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05/Feb/2019

Thyroidectomy

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.

 

 

 

Surgical Procedure:

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.

Post-surgical Recovery:

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:

  1. sore throat, like a mild cold for 48 hours. This is purely mechanical: from intubation and removing the gland
  2. numbness around incision area. This is because of surgical exposure. It lasts for a few weeks
  3. 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.

 


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31/Dec/2018

What are Sinuses?

Sinuses are the spaces within the bones of the face. They are supposed to be filled with air. Several theories exist as to why we have them. I have 2 favorites; Sinuses make our heads lighter, making it easier for the spine to carry, and sinuses are crumble zones, like the hood of a car crumbles during a collision to protect the cabin. Sinuses crumble to protect the brain. We do not breathe through our sinuses, we breathe through our noses.

What makes my Sinuses hurt?

Sinuses are lined with a thin layer of tissue that contain mucus glands. These glands make mucus that have to drain into the nose. Anything that stimulates those glands to make more mucus (such as allergies or infections) or blocks mucus drainage (such as swelling, nasal septum deviation, or polyps) will cause pressure or pain in the sinuses.

What is Sinus surgery?

Sinus surgery is a procedure that aims to open the passages of the sinuses to help mucus drain. It improves symptoms of sinus disease and creates easier access for the medications to reduce mucus production. Other reasons for Sinus surgery include: removal of tumors, removal of fungus, control of nose bleeds, drainage of abscesses in the eye sockets, drainage of tears, access to brain tumors, among many more.

The technological revolution in sinus surgery is AMAZING: the video cameras are small and Hi-definition; and we are able to link our surgical instruments to the CT scan of your sinuses. This truly creates surgical precision.

Sinus surgery is used as a last resort when other medical methods have failed. They include: sprays, allergy pills, irrigations, steroids, antibiotics, etc. In most cases, it is an outpatient procedure with very few complications in experienced hands.

How do I know if I need Sinus surgery?

The decision for surgery is based on multiple factors:

Do you truly have a sinus infection or it just in your nasal passages?

How long have you had problems?

Is the infection chronic or it comes-and-goes?

Have you tried every possible treatment to avoid surgery?

What is the cause of your problem: anatomical obstruction, allergies, or fungus?

What does your CT scan of the sinuses show?

What does your ENT doctor see on the office endoscopy?

How much has the infection affected your work schedule?

Does the sinus infection make your Asthma worse?

How much discomfort do you have from the sinus disease?

 

There are a number of criteria that are taken into considerations before the decision for surgery is made. There are a number of people that will have an accidental finding of sinus disease on a CT scan that was done for other reasons: to evaluate brain, eyes, teeth, neck masses, etc. It is important to consult your ENT specialist about the importance of these problems.

 

If you have a CD-ROM disc of your head, neck, or sinuses, Please, bring it with you to your ENT appointment. I would be happy to review the images with you. As you know, a picture is worth a thousand words. I am very proficient at reading these images, explaining the anatomy, and suggesting the next best course of treatment.


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