bone. If your surgeon is telling you that they need to "split your chest" or "open your sternum", doublecheck to make sure that you have identified a highly- experienced thyroid surgeon. If you aren't sure where to start, check out our blog post on the top 3 ways to find the  best thyroid surgeon. 

Figure 1: CT scan image of a massive substernal goiter indicated with orange arrows. The goiter surrounds the windpipe (trachea) which is identified with the blue arrow. The dark black areas on each side represent the lungs.

Reasons for thyroid surgery #4 Autoimmune Thyroid Disease

Autoimmune thyroid disease (Hashimoto’s Disease and Graves’ Disease) is the most common cause of an underactive thyroid (hypothyroidism) or overactive thyroid (hyperthyroidism) in the United States and many other countries. In both conditions, the immune system of the body attacks the thyroid gland (Hashimoto’s) or thyroid hormone receptors (Graves’). Thyroid removal is more commonly needed for Graves’ disease, but more recent studies are showing excellent outcomes with complete (total) thyroidectomy for patients with symptomatic, difficult to control Hashimoto’s disease.

Hashimoto’s thyroiditis, or Hashimoto’s disease, is a chronic inflammatory condition of the thyroid gland caused by an autoimmune event where the patient develops antibodies to thyroglobulin (a normal protein produced by the thyroid gland). Long- standing Hashimoto’s thyroiditis is frequently associated with a diseased thyroid gland (secondary to inflammation and scarring). This ultimately leads to decreased thyroid hormone production (hypothyroidism) and subsequent symptoms. A select group of patients with Hashimoto’s disease ultimately need thyroid surgery due to uncontrolled symptoms, fluctuating levels of thyroid hormone and thyroid medication, or persistent symptoms despite optimal medical treatment.

Patients with Graves' disease produce antibodies (immune proteins) that have the ability to link to a type of receptor on the thyroid cells, called thyroid stimulating hormone (TSH) receptor, just as TSH will do. In this way, the thyroid stimulating antibodies push the thyroid cells to produce hormone in a continuous and unregulated fashion. The thyroid cells basically get tricked into producing more and more thyroid hormone, thus producing hyperthyroidism.

Patients can be quite ill due to Graves' disease.  Usually, your endocrinologist will have attempted to control your Graves' disease with methimazole and or  PTU (propylthiouracil).  Neither of these medications are good or safe to take long-term. Additionally, other medications are often needed to control heart rate and blood pressure that are elevated as a result of the hyperthyroidism. Radioactive iodine treatment to ablate or burn out the thyroid¾and therefore decrease production of thyroid hormone¾ is an option, but this frequently does not cure Graves’ disease even after multiple doses.

Despite optimal medical efforts to control your hyperthyroidism/Graves' and its sequelae, thyroid surgery is frequently the only option to definitively treat this potentially life- threatening disease.  Uncontrolled Graves' disease with thyrotoxicosis is a rare, but very serious medical condition requiring the most expert of thyroid surgeons to perform a safe and quick operation, as well as an expert anesthesia team to manage anesthesia when you are in a hyperthyroid-induced toxic medical state. Total thyroid removal is necessary to cure Graves’ disease.

Thyroid surgery for autoimmune thyroid disease should only be performed in the hands of an expert surgeon and care team. Due to the inflammation and thyroid hormone imbalance, thyroid removal in these patients is very challenging and should not be handled by and inexperienced surgeon, care team, and anesthesiologist. For more information about our thyroid center of excellence, please visit www.thyroidcancer.com.

Summary

Millions of people are diagnosed with thyroid disease each year. Some need thyroid removal to cure or treat their thyroid disease. When thyroid surgery is necessary, you need to find an expert team with experience in thyroid surgery to spearhead your cure. This is crucial in order to have a thyroidectomy that goes as planned without complication or a difficult recovery. Our team of thyroid cancer experts is here to help and guide you every step along the way and will be there for you after your thyroid removal. To learn more and become a patient, please see our resources below.

Additional Resources

• Become our patient by filling out the form at this link. 
• Learn more about The Clayman Thyroid Center here. 
• Learn more about our sister surgeons at the Scarless Thyroid Surgery Center, Norman Parathyroid Center, and Carling Adrenal Center
• Learn more about the Hospital for Endocrine Surgery.