Reasons for Surgery:
The reasons for thyroid removal include: nodules that are large and press on breathing or swallowing organs, nodules that are difficult to determine whether they are cancerous or not, nodules that are proven to be cancer, over-active thyroid gland that is difficult to control with medications, over-active thyroid that causes eye disease, etc.
Each decision for surgery is discussed in depth and is based on patient preferences, of the risks versus benefits of the surgery, medical condition of the person, concern for cancer, concern for breathing or swallowing problems, and guidelines listed by The American Thyroid Association.
I perform an ultrasound in my office to determine the extent of surgery and how difficult it is to perform. The ultrasound is like a road map, it shows how the disease impacts nearby structures: invasion, destruction, blood supply, and metastasis to the closest lymph nodes.
I also perform evaluation of the vocal cords function prior to the surgery to determine whether the nerve that innervates the voice box is still working. That nerve is called the Recurrent Laryngeal Nerve, and it runs underneath the thyroid gland. When injured, it may lead to the temporary and even permanent hoarseness.
I believe in comprehensive evaluation and transparent discussion. Throughout your appointment both the ultrasound as well as vocal cord evaluation are on display. I show my patients the images, explain what we are looking at, and even draw to illustrate what has happened to the thyroid gland, what is abnormal and what is not, and what would be the best treatment. I believe that a picture speaks louder than words.
Risks of Thyroidectomy:
Injury to Superior Laryngeal Nerve: happens very frequently because that nerve lays on top of the thyroid gland. Damage to that nerve makes raising voice difficult. Often it is temporary
Injury to Recurrent Laryngeal Nerve: happens rarely, but it is the main reason why thyroidectomy is not easy to master. It is runs underneath the thyroid gland. It enters voice box and affect voice and breathing. Damage to one nerve leads to hoarseness, damage to both of the nerves lead to difficulty breathing.
Injury to Parathyroid glands. Normally we have 4 glands, 2 on each side. All 4 glands lay on thyroid gland and share its blood supply. Their function is to maintain the calcium level in our blood stream. The injury is usually by accidental removal or by disrupting blood supply. Permanent injury is rare, temporary injury is very common.
Injury to Trachea: extremely rare even in the inexperienced hands. Trachea is made of cartilage and easy to identify. It may have to be partially removed in case of cancer.
Injury to Esophagus. It is also very rare and difficult to manage.
The thyroid gland has been designated to have right and left sides (lobes ). If disease involves only one side, the other side may frequently be spared. Saving one side has multiple benefits: thyroid function may stay the same, injury to one nerve leads to hoarseness and not breathing issues, as long as at least one of the parathyroid glands is preserved no calcium replacement is necessary. Majority of the patients may be released home the same day of surgery.
If the entire gland must be removed, both of the Recurrent Laryngeal Nerves and all of the parathyroid glands are at risk. The nerve function is monitored during the entire procedure with electrodes, the parathyroid gland function can only be confirmed after the surgery with a blood test. As a result, patients are kept overnight for monitoring their breathing and Calcium levels in the blood stream.
Most of the patients with a complete thyroidectomy will be given prophylactic calcium pills and vitamin D. Every patient will be started on the thyroid hormone pills.
For the most part, the surgical time from the incision to closure takes 45 minutes for half of the gland and 60 minutes for the entire gland. I believe in efficiency over rushing. Even if it is cancer, many structures can be spared. I am a true believer that limitations that may be posed by cancer should not be worsened by surgery.
Sometimes, I request pathology evaluation of the removed tissue during the time of surgery. On rare occasion the diagnosis made during quick review will change the course of the surgery. The same may happen if I find abnormal lymph nodes or thyroid invasion into surrounding organs. As a result, I normally ask permission to make decisions if total gland will be removed while a patient is asleep.
The surgery is not very painful. Most of my patients report soreness for 24 hours requiring pain medications. After that, Ibuprofen is adequate to be comfortable. The neck function is not restricted and most of the patient don’t have stitches that need to be removed. The recovery period is between 5-7 days.
All patients experience:
- sore throat, like a mild cold for 48 hours. This is purely mechanical: from intubation and removing the gland
- numbness around incision area. This is because of surgical exposure. It lasts for a few weeks
- mild voice changes. This is because of all of the manipulation around the nerves and intubation. It may resolve from 1 week to a few month
The incision is based on the size of the thyroid gland. It is placed into the skin crease. The final scar appearance is judged in 3-6 months. I choose the neck skin crease because it is natural fold and the point of least tension. As a result, the majority of the scars are nearly invisible.