How do I know if I will need thyroid surgery?
Thyroid nodules (growths in the thyroid gland) are extremely common—up to 10% of all women. Thyroid nodules are important for two reasons. First, the neck is not rated for growth and development. With growth of the nodules, there can be compression on trachea, nerves to the voice, or esophagus. This can cause symptoms of shortness of breath, chronic cough, voice hoarseness or change, and issues related to swallowing. The other issue is cancer. Fine needle aspiration can help diagnose cancer.
A fine needle aspiration is a biopsy using a tiny needle, about the same gauge as for drawing blood. Using the ultrasound, the needle is guided into the area. A few drops of blood are taken and specimen prepared for the pathologist. The procedure takes minutes and there are no restrictions following. Patients are fine to drive following the procedure. A band aid is placed for sympathy purposes.
This depends on the skill of the thyroid surgeon, the type of surgery being performed, and the severity of the disease. A thyroid lobectomy (partial thyroid removal) typically takes about 30 minutes to 45 minutes. A total thyroidectomy can take about 45 minutes to 75 minutes depending on the degree of difficulty of the operation and whether lymph nodes are removed at the same time. Parathyroidectomy is shorter usually lasting only about 15 minutes if the diseased gland is localized or slightly longer if the doctor needs to evaluate all 4 glands. Patients typically spend an hour in the recovery room and then will be either discharged home or admitted overnight to the hospital. The great majority of patients undergoing surgery will go home same day. Patient with significant health issues or those traveling from a distance will stay overnight.
Standard incisions are less than 4 cm. The scar may need to be bigger for large thyroid goiter or patients with larger necks. For reoperations, the doctor will attempt to use the original incision and revise it if necessary to improve cosmetic outcome. Drains are not typically used except in the case of massive goiter or neck dissection for metastatic thyroid cancer.
There are three main risks of thyroid and parathyroid surgery that a surgeon should discuss with any patient that is preparing for a thyroid or parathyroid operation. The first risk is bleeding. Please notify the team if you are taking any medication that might thin the blood. Examples are Coumadin (warfarin), Plavix, Pletal, Fish Oils, and high dose Vitamin E. Notify the team if you have required Lovenox bridge in the past or if there is any family history of bleeding problems.
The risk of permanent recurrent laryngeal nerve injury is approximately less than 0.5% in the hands of an experienced endocrine surgeon. This type of injury causes hoarseness of the voice and can be temporary or permanent. There is also a risk of injury to the external branch of the superior laryngeal nerve that can result in loss of tone in the voice or inability to yell or sing.
Another risk of thyroid surgery is injury to or inadvertent removal of normal parathyroid glands causing low calcium. In the hands of an experienced thyroid or parathyroid surgeon, that risk is small. The parathyroid glands control calcium metabolism in the body, which can lead to problems with muscle contraction. This type of complication can be temporary or permanent. If this occurs, patients can become hypocalcemic (low blood calcium levels) and may require daily calcium supplements.
Synthroid is synthetic human thyroid hormone that serves to provide thyroid hormone to your body after a part or all the thyroid is removed. It helps to control the body’s metabolism. It is a small colored pill (each dose has a different color) and is best absorbed on an empty stomach. As with most medications, it is best taken at the same time each day. Most patients prefer to keep it by their alarm clock and take it immediately upon rising in the morning.
Thyroid levels are monitored with blood tests that will be performed several weeks after thyroid surgery. The thyroid hormone that is secreted by the thyroid right before it is removed lasts for up to six weeks! There is no utility checking levels right away. The starting dose is calculated by weight. There is no “high” or “low” dose…only different sized people who metabolize the drug differently. How you feel will also be taken in to consideration when adjusting dosage.
TSH stands for thyroid stimulating hormone. It is the hormone that the brain makes to stimulate or stop the thyroid from making thyroxine (which is thyroid hormone) that affects the body. When the body has enough thyroxine, there is no need for the thyroid to be stimulated to make more, so the TSH is low. When the body needs more thyroxine, the brain encourages the thyroid to make more so the TSH increases. To recap, a low TSH means the body has more thyroid hormone and a high TSH means the body needs more thyroid hormone.
Depending on the lab, normal range is between 0.5- 4.5. Understand that “normal” simply means that 90% of the bell curve among healthy people falls within this range. Every person has their own personal set point at which they function best. It is for this reason that TSH levels are measured both before and after surgery. Thyroid cancer patients will need to maintain an especially low TSH after surgery to prevent recurrence.
Usually no. The one exception is in patients taking Coumadin. The Coumadin and Synthroid levels will need to be closely followed. If you become pregnant anytime after thyroid surgery, make sure your doctor is aware you are taking Synthroid as TSH fluctuates during pregnancy.
Yes, this is called Armour or porcine thyroid. It is called the “natural” thyroid supplement as it is made from animal thyroid rather than synthetic human extract. Please check with your surgeon or physician prior to choosing Armour as levels will be monitored differently. If you have a preference, please make it known to your surgeon.
Yes, but it may not make a large difference for most patients. The reason generic drugs are generic is that there is some minor differences in the patented formula. There are also multiple different labs all making their own version of the generic formula. Taking patented Synthroid may be important for patients who find it difficult to regulate their thyroid levels as they are assured the same medication with each refill. These patients are more the exception than the rule.
Constipation. The body soon adapts and this problem passes. Racing heart beat, flushing, or sweating can be signs of too much medication.
Over half of patients do well on their original post operative dose. The vast majority of the others require only one or two dose changes. The exceptions tend to be patients who had difficulty regulating their levels preoperatively (Graves and Hashimotos) as it takes up to six weeks for the thyroid antibodies to wash out of the system
No. If your body does not have enough thyroid hormone, your metabolism will slow and you will gain weight. If you take your medication, this will be avoided. Your TSH will be closely monitored for this reason.
Maybe—but not from Synthroid. Many patients find that they feel better after thyroidectomy because the underlying problem thyroiditis, large goiter, cancer, etc. has been removed. It is difficult to make healthy life choices when you feel bad.
All patients complain of fatigue for the first few weeks after thyroid surgery, more so than patients undergoing other types of surgery. Often patients feel fine in the morning only to have run out of energy by mid afternoon. This will pass. This is not hypothyroidism.
Parathyroid glands are small glands that control the body’s ability to regulate calcium. There are four glands that are attached to the thyroid gland at each upper and lower pole. During surgery, they are carefully removed from the thyroid and allowed to live on their own blood supply. They are very fragile and may have short or long term problems adjusting after surgery
The body can function normally with ½ of 1 gland only but may require an adjustment time.
You will experience symptoms of low calcium. This can range from a shaky, nervous feeling progressing to numbness of the lips and fingers. If it progresses, the hands and toes cramp such that it is difficult to straighten. In severe cases, it can be difficult to breathe.
The calcium level and parathyroid hormone levels are monitored both the evening of surgery and the morning after surgery if there is a need for overnight stay. Depending on your levels, you will be given specific instructions on what your risk factors are. Patients undergoing surgery for large goiters, Hashimoto’s thyroiditis, and Graves disease are particularly susceptible to hypocalcemia. In large goiters, it can be a long traveling distance to separate the parathyroid glands. In Hashimoto’s and Graves disease, the same inflammation that affects the thyroid can also affect the parathyroid glands.
Take calcium. Almost always, the symptoms of numbness, tingling, and cramping can be controlled by swallowing calcium. The key is to take enough. Most patients have problems because they do not take adequate amounts.
If you have symptoms, start taking 2 tablets Calcium + Vit D tablets (any brand is fine but calcium citrate is better absorbed that calcium carbonate) with meals and before bedtime. That is 8 tablets at a minimum daily. If symptoms are still present, supplement with TUMS (chewable calcium carbonate) 2 tablets every hour on the hour. If symptoms still persist, you can double up on everything. Simple tricks like taking extra magnesium (which will also help with constipation issues with all the calcium) and taking the calcium with orange juice (the acid helps to break down the calcium) may also help. Avoid carbonated soft drinks as they contain phosphoric acid that leaches calcium from the bones. If symptoms are so severe that the above does not work and you are taking in excess of 30-40 pills daily, you will need to call the office or be seen in the emergency room.
The lowest calcium levels after thyroid surgery usually happen 3-4 days after surgery. Obviously, all patients will be at home by this time. If you do not have any symptoms at all by 3-4 days post operatively, you probably will not. If you were instructed to take extra calcium in the hospital based on your lab tests, but are feeling great at this point, you can stop the extra calcium.
Symptoms can range from a few days to a few weeks. If you are still having regular symptoms two weeks out from surgery, you will need special monitoring by either surgeon or endocrinologist. In cases of permanent hypoparathyroidism, patients will require lifelong calcium and vitamin D supplementation. This is extremely rare.
The recurrent laryngeal nerves are the nerves that enable the vocal cords to vibrate back and forth to produce sound. They also allow the cords to fully close to cough or clear the throat. They are recurrent because they start at the vagus nerve in the carotid sheath and then “recur” or loop around blood vessels in the chest before traveling next to the trachea,
under the thyroid, on the way to the cricoid (voice box). The right nerve loops around the subclavian vessels and the left side loops around the aorta of the heart.
The nerves are tiny—often smaller than the diameter of dental floss. The nerves are underneath the thyroid, all the surrounding blood vessels, and often near the parathyroid glands. They can have multiple branches, travel in and out of the thyroid, and sometimes travel on top of thyroid. Injury can happen even with the most careful dissection. Injury can range from bruising of the nerve to transsection.
The voice can be different after any surgery, especially because of the endotracheal intubation (breathing tube). Issues with the voice after surgery can have a variety of forms. Patients may notice that the voice is raspy, coarse, deep, hoarse, or weak. If singing, there may be difficulty with hitting high notes. If yelling, there is difficulty projecting the voice. Some patients notice that the voice “wears out” by the end of the day or after prolonged talking.
About 1/500. Patients with large goiters, large cancers, and inflammation from Hashimoto’s thyroiditis, and Graves disease are at higher risk.
If symptoms of hoarseness or weakness persist past three months from surgery, patients are referred for voice therapy. The reason to wait three months is that most patients recover spontaneously by that time. If the vocal cord remains paralyzed, there are outpatient procedures that can be performed by a voice specialist to strengthen the cord. Patients in voice vocations such as singers or professional speakers should receive special counseling and assessment prior to undergoing surgery.
Dr. Garner. All Rights Reserved 2017