Endocrine Diseases

The scarless thyroidectomy procedure allows the surgeon to access the thyroid gland through the patient’s mouth, which is referred to as a “transoral” approach. Unlike traditional thyroid surgery, which leaves a noticeable scar on the patient’s neck, this surgery doesn’t leave any outwardly visible scarring. Endocrine surgeons, Christina Maser, MD, and Farah Karipineni, MD, performed the first scarless thyroidectomy in the Valley on December 13, 2018, at Fresno Heart and Surgical Hospital in North Fresno.

Thyroid disease typically occurs when your thyroid is overactive or underactive; releasing too many or too few hormones. Thyroid disease can also be in the form of growths within the thyroid called thyroid nodules. These can be either benign (non-cancerous) or malignant (cancerous) growths.

Thyroid disease has many symptoms, and several of these overlap with several other diseases. This is a list of possible symptoms which may be associated with thyroid problems.

• Fatigue
• Weight Changes
• Depression and Anxiety
• Family history of thyroid problems
• Menstrual Irregularities and Fertility Problems
• Bowel Problems
• Hair/Skin Changes
• Neck Discomfort/Enlargement
• Muscle and Joint Pain, Carpal Tunnel/Tendonitis
• Having difficulty breathing and/or swallowing
• Changes in your voice
• Anxiety/agitation
• Tremors
• Heart palpitations and irregularities
• Insomnia
• Changes in vision

Over activity of the thyroid gland leads to increased metabolism in every body system. This can occur due to inflammation of the thyroid or it can be due to growth of the thyroid.

Over activity of the thyroid gland leads to increased metabolism in every body system. This can occur due to inflammation of the thyroid or it can be due to growth of the thyroid. Growth of some nodules within the thyroid can cause hyperthyroidism, as can autoimmune diseases such as Graves’ disease. This can lead to weight loss, changes in hair and nails, diarrhea, heart palpitations, anxiety, insomnia, and occasionally fatigue. The overactivity can also leading to bone and muscle loss. You can experience increased heart rate and blood pressure which can sometimes lead to abnormal heart rhythms. If you have a condition known as Graves’ disease, you could have pain in your eyes with swelling in the muscles of the eyes and changes in vision.

Diagnosis and Treatment of Hyperthyroidism

Once hyperthyroidism is suspected, blood tests are done to determine the level of overactivity. Medications are used to control symptoms and reduce the amount of thyroid hormones in the blood stream. This usually improves how a patient feels, and occasionally cures the problem. Depending on the reason that hyperthyroidism has occurred, either radioactive iodine ablation treatment or surgery may be recommended. To help guide treatment, tests such as a thyroid ultrasound or thyroid scan may be recommended.

Under-activity of the thyroid gland leads to a decrease in metabolism. This typically happens because of a disease called Hashimoto’s thyroiditis. Symptoms of hypothyroidism can include fatigue, constipation, changes in hair and nails, weight gain, and changes in mood. Hypothyroidism is typically diagnosed based on blood work.

Diagnosis and treatment of Hypothyroidism

Many patients can have fluctuating symptoms, and testing may not reveal significantly abnormal lab results with the first test. Your doctor may run blood tests at different times to try to diagnose this condition. Once the thyroid function is clearly found to be abnormal, medication to help support the thyroid hormone levels is started.

Thyroid nodules, or growths within the thyroid, are usually seen in patients who have a normally working thyroid gland. Thyroid nodules are lumps that are solid or filled with fluid that form within your thyroid.

The reasons for developing a nodule are unclear. It is thought that hormones and diet may play a role, but pinpointing the dietary factors has proven difficult. Genetics can also play a role, so if thyroid issues run in the family (especially cancer), be sure to tell your doctor. Cancer can be found in these growths, which is the reason they usually need to be further investigated. Thyroid nodules are present in greater than 50% of the population, and overall, roughly 10-15% will be cancerous on final biopsy.

Nodules can cause symptoms depending on their size. Patients may experience a sensation of needing to clear their throat, or have difficulty swallowing. Sore throat and voice changes can also occur. There are several other reasons to have these symptoms, and only your doctor can tell for sure if these symptoms are caused by the thyroid.

Some patients may have only one nodule, or there can be multiple nodules. In general, the more nodules that are present, the more likely it is that the nodules are not cancerous. If the thyroid is enlarged and multiple nodules are present, this is termed a thyroid goiter. Once nodules are present on both sides, patients are more likely to develop symptoms of ‘compression’ with difficulty swallowing and pressure on their trachea (windpipe).

Diagnosis of Thyroid Nodules

Once a nodule is found, either noticed by the patient themselves or by a doctor, an ultrasound is usually ordered. This is the most sensitive test for the thyroid and can determine the size and number of nodules. Ultrasound can also determine if there are any suspicious characteristics of the nodule which will let us know if there is a possibility of cancer. If a nodule is larger than 1 centimeter, a biopsy is recommended to determine the risk of cancer within the nodule. This is in the form of a fine needle biopsy. Ultrasound will guide the small biopsy needle into the most suspicious area of the growth. This is a procedure that is done in an office or outpatient setting. Most commonly, an endocrinologist, radiologist, or surgeon will perform this procedure. This takes around 15-20 minutes for the actual biopsy, and most patients have only mild discomfort.

The Results of the Biopsy Generally Fall into One of Four Categories

• Benign: The majority of nodules are benign, meaning no cancer. These nodules can be observed with routine ultrasound, but if they enlarged, a repeat biopsy or surgery may be indicated.
• Malignant: Cancer of the thyroid can usually be determined or strongly suspected based on this biopsy. If cancer is determined, then surgery is needed to remove the thyroid. Thyroid cancer is typically very slow growing, but surgery is usually undertaken fairly swiftly.
• Indeterminate: This is the result when there are too many cells placed closely together, but we can’t tell if there is cancer or not unless we can inspect the capsule of the nodule. This can only be done with the portion of the thyroid containing the nodule removed (with surgery). The concern in this case is that the nodule represents a cancer called Follicular.
• Insufficient: This means that there were not enough cells collected in the biopsy for the pathologist to make a determination of what the lesion is. In this case, typically the biopsy is repeated, or further surveillance can be suggested.

Other tests can be done to evaluate the thyroid. A thyroid scan (aka nuclear medicine or iodine scan) can help determine the source of overactive thyroid. A thyroid scan uses a radioactive tracer and a special camera to measure how much tracer the thyroid gland absorbs from the blood. The tracer can be swallowed or injected. The scan can show the size, shape, and location of the thyroid gland.

Computed Tomography (CT) scans and Magnetic Resonance Imaging (MRI) are also available. These are used mainly in cases of cancer recurrence, and not routinely used. However, many patients are initially found to have a thyroid nodule when a CT or MRI is done for another reason.

Once a nodule has been diagnosed as benign, routine ultrasound is used at 6 or 12 month intervals to see if the nodule is growing. If the thyroid is under-active, nodules are more likely to enlarge. If a nodule enlarges, even though a biopsy was benign, it should be further treated with a second biopsy or surgery to remove it.

When Would Surgery Be Considered?

• Hyperthyroidism
• Enlarging thyroid nodules
• Nodules suspicious or positive for cancer
• Symptomatic nodules or benign goiter causing symptoms

The most common cancer found in the thyroid is Papillary Thyroid Cancer. The main treatment is surgical removal followed by radioactive iodine ablation therapy (RAI). Once surgery removes the cancer in the thyroid, as well as any surrounding lymph nodes to determine local spread of cancer, the stage of cancer can be determined. For cancers 1-1.5 cm or greater, cancers that are in multiple locations in the thyroid, or cancers that show spread to surrounding lymph nodes, RAI is recommended. RAI is done by a nuclear medicine physician, either in a radiology department of a hospital, or in an imaging center.

This involves preparing the body by starving any remaining thyroid cells for iodine and thyroid hormone. The thyroid medications are adjusted, and often patients are changed to a short acting medication temporarily. At approximately 4 weeks after surgery, a low iodine diet will begin and will continue through the treatment. The treatment begins first with a set of blood tests and possibly a diagnostic scan to plan treatment. The dosage of radiation is then determined, and patients return to take the radiation pill. Once the pill is taken, patients are considered radioactive. There will be specific precautions to observe during the following 5-7 days that there is danger of radiation exposure. Please note, this treatment is fairly safe for the patient, but the danger will be to those around you who still have their thyroid. This is particularly true for children and animals. Specific precautions are given by the nuclear medicine doctor, and are unique to each patient. There is a post-treatment scan done several days after the radiation is given and this scan will determine if cancer has spread anywhere in the body. Approximately 7 days after the radiation pill is given, patients are instructed to re-start the thyroid hormone.

Most patients will not feel normal while they are preparing for this treatment. This is a temporary feeling, and the long term risks of this treatment are minimal. The most common side effect is dry mouth due to irritation of the salivary glands. Usually patients are instructed to use lemon and other such things that stimulate saliva. Nausea and vomiting are also possible, but this only lasts for a few days after the treatment is given.

Once your doctor has recommended that you be evaluated by an endocrine surgeon, they will forward information to the surgeon regarding your diagnosis. There will be some basic paperwork to fill out prior to the visit. Completing this paperwork prior to your appointment will make your visit go smoothly. It is necessary to list all medications and supplements that you take, as well as any and all medical problems and surgeries. We make efforts to obtain all of your test results, but if you have specific testing done please mention that as well so we can obtain those results. If more testing is required, we will help to arrange that. Ultrasounds and biopsies can sometimes be done in the office, but this may require an additional appointment depending on the schedule for the day. Typically surgery can be schedule within weeks after your appointment.

For more information, please visit:

• EndocrineSurgery.org
• American Thyroid Association
• Graves’ Disease & Thyroid Foundation

Typically, we either recommend taking out half, or all of the thyroid. If a patient has a nodule on one side of the thyroid which is either indeterminate according to the list above, or benign but enlarging, a hemi-thyroidectomy can be an option. This involves taking out the half of the thyroid which contains the nodule. This is beneficial if the thyroid is functioning normally, since patients may not need thyroid medications long term. The part of the thyroid which is removed is then examined for cancer. It usually takes at least 48 hours for the results. If cancer is found, the other half of the thyroid will need to be removed, which means a second surgery must be performed. This is done to provide optimum treatment and follow up care for thyroid cancer.

Alternately, if there are nodules on both sides of the thyroid, hyperthyroidism, or thyroid cancer, then the whole thyroid is removed with a total thyroidectomy. This surgery takes around 2 hours to perform, and patients are asleep under general anesthesia for this time. After this surgery is done, the patient will need to take thyroid medication every day for the rest of their lives.

The Risks Involved with Thyroid Surgery Include

• Bleeding – usually less than a teaspoon of blood is lost, but this depends on the diagnosis and blood vessels supplying the gland.
• Infection – the risk of infection is very low.
• Injury to the nerves in your vocal cords – the possibility of injury to the nerves controlling the vocal cords is a significant concern. It can be an injury that the surgeon recognizes, or it can be unrecognized during the surgery. This injury can lead to hoarseness which is typically temporary; it is permanent in <1% of cases. It is not unusual to have a slightly raspy voice after the surgery for a couple of days simply due to the breathing tube used for anesthesia.
• Bleeding and possible airway obstruction
• A sharp rise in thyroid hormone levels (only around the time of surgery)
• Parathyroid gland – these glands are next to the thyroid gland and can be bruised or accidently removed or experience blood loss. Damage to these glands will lead to low blood calcium which is usually treated with calcium supplements.

Recovery Following Surgery

The recovery after thyroid surgery is usually fairly well tolerated. Occasionally, it is necessary to stay one night in the hospital, but most patients go home the same day. Due to the risk of low calcium after the operation as listed above, patients are typically recommended to take calcium supplements for 2 weeks after surgery.

You can usually eat and drink normally the night of the surgery. The incision is normally closed with dissolvable sutures and surgical tape or surgical glue.   A small bandage may be placed on your neck following surgery and will normally be removed the following morning. There are no dietary restrictions.

You will be able to shower the very next morning and the incision can get wet. However, no swimming or soaking in a tub for a month.

Patients normally feel well following the surgery, but will have fatigue for approximately 2 weeks. This is simply due to healing from having a surgery – think of it as the body putting energy into healing as top priority. Since most patients don’t feel ‘ill’ before surgery, this can be aggravating to patients. The only restriction after surgery is no driving for 3 days.

Pain usually is controlled with pain medications taken by mouth and many patients switch over to Tylenol or Advil within 24 hours of surgery.

Thyroid medication is usually started the day after surgery. Thyroid medication is given to absolutely all patients who have had their whole thyroid gland out. This medication will be necessary to take every day for the rest of your life. If you have had a hemi-thyroidectomy, a low dose of medication is typically given for a short period of time to help the remaining thyroid rest, which reduces the likelihood of forming a nodule on the opposite side. Please wait at least 30 minutes after taking your thyroid medication before taking your calcium supplement, and at least 1 hour before eating. This will allow better absorption of your thyroid medication. The thyroid medication simply does not absorb into the system if it is not alone in your stomach. Some patients opt to take the medication at bed time; it is necessary to make sure that it is taken on an empty stomach in this situation as well.

The thyroid medication dosage will initially be based on a patient’s weight. This is then adjusted to levels measured in the blood with simple blood tests approximately 6 weeks after surgery. Because it takes the body awhile to adjust to changes in the medication, there may be 4 – 6 weeks between adjustments in the dose and blood tests. Many patients fear that they will gain weight on thyroid medication. There may be some fluctuations in weight around the time of your surgery, but once the medication is adjusted to your normal function, as determined by your levels before surgery, then there should be no weight gain. This has been the subject of multiple research studies, and the research shows that there is no statistical change that is not accounted for based on changes in exercise, diet, or age. (Yes, we do tend to gain pounds as we age.)