Thyroid Surgery

What is the thyroid and what does it do?

The thyroid gland is a large butterfly-shaped organ in the front of your neck, wrapping around the trachea (windpipe). It has two lobes (left and right) connected by a small bridge called the Isthmus, each about 5x3x2 cm in size. Its main job is to produce the hormone Thyroxine (T4), which is converted to its active form, T3, outside the thyroid. These hormones are essential for controlling your metabolism.

The levels of T4 and T3 are tightly regulated, with the brain constantly monitoring and adjusting their production through a signal called Thyroid Stimulating Hormone (TSH). Iodine is vital in your diet for making these hormones, known as thyroid hormones, which are assessed through blood tests.

Another hormone produced is Calcitonin, which helps lower calcium levels in the blood by moving it into the bones. This works against Parathyroid Hormone (PTH), produced by four parathyroid glands next to the thyroid, which increases calcium levels.

What is a Goitre?

Goitre is a medical term that is used to describe the condition characterized by the ‘enlargement of the thyroid gland.’ There are a variety of reasons why a thyroid gland may become enlarged, leading to this condition. The enlargement can present itself as smooth throughout, which is referred to as a diffuse goitre, or it may be nodular in nature, known as a nodular goitre. Some of the underlying causes of a goitre are listed below.

• Diffuse Goitres

• Iodine deficiency (most common world wide).

• Graves Disease (autoimmune). 

• Acute thyroiditis (inflamed thyroid, including Hashimoto’s).

• Goitrogen ingestion (foods that stimulate growth).

• Lymphoma. 

• Pituitary adenoma (tumour) secreting TSH.

• Amyloidosis.

• Nodular Goitres

• Benign multi-nodular goitre (MNG).

• Thyroid cancer. 

• Thyroid adenoma (benign nodule).

What is Hypothyroidism (underactive) and hyperthyroidism (overactive)?

• Thyroid hormone levels are usually well-regulated. However, certain conditions can cause too much hormone production, resulting in hyperthyroidism (overactive thyroid). Conversely, some conditions can lead to too little hormone production and hypothyroidism. A blood test will assess these hormone levels when a thyroid issue is suspected. Before any surgery, it is vital to address any significant abnormalities. Below are the signs and symptoms of hypo- and hyperparathyroidism.

Hyperthyroidism (overactive)

• Palpitations.

• Increased heart rate.

• Sweating.

• Tremor.

• Anxious.

• Diarrhoea.

• Muscle weakness.

• Intolerance of heat.

• Protruding eyes (exophthalmos – graves disease).

Hypothyroidism (under-active)

• Abnormal weight gain.

• Tiredness. 

• Fatigue and lethargy.

• Slow heart rate.

• Intolerance of cold.

• Hair loss.

What tests do I need before thyroid surgery?

To diagnose a thyroid problem, doctors usually use blood tests and imaging. Common tests include:

• Thyroid ultrasound

• CT scan of the neck

• Thyroid nuclear scan

• Blood tests for function and antibodies

• Thyroid Ultrasound

Most commonly, only a Thyroid / Neck Ultrasound is needed prior to proceeding with surgery. This ultrasound provides a detailed and clear view of the gland, as well as any nodules that may be present. If there happens to be anything suspicious identified during the ultrasound examination, a biopsy may be arranged at the same time for further evaluation. In many cases, a thyroid ultrasound is the only imaging study required to assess the condition thoroughly.  

• CT Scan

A CT scan is typically performed if thyroid cancer is diagnosed and in cases where there is a very large thyroid gland extending into the chest or causing compression of surrounding tissues. This imaging study is also indicated for patients who present with symptoms suggestive of compression of various neck structures, such as the oesophagus, which can lead to swallowing difficulties, or the trachea, which may cause breathing challenges. By conducting a CT scan, we are able to obtain a more detailed visualization of the gland as well as the surrounding structures that may be affected, thereby aiding in the surgical planning process.

• Thyroid Nuclear Scan

This procedure is not usually necessary for every patient. However, it may be arranged specifically to confirm the diagnosis of Graves' disease or to exclude it if you have a single nodule that is overactive. Dr. Green will take the time to thoroughly check whether the nodule is the sole cause of the thyroid overactivity or if the entire gland is overactive, as seen in cases of Graves' disease. A thyroid scan can effectively reveal the presence of Hot-nodules, which are classified as overactive, or Cold-nodules, which are underactive. It is important to note that Cold-nodules can sometimes indicate a risk of thyroid cancer, occurring in approximately 20% of cases. If these Cold-nodules are indeed present, a hemithyroidectomy is typically recommended as the next step in management.

Thyroid Function Studies and Antibodies (Blood Tests)

Thyroid function blood tests are important before surgery. They help Dr. Green find out if your thyroid is normal (euthyroid), underactive (hypothyroid), or overactive (hyperthyroid). If you have an overactive thyroid, surgery is not safe, and you will need medication to lower the activity before the procedure.

A thyroid function test includes:

• Thyroid Stimulating Hormone (TSH): A hormone from the pituitary gland that tells the thyroid to produce more hormones.

• Thyroxine (T4): A hormone released by the thyroid that speeds up chemical reactions in your body. T4 is converted to the active hormone triiodothyronine (T3) in the blood.

• Triiodothyronine (T3): The active hormone that regulates many body functions, including metabolism, growth, body temperature, heart rate, mood, muscle strength, weight, and reproductive hormones.

• Thyroid Antibodies: are tested to confirm diagnoses like Graves' disease or Hashimoto's thyroiditis. These are autoimmune antibodies, meaning they attack the body's own tissues. In the case of thyroid antibodies, they target the thyroid gland. This can lead to various thyroid conditions, such as overactivity (Graves' disease) or damage to the gland (Hashimoto’s thyroiditis).

• Vocal Chord Check

This is not a routine test that is commonly performed. However, there will be specific circumstances in which Dr. Green feels it is necessary to assess the function of your vocal chords prior to proceeding with the surgical operation. If you are experiencing symptoms such as a hoarse voice or if a large cancer has been diagnosed, a vocal chord check is likely to be requested. This evaluation requires the use of a small fibre-optic camera that is gently passed through your nose and into your throat in order to observe how your vocal chords move during this examination. Additionally, this procedure may also be performed after surgery if there is any concern that the nerve which controls the vocal chords, known as the recurrent laryngeal nerve, may have sustained an injury.

 Why do I need a biopsy of my thyroid nodule?

Any lump in the neck or thyroid needs a biopsy to confirm its nature, especially to check if it is cancerous. For thyroid lumps, a Fine Needle Aspiration (FNA) biopsy is done. Nodules larger than 10mm or suspicious smaller ones are biopsied. An FNA collects a sample of cells from the thyroid nodule for microscopic examination. A pathologist then assesses the cells using the Bethesda Criteria to determine the risk of cancer, leading to recommendations for surgery or observation based on the results.

Bethesda Criteria Results

Result. Chance of cancer

Recommendation

1. Non-diagnostic - 10% risk

Repeat biopsy.

2. Benign. <3% risk

Can observe.

3. Atypical lesion. 10-15% risk

Possibly observe or remove.

4. Follicular neoplasm (tumour) 15-30%.

Remove or possibly observe.

5. Possibly cancerous. 60-70% risk

Surgical Removal

6. Cancerous 90-99% risk

Surgical Remove.

 What is a thyroid adenoma?

A Thyroid adenoma is a non-cancerous tumor of the thyroid gland known as Follicular adenoma. These tumors are not harmful and do not spread. They usually appear as a lump in the neck or are found during imaging done for other reasons. They can be small (<1cm) or large (>10cm). If found, a biopsy is done to confirm it is benign.

Reasons to remove a follicular adenoma include:

• It compresses important structures, causing issues like coughing or difficulty breathing (trachea) or swallowing problems (oesophagus).

• It’s larger than 3 cm, as larger tumors make biopsy results less reliable and may mask thyroid cancer.

• A biopsy suggests potential thyroid cancer.

• It’s overactive, leading to hyperthyroidism.

• It is cosmetically unappealing.

 What is Graves Disease?

Graves disease is an autoimmune disorder that makes the thyroid gland swell and become overactive. It can also lead to eye problems, including double vision. In this condition, the immune system mistakenly triggers the thyroid to produce too much hormone, a state known as hyperthyroidism. This happens because immune cells create antibodies that stimulate the thyroid receptors, which are usually activated by a hormone called Thyroid Stimulating Hormone (TSH). These antibodies are known as TSH Receptor Antibodies. A blood test can confirm Graves disease by looking for these antibodies. The ongoing stimulation causes the thyroid to enlarge (Graves Goitre) and overproduce hormones. Without treatment, your eyes may be affected, causing redness (chemosis), bulging eyes (Exophthalmos or Proptosis), and eventually double vision (diplopia). An eye exam may be needed to check for these symptoms.

Treatment of Graves Disease

Graves disease can be treated in three ways:

1. Medication

2. Radioactive iodine

3. SurgeryMedical management

Medical Management

Medical management of hyperthyroidism primarily involves the use of specific medications aimed at controlling the various symptoms associated with the condition. Typically, drugs such as Carbimazole or Propythiouracil (PTU) are prescribed to effectively manage these symptoms and can sometimes lead to a remission of the disease. However, it's important to note that some individuals may experience difficulty tolerating these medications, or there may be instances when they become less effective over time. In such circumstances, alternative treatment options like surgery or radioactive iodine therapy may become necessary to ensure proper management of the condition.

Radioactive Iodine (RAI)

Radioactive Iodine (RAI) treatment involves the administration of iodine tablets that contain a small amount of radiation (I131) specifically designed to destroy overactive thyroid cells. During the treatment process, patients are required to remain isolated for approximately 3 to 4 days to allow the radiation to effectively work within the body. The side effects associated with RAI are generally minimal and differ markedly from those experienced with external radiation therapy. As the thyroid gland absorbs the administered iodine, the radiation then acts to destroy the malfunctioning cells. It is crucial to understand that following this treatment, patients may become hypothyroid and consequently require Thyroxine medication for life. One of the significant advantages of RAI is the fact that it eliminates the need for surgical intervention, thereby allowing antithyroid medications to be discontinued. However, it's worth noting that RAI may not always yield successful results, and there is a possibility that Graves' disease could recur, which may necessitate further surgical decisions. Additionally, RAI treatment is deemed unsafe for pregnant women and is not recommended for individuals who present with eye symptoms or those with a large thyroid gland that is causing swallowing or breathing complications, as this treatment could potentially exacerbate these issues.

Surgical Management

Surgical management is considered a definitive treatment option for Graves' disease. The surgical procedure typically involves the complete removal of the thyroid gland, necessitating that patients take lifelong thyroxine medication post-surgery. The primary benefit of undergoing this surgical intervention is its effectiveness in 'curing' Graves' disease, thereby eliminating the need for ongoing antithyroid medication. Surgery is usually regarded as the most optimal choice when the thyroid gland is significantly enlarged and exerts pressure on surrounding anatomical structures, or when the patient is exhibiting eye symptoms that require prompt attention.

Thyroid cancer

Thyroid cancer is typically characterized as a very slow-growing type of cancer that often demonstrates an excellent prognosis for those affected. It tends to occur more frequently in younger patients, and the condition usually presents itself as a noticeable lump in the neck or within the thyroid gland. This early detection can lead to effective treatment options and a favorable outcome.

There are four Main types of thyroid cancer:

• Papillary Thyroid Cancer (PTC)

The most common type of thyroid cancer is papillary thyroid carcinoma (PTC), often seen in younger patients but can occur at any age and in any gender. PTC often appears in multiple spots, known as multifocal. It spreads through lymph nodes, so removing nearby lymph nodes is a typical part of treatment to evaluate the disease's extent. These tumors usually have a very good outlook and grow slowly, particularly in younger patients. They do not need chemotherapy but may require Radioactive Iodine (RAI) treatment in more advanced cases alongside surgery.

• Follicular Thyroid Cancer (FTC)

  Another common type of thyroid cancer tends to occur in older patients compared to papillary thyroid carcinoma (PTC). While it can happen in individuals of all ages, there is a slight increase in cases observed among women. These tumors uniquely spread through the bloodstream, which means that lymph node removal is not typically necessary for effective treatment. When diagnosed early and meticulously removed, they usually present a good prognosis, allowing for a positive outlook for affected patients.

• Medullary Thyroid Carcinoma (MTC)

• Medullary thyroid carcinoma is a rare type of thyroid cancer. These tumors are aggressive and can spread to nearby lymph nodes. The main treatment is complete removal of the tumour and surrounding lymph nodes. These tumors are often linked to genetic conditions like MEN syndrome. Aggressive surgery and testing for genetic syndromes are crucial for treatment. The outlook is poor if the tumor isn't completely removed.

• Anaplastic Thyroid Carcinoma

·Anaplastic thyroid carcinoma is an extremely rare and particularly aggressive form of thyroid cancer that poses significant clinical challenges. Unfortunately, anaplastic carcinoma is rarely curable, and treatment approaches are generally palliative in nature, aiming to alleviate symptoms rather than eradicate the disease. Overall survival rates for patients are often less than 12 months from the time of diagnosis, highlighting the urgent need for early detection and effective management of this aggressive cancer type.

What is a Hemithyroidectomy and Total Thyroidectomy?

• Hemithyroidectomy

This surgical procedure involves the careful removal of a single lobe of the thyroid gland. This operation is often performed in cases involving solitary nodules or when the diagnosis of a particular nodule remains uncertain. Typically, the remaining lobe of the thyroid should be able to adequately adjust and continue to produce sufficient levels of thyroxine, thus eliminating the need for any medication following surgery in the majority of cases.

• Total Thyroidectomy

This procedure involves the complete removal of your thyroid gland, which is a crucial endocrine organ. The operation effectively entails performing two hemithyroidectomies to ensure that all thyroid tissues are excised. Following the surgery, you will need to be placed on thyroid replacement therapy, specifically with a medication called Thyroxine. It is vital to understand that this therapy MUST be continued for the remainder of your life to maintain proper metabolic function and overall health.

What is involved in the operation?

Procedure Details:

• Anesthesia: Both operations are performed under general anesthesia.

• Hospital Stay: Typically requires an overnight stay; a total thyroidectomy may require two nights if calcium levels are low post-surgery.

Surgical Approach:

• Incision: A small incision (3-6 cm) is made in a skin crease on the front of the neck, larger if necessary for large glands or lymph node removal.

• Thyroid Removal: The thyroid is carefully dissected from surrounding structures, with attention to:

  • Blood Vessels: Multiple small blood vessels must be controlled, along with the major blood supply to the thyroid.

  • Parathyroid Glands: Small glands attached to the thyroid that regulate calcium levels. Preserving these is crucial; damage carries a 1% risk of requiring lifelong calcium replacement. If damaged, a gland may be reimplanted in the neck muscle and may regain function in about six months.

Nerve Protection:

• Recurrent Laryngeal Nerve (RLN): Critical for voice and swallowing; damage (less than 1% chance) can lead to a weak voice and swallowing difficulties.

• External Branch of the Superior Laryngeal Nerve (EBSLN): Important for voice projection and pitch control, with significant implications for singers and public speakers.

Post-Operative Care:

• Drain Placement: A drain may be used to manage fluid accumulation.

• Stitches and Dressings: Dissolving stitches are used, and dressings can be showered over.

• Recovery: Patients can eat and drink immediately after surgery but may experience a painful neck and sore throat, manageable with pain relief.

Monitoring:

• A blood test will assess the function of the parathyroid glands post-surgery. Up to 20% of patients may experience temporary loss of function and will be started on calcium tablets as needed.

This summary provides a concise understanding of what to expect before, during, and after thyroid surgery. For any questions, please consult Dr Ben Green’s rooms for an appointment.

Do I need to take Thyroxine Medication?

Thyroxine is a vital hormone that is produced by your thyroid gland, playing a crucial role in regulating and controlling your overall metabolism. It is essential to understand that you cannot live without an adequate supply of thyroxine. Following your surgery, you will be commenced on a thyroxine regimen immediately to help support your body's needs. While most individuals typically require a standard dose of 100mcg, it is important to note that this dosage may vary depending on factors such as your body size and the results of your pre-operative blood tests. After your operation, your hormone levels will be closely monitored and adjusted as necessary by Dr. Green, your general practitioner, or endocrinologist. Initially, you will need to undergo regular blood tests to determine the ideal dosage that works best for you. Over time, as your levels stabilize, this monitoring may decrease to potentially just annual blood tests, providing a more manageable routine for your ongoing care.