Thyroid Surgery
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Thyroid Surgery
Thyroid Surgery is the cornerstone of treatment for most types of thyroid cancer. If the physician suspects that the cancer has spread to lymph nodes in the neck, these will also be removed during surgery. A complete surgery is sufficient treatment for the majority of patients with thyroid cancer.
How thyroid surgery is performed
Thyroid surgery is done through a 1-2 inch incision that is placed in one of the skin creases of the neck, just above the collarbones. We remove one half of the thyroid at a time, so the incision for a thyroid lobectomy and total thyroidectomy are the same size. The size of the incision is kept small as possible for the best cosmetic result.
The crucial parts of the surgery are:
- exposing the thyroid gland
- identifying and protecting the parathyroid glands
- identifying and protecting the nerve to the vocal cord
- removal of the thyroid gland
In most cases, surgery is approximately 1.5 hours for thyroid lobectomy, and 2 hours for a total thyroidectomy. Patients are completely asleep for these procedures.
Thyroidectomy Surgery
A thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. The thyroid is a butterfly-shaped gland located at the base of the neck, and it plays a crucial role in producing hormones that regulate metabolism and various bodily functions. Thyroidectomy is performed for various reasons, including the treatment of thyroid cancer, large thyroid nodules, hyperthyroidism, or other thyroid disorders. Thyroidectomy is considered the cornerstone of treatment for most types of thyroid cancer. At the Center for Endocrine Surgery Los Angeles, our experienced surgeons will meticulously evaluate for any potential spread of cancer to the lymph nodes in the neck. If detected, these affected lymph nodes will also be carefully excised during the surgery. For the vast majority of patients with thyroid cancer, a comprehensive and precise surgery serves as an effective and often curative treatment approach.
Thyroidectomy surgery overview
Preparation:
- Medical Evaluation: Before the surgery, the patient undergoes a comprehensive medical evaluation, including blood tests, thyroid function tests, and possibly imaging studies.
- Medication Adjustments: Thyroid medications may be adjusted in the days leading up to the surgery.
- Fasting: Patients are usually instructed to fast for a certain period before the surgery.
- General Anesthesia: Thyroidectomy is performed under general anesthesia, meaning the patient is unconscious during the procedure.
Thyroid Surgery Step by Step
When to Stop Eating Before Surgery
You are allowed to eat solid food and drink until 8 hours before you are scheduled to arrive for surgery. After that, you can still drink water and clear liquids (anything you can see through) up until 2 hours before you are scheduled to arrive. We encourage our patients to stay hydrated prior to surgery.
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When to arrive for surgery
The nursing staff in charge of the perioperative area will contact you the day prior to your operation with specific instructions on when to arrive. In general, you are asked to arrive a few hours prior to the scheduled time for the operation. This allows adequate time for you to meet the nurses that will take care of you during the operation, the anesthesia team, and the surgery team.
Checking-in
Once you are checked in, you will be brought to the preoperative area. You will have a private space to change your clothes. The operating room nurses, anesthesiologists, and surgery team will come greet you, prepare you for surgery, and answer any last-minute questions. When the operating room is ready, the anesthesiologists may give you some medication to relax. Most people say they do not remember anything past this point when they wake up in recovery.
Anesthesia
In the operating room, the anesthesiologists will give you medication to fall asleep. Once you are completely asleep, they will insert a breathing tube or a laryngeal mask.
Patient Positioning and Preparation
We make sure all of your pressure points are padded and support your head. We will tuck your arms by your sides and cover you with a blanket and air warmer. Finally, we do place a soft gel roll behind the shoulders to lift and extend the neck.
Neck Ultrasound
Our skilled surgeons at the Center for Endocrine Surgery Los Angeles always conduct a neck ultrasound in the operating room prior to surgery. This crucial step allows us to carefully map out the intricate anatomy of the neck before proceeding with the operation.
Incision
The surgeon carefully selects the ideal location to make an incision on the front of the neck. The size and location of the incision depend on the type of thyroidectomy and the surgeon's preference. Our goal is to keep the incision as small as possible.
Exposing the Thyroid Gland
The surgeon carefully dissects and exposes the thyroid gland. The goal is to identify and protect adjacent structures such as the parathyroid glands and the recurrent laryngeal nerve.
Strap Muscles
The strap muscles of the neck are moved aside to access the thyroid gland. In some cases, these muscles may need to be split and reattached.
Superior Pole
Upper Portion of the Thyroid: The upper portion of the thyroid contains important structures such as the upper parathyroid gland, a branch of the superior laryngeal nerve, and blood vessels supplying the thyroid. Care must be taken to preserve the parathyroid gland and the nerve while dividing the blood vessels.
Inferior Pole
Lower Portion of the Thyroid: The lower portion of the thyroid contains the parathyroid gland and the recurrent laryngeal nerve. Normal parathyroid glands are small and delicate, roughly the size of a grain of rice. Special care is taken during surgery to avoid damage to these glands. The parathyroid gland is carefully separated from the thyroid, and if needed, it may be transplanted into the sternocleidomastoid muscle for blood supply.
Identifying and careful dissection of the recurrent laryngeal nerve is the most crucial portion of thyroid surgery. The recurrent laryngeal nerve controls the motion of the vocal cord.
Before separating the thyroid gland from the trachea, we confirm that we can follow the entire course of the nerve into the larynx.
Thyroid Gland Removal
Depending on the reason for the surgery, the surgeon may perform a total thyroidectomy (removing the entire gland) or a partial thyroidectomy (removing only a portion).
Closure
The incision is closed with sutures that are dissolvable and placed underneath the skin. At our practice, we use steristrips, along with medical tape and skin glue, to safeguard incisions and promote optimal healing post-surgery.
Recovery from thyroid surgery
Postoperative Care:
- Hospital Stay: The length of hospital stay varies but is typically one to two days for uncomplicated cases.
- Pain Management: Pain medications may be prescribed to manage postoperative discomfort.
- Thyroid Hormone Replacement: Patients who undergo total thyroidectomy will need lifelong thyroid hormone replacement therapy to maintain normal bodily functions.
- Monitoring: Regular follow-up appointments are scheduled to monitor thyroid hormone levels, adjust medications, and assess for potential complications.
Recovery after a thyroidectomy, the surgical removal of the thyroid gland, can vary depending on the extent of the surgery, the reason for the procedure, and individual factors. Here's a general overview of thyroidectomy recovery and long-term care:
Immediate Recovery:
- Hospital Stay: Most people stay in the hospital for a day or two after a thyroidectomy, although this can vary.
- Pain Management: Pain and discomfort are common after surgery. Pain medications prescribed by your doctor can help manage this during the initial recovery period.
- Monitoring: The medical team will monitor your vital signs, calcium levels, and signs of complications like bleeding or infection.
- Activity: Initially, rest is essential, but gentle movement and short walks are encouraged to prevent complications like blood clots.
- Diet: You may start with a soft or liquid diet initially, gradually progressing to a normal diet as tolerated.
Short-Term Recovery (First Few Weeks):
- Follow-up Appointments: Attend scheduled follow-up appointments with your surgeon to monitor your progress.
- Medication Management: If the entire thyroid gland is removed, you'll likely need thyroid hormone replacement medication for the rest of your life. Regular blood tests will be necessary to adjust the medication dosage.
- Scar Care: Follow your surgeon's instructions for caring for the incision site to minimize scarring.
- Avoid Straining: Avoid heavy lifting and strenuous activities for a few weeks to allow your body to heal.
Long-term Monitoring:
- Thyroid Hormone Replacement: Take thyroid hormone replacement medication as prescribed by your doctor to maintain normal thyroid function.
- Regular Monitoring: Regular blood tests to check thyroid hormone levels and calcium levels are important for ongoing management.
- Diet and Nutrition: A balanced diet is crucial for overall health. If your surgery affects calcium levels, ensure an adequate intake of calcium through diet or supplements.
- Lifestyle Adjustments: Some people may experience changes in voice or swallowing post-surgery. Speech therapy or dietary modifications may be helpful.
- Symptom Recognition: Be aware of symptoms related to thyroid hormone imbalance, such as fatigue, weight changes, or mood swings, and promptly report them to your healthcare provider.
- Sun Protection: If the scar is exposed to the sun, use sunscreen to prevent hyperpigmentation.
- Regular Check-ups: Continue with regular check-ups with your endocrinologist or healthcare provider to monitor your overall health.
Thyroid Surgery Scars
Thyroidectomy Video
Thyroid Lobectomy Benefits
- No risk to the opposite vocal cord nerve
- No risk of insufficient parathyroid hormone
Thyroid Lobectomy Risks
- 25% chance of needing thyroid hormone supplementation
- 2.5% risk of temporary hoarseness
- <1% hematoma, infection
- May need 2nd surgery to remove other half of thyroid
Total Thyroidectomy Benefits
- Required to receive radioactive iodine
- Allows monitoring using a blood test (thyroglobulin)
Total Thyroidectomy Risks
- Will need lifelong replacement of thyroid hormone (100%)
- 5% risk of temporary hoarseness
- <1% hematoma, infection
- 3% risk of insufficient parathyroid hormone
What is Scarless Thyroid Surgery?
Thyroid stimulating hormone suppression
Following surgery, patients may be treated with thyroid hormone to provide physiologic hormone replacement and to sufficiently suppress pituitary gland secretion of thyroid stimulating hormone (TSH), which is a growth-promoting factor for many types of thyroid cancer. All patients treated with total thyroidectomy (complete thyroid removal) require thyroid hormone therapy with levothyroxine; approximately 25% of patients treated with lobectomy (partial thyroid removal) require thyroid hormone therapy. Thyroid hormone replacement is usually provided as a daily oral pill called levothyroxine. Your endocrinologist will monitor blood tests, including a TSH level, to determine the optimal dose for managing your thyroid hormone balance and the recurrence risk of your thyroid cancer (see Dynamic Risk Stratification below). In general, patients with more aggressive disease and higher risk of recurrence are initially managed with levothyroxine to suppress the TSH level (<0.1mIU/L), while patients with lower risk of recurrence and/or other health factors that would increase their risk from side effects are managed with a TSH in the lower half of the normal reference range (2-0.5mIU/L). Levothyroxine thyroid hormone therapy and TSH suppression in thyroid cancer patients are individualized and change over time based upon the risk of disease recurrence.
Will I feel different taking thyroid hormone pills?
Fortunately, a well-tolerated and safe form of thyroid hormone therapy is available, called levothyroxine (also known as Levoxyl or Synthroid; Tirosint is a gluten free formulation). This is the recommended medication to treat hypothyroidism following thyroid surgery and to suppress TSH in patients with a history of thyroid cancer. Most patients achieve a normal thyroid balance and feel well within 6-8 weeks of starting therapy or sooner when followed by an endocrinologist. Your doctor will monitor thyroid function tests over time to ensure that your dose is optimal for both your thyroid balance and controlling your thyroid cancer. More information about thyroid hormone tests and thyroid hormone medication can be found here: Normal Thyroid Hormone Levels.
Radioactive iodine (RAI) ablation therapy
Patients with a high risk of disease recurrence may also be offered radiation therapy with radioactive iodine. At UCLA, we estimate that about 1 in 4 patients may need radioactive iodine as part of their thyroid cancer treatment. Radioactive iodine takes advantage of the preferential uptake of iodine by thyroid tissue to allow radiation treatment of residual and microscopic thyroid cancer with minimal side effects on other organs. Therapy is done in collaboration with a nuclear medicine physician and is given by an oral pill that the patient swallows. Patients remain isolated at home or in the hospital for several days after taking the radioactive iodine, followed by an imaging scan 5 days after therapy. To improve the efficacy of RAI therapy, patients are asked to follow a low iodine diet for 10-14 days prior to therapy and may be instructed to withdrawal from thyroid hormone medication or receive an injection of Thyrogen to sensitize any remaining thyroid tissue to RAI. Additional information about radioactive iodine therapy and a low iodine diet can be found on the patient education site. Radioactive iodine therapy is generally safe and can be highly effective for some kinds of thyroid cancer. Common side effects include dry mouth and eyes after therapy. Recent data suggests that even lower doses of radioactive iodine may be effective in reducing the risk of thyroid cancer recurrence, further reducing the risks of side effects from radioactive iodine ablation therapy.
Dynamic Risk Stratification informed by ongoing surveillance with tumor markers and imaging
After initial therapy for thyroid cancer, patients continue regular disease surveillance under the care of an endocrinologist. Ongoing disease monitoring includes measurement of tumor marker thyroglobulin in the blood and thyroid/neck ultrasound imaging at regular intervals.
Thyroglobulin levels are usually evaluated 4-6 weeks after initial therapy, at 6 months, and then every 6-12 months based upon clinical response. Thyroid ultrasound surveillance typically occurs at 12 months after therapy and annually thereafter.
Your endocrinologist will follow your tumor marker thyroglobulin over time. Persistently elevated or a rising thyroglobulin tumor marker may prompt your physician to perform other evaluations to locate persistent or recurrent thyroid cancer, such as a physical exam, neck ultrasound or computed tomography (CT) imaging, or iodine uptake whole body scans.
At the UCLA Endocrine Center, we utilize a strategy of dynamic risk stratification during thyroid cancer follow-up. Dynamic risk stratification incorporates measurement of tumor markers and imaging surveillance information to continually re-evaluate in each patient the risk of clinically significant thyroid cancer recurrence or progression. This risk stratification then guides recommendations for further diagnostic evaluation, TSH suppression and additional therapy in a way that optimally balances the benefits of additional treatment with risks and side effects. For example, thyroid hormone suppression of TSH is relaxed in patients with excellent response to treatment and low risk of recurrence to minimize the risk of heart arrhythmias and osteoporosis that can result from long term TSH suppression therapy.
Active Surveillance of Low-Risk Thyroid Cancer
While surgery is the initial management for most thyroid cancers, in an appropriately selected group of patients with low risk disease, active surveillance may be an alternative strategy to immediate surgery. Recent data suggest that management with active surveillance may allow patients with low risk disease to avoid or delay surgery for thyroid cancer without significant increases in disease spread or overall survival outcomes.
Active Surveillance of Thyroid Cancer
UCLA endocrine surgeon James Wu, MD, presented a live-streaming webinar to discuss active surveillance of low-risk tumors, a recommended treatment approach for many incidentally discovered papillary thyroid cancers.
Treatment of Recurrent Thyroid Cancer
Every year, approximately 50,000 new diagnoses of thyroid cancer are made. Since very few patients die from their thyroid cancer, recurrences are frequently encountered. Fortunately, most recurrences in the neck can still salvaged with surgical resection.
Recurrences can be detected through blood tests, neck ultrasound, and physical examination. Consultation with an endocrinologist and endocrine surgeon should be sought to determine the site and extent of recurrent disease.
Treatment options for recurrent thyroid cancer include additional surgery, use of radioactive iodine, targeted therapies, and in some cases, observation with close monitoring. The choice of further treatment often hinges on the location and extent of the recurrent disease and response to prior therapy. Diseased lymph nodes in the neck are usually removed surgically. Disease outside the neck is often treated with radioactive iodine, external beam radiation, or new systemic targeted therapies.
Management of Advanced Thyroid Cancer and Anaplastic Thyroid Cancer
For advanced thyroid cancer that persists or recurs after surgery, radioactive iodine ablation, and thyroid hormone TSH suppression, additional therapies may be required. Furthermore, patients with poorly differentiated or anaplastic thyroid cancer often require systemic targeted therapy or immunotherapy given in collaboration with medical oncologists.
Improved understanding of the pathogenesis of these cancers is leading to the development of new agents aimed at specific oncogenic mechanisms, called targeted therapies. Targeted therapies approved for the treatment of advanced thyroid cancer include tyrosine kinase inhibitors (lenvatinib, sorafenib, and cabozantinib), multi-kinase inhibitor vandetinib, and RET fusion inhibitor selpercatinib. Additionally, are ongoing to evaluate BRAF inhibitors and immunotherapy with checkpoint inhibitors in patients with advanced thyroid cancers.
In rare situations, thyroid cancer spreads to other sites in the body, including the lungs, bones, and brain. Disease in these sites may not be amenable to surgical resection and therefore adjuvant therapies are often used. Lung metastases are the most common site of distant thyroid cancer spread. When lung metastases are large or cause symptoms like shortness of breath, treatment with radioactive iodine, external beam radiation, or targeted therapies may be recommended. Bone thyroid cancer metastases can also occur rarely and may cause bone pain or increased risk of fracture. Treatments available for thyroid cancer bone metastases include external beam radiation, systemic targeted therapy, and bone strengthening medications.
Thyroglossal Duct Surgery (Sistrunk) Operation
Thyroglossal duct surgery, also known as a Sistrunk operation, is when a thyroglossal duct cyst is removed along with most of the thyroglossal duct. The thyroglossal duct runs from the base of the tongue down to the thyroid in the middle of the neck. This includes removing a small portion of a thin bone known as the hyoid bone, since the tract runs through this bone.
The Procedure:
- Anesthesia: You'll be asleep during the surgery under general anesthesia.
- Incision: A small incision is made along a skin crease high up on the neck, usually between 1-2 inches long.
- Cyst and Duct Removal: The surgeon removes the cyst and a portion of the thyroglossal duct to prevent recurrence.
- Closure: The incision is closed absorbable stitches and doesn't require removal.
After the Operation:
- Recovery Room: Monitored as you wake up from anesthesia.
- Hospital Stay: Sistrunk operations are outpatient operations, and patients go home the same day after a 4-6 hour observation period.
- Pain Management: You'll receive instructions and possibly pain medication for comfort.
- Follow-up Care: Regular follow-up appointments to monitor healing.
Recovery:
Most resume normal activities within a week. No special diet is required after surgery, though many patients prefer softer foods if they have a sore throat afterwards. Recovery typically takes 4-5 days. Patients experience the most soreness after the operation in days 1 and 2. After that, most patients do not take any additional pain medication. Due to the physical stress of the operation and undergoing anesthesia, most may still feel more fatigue than usual in days 3-5.
Conclusion:
Thyroglossal duct cysts are a manageable condition, and with proper diagnosis and treatment, individuals can lead healthy, symptom-free lives. If you have any concerns or questions about thyroglossal duct cysts, please see us for a consultation.