Our goal is for your journey through surgery and recovery to be as comfortable and convenient as possible. By reading and following these instructions, we can work together to ensure a successful surgery and recovery. If you have any questions or concerns, our telephone number is: 713-532-3223.

Introduction
The thyroid gland is located in the lower part of the neck, below the Adam's apple and just above where the collarbones join the breastbone. The thyroid gland has two lobes, one on either side of the windpipe, which are joined by an island of tissue called the thyroid isthmus. The thyroid gland makes hormones that control the body's overall energy level. Too much thyroid hormone will make you lose weight, feel hot, shaky and nervous and can cause your heart to have extra beats or palpitations. Too little thyroid hormone will make you feel cold, sluggish or confused, and will cause you to gain weight.

Thyroid surgery involves removal of all or some of the thyroid gland. Surgery can be indicated to remove benign (non-cancerous) or malignant (cancerous) tumors of the thyroid. Surgery may also be needed when medical treatment alone cannot control over-production of thyroid hormone.

Before Surgery
Please see our handout, "General Pre-operative Instructions," which will answer most of your questions about what to do before surgery. Instructions specifically related to thyroid surgery:

• If you are taking medications to reduce the amount of thyroid hormone your body produces, be sure to take this medication up until the day of surgery, as instructed by your doctor.

Surgery
Thyroid surgery requires an incision 3 to 4 inches long, placed just above where the collarbones join the breastbone. Rarely is a larger incision required and we make every effort to keep the incision line as small and inconspicuous as possible. In removing all or a portion of the thyroid gland, no muscles in your neck will be cut. The muscles will be stretched or retracted to the sides to allow us to see and remove the necessary portion of the thyroid. During the procedure we will take great care to identify the nerves to the voice box or vocal cords that are found just behind the thyroid gland. Additionally, we will identify and preserve the four small glands called the parathyroid glands, which lie next to the thyroid gland. These four very small glands produce a hormone called parathormone, which controls calcium levels in the blood. These glands will not be removed.

The smallest operation that can be done on the thyroid gland requires removal of at least half of the thyroid tissue in your neck. This is called a thyroid lobectomy. A thyroid lobectomy is always required because of the particular anatomy of the thyroid gland and other structures of the neck. No smaller operation can be done safely. Once the diseased portion of the thyroid gland is identified and removed, it is sent to the pathology laboratory for immediate examination under a microscope, to determine if the disease process is cancerous or benign. This analysis is called, "Frozen Section." Even when no cancer is suspected, we always send a frozen section to the lab for examination, just to be safe. If no cancer is found, the procedure is finished and sutures are placed to close the skin incision. If cancer is found, total removal of the thyroid gland is performed. Some or all of the lymph nodes in the neck may also be removed, depending upon the type of thyroid cancer that is found at the time of surgery.

Immediately Following Surgery
You will awaken in the Post Anesthesia Care Unit (PACU). You will likely have a sore throat and some initial pain when swallowing. The PACU nurses will give you medications as needed to keep you comfortable and pain free. However, the sore throat and some difficulty swallowing may last for 3-7 days. This is normal.

There will be a small tube, less than ¼ of an inch wide, that will exit from the skin of the neck. This is called a drain and it is designed to prevent any fluid from building up in the area of the surgery. The drain will be removed prior to your discharge from the hospital.

After you have awakened from the effects of anesthesia, you will be moved to your room in the hospital. You may begin drinking liquids and then gradually resume a regular diet. While in the hospital, blood tests may be necessary to check the blood level of calcium. As you recall, the blood level of calcium is controlled by the parathyroid glands. Even though the glands are not removed, they may go into shock for a short period of time and your blood level of calcium may drop. Symptoms of low blood calcium include numbness of the fingers or lips, muscle cramps, or facial twitching. If you or your family notice these symptoms, be sure to notify your nurse. This situation is not uncommon and when it occurs, it is usually short-lived lasting from 1 to 7 days. If low blood calcium levels are confirmed by the blood tests, you will be given oral supplements (usually Tums^® tablets) until the shock to the parathyroid glands passes and your blood levels of calcium return to normal. If you are sent home on oral calcium supplements and the symptoms of low blood calcium level develop again, call Dr. Alford's office and/or your endocrinologist.

If you have a thyroid lobectomy, you can expect to be discharged from the hospital the day after surgery. If you have a more extensive surgical procedure such as removal of the entire thyroid gland (total thyroidectomy) you will go home when:

1.The fluid from the drain tube has decreased to an acceptable amount
2.We are sure that your blood levels of calcium are normal

This can occur as soon as the day after surgery or may take up to 5 days - two days is about the average hospital stay. In all cases, you will only be sent home when it is safe to do so. You will stay in the hospital as long as it is medically necessary.

At Home

• Eating: You may eat or drink whatever you like. Most people prefer liquids or soft foods, due to the mild sore throat which is normal for 3-7 days following surgery.
• Bathing: 24 hours following the removal of the drain, you may bathe or shower normally. You do not need to keep the stitches or tapes over the stitches dry; however, when you finish bathing or showering, be sure to "pat dry" the area of surgery.
• Medications: You will take an antibiotic for 5 days after surgery. This should be taken as prescribed until the entire prescription is gone. At discharge from the hospital, a prescription for pain medication will be given to you. By the second day after surgery, most people receive adequate pain relief from Tylenol^®; however, if you need prescription-strength medicine to be comfortable, you should take it. If you need this prescription medicine, be sure to take it with food to prevent upset stomach. Do not take aspirin, Advil^®, Motrin^®, ibuprofen or NSAIDS, until after your stitches are removed (see list provided by nurse).
• Driving: You may not drive for at least 1 week following surgery. This is because the muscles of the neck will be stiff and sore, which makes it difficult for you to safely look side to side or behind you while driving. You may not drive while taking prescription-strength pain medicine.
• Follow-up Visits: Your first office visit will occur 7-10 day after surgery. At this time, your stitches will be removed and we will discuss the results of the pathology report (tests done on the tissue removed at the time of surgery). Your second office visit will occur approximately 1 month after surgery and will ensure that your wound is healing well and your recovery is progressing appropriately.

Thyroid Medications
Some people must take artificial thyroid hormone pills by mouth after thyroid surgery. If this is necessary, your family doctor, internist, primary care physician or endocrinologist will dispense this medication and let you know when to take it and how much to take.

Potential Surgical Risks And Side Effects
Any time someone has surgery they are at risk for bleeding, infection, or development of scars. Each of these occurs very rarely. Blood transfusions are almost never necessary.

Due to the closeness of the nerves of the voice box to the thyroid gland, there is a risk of damage to these nerves, which can cause a change in the voice, hoarseness and difficulty swallowing and/or eating. These side effects are VERY RARE.

Temporary low blood levels of calcium do occur about 30% of the time. This situation is rarely permanent; however, if it is permanent, you will need to take supplements for the rest of your life.

As a result of surgery, you may have to take artificial thyroid hormone by mouth for the rest of your life.

We always do a "frozen section" - a test performed by the pathologist during surgery to determine whether or not the thyroid tissue removed from the neck contains cancer. This test is not done on all of the tissue removed during surgery - only a sample of the tissue is tested. To be sure that no cancer is present, all of the tissue removed during surgery will be processed and examined by a pathologist over the 3-5 days following your surgery. Less than 10% of the time, this more thorough and complete examination of the thyroid tissue removed from the neck will reveal something that could require another operation or further testing or medication. You will be called by Dr. Alford or his nurse as soon as the results of this testing are complete.

When To Call The Doctor

Remember that there are no bad questions - you are encouraged to call Dr. Alford's office whenever you have concerns: 713-532-3223.

1. If you have fever over 101.5º that is not relieved by Tylenol^®.
2. Bleeding, redness, drainage, swelling or excessive pain at the surgery site.
3. Suspected reaction to medications.