Recovery after thyroid surgery: voice, calcium, scar and follow-up

In the first days after thyroid surgery, most people feel tired and have some discomfort in the neck. Pain is usually moderate and is eased with the painkillers prescribed by the doctor. The surgeon decides how long you stay in hospital, based on the extent of the operation and how the first hours and days after the procedure go.

In the first few days, it is common to have:

• pain or discomfort on swallowing and a feeling of a "lump" in the throat
• tightness and mild swelling around the incision on the neck
• mild hoarseness or a voice that tires more quickly
• a scratchy throat from the breathing tube used during a general anaesthetic

Eating usually returns to normal gradually: first fluids, then soft and puréed food, then your usual meals as swallowing becomes easier. Cold drinks may soothe the throat. Sudden tilting of the head backwards and sharp turning of the head should be avoided, but the neck should not be kept completely stiff. If a drain, a thin tube that removes fluid from the wound, was placed during the operation, the surgeon decides when it is removed.

Thin nerves that move the vocal cords run close to the thyroid gland. During the operation, the surgeon takes care to preserve them. Even so, the voice can change temporarily because of slight stretching or swelling of the surrounding tissue, and also because of the breathing tube used during the anaesthetic. This is why mild hoarseness, a quieter voice and tiring more quickly when speaking are common in the first days and are usually temporary. The voice normally recovers within a few days to a few weeks, and less often recovery takes several months. Some people find it harder to reach high notes for a while, which matters for those who sing or speak a lot. A permanent change in the voice is rare.

In the first weeks, it helps to:

• speak in moderation, without shouting or long conversations
• drink enough fluids during the day
• avoid tobacco smoke and dry air in the room
• be patient, as the voice recovers gradually

If hoarseness lasts longer than two to three weeks or gets worse, the surgeon may refer the patient to an ear, nose and throat (ENT) specialist to have the vocal cords examined. Choking or coughing when drinking fluids should be reported to the surgeon without delay. Difficulty breathing or noisy, high-pitched breathing is not expected, and in that case you should call an ambulance on 194 without delay.

On the back of the thyroid gland there are small parathyroid glands, usually four. They produce parathyroid hormone (PTH), which keeps the level of calcium in the blood normal. When the whole thyroid gland is removed, the parathyroid glands may temporarily work less well, so the calcium level in the blood can drop. After removal of one lobe, this is rare. This is why, after removal of the whole gland, the doctor usually checks calcium and, if needed, PTH.

Signs of low calcium usually appear in the first few days after the operation:

• tingling or a pins-and-needles feeling around the lips
• tingling in the fingertips and toes
• cramps or stiffness in the muscles of the hands and face

If tests show low calcium, the doctor may prescribe calcium and vitamin D supplements. This treatment is usually temporary, until the parathyroid glands start working normally again. The dose is only changed as agreed with the doctor. A drop in calcium is rarely permanent; when it is, long-term treatment and regular check-ups are needed. If tingling or cramps start at home, you should contact the surgeon or the emergency service without delay. Cramps that spread or do not ease, and difficulty breathing, require a call to an ambulance on 194.

The incision is usually made on the lower front of the neck, in a natural skin crease where possible, so that the scar is as discreet as possible. The wound is closed with dissolvable stitches, stitches that need to be removed, or skin glue. On discharge, the surgeon explains how to care for the wound, when you can shower and whether and when the stitches will be removed.

General wound care:

• keep the wound clean and dry, without rubbing
• wash your hands before touching the wound or dressing
• no baths, swimming pools or sea swimming until the surgeon approves it
• no creams or oils on the wound until it has fully healed

In the first months, the scar is usually red and slightly raised, and then it gradually fades and softens. During the first year, it is advisable to protect the scar from the sun with a scarf or a high-SPF sun cream. Scar massage and silicone products are used only once the wound has fully healed, and on the doctor's advice.

Whether hormone replacement is needed depends on how much thyroid tissue was removed. After removal of the whole gland, the body no longer makes thyroid hormones, so lifelong replacement treatment is needed every day. After removal of one lobe, the remaining part of the gland often makes enough hormone, but some patients still need treatment. Blood tests show this.

The dose is set by the doctor, mainly according to the TSH result, and should not be changed on your own. The first hormone check is usually done six to eight weeks after the operation, and then according to the surgeon's or endocrinologist's plan. The doctor also explains how to take the treatment. Some supplements, such as calcium and iron, reduce its absorption if taken at the same time. They are therefore taken a few hours apart, as instructed by the doctor. If your body weight changes noticeably after the operation, this is a reason to check TSH and discuss the treatment with your doctor.

The first follow-up appointment with the surgeon is usually within the first two weeks after the operation, and the exact date is arranged on discharge. The follow-up plan depends on the extent of the operation and the results, and usually includes:

• an examination by the surgeon and a wound check, with stitch removal if needed
• blood calcium and, if needed, parathyroid hormone (PTH), usually after removal of the whole gland
• TSH and free T4 (FT4), to check how the remaining part of the gland is working or to adjust hormone replacement
• thyroglobulin with thyroglobulin antibodies, and a neck ultrasound (of the thyroid area and lymph nodes), when the histology report and treatment plan call for them, for example after surgery for thyroid cancer

The histology report on the removed tissue arrives after the operation, and the surgeon explains it at the follow-up appointment. This report determines whether further check-ups or treatment are needed. Prices for the surgeon's follow-up appointment, stitch removal, the tests listed and a thyroid ultrasound can be found in the Maja Hospital price list.

Gentle walking is recommended from the first days, as it helps recovery. Most people gradually return to their usual daily activities within one to two weeks. Office work is usually possible sooner than physically demanding work. When sick leave is needed, its length is set by your GP, in line with the surgeon's report and recommendation.

As a rough guide, subject to the surgeon's final assessment:

• lifting, running and heavier physical work are usually avoided for two to four weeks
• swimming in a pool or the sea is possible once the wound has fully healed and the surgeon approves it
• driving is possible once you can turn your neck freely and are not taking medicines that slow your reactions
• jobs that involve a lot of speaking may require a longer period of voice rest

Most symptoms after thyroid surgery ease from day to day. Some signs, however, need a quick response, although not all are equally urgent.

Call an ambulance on 194 without delay if you have:

• difficulty breathing, noisy high-pitched breathing or a feeling of choking
• swelling of the neck that grows quickly or becomes tense
• muscle cramps that spread or do not ease

Contact the surgeon without delay, or the emergency service if the surgeon is not available, if you have:

• tingling around the lips or in the fingers
• a temperature of 38 °C or higher
• redness, warmth, bleeding or pus from the wound
• choking when drinking fluids or difficulty swallowing that is getting worse
• hoarseness or a weak voice that is getting worse
• pain that is getting worse and does not ease with the prescribed medicines