Thyroid Disease & Surgery

There are four subtypes of cancer that arise from the thyroid gland itself. In addition, rarely lymphoma or cancers from other areas in the body can spread to the thyroid gland.

• More than 80% of thyroid cancers are papillary thyroid carcinoma. This is generally a low grade, slowly spreading cancer that is often successfully removed with surgery. Additional treatment is sometimes indicated depending on the extent and characteristics of the tumor. Lymph node removal and/or administration of radioactive iodine to treat residual microscopic disease are among these therapies.
• Follicular cancer represents about 10% of primary thyroid cancers and can spread to other areas in the body in about 10-30% of patients. Treatment is usually limited to surgical removal of the thyroid.
• Medullary cancer, which can be hereditary, accounts for less than 10% of thyroid cancers and can be associated with other abnormalities of the endocrine system.
• Anaplastic cancer is a very rare form that generally occurs in older patients. Treatment may involve radiation, chemotherapy, and/or surgery.

The thyroid gland can over- or under-produce thyroid hormone. Symptoms of hyperthyroidism (excessive thyroid hormone) include tremors, palpitations (racing heart), trouble sleeping, heat intolerance, weight loss, hair thinning, nervousness, irritability, muscle weakness and abnormal menstrual cycle.

Symptoms of hypothyroidism (inadequate thyroid hormone) include lethargy, weakness, cold intolerance, dry skin, depression, constipation, forgetfulness, weight gain, joint pain, and abnormal menstrual cycle.

Thyroid ultrasound is a painless procedure and uses no radiation. During the procedure, the patient lies on a comfortable table with his or her neck slightly extended. The ultrasound technologist uses a transducer coated with gel to scan over the thyroid gland and obtain a series of standard images. Both lobes are measured, and any nodules that are seen are measured. Color Doppler ultrasound is utilized to help determine the vascularity of the gland as a whole, as well as any focal abnormalities.

The exam takes 15 to 45 minutes to complete, depending on the number of nodules.  The radiologist spends time evaluating the information obtained by the sonographer and compares the findings to any prior examinations. Although ultrasound cannot definitively differentiate benign from cancerous nodules, there are a number of features that the radiologist uses to help determine whether a biopsy is needed. Features of a nodule that increase the likelihood of cancer include irregular shape, a large proportion of solid tissue, calcifications within the nodule, and increased vascularity.

Based on these observations, the radiologist then generates a report to the referring clinician. Often, the radiologist will then make recommendations for follow-up imaging or for fine needle aspiration/biopsy.

A fine needle aspiration (FNA), is an extremely safe, minimally invasive biopsy procedure typically performed by a radiologist using ultrasound guidance to help target the abnormal area.

The FNA procedure takes about 30 to 60 minutes, depending on the number of nodules being sampled. The radiologist will explain the procedure to the patient, including the risks of FNA. These include mild pain at the biopsy site and the potential for bleeding or infection. In a some cases, the pathologist is unable to make a definite diagnosis based on the FNA sample, which may lead to a second biopsy or surgical removal of part of the thyroid gland for final diagnosis.

The FNA procedure is performed with the patient lying comfortably on a table, with their neck slightly extended. In the procedure room, the radiologist is assisted by an ultrasound technologist who assists with various instruments used for the FNA and operates the ultrasound machine for the radiologist.

To do the FNA, the radiologist scans the neck with the ultrasound probe and places a mark at the skin entry site for the needle. This area is cleaned with an antibacterial solution, and then a local anesthetic such as lidocaine is administered. Next, several samples are obtained from the nodule or nodules. Typically, anywhere from one to three nodules may be sampled at each visit. The final report is typically available in 2 or 3 days.

Symptoms after the procedure are generally mild and may consist of slight tenderness or bruising at the biopsy site. There are no restrictions on activities after the procedure.

A small incision is made low in the neck. Once the underlying muscles are retracted, the thyroid gland is exposed. Prior to its removal, the structures surrounding the thyroid gland (blood vessels, nerves, parathyroid glands and lymph nodes) are carefully examined, both to assess any abnormalities and to minimize the risk of injury.

Careful surgical dissection allows removal of the diseased portion or the entire gland. A microscopic review of the removed portion will guide future treatment such as additional surgery, radio-iodine therapy and thyroid medication. Some patients may be discharged the same day, while others require an overnight hospital observation.

Thyroid surgery is safe and in appropriately selected patients can have significant benefits. However, any operation has some general and specific risks. The general risks of this surgery include a reaction to the anesthetic, prominent scar, wound infection, and blood clots. The more specific risks include:

1. Bleeding: Bleeding following surgery is rare but can result in a clot in the neck tissue which can, in turn, put pressure on the windpipe. This can lead to difficulty breathing and is treated with a second operation to remove the clot.
2. Low Calcium Level (Hypocalcemia): Some patients can experience a drop in their blood calcium below levels that are normal following surgery. This is usually treated with calcium tablets and typically improves with time. In extremely rare situations, all 4 parathyroid glands are inadvertently removed or lose their blood supply, which can result in permanent hypocalcemia requiring lifelong calcium supplementation.
3. Voice Hoarseness: Some patients may experience hoarseness or changes in the caliber of their voice following surgery. In the majority of cases, this is a temporary event. However, in 1-2% of cases, injury to the recurrent laryngeal nerve results in permanent voice changes. Additional surgery or speech therapy can be helpful in some cases.
4. Loss of Airway: If the nerves supplying both vocal cords are injured during the surgery, this can lead to a blockage of the windpipe, requiring the need for a tracheostomy (an artificial airway created through the neck). This event is exceedingly rare and occurs in less than 1% of cases.

After surgery, many patients will be able to go home the same day or the following morning. Recovery is fairly quick, and the procedure causes little discomfort. Patients usually resume normal activity within a couple days, and some patients return work within days of the surgery.

Diet: You may experience some decrease in your appetite, nausea and occasionally vomiting. Therefore you may do better with light meals for the first 24-36 hours following surgery.

Activity: Do not engage in potentially hazardous work or make important personal or business decisions if taking pain medications. Do not drive until narcotics are no longer required for pain control.

Elevate the head whenever possible. When sleeping, use 2-3 pillows if possible. We recommend that patients avoid driving until they are comfortable moving their neck in all directions and until they are OFF narcotics.

Wound: Leave butterfly strips in place if present. You may notice some bruising around the incision or below your scar. You may shower 24 hours following surgery. Avoid baths for 2 weeks. No special ointments or creams are required.

The scars are often hidden in natural skin folds in the neck and usually heal well, becoming less pronounced with the passage of time.

Medication: Take pain medication and any supplements as instructed. Keep in mind that pain medications can sometimes cause nausea and are better tolerated if taken with some food. If you develop constipation, you may use over the counter stool softeners such as MiraLAX or Dulcolax 1-2 times daily. Please contact your pharmacy to obtain a refill. We can work directly with them to expedite the prescription. We are unable to refill medications on the weekend.

Take pain medication, calcium/vitamin D supplements and thyroid replacement, if applicable, as instructed. If you develop numbness or tingling around your mouth or fingertips, take 2 additional calcium pills and contact your physician as this may represent a sign of low calcium levels.

Follow Up: Please schedule an appointment to see your surgeon 2 weeks following surgery. If necessary, you should also get your calcium and parathyroid hormone levels checked 6 months after surgery. If on thyroid replacement therapy, a blood test will be checked by your surgeon or endocrinologist in a few weeks to ensure appropriate dosage. Call your surgeon’s office and their staff will be happy to make the necessary arrangements for you.