Thyroid Surgery Complications: Low Serum Calcium

One of the risks factors associated with a total thyroidectomy is the possibility of low serum calcium after the operation, either on a temporary or permanent basis.

There are four small glands, a little less than pea-size, that live next to the thyroid gland that are called “parathyroid glands’. They get their name from their location and have absolutely nothing to do with thyroid gland function.

These glands make a hormone called PTH, or parathyroid hormone, a hormone whose job it is to keep the level of calcium in the blood normal. It does this by many mechanisms, helping you absorb calcium from your diet, managing the calcium in bones, and so on.

If one were to lose all four of his or her parathyroid glands, the serum calcium would take a serious drop and replacement calcium and Vitamin D would probably have to be taken for life.

When performing thyroid surgery, it is prudent to look for and preserve these glands immediately after locating and preserving the recurrent laryngeal nerve, discussed elsewhere. On the surface this seems like a simple thing to do, but it isn’t always for several reasons.

• First, not everyone has 4 parathyroid glands, some have 5 or more and others may have only three or less. 

• Next, their location in the neck can be extremely variable, in fact, one or more may not actually be in the neck at all, but rather in the upper chest or other atypical location. 

• Finally, they are sometimes rather nicely camouflaged sitting in the soft fatty tissues of the neck. It can often require an experienced thyroid surgeon to discern the very subtle color differences between parathyroid tissue and normal adjacent fat and soft tissue.

If one were to lose all four glands, or if all four glands died from lack of blood supply secondary to the trauma of surgery, that patient would in all likelihood have permanent low calcium after surgery. This, of course, assumes the patient has the normal number of parathyroid glands. It is possible to lose the function of one or two parathyroids and have no calcium difficulties whatsoever, because the remaining two glands can almost always take up the slack and maintain normal calcium levels. This is why we virtually never see even temporary low calcium after only a partial thyroidectomy since the glands on the unoperated side are left unmolested. 

Again, this always assumes the patient started out with 4 parathyroid glands, and there is never any guarantee or that. Temporary low calcium levels can be seen after thyroidectomy simply because the parathyroid glands became bruised or swollen after surgery, thus making it difficult for them to produce normal amounts of parathyroid hormone. These patients may have a temporary low calcium that requires minimal or no calcium replacement and in time the parathyroid glands function well once again.

When a patient with thyroid cancer undergoes a radical or total thyroidectomy  all of the thyroid gland is always removed and there is the risk of low calcium after surgery. The treatment for low calcium after total thyroidectomy is to supplement the diet with calcium and perhaps Vitamin D until the situation corrects itself. 

There are a number of calcium supplements in various forms such as pills, syrups, and liquids that perform the job quite nicely. Most instances of temporary low calcium resolve in as little as a few days to as long as a month or two. As long as sufficient living parathyroid tissue is left behind after surgery, the calcium levels should ultimately be just fine.

Thyroid Nodules Treatment

If your nodule is not cancer and is not causing problems, your doctor may watch your nodule closely. If your thyroid nodule is causing hyperthyroidism, your doctor may recommend a dose of radioactive iodine, which usually comes in a pill that you swallow. Your doctor may have you take medicine (antithyroid pills) for a few weeks to slow down the hormone production. Your thyroid hormone level needs to be normal before you can be treated with radioactive iodine.

If your nodule is cancer or is so large that it causes problems with swallowing or breathing, you'll need surgery to remove the nodule. You may also need treatment with radioactive iodine to destroy any left over cancer cells. After surgery, you may need to take thyroid medicine for the rest of your life.

Thyroid Nodule Surgery:  The extent of your thyroid nodule or tumor surgical removal will be determined by your doctor after evaluation your health history and diagnostic tests, family history and other factors.But in general either a partial or complete thyroidectomy (thyroid removal surgery), is recommended for:

• Thyroid cancer or indeterminate lesions that cannot be classified from a fine needle aspiration biopsy.

• Large thyroid nodules that cause obstructive symptoms, such as problems breathing or swallowing.

• Thyroid nodules that cause pain.

• Cosmetic reasons, to remove large visible thyroid nodules.

Radioactive Iodine: Iodine-131 concentrates in the thyroid tissue and cause tissue destruction. I-131 can be administered as a capsule or in liquid form.

• I-131 can be used to treat multinodular goiters with nodules that are producing extra thyroid hormone. Such cases are indicated by a low TSH level and elevated thyroid hormone level in the blood or a "hot" nodule on radionuclide thyroid scan. 

• After I-131 destroys the thyroid, the patient develops an underactive thyroid (hypothyroidism) and requires thyroid hormone replacement for life to maintain a normal level of thyroid hormones in the blood. Thyroid hormone replacement consists of simply a pill taken once daily by mouth, which is safe, easily tolerated, and relatively inexpensive.

Thyroid Hormone Suppression: There is controversy regarding whether physician-supervised administration of thyroid hormone may shrink the size of thyroid nodules. Many doctors believe that thyroid hormone does not effectively shrink nodules. Furthermore, there is the risk of high blood levels of thyroid hormone in patients with multiple thyroid nodules (multinodular goiter). However, clinical trials have shown that suppressive therapy may be successful in shrinking some thyroid nodules. Doctors may make this decision on a case-by-case basis and studies are still ongoing to determine the efficacy of this type of treatment. It is important to discuss the pros and cons of suppressive thyroid hormone therapy with your doctor.