Today hyperthyroidism is usually detected very early, as physicians regularly check thyroid levels in their patient’s blood tests. Thyroid function testing may detect a problem even before any symptoms begin. This condition may be treated with drugs that counter the effects of thyroid hormone, and/or prevent its release or overproduction. Radioactive iodine that is selectively taken up by thyroid cells (thyrocytes) is the most commonly employed treatment to permanently destroy thyroid function and reduce thyroid hormone secretion.
Another equally effective treatment option is surgical removal of all or most of the diseased thyroid gland. Surgery rapidly controls excess thyroid hormone production and is an option for those patients who do not tolerate anti-thyroid drugs, do not want radiation treatment, for women of child bearing age who do not want to wait for months following radiation treatment to conceive, and in very sick patients who need immediate intervention.
This disorder may also be diagnosed early with blood tests that measure thyroid and pituitary hormone levels. A patient with this disorder is given thyroid hormone—either a natural bio-identical version extracted from pig thyroid glands or a synthetic thyroid hormone (e.g. Levothyroxine) and is thus restored to a normal, healthy metabolic state.
Treating Thyroid Cancer
Thyroid cancers in the early stages do not cause symptoms and are diagnosed by the doctor or the patient after feeling a lump/ nodule in the neck. Some nodules and cancers are picked up as incidental findings on imaging studies performed for other reasons (carotid Doppler, PET scans, CT scans, MRI, Sestemibi scans etc.) Thyroid cancers are almost always treated by surgical removal of all or part of the thyroid gland and surrounding lymph nodes (if involved), depending on the type and size of the tumor.
Since it is impossible to tell if the cancer has traveled beyond the neck, the patient is usually given radioactive iodine several weeks after surgery to scan the body for evidence of spread after surgery (if the entire thyroid gland has been removed). Depending on the findings noted on the final pathology report (e.g. indicating aggressive behavior, incomplete excision, lymph node metastases), an additional treatment dose of radioactive iodine may then be given to destroy normal remnant thyroid tissue in the neck, cancer cells that have spread outside the gland itself, spread to the neck or upper chest lymph nodes or to more distant areas in the body. Overall survival rates for thyroid cancer beyond 5 years are over 95% when still confined to the thyroid gland itself. Even higher cure rates are possible for early stage disease in patients under the age of 45.
Thyroid surgery is a frequently performed operation for conditions including:
- An enlarged thyroid gland
- A hyperactive or over active thyroid gland
- A growth or tumor inside the thyroid gland
Enlarged thyroid glands are often called goiters. A goiter may represent a diffusely enlarged gland with or without multiple nodules or cysts (solid or fluid filled growths within the gland of varying sizes). A goiter may or may not be associated with either excessive amounts of thyroid hormone production (hyperthyroidism) or underproduction of hormone (hypothyroidism). In some cases antibodies produced by the body act to either destroy the function of the thyroid gland (Hashimoto’s Thyroiditis) or stimulate over production of hormone (Graves’ Disease). Hormone supplements or radiation (radioactive iodine) are often used to normalize thyroid hormone production. Benign goiters can be monitored without surgical treatment unless they contain a cancer, enlarge to the point of causing symptoms (difficulty swallowing or breathing) by pushing and narrowing the windpipe (trachea) or esophagus, grow deep inside the upper chest (substernal goiter), cause cosmetic deformity of the neck or when rapid control of hyperthyroidism is needed.
Partial or total thyroidectomy (complete thyroid removal) may be required for thyroid enlargement (goiter) if any of the following conditions are present:
- Uncontrolled Hyperthyroidism
- Cosmetic deformity of the neck
- Symptoms such as difficulty breathing or swallowing
- Continued growth into the upper chest (substernal goiter)
- Cancer cells found on fine needle aspiration biopsy
Tumors or lumps within the thyroid gland can be either benign or malignant (cancerous). To define a nodule as either benign or malignant, a fine needle aspiration biopsy is the most direct and reliable test.
A small amount of tissue is removed with a very small needle placed inside the mass that is easily accessible from the front of the neck with ultrasound guidance. The tissue sample is smeared on a glass slide and stained before viewing under the microscope. If the cytopathologist (a pathologist trained to evaluate cellular architecture and other characteristics) is unable to exclude cancer with adequate tissue sampling, then surgery is usually required to remove a part or all of the thyroid gland for a definitive diagnosis and treatment of a possible cancer. For a biopsy result indicating a nodule of undetermined significance (grey zone), additional biopsies are subjected to special immunostains for tumor markers or molecular genetic analysis to help achieve a more definitive diagnosis. Some of these nodules can be monitored further and only removed if there are signs of continued growth or changes occur suggesting more malignant characteristics on ultrasound imaging. Surgery may also be required for thyroid cysts, which return after multiple attempts to remove the fluid by needle aspiration fail to eliminate the problem.
At surgery the amount of thyroid (partial or total) to be removed has usually been already predetermined based on careful evaluation of a patient’s clinical risk profile (age, gender, family cancer history, exposure to radiation, etc.), tumor characteristics (size, and number of nodules, type of cancer suspected on cytology, and molecular genetic analysis if available), and/or the specific findings by the surgeon (e.g. invasion of the cancer into local structures, involvement of multiple areas of the gland, the presence of enlarged, cancer containing lymph nodes next to the thyroid (regional metastases) where there is a higher risk of either return of cancer in the neck or spread to distant areas of the body (distant metastases). Most malignant thyroid tumors (thyroid cancers) require removal of the entire thyroid gland and involved lymph nodes in the central neck compartment for cure. For low risk patients under the age of 45, small tumors (≤1.5 cm) confined to one side (lobe) of the thyroid gland, with no evidence of disease in the opposite lobe, or lymph node involvement or spread outside the gland on pre-operative ultrasound, partial removal (lobectomy) may be adequate treatment. Benign thyroid tumors, cysts and some goiters may also only require partial removal of the thyroid gland. Even after partial removal, many patients will still need to take thyroid hormone supplements after surgery to maintain normal metabolism and weight.
Read more about current guidelines:
The operation is performed in the hospital operating room. Most patients are admitted the day of surgery and go home either that evening or the following morning. This depends on the time of day that the surgery starts as well as the extent of surgery. More complicated surgery will require a longer period of observation in the hospital before discharge.
The operation is usually performed under general anesthesia (medically induced sleep). Some surgeons do the operation with the patient awake and with light sedation and local anesthesia (which numbs the area of the body being operated on).
The safety of either approach is equal; however, many surgeons prefer to perform the procedure under general anesthesia for several reasons:
- The surgeon has more options available, especially those that require access to other parts of the neck or upper chest
- General anesthesia offers more control, which usually allows the surgeon to achieve the goals of the procedure in less time with less pain for the patient
The usual incision is placed in the midline of the lower neck and parallel to the natural horizontal tension skin lines or creases when present. In young patients the incision is situated low in the neck at the level of a shirt collar, above the level of the clavicles. The length of the incision depends on the size of the thyroid gland that needs to be removed. Usually it is no more than the size of the area between the two large muscles (sternocleidomastoid) that run up and down the neck). Some incisions can be as small as one inch. However, the key to an inconspicuous scar, regardless of its length, is the use of delicate soft tissue handling techniques and meticulous wound edge approximation. Longer incisions are needed for safe exposure of the surgical field, especially if the patient has a large goiter. Attempting to squeeze a large thyroid gland through a very small incision can cause excessive trauma to the wound skin edges and this may lead to poor healing and adverse scaring. If there is a prior scar from previous thyroid surgery that site will usually be used for the incision by removing the old scar. In young patients who heal quickly, scars generally are more elevated and red in the first six to eight months of healing but eventually flatten and lighten. Certain topical agents including fresh aloe vera gel and dimethicone silicone gel may be of benefit for the first 8 weeks of healing. Your surgeon will discuss methods of wound care to achieve the best possible scar. It is important to avoid direct sun exposure for the first year to prevent darkening of the scar.
A small, soft silicone drain may be placed at the time of surgery according to the surgeon’s judgment and is usually removed before discharge from the hospital. This prevents the accumulation of blood and fluid under the skin and reduces the need to drain this collection in the office.
Most stitches are placed under the skin level and dissolve on their own. There may be one long stitch, called a “pull-out," that is removed painlessly on your first post-operative visit in the office. Surgical tape strips (Steri Strips) and/or adhesives are placed across the wound and may be removed soon after surgery once the skin has healed sufficiently. You can bathe with the strips on the skin after the initial bandage has been removed.
Risks and Complications
In skilled hands, there are several rare potential risks of thyroid surgery.
- Vocal cord paralysis
- Low blood calcium
- Bleeding inside the neck
- Failure to cure the disease
- Anesthetic Risks
Voice Impairment Following Thyroidectomy
Injury to the nerves that control the vocal fold muscles generally occur in less than 1% of patients and almost never represent a permanent problem. However, a brief period of hoarseness or difficulty singing with pitch control, early voice fatigue and difficulty projecting the voice may occur from either minor swelling of the vocal folds themselves, trauma to the muscles that raise or lower the larynx (voice box) or from a weak or immobile vocal fold (paralysis). Some surgeons will use a nerve monitoring system during the surgery when performed under general anesthesia to alert of inadvertent stretch or other injury to the laryngeal nerves. However, nerve monitoring has not been proven to reduce the incidence of vocal fold palsies, especially in the hands of expert surgeons. Vocal fold mobility is usually documented both prior to and after thyroid and parathyroid surgery using a thin flexible telescope for viewing the larynx. The majority of patients with voice impairment improve without treatment. However, some patients will require a brief period of vocal rehabilitation from one of our center’s voice therapists.
Parathyroid Gland injury and Hypocalcemia
Depending on the extent of surgery and number of bruised or autotransplanted parathyroid glands, temporary hypoparathyroidism (under-production of parathyroid hormone) can occur and blood calcium levels may drop below the normal range. This complication may be seen in approximately 10% of patients and also depends on the extent of surgery and whether lymph nodes are removed from the neck for proven or suspected cancer involvement. Within 6 hours following a total thyroidectomy, very low calcium levels in the blood will cause a spectrum of symptoms including muscle spasms, tingling or numbness around the lips (paresthesias) or upper or lower extremities and rarely difficulty breathing from vocal fold muscle spasms. Any time after surgery, the aforementioned signs of a low calcium levels should immediately be reported to your nurse or surgeon who will start you on supplemental calcium and Vitamin D to prevent further symptoms before hospital discharge and continued at home for weeks to months until there is recovery of parathyroid gland function. Some surgeons prefer to give calcium and vitamin D as an oral supplement prophylactically if the problem is anticipated and a blood sample reveals very low parathyroid hormone immediately after surgery before any symptoms develop.
Bleeding Following Thyroidectomy
In general, hemorrhage (bleeding causing a hematoma or blood accumulation in the neck) after thyroid surgery is a rare event but can occur suddenly within the first 24 hours following surgery. You should immediately report any rapid swelling of the neck, sudden tightness, difficult breathing or loss of voice to your surgeon or have someone call 911.
Complications from Anesthesia
In general, complications associated with local or general anesthesia are exceedingly rare. Nausea in the immediate postoperative period can be managed well with medications given intravenously. Some patients will develop a sore throat and mild hoarseness associated with insertion of the endotracheal tube (breathing tube).
What to Expect After Thyroid Surgery
You will usually wake up in the recovery room. You may have a mild sore throat, as well as neck pain and you may need to urinate. The nursing staff in the recovery room will monitor your vital signs closely, administer fluids and adequate pain medicines to make you comfortable, and take care of your immediate needs to ensure a smooth recovery. You will be able to talk and can start drinking fluids when you are fully awake. The surgical team will follow you closely as well. If you have had your entire thyroid removed, blood will be drawn to follow your blood calcium levels and replace it, if it is too low.
Once you are discharged from the recovery room you will be placed into a step-down unit where you will be able to get out of bed, eat and talk with visitors and family. The bandage on your neck will be replaced or removed before your discharge. If you have a drain present, it will usually be removed prior to discharge. You will be sent home with either a waterproof protective bandage or just Steri Strips that will allow you to shower. The surgical team will give you prescriptions for pain medications and possibly antibiotics, as well as thyroid hormone replacement, depending on the extent of surgery.
The duration of hospital recovery after thyroid surgery will vary from patient to patient and surgeon preference. Patients who have a total thyroidectomy performed may need to stay overnight depending on the overall extent of surgery, calcium levels, nausea control and management of other medical problems. Many healthy patients can be discharged within 23 hours after surgery if they are stable.
However, if your surgery started late in the afternoon, you should be prepared to stay overnight. You will usually see your surgeon for your first post-operative visit within two weeks after your surgery for suture removal and wound inspection. You will usually see your endocrinologist or primary care physician after your first postoperative visit as suggested by your surgeon. Your medications may be adjusted at that time. Once the final pathology report comes back, and reviewed by your surgeon and endocrinologist, the team will make recommendations for any additional treatment.
Radioactive iodine (RAI) is an orally administered pill containing a radioisotope of iodine (131I) that is preferentially absorbed by thyroid cells in the body. This is because all thyroid cells have a special iodine pump (sodium/iodine symporter) that normally transports the iodine from ingested food into the thyroid cells to be used in the production of thyroid hormone. Only thyroid cells, and to a lesser extent, salivary gland cells will take up RAI and may be detected by a special camera that images the emitted beta and gamma radiation emitted anywhere in the body. When given for therapy, RAI acts like a heat-seeking missile to hunt down and destroy only thyroid cancer cells by releasing internal radiation within the thyroid cell itself. Unlike chemotherapy or external types of radiotherapy, this target specific therapy causes little harm to normal healthy cells and because of its short half-life and rapid uptake by thyroid cells, it is eliminated from the body within 3-5 days.
In selected patients, 4-8 weeks following a total thyroidectomy for cancer treatment, RAI is first given in a very low dose to scan the entire body for the presence of:
- residual normal thyroid tissue in the neck still adherent to the trachea
- thyroid cancer cells that were not possible to remove during surgery
- thyroid cancer cells in small lymph nodes not seen or removed during surgery
- distant spread of thyroid cancer (metastases outside the neck).
To enhance the uptake of RAI, patients will usually begin a low iodine diet 7-14 days before the scan to starve thyroid cells of iodine (http://www.thyca.org/rai.htm) and minimize any competition between food sources of iodine and the RAI given as a pill in the nuclear medicine department of the hospital.
To further stimulate thyroid cancer cells to absorb the RAI, a pure synthetic form of thyroid stimulating hormone (rhTSH) called Thyrogen (http://www.thyrogen.com/pdfs/Understanding_Thyrogen.pdf), is injected intramuscularly before the scan. Depending on the amount of uptake seen on the total body scan images, a second higher treatment dose of RAI is given to:
- destroy the tiny remnant of normal thyroid tissue still attached to the trachea
- destroy any residual microscopic cancer still in the neck
- destroy microscopic cancer in lymph nodes that will take up the RAI
- destroy distant spread of cancer outside the neck
In recent years, smaller doses of RAI have been shown to be as effective as higher doses when specifically used to destroy any residual normal thyroid tissue. This so-called remnant ablation is useful in selected patients to help improve the sensitivity and reliability of using a simple blood test to detect either persistent cancer or the recurrence of cancer in the body. This thyroid tumor specific protein is called thyroglobulin. When there is no thyroid tissue in the body, long-term follow-up is easier for your endocrinologist as the thyroglobulin blood test will show low or undetectable levels. In addition, if thyroid cancer ever does recur, and if it can take up more RAI, it can be treated successfully in many cases. In rare cases, there will be no uptake of RAI if all thyroid tissue has been removed at the initial surgery and no RAI will be given for ablation. However, not all thyroid cancers will take up RAI, especially if they have recurred or are of a certain more aggressive type and therefore it is not useful as a form of treatment. In this setting, other types of radiation (external beam) are employed as well as newer molecularly targeted drug therapies to stop the progression of cancer. Many new promising drugs are currently being tested for the treatment of advanced cases of thyroid cancer.
The use of RAI for low risk patients has become more controversial in recent years as more patients are being treated for small tumors detected on ultrasound imaging or incidentally by body scans obtained for other illnesses. The concept of a tailored, individualized approach to treatment is our center’s philosophy. A team approach with your surgeon, endocrinologist, nuclear medicine physician and other healthcare professionals will guide you in selecting the most effective treatment with lowest possible adverse effects.
Treating Primary Hyperparathyroidism
The disease can now be detected even before symptoms or bone related problems develop because of routine blood chemistry analysis. There is currently no medical treatment to eradicate primary hyperparathyroidism. Once a correct diagnosis is rendered, surgical removal of the tumor(s) can cure this disease. The treatment is safe and effective, achieving an overall cure rate of 95% or better, but does require the expertise of a highly skilled parathyroid surgeon.
Diagnosis of Hyperparathyroidism
Prior to the advent of routine blood chemistry testing, PHPT (primary hyperparathyroidism) often presented with severe symptoms and advanced bone and kidney disease. These patients often developed painful renal colic (bouts of severe pain due to passage of kidney stones) and kidney stones, profound muscle weakness, and evidence of severe bone demineralization (osteoporosis). Over the past decades, early detection of elevated blood calcium and elevated intact parathyroid hormone (iPTH) has facilitated the diagnosis of hyperparathyroidism, often before the development of symptoms or significant kidney or bone involvement. The correct diagnosis and evaluation of PHPT rests primarily on:
- A persistent elevation of blood calcium documented with testing over a several-month period.
- Other associated abnormal blood tests including low phosphorus, elevated alkaline phosphatase, and low vitamin D levels.
- The finding of an elevated or high normal intact parathyroid hormone level associated with elevated blood calcium (where normally a low iPTH is encountered) is strong evidence of primary hyperparathyroidism.
- Elevation of blood calcium and parathyroid hormone levels may both fluctuate and even be normal but parathyroid hormone levels usually remain elevated. Therefore, multiple blood samples may be required before the diagnosis of PHPT can be made with confidence.
- Other causes of elevated blood calcium (certain diuretics, or water pills, excessive Vitamin D intake, sarcoidosis, and rarely metastatic cancer) must also be considered in the initial evaluation.
- The amount of urine calcium collected over a 24-hour period may also be determined to eliminate the small possibility of an inherited benign genetic disorder in which the kidneys fail to eliminate enough calcium in the urine and cause elevation of blood calcium. This disorder is called Familial Benign Hypocalciuric Hypercalcemia (FHH) and may mimic primary hyperparathyroidism. In this disease, there is an abnormal function of the calcium sensing receptor (CASR) needed to regulate normal parathyroid gland hormone release and filtration of calcium by the kidneys. A family history of elevated blood calcium may suggest this disease but is not always known. In cases where biochemical tests remain inconclusive, in order to avoid surgical treatment that is not helpful or needed, testing for FHH-associated mutations in the gene that controls the expression of the CASR may be needed to confirm the diagnosis.
- A bone mineral density study called a DEXA scan will often be ordered as a baseline or to document the degree of mineral loss from your bones and osteoporosis. This is a specialized X-Ray examination of the density of three key representative bone sites (hips, lumbar spine and forearm). Bone thinning at the forearm site is often a more sensitive indicator of the severity of the problem.
Imaging Studies to Locate Abnormal Parathyroid Glands
For further documentation of enlarged single or multiple parathyroid glands, and to help guide the surgeon to the specific location of the abnormal gland, one or more imaging studies are usually ordered before the actual surgery:
- Sestamibi /CT-fusion radioisotope Scan
- High-resolution Ultrasound
- 4-D contrast-enhanced CT scan
Who Should be Treated for Primary Hyperparathyroidism
While there are established guidelines for who should be treated for PHPT, these are only guidelines and may not be applicable to all individuals. Since "asymptomatic" PHPT is a relatively new clinical entity, the long-term effects of even modest blood calcium elevations are still not clear. In some studies, even mild hypercalcemia was associated with decreased long-term survival due to kidney and cardiovascular disease. Since with minimally invasive surgery over 95% of patients will be cured, earlier treatment in the course of the disease has become a more common approach. The table below outlines the current conservative guidelines for the surgical management of PHPT. Less stringent criteria have more recently been suggested because of the higher success rates and safety of surgery using localizing studies.
Asymptomatic patients are now treated more often at all ages. Surgery decreases the risk of fracture in patients with osteoporosis by 30% over 20 years. Neuropsychiatric and cardiovascular disease may also improve after treatment.
NIH Guidelines for the Surgical Treatment of PHPT
- Serum calcium level > 1 mg/dl above the upper normal range
- Bona fide symptoms (extreme fatigue, muscle weakness, memory loss, confusion, depression, mood swings, stomach ulcers, abdominal pain/renal colic, hard stools, excess urination & thirst, kidney stones, frequent bone fractures, cardiovascular disease/ hypertension).
- Evidence of any organ involvement (kidney stones or advanced bone disease)
- Reduced kidney function, glomerular filtration rate < 60 mL/min
- Osteoporosis documented on densitometry at any site (T score < -2.5 SD)*
- Age less than 50
- Close medical observation not possible or not desired by patient choice.
* Surgery is recommended when the T-score is - 2.5 or less at the lumbar spine, femoral neck, total hip, or distal one-third of the radius bone in peri- and postmenopausal women and in men age 50 and older, and when the Z-score is - 2.5 or less in premenopausal women and in men under 50 yrs. of age.
Monitoring for Patients who Wish to Defer Surgery
Calcium lowering drugs for long-term treatment of PHPT are still investigational but may hold future promise, especially for patients not fit for surgery. However, compliance, adverse effects and cost must be considered in light of a readily available and lower cost surgical treatment option. All patients should avoid certain types of diuretics (water pills) and maintain adequate fluid intake. Ambulation is important to maintain healthy bone mass. There are no specific guidelines with regard to dietary calcium but a minimum of 500 mg/ day is generally adequate. One should certainly avoid excess calcium and vitamin D supplements (~1,000 mg elemental calcium/day and 400-800 IU Vitamin D3/day) until a cure is rendered, to avoid raising calcium blood levels further. Estrogen replacement therapy may have important benefits for maintaining bone mineral density in normal post-menopausal women and should also be discussed with your physician. In terms of testing, bone mineral density should be assessed yearly, especially for women who may have a dramatic change after menopause. Yearly serum and 24 hour urine calcium determinations should be routine.
Once the diagnosis of PHPT is confirmed your internist or endocrinologist will refer you to a Head & Neck Parathyroid Surgeon with specialized training and extensive experience in the surgical treatment of PHPT. Surgery is the only definitive treatment for this disease. Long-term cure rates of greater than 95% are possible when a surgeon with extensive experience performs the procedure. Most surgeons perform the procedure in 1 hour or less under general anesthesia or local anesthesia with sedation.
Areas of Controversy
In rare circumstances the enlarged parathyroid gland will be hidden within the substance of the thyroid gland instead of behind it, or inside the thymus gland (a gland in the upper chest behind the sternum) in the upper chest, necessitating a partial thyroidectomy or thymectomy. If the imaging studies fail to identify a single enlarged parathyroid gland or if there is a suggestion on the initial side of exploration that more than one gland is enlarged and over producing hormone (based on the blood sampling during surgery), then a complete exploration of both sides of the neck is mandatory (4 gland exploration). This facilitates removal of all abnormal parathyroid glands and secures identification of normal glands. The equivalent of at least one normally functioning gland must be left behind to prevent over-treatment and the need for life-long calcium and vitamin D supplementation. In a small number of patients, the offending gland will not be found at surgery due to its presence in an unusual location (such as is in the chest) and additional investigations and a second surgery will be necessary.
Minimally Invasive Parathyroidectomy (MIP)
Patients with only one enlarged gland are usually suitable for minimally invasive parathyroid surgery (~90%). This kind of surgery relies on pre-operative tests to localize a single abnormal gland to one side of the neck. This permits a focused operation that reduces the complication rates, operative time and post-operative recovery.
This more limited, less invasive surgical approach has now become routine in our center. Because only a limited area of the neck containing the enlarged gland is explored, a smaller incision at the base of the neck is utilized and can be done either open using small instruments or with the use of a 5 mm telescope attached to a video camera, resulting in a barely visible scar after one year of healing. This type of procedure can be performed reliably with the use of parathyroid hormone blood sampling prior to and following removal of the offending gland(s) during the actual operation. This rapid intra-operative hormone test can reduce the surgical time needed to explore the neck and gives the surgeon a greater degree of “biochemical” certainty that only a single gland is causing the problem. When more than one gland is involved (hyperplasia) the hormone assay also helps the surgeon titrate the amount of parathyroid tissue needed to be removed to prevent over treatment. Another minimally invasive procedure utilizing a preoperative injection of a radioactive isotope and “radio-guided surgery” (MIRP) is performed by some of our surgeons with excellent results. In this situation the surgeon uses a special Geiger counter to measure the higher concentrated amount of activity from the removed tissue compared to the background activity, which also reliably confirms excision of the gland(s) causing the problem.
While these surgical approaches can decrease the duration of the operation for single gland disease, recent studies suggest that in rare cases, multi-gland disease can still be missed in some patients and long-term recurrence of PHPT may occur. Patients with suspected hyperplasia (a condition involving more than one gland with over-production of parathyroid hormone seen in approximately 10% of patients) will usually require the traditional operation, where both sides of the neck are explored. These patients may require the removal of more than one gland.
Minimally invasive parathyroid surgery permits most patients to be discharged from the hospital on the same day as surgery after a period of observation and recuperation. This also allows early return to work. Once the calcium in the blood returns to normal, most patients will be started on oral calcium with Vitamin D for a few weeks to allow depleted bone stores of calcium to be restored. However, this may take a year or more to normalize and many patients, especially post-menopausal woman, will need calcium and vitamin D supplements for life to maintain good bone strength.
The operation is performed in the hospital operating room. Most patients are admitted the day of surgery and go home either that evening or the following morning after a minimum of 6 hours for observation and recuperation.
Most surgeons perform the procedure in less than 1 hour under general anesthesia. Some surgeons do the operation with the patient awake and with light sedation and local anesthesia (which numbs the area of the body being operated on).
The safety of either approach is equal; however, many surgeons prefer to perform the procedure under general anesthesia:
- The surgeon has more options available, especially those that require access to other parts of the neck or upper chest.
- General anesthesia offers more control, which usually allows the surgeon to achieve the goals of the procedure in less time with less discomfort for the patient.
The standard incision is usually made in the lower, base of the neck, parallel to and above the collarbone, in the midline. If there is a prominent skin crease in the patient's neck, most surgeons will try to put the incision within the crease to conceal it. Most incisions result in nearly imperceptible scars when plastic surgical techniques are utilized but it takes several months of healing and patience. Your surgeon will discuss wound care methods to help achieve the best possible scar.
Most stitches are placed under the skin level and dissolve on their own. There may be one long stitch, called a "pull-out," that is removed painlessly several days to a week after surgery in the office. Surgical tape strips and/or adhesives are placed across the wound and may be removed soon after surgery once the skin has healed sufficiently. You can bathe with the strips on the skin after the initial bandage has been removed.
A small silicone drain may be placed at the time of surgery and is removed before discharge from the hospital. This prevents the accumulation of blood and fluid under the skin and reduces the need to drain this collection in the office. It has no effect on the scar or healing.
Risks and Complications
In skilled hands, there are several rare potential risks of parathyroid surgery.
- Vocal cord paralysis
- Low blood calcium
- Bleeding inside the neck
- Failure to cure the disease due to a missed second enlarged gland
- Anesthetic Risks
Injury to the nerves that control the vocal fold muscle and hypoparathyroidism (low parathyroid hormone) resulting in lower than normal calcium levels) generally occur in less than 1% of patients and almost never represent a permanent problem. However, a brief period of hoarseness may occur as well as the need for calcium and vitamin D replacement for several months. Bleeding and anesthesia-related complications are exceedingly rare. Some patients will experience nausea, a mild sore throat or discomfort when swallowing all of which generally resolve within a short period of time.
In a few patients, calcium may rapidly be drawn back into the bone stores causing a sudden fall in blood calcium levels up to a week following surgery, the “Hungry Bone Syndrome.” Signs of low calcium such as tingling, numbness or muscle cramps should immediately be reported to your surgeon. You may be discharged on supplemental calcium and Vitamin D as a precaution. Generally, once the blood calcium levels return to normal, only yearly, routine blood monitoring and bone mineral density testing (in postmenopausal women) is needed.
In rare instances, a single enlarged parathyroid gland may be the first manifestation of evolving multi-gland disease and previously normal glands may eventually enlarge resulting in a recurrence of PHPT many years after surgery. Chronic vitamin D deficiency may be the trigger for uncontrolled growth of parathyroid glands. There is no way to predict the rare patient who may develop another enlarged gland and recurrent disease. Therefore, you should have a yearly calcium and vitamin D level performed with your medical doctor or endocrinologist.
What to Expect After Parathyroid Surgery
You will usually wake up in the recovery room. You may have mild throat and neck discomfort, and you may have to go to the bathroom. The nurses in the recovery room will closely monitor your vital signs and take care of your every need. They will administer fluids and pain medicines, and help you recover quickly and smoothly.
You will be able to talk and can start drinking fluids when you are fully awake. The surgical team will follow you closely. Blood tests may be sent to check your calcium levels before discharge and you may be given some calcium and vitamin D if the levels are too low.
In the recovery room you may have a drain present but it will usually be removed before your discharge. You will be sent home with a waterproof bandage that will allow you to bathe or shower. Once you are discharged from the recovery room you will be moved to an ambulatory recovery unit where you will be able to get out of bed, eat and talk with visitors and family. Most parathyroid surgery patients go home after several hours of observation and recuperation on the same day as the surgery. You will usually see your surgeon four to seven days after your surgery for suture removal and wound inspection. Your medications may be adjusted at that time.
Office Ultrasound & Guided Fine Needle Aspiration Biopsy
The physicians and surgeons of the Center for Thyroid and Parathyroid Surgery have the capability of rapidly diagnosing the specific nature of a neck mass by directly obtaining a small sample (biopsy) of tissue using a fine needle aspiration biopsy (FNAB) technique (withdrawing a small amount of tissue or fluid through a tiny needle placed inside the neck mass in the office using local anesthesia). The precision of this technique is enhanced with the use of ultrasound guidance in the office to avoid sampling errors and/or a misdiagnosis. The sample is then sent to a cytopathologist (an expert in evaluating groups and individual cells smeared on a microscope slide and stained to see if they represent a cancer).
Evaluation of a Neck Mass/Lump/Swelling
Most neck lumps, swellings or masses are painless, and often do not cause any symptoms, yet may represent life-threatening cancer or infection. Some neck masses, on the other hand, are benign cysts that may require no treatment other than a fine needle aspiration biopsy (FNAB) with drainage of the fluid through a small needle. A more complete aspiration of the fluid may be achieved with ultrasound guidance, and often the fluid may never return. Some masses are benign (non-cancerous) tumors or inflamed lymph nodes that may not need treatment other than periodic examination for signs of change or growth.
Advanced Ultrasound Imaging Technology
High-resolution ultrasound imaging technology has become a routine extension of the surgeon’s fingers during the physical examination (palpation). It is the “Gold Standard” for the initial evaluation of thyroid nodules, enlarged parathyroid glands, and other neck pathology. Since there is no ionizing radiation exposure or known adverse effects from high frequency sound wave energy, the technology is safe and no different than what is used to examine the fetus during pregnancy. The procedure does not require any preparation and contrast agents are not used, further reducing any medical risks. The procedure is performed in a comfortable reclining position in an exam chair and there is no concern for the claustrophobic patient as is often the case with MRI or CT scans.
The ultrasonographic examination is important, because physical examination by palpation alone can be inaccurate, both in determining nodule size or its origin from the thyroid rather than nearby tissues. Ultrasound imaging is also helpful in detecting deep nodules toward the back of the thyroid gland that are often missed by the most careful clinician, especially in heavy set individuals with thick necks. The modern higher frequency (13 MHz) ultrasound transducers have enhanced the detection of pea-sized nodules (2-3mm) that would have escaped detection altogether.
Ultrasound permits three-dimensional imaging of anatomy in real time with unlimited multiplanar cross section views. It can determine the relative compressibility (elastography) of the nodule, with firmer nodules often indicating a greater possibility of cancer. Sono-palpation allows the sonographer to literally move structures around in the neck to determine if a cancer containing lymph node or tumor has invaded adjacent structures causing fixation. The vascularity (degree of blood flow) can be measured within and around tumors to aid diagnosis. Thyroid nodules and lymph nodes near the thyroid gland can be better characterized as benign or suspicious for cancer based on specific imaging characteristics (see below). A simple, benign cyst or small nodules with clearly benign ultrasonographic features can often be distinguished from a malignant tumor, thus eliminating the need for a biopsy altogether. Small benign tumors can be followed for growth or change at defined intervals with a high level of precision.
Thyroid Nodule Evaluation & Role of Ultrasound Imaging
In the general population, the prevalence of thyroid nodules ranges from 4-8% by clinical examination (palpation) of the neck, and up to 68% detection by current high-resolution ultrasound imaging technology. The prevalence increases with age to as high as 76% over the age of 60 years in regions of iodine insufficiency with ultrasound detection, and also increases after exposure to low dose head & neck ionizing radiation in youth. While thyroid nodules are very common, over 90% of thyroid nodules are benign and do not need treatment. Tiny, asymptomatic thyroid cancers may grow slowly over many years before reaching a size that warrants a biopsy or treatment. High-resolution ultrasonography is perhaps even more useful for imaging those nodules that have a high probability of being benign, thus eliminating the need for a biopsy altogether, patient anxiety and over consumption of medical resources. The avoidance of unnecessary biopsies has become an important issue as more and more benign thyroid nodules are being detected every year by high-resolution ultrasound or by other neck imaging studies.
When a thyroid nodule is discovered, our Center’s specialists will perform a complete history and physical examination, focusing on the thyroid gland, adjacent neck lymph nodes and endoscopic evaluation of vocal fold mobility.
Factors in the past medical history or physical exam that may increase the risk of malignancy are listed below:
- History of childhood or adolescence head & neck irradiation (e.g. nuclear reactor fallout, radiation for childhood cancers, adenoid enlargement, acne)
- Excessive numbers of diagnostic x-ray examinations (CT scans, mammography)
- Adulthood radiation exposure for treatment of Hodgkin’s lymphoma
- Total body irradiation for bone marrow transplantation
- A family history of thyroid carcinoma, or thyroid cancer syndrome (e.g., Cowden’s syndrome, familial polyposis, Carney complex, multiple endocrine neoplasia [MEN] 2, and Werner syndrome) in a first-degree relative
- Rapid growth of a solid nodule
- Changes in voice quality/ hoarseness
- Vocal cord paralysis noted on visual examination by your physician
- Lateral neck mass away from the thyroid, especially if cystic (with fluid content)
- A very hard thyroid nodule, especially if fixation/ invasion of adjacent structures
- Ultrasonographic features suggesting malignancy
Advantages of Ultrasound Guided FNAB
Ultrasound guided fine needle aspiration biopsy (FNAB) is a simple, safe, rapid, office procedure that has revolutionized the diagnosis of swellings or lumps in the necks. When a neck mass or thyroid nodule is detected either on physical examination or as an incidental finding on another imaging study of the neck, the next best evaluation is with ultrasound imaging. High-resolution ultrasound imaging is now routinely used to help the radiologist or surgeon decide when a FNAB is required. Ultrasound guided (FNAB) is the most accurate and cost-effective method of evaluating a neck mass or thyroid nodule.
Combining ultrasound imaging with FNAB allows the radiologist or surgeon to guide a tiny needle into virtually any structure in the neck to remove cells for analysis. Without the use of ultrasound guidance, FNAB is a “blind” procedure, which may not sample the actual tumor, giving the false impression that a mass is benign. In addition, fluid-containing areas within a nodule, from degeneration of tissue or internal bleeding, may contain too few, if any cells, and the actual cancer cells may be hiding within the wall or a solid area within the cyst. Without an ultrasound guided FNAB, cancer cells would be impossible to biopsy, and this causes a sampling error and a false impression that cancer is not present (false negative biopsy result). Multiple areas within a specific large mass that are of concern can be sampled more thoroughly by this technique, also potentially avoiding a sampling error. Using ultrasound in this way improves the precision of the biopsy, helps to avoid bleeding or other potential small risks of the procedure, and reduces the number of inadequate tissue samples and need for repeat biopsies. Fluid containing or cystic areas where few cells are situated can be strategically avoided to improve the cellularity of the smears for more accurate cytopathologic interpretation.
The use of ultrasound guided FNAB often eliminates the need for more invasive, open surgical procedures in the hospital, along with the potential for bleeding, infection and unsightly scars. More importantly, using this technique may prevent the spread of cancer to distant areas of the body by allowing the earliest possible diagnosis and subsequent treatment while the cancer is still in its most curable stage.
The FNAB takes only a few minutes, with virtually no adverse effects. Since a needle the same size or smaller than that used to draw blood samples is employed, there is no significant risk of bleeding, spreading cancer cells along the path of the needle or significant complications. The procedure is done in a comfortable reclining position. Pain is minimized by the use of both topical and local anesthetics. No special preparation is required other than avoiding non-steroidal anti-inflammatory medications (aspirin, Advil, Aleve, Naprosyn etc.) that may cause excessive bruising. One can resume normal, non-athletic activities immediately following the FNAB. An accurate diagnosis is rendered by world-class cytopathologists on our team and results are usually available within several business days.
Surgeon-Performed Ultrasound and FNAB
Our Center’s physicians and surgeons have perfected a technique that involves a thorough sampling of multiple areas of the neck mass or thyroid nodule of concern by performing ultrasound guided FNAB. However, performing the procedure requires training, skill and practice, as the diagnosis can be missed if the wrong area is sampled, or the specimen has an inadequate number of cells to be properly examined by a cytopathologist. Many of our Center’s physicians and surgeons have received special training and certification in Head and Neck Ultrasound and Fine Needle Aspiration Biopsy through the American Association of Clinical Endocrinologists, and other certifying organizations. A surgeon-performed ultrasound can add a greater level of precision to the study because of an expert knowledge of regional surgical anatomy. In our Center, ultrasound guided FNAB will correctly diagnose the vast majority of thyroid nodules and other neck masses with an extremely low rate of false negative and false positive biopsies, thus reducing the risk of missing a true cancer in the gland or subjecting patients to unnecessary surgery for benign nodules. The number of non-diagnostic biopsies in our Center, due to inadequate sampling has been reduced to 1%, when performed with ultrasound guidance.
In addition to using ultrasound to evaluate and biopsy thyroid nodules and other neck masses with precision, surgeon-performed ultrasound is essential for the identification of abnormal anatomy and when searching for the location of enlarged parathyroid glands or a single parathyroid adenoma. Non-physician ultrasonography technicians (ultrasonographers), if not dedicated to neck imaging, may miss these abnormal structures on routine screening evaluations. Having a true working mastery of regional neck anatomy is a distinct advantage for the surgeon ultrasonographer.
Thyroid Nodules: Ultrasound Guided FNAB Indications
Although there are certain characteristics of the ultrasonographic (US) images that may help distinguishing benign from malignant thyroid nodules, there is also some overlap in these features. In addition, there is some degree of inter-observer variability in characterizing a nodule as potentially malignant on ultrasound imaging. This is due to the varying skills and experience of the ultrasonographer as well as some subjectivity in the interpretation of images. Because of the inconsistent predictive value of US features alone, FNAB and cytopathologic evaluation of a thyroid nodule is usually required before deciding whether a patient requires thyroidectomy, both for confirmation and treatment of cancer, versus simple observation with periodic ultrasound imaging.
Specific ultrasound imaging criteria that may indicate the need for a biopsy have been established by several organizations, listed below, based on an increased risk of finding cancer on FNAB.
- American Thyroid Association
- Academy of Clinical Thyroidologists
- American Association of Clinical Endocrinologists
- Society of Radiologists in Ultrasound
- National Comprehensive Cancer Network
Ultrasonographically suspicious features for cancer may include:
- punctate echogenic foci, macro or microcalcifications (tiny <= 1mm calcifications)
- hypoechogenicity (less dense) solid nodules
- irregular, microlobulated, spiculated or ill-defined borders
- taller-than-wide in shape
- absence of a hypoechoic halo
- increased central nodular blood flow
- abnormal lymph node architecture suggesting cancer spread (metastases)
While no single suspicious US characteristic of a thyroid nodule can predict cancer, a combination of features is highly predictive with and overall sensitivity of 83%. More recent studies suggest that the four most sensitive and specific US criteria for detecting malignant nodules are shape taller-than-wide, irregular/blurred margins (spiculated), marked hypoechogenicity (darker than muscle), and the presence of calcifications (both micro or macrocalcifications). The diagnostic accuracy of ultrasound criteria for malignancy is higher for nodules >= 1 cm.
In general, most thyroid nodules >= 10 mm that are not pure cysts will undergo an ultrasound guided FNAB, especially if there are any of the aforementioned US features that have been shown to increase the probability of finding cancer on biopsy. All nodules >= 1.5 cm should be evaluated by FNAB unless clearly benign US features are noted (e.g. pure cysts without blood flow, isoechoic nodules, spongiform nodules; aggregates of microcystic areas greater than 50% of the total nodule volume). Other nodules that should be biopsied include those with prior biopsies that failed to give an accurate diagnosis (due to insufficient cells for interpretation, and therefore non-diagnostic), follicular lesions of undetermined significance, previously biopsied benign nodules exhibiting > 50% volume growth, or exhibiting new, suspicious US features to suggest malignancy. In addition, all nodules should undergo a FNAB that are detected incidentally on FDG-PET scans or Sestamibi scans, so called “incidentalomas” (because of a much higher risk of cancer). Smaller sub-centimeter nodules should also be evaluated by FNAB (6mm to 9mm in largest dimension) when suspicious US features for cancer are noted, in patients with a past medical history/ physical findings that increase the risk of thyroid cancer, or in patients having had only partial thyroidectomy in the past for thyroid cancer.
Cytopathology and Diagnosing Thyroid Cancer
Once a FNAB is obtained, one of our expert thyroid cytopathologists will review your slides and render a specific diagnosis. The accuracy of thyroid FNAB is dependent on both the skill and experience of the person obtaining the sample, as well as the diagnostic expertise of the cytopathologist interpreting the microscopic findings. In the best centers, the accuracy of FNAB diagnosis is over 90%.
To further improve the predictive accuracy of the biopsies we perform, state-of-the-art immunohistochemistry for tumor specific protein expression, and molecular genetic testing panels are being utilized. While this type of ancillary testing has not yet gained widespread use, it may accelerate a more definitive diagnosis and treatment of thyroid cancer. The use of “molecular classifiers” may also reduce the number of indeterminate biopsy reports, the need for additional biopsies and provide more definitive reassurance for patients with benign nodules who do not need surgery. There is an expectation that unnecessary diagnostic partial thyroidectomies for indeterminate biopsy results may become obsolete, as this technology is refined. The proper diagnosis, treatment and follow-up strategies for thyroid cancer will likely depend more heavily on both the pathologic features of the tumor and molecular genetic profiling in the near future. Physicians within our Center work as a team to formulate individualized treatment and follow-up programs tailored to each patient’s clinical and molecular risk profile for predicting tumor recurrence and mortality.
Neck Lymph Nodes: Ultrasound Guided FNAB Indications
As supported by published guidelines, it is now a routine practice to screen all patients for lymph node metastases prior to surgery for biopsy proven thyroid cancer. Enlarged cervical lymph nodes or normal sized lymph nodes with suspicious characteristics on ultrasound imaging, such as a round rather than elliptical shape, hyperechogenicity (brighter rather than darker) the presence of calcifications, increased/ abnormal blood flow, cystic degeneration, ill-defined borders and loss of normal anatomic architecture (echogenic hilus), may represent metastatic spread of thyroid carcinoma and should be evaluated by FNAB. A definitive diagnosis of thyroid cancer in a lymph node is possible by staining or measuring needle fluid for thyroglobulin, a protein specific marker for thyroid cells. Other causes of abnormal cervical lymph nodes include tuberculosis, other unusual infections and lymphoma (primary cancer of the lymph node itself) and may also need further evaluation with FNAB.
Preoperative identification of the regional spread of thyroid cancer to lymph nodes in the neck permits more accurate cancer staging and treatment planning. Central and/or lateral compartment lymph node dissection/removal at the same time as the initial thyroidectomy represents a more complete cancer operation and may reduce the risk of future recurrences and need for revision surgery.