Thyroid Surgery

Dr Green is an endocrine surgeon, which means he is qualified and experienced in performing thyroid surgery. Brisbane based patients with a referral are welcome to make an appointment for a consultation. Read on to find out more about this procedure.

What is the thyroid and what does it do?

The thyroid gland is one of the largest endocrine organs in your body. It is a butterfly shaped organ that is located in the front of your neck and wraps around the front surface of your trachea (wind-pipe).

The gland is describes as being made of two lobes (left hemithyroid and right hemithyroid) connected by a small bridge called the Isthmus. The usual size of a thyroid lobe is approximately 5x3x2cm.

The thyroid glands main function is to produce a hormone called thyroxine (T4). Thyroxine is then converted to its active form away from your thyroid to T3. These hormones have vital roles in maintaining your metabolism.

The level of thyroxine and T3 are kept in tight ranges. Your brain is constantly monitoring the level and adjusting the message it sends to the thyroid to either increase thyroxine production or to reduce it. The messenger that is sent to the thyroid is called thyroid stimulating hormone (TSH). Iodine is an important ingredient required in your diet for the production of these hormones. T4, T3 and TSH are collectively referred to as your thyroid hormones and are checked via a blood test to determine your thyroid's level of functioning.

Calcitonin is also anther hormone that is produced. Its main role is to help control calcium levels in the body. Calcitonin aims to lower calcium levels by moving calcium from the blood into your bones. This is the opposite effect of parathyroid hormone (PTH), which is produced by four parathyroid glands located next to the thyroid.

What is a goitre?

‘Goitre’ is a medical term given for enlargement of the thyroid gland.

There are a number of reasons why a thyroid can become enlarged. The enlargement can be smooth (diffuse goitre) or nodular in nature (nodular goitre). Some of the causes of a goitre are listed below.

Diffuse Goitres Nodular Goitres
  1. Temporary swelling in neck, with feeling something is stuck.
  2. Bruising, scaring.
  3. Temporary Stiff neck.
  4. Iodine deficiency (most common world wide).
  5. Graves Disease (autoimmune).
  6. Acute thyroiditis (inflamed thyroid, including Hashimotos).
  7. Goitrogen ingestion (foods that stimulate growth).
  8. Lymphoma.
  9. Pituitary adenoma (tumour) secreting TSH.
  10. Amyloidosis.
  1. Benign multi-nodular goitre (MNG).
  2. Thyroid cancer.
  3. Thyroid adenoma (benign nodule).

What are hypothyroidism and hyperthyroidism?

Normally your thyroid hormone levels are kept within tight ranges and controls. There are several conditions that can result in an excess mount of hormone production leading to Hyperthyroidism (overactive thyroid). Vice versa there are conditions that can lead to an underactive thyroid and hypothyroidism.

A blood test will check for these levels whenever any thyroid related disease is suspected. Prior to any thyroid surgery it is important that any severe abnormality is corrected.

Below are the signs and symptoms associated with hypo and hyperparathyroidism.

Hyperthyroidism (overactive)

Hypothyroidism (underactive)

  1. Palpitations.
  2. Increased heart rate.
  3. Sweating.
  4. Tremor.
  5. Anxious.
  6. Diarrhoea.
  7. Muscle weakness.
  8. Intolerance of heat.
  9. Protruding eyes (exophthalmos – graves disease).
  1. Abnormal weight gain.
  2. Tiredness.
  3. Fatigue and lethargy.
  4. Slow heart rate.
  5. Intolerance of cold.
  6. Hair loss.

What is a thyroid adenoma?

A thyroid adenoma is a benign tumour of the thyroid gland called a follicular adenoma. These kinds of tumours are not dangerous and have no ability to spread around the body. Thyroid removal surgery is not necessarily required.

Follicular adenoma normally presents either as a lump in your neck or is found accidentally whilst having a scan of your neck for other reasons.

They can vary in size from very small <1cm to very large >10cm.

When they are found in your neck a biopsy will be arranged to confirm the diagnosis.

The indications to remove a follicular adenoma include:

Why do I need a biopsy of my thyroid nodule?

Any lump in the neck or thyroid needs a biopsy to confirm what is. The most important thing is to determine if the lump is cancerous or not.

For thyroid lumps or nodules a biopsy called a fine needle aspiration (FNA) is performed. All nodules larger than 10mm or smaller ones that look suspicious will be recommended for biopsy. An FNA allows a sample of cells form the thyroid nodule to be collected and then examined under the microscope. From here the pathologist will give a grading as to their likelihood of being cancerous.

The grading scale is called the Bethesda criteria and depending on the level a recommendation for surgery or observation will be made.

Bethsda Criteria

Chance of cancer

Recommendation

1. Non-diagnostic.

10%.

Repeat biopsy.

2. Benign.

<3%.

Can observe.

3. Atypical lesion.

10-15%.

Possibly observe or remove.

4. Follicular neoplasm (tumour).

15-30%.

Remove or possibly observe.

5. Possibly cancerous.

60-70%.

Remove.

6. Cancerous.

90-99%.

Remove.

What is Grave's disease?

Graves disease is an autoimmune disease that affects the thyroid resulting in it becoming enlarged and overactive. It may also be associated with some changes in your eye and resulting double vision.

As an autoimmune disease, your body’s immune system unnecessarily stimulates your thyroid gland making you develop hyperthyroidism. The immune cells produce antibodies that can activate the receptors on the thyroid that normally receive messages form the brain to increase thyroid activity. The messenger is normally called thyroid stimulating hormone (TSH). The antibodies can mimic this and are known as TSH receptor antibodies. To confirm the diagnosis of Grave’s disease a blood test will be arranged to look for the presence of these antibodies.

The constant stimulation of your thyroid results in the gland becoming enlarged (Grave’s goitre) and overactive. If untreated your eyes can also become effected resulting in a red eye (chemosis), protruding bulging eyes (exopthalmous / proptosis) and eyes that are bulging (proptosis) and eventual double vision (diplopia). You may be asked to have an eye exam to look for these features.

Grave's disease – why might I need thyroid removal surgery?

Grave's disease can be treated in 3 different ways:

  1. Medical.
  2. Radioactive iodine.
  3. Thyroid removal surgery.(thyroidectomy)

Medical management

Medical management uses medications that control the symptoms of the hyperthyroidism occasionally result in the gland heading into remission.

Some people cannot tolerate these drugs or after time they fail work. In these circumstances surgical intervention or radioactive iodine treatment may be indicated.

Radioactive Iodine (RAI)

RAI uses iodine tablets that have been mixed with a small dose of radiation (I131) to destroy the thyroid cells. RAI treatment requires you to be isolated in a room for 3-4 days whilst the radiation does its work.

RAI treatment burns the thyroid gland out resulting in it becoming underactive and requiring Thyroide replacement medication. The advantage is that no surgery is required and antithyroid medications are no longer required.

RAI treatment is not possible if you are pregnant or have a large bulky thyroid. Secondly, the effects tke some time to occur and are not always permanent.

Surgical management

Thyroid removal surgery is a definitive method of treating Grave’s disease. The operation requires removal of the entire gland, which will then need replacement with life-long thyroxine medication. The advantage of surgery is that the graves will be effectively ‘cured’. There will be no further need to take antithyroid medication.

Surgery is the preferred method to control when the gland is very big and causing compression of structures and also when there are eye signs present.

Thyroid cancer

Thyroid cancer is usually a very slow growing cancer with an excellent prognosis. It tends to occur in younger patients and usually presents as a lump in the neck or thyroid.

There are four main types of thyroid cancer:

Papillary Thyroid Cancer (PTC)

Follicular thyroid cancer (FTC)

Medullary

Anaplastic

Thyroid cancer is diagnosed on a biopsy of the thyroid nodules. It is treated usually with a total thyroidectomy. This allows further treatment with radioactive iodine (RAI) to destroy any cancer cells that may have escaped. It also allows a blood test looking for thyroglobulin, which is a protein produced by the thyroid and thyroid cancer cells to be used to monitor possible recurrence. This is particular important in PTC and FTC.

Papillary thyroid cancer often spreads to the lymph nodes and it is usual for the lymph nodes around the thyroid and trachea to be removed at the same time as the thyroid.

What images and tests do I need before thyroid removal surgery?

Thyroid / neck ultrasound

Most commonly only a thyroid / neck ultrasound is needed prior to surgery. The ultrasound allows a good view of the gland and any nodules. A biopsy may be arranged at the same time if there is anything suspicious to find. Often a thyroid ultrasound is the only imaging required.

CT scan

A CT scan is usually only performed if thyroid cancer is diagnoses or if you have a very large gland extending into the chest or causing compression. This allows a better visualisation of the gland and what structures may be involved at the time of thyroid surgery.

Thyroid nuclear scan

This is not usually necessary. It may be arranged to confirm or to exclude Grave’s disease if you have a single nodule that is overactive. Dr. Green will be checking to see if the nodule is the only cause of the overactivity or if the whole gland is overactive as in Grave’s disease.

A scan can reveal hot nodules (overactive) or cold nodules (underactive).

Cold nodules can indicate a thyroid cancer in approximately 20%. If these are present a hemithyroidectomy (partial thyroid removal surgery) is usually recommended.

Thyroid function studies and antibodies

Thyroid function blood tests are essential prior to surgery. This allows Dr Green to determine if you have normal function (euthyroid) or underactive thyroid (hypothyroid) or overactive (hyperthyroid).

If you are hyperthyroid it is not safe to operate in these cases you will need to commence medication to reduce the overactivity prior to surgery.

Antibodies are requested to confirm a particular diagnosis such as Grave’s disease or Hashimoto’s thyroiditis.

Vocal chord check

This is not a routine test. However, there will be circumstances where Dr. Green wishes to assess the function of your vocal chords prior to operating. If you have a hoarse voice or a large cancer is diagnosed a vocal cord check is likely to be requested. This requires a small fibre-optic camera to pass via your nose and into your throat to look at how your cords move.

This may also be done post-surgery if there is any concern the nerve to the vocal chords (recurrent laryngeal nerve) has been injured.

What is a hemithyroidectomy and total thyroidectomy?

Hemithyroidectomy

This is the removal of a single lobe of the thyroid gland. This is often done for single nodules or where the diagnosis of a nodule is unknown. The remaining half of the thyroid should be able to accommodate and produce enough thyroxine to avoid needing any medication after surgery (in most cases)

Total thyroidectomy

This is complete thyroid removal surgery. The operation effectively requires two hemithyoidectomies. After the operation you will need to be put on thyroid replacement therapy with thyroxine. This MUST be continued for life.

What is involved in the operation?

Both operations are performed under a general anaesthetic. Usually only an overnight stay is required. A total thyroidectomy might require two nights if the calcium levels are low after the operation.

Once you are asleep, a small 3-6cm incision is made in a skin crease over the front of your neck (may be larger for big glands or if lymph nodes are to be removed).

During the entire operation particular concern is placed on finding your parathyroid glands (small pea size glands attached to the thyroid that control calcium). These glands need to be preserved. If they are damaged and the thyroid surgeon does not realise, you will end up on life-long calcium replacement (1% chance). If one of these glands can not be preserved during the operation it will be reimplanted in a muscle in your neck and will eventually work in about 6 months’ time.

Other important structures that are carefully looked after include nerves to your voice box. These are the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve. If the RLN is damaged you will be left with a weak husky voice and swallowing difficulties (<1% chance) this is a major complication and finding this nerve is critical during the operation. The EBSLN is important in projecting your voice and controlling pitch and damage will reduce your ability to do these things. This has major implications for singers and public speakers.

Once awake a blood test will be performed to check that the parathyroid glands are working. If not (up to 20% temporarily stop) you will be started on calcium tablets and slowly weaned off over the next few weeks.

You will be able to eat and drink straight after your thyroid surgery, although you will have a painful neck and a sore throat. This is usually well controlled with tablet analgesia.

What are the possible complications?

Thyroid surgery is a common operation performed by Dr. Green for which he has been well trained. The vast majority of patients will follow the “usual” path of recovery and be discharged from hospital feeling well 1 or 2 days after their operation.

Despite this, things may not always go according to plan and a small number of patients may experience a significant complication. These are listed below. Some are common and others are less common but very important if they happen. While the following list is a guide, it is not comprehensive.

The information below will help you understand some of the possible problems that can result from having a thyroid surgery. “Complications” are listed below. Some are common and others are less common but very important if they happen. While the following list is a guide, it is not comprehensive.

If you would like more information after your consultation and after reading this page, please feel free to discuss any issues with Dr Green. You may wish to arrange an additional appointment to discuss your surgery further. If this is the case please inform either Dr. Green or the reception staff.

Note that all patients having their thyroid removed need to take thyroxine tablets permanently.

Thyroid surgery – possible complications

Common (up to 10% of cases)

Uncommon (less than 5% of cases)

Rare but important (less than 1% of cases)

  1. Temporary nerve palsy (hoarse voice).
  2. Temporary hypoparathyroidism (low calcium that requires tablets for a few weeks - total thyroid).
  3. Stiff neck.
  4. Temporary feeling of pressure in throat for a few weeks.
  1. Permanent hypoparathyroidism (low calcium that requires tablets for life) – 2% (total thyroid).
  2. Wound infection.
  3. Lumpy scarring (Keloid).
  4. Long term altered swallowing sensation.
  1. Anaesthetic complications.
  2. Bleeding requiring second operation to control.
  3. Permanent nerve palsy (weak hoarse voice).
  4. Need for a tracheostomy (breathing tube into trachea through skin to help breathe).

There is the chance a second operation may be required following a hemi-thyroidectomy if the pathology reveals more complicated disease than first diagnosed on biopsies.

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