| Surgical
Treatment of Thyroid Disease |
Index to this Health
Guide
Introduction
Preoperative Investigation
Indications for Surgery
Course in Hospital
Side Effects of Operation
Postoperative Treatment
Operative Results |
Health
Guides on Thyroid Disease
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Introduction
At one time, thyroid
disease, particularly in the form of marked enlargements and overactivity,
was only curable by surgical treatment. Indeed, the Nobel Prize
in medicine was awarded to Professor Theodore Kocher of Switzerland
in 1909 for making thyroidectomy a safe procedure. In the last 50
years, medical discoveries regarding the thyroid gland have been
numerous and have resulted in decreasing the need for surgical treatment.
However, surgical treatment is still an essential part of the treatment
of many thyroid conditions even at the present time.
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Preoperative
Investigation
Enlargements or dysfunctions
of the thyroid gland can be of varied nature so that patients with
these problems must undergo appropriate investigation to make a
proper diagnosis. The tests that are carried out usually consist
of thyroid function tests, radioactive thyroid scans, thyroid ultrasound
and most importantly, fine needle aspiration biopsy (FNAB) of they
thyroid gland. Based on the results of these tests along with a
suitable history, a doctor may refer the patient to see a surgeon
to determine whether surgical treatment is appropriate and might
be helpful in a particular situation.
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Indications
for Surgery
Surgical treatment is
particularly indicated in those patients with nodules that are considered
to be cancerous which is primarily detectable by FNAB. While
FNAB can detect cancerous tissue, it more frequently reports malignancies
as showing "cellular" or "follicular" lesions so that
even though FNAB diagnosis may not indicate a strictly cancerous
diagnosis, it may indicate a diagnosis that is sufficiently suggestive
of cancer to warrant surgical treatment.
Patients with an overactive
thyroid enlargement may require surgical treatment. This is particularly
true of such patients who have nodules in the thyroid gland either
solitary or multiple. It is less true for patients with Graves'
disease, but even here, patients with a bulky enlargement or those
with Graves' disease who have an associated solitary nodule which
is cold on scanning or the unusual patient with a poor radioactive
iodine uptake may all be eligible for surgical treatment.
Patients who have experiences radiation
in the distant past for skin problems of the head and neck area
may develop a nodularity of the thyroid gland which may require
surgical treatment, particularly since there is 30 to 60% frequency
of cancer in such glands. In Canada, the usual indication for such
radiation was the treatment of acne or blood vessel tumours of the
facial skin or occasionally an "enlarged thymus."
Patients on occasion may develop
an enlargement of the thyroid gland to the extent that there is
pressure on the swallowing tube or windpipe creating a sense
of difficulty in swallowing or a sense of oppression and difficulty
in breathing. This can be verified on x-ray examination of the chest
where the windpipe can be seen to be deviated by the enlarged thyroid
gland. In this situation surgery is effective and may be preferred.
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Course
in Hospital
The patient requiring
thyroid surgery is usually admitted to hospital the day before
surgery after suitable preoperative testing which may include
a chest x-ray, an electrocardiogram, and various blood tests including
thyroid function tests. The surgical treatment is carried out
through a relatively short incision in the lower central portion
of the neck. The central muscles of the neck are parted and the
lobe of the thyroid gland is removed after careful dissection
which involves the recognition and preservation of the superior
laryngeal nerve, the recurrent laryngeal nerve, both of which
go to the vocal cord, and parathyroid gland which control the
level of calcium in the body.
In some situations, only a portion
or a half of the thyroid gland requires removal, and this is
particularly true of benign conditions. The thyroid gland is
made up of two symmetrical lobes and where there is enlargement
of both lobes or malignancy or a bulky Graves' disease problem,
a removal of most of the thyroid gland may be required.
If cancer is present in the thyroid
gland, the surgeon should make a search for a spread of cancer
to lymph nodes of the neck. If the lymph nodes of the neck are
involved, they may require removal by an operation called a
modified neck dissection in which there is a minimal derangement
of function and appearance. The thyroidectomy incision may have
to be extended along the lower neck in order to enlarge the
exposure of the neck to carry out such a neck dissection.
Following operation, the incision
is stitched carefully and the patient usually is able to be
discharged on the first or second day following surgery. Sutures
are able to be removed by the second postoperative day and the
patient is expected to return to be seen by the surgeon a week
following surgery for further assessment.
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Side
Effects of Operation
Immediately after surgery,
the patient will experience a swelling of the neck in the
area of the incision, a sore throat, some difficulty in swallowing,
and some discomfort of the back of the neck from the position
it was in at the time of surgery. All these problems are usually
of moderate degree and disappear spontaneously after days or a few
weeks time.
Occasionally fluid will build up
underneath the incision and the surgeon will have to drain this
with a needle and syringe. This is easily managed by such technique
and it is as a rule unnecessary to open up an incision to drain
such a fluid collection.
Infrequently there will be some derangement
of voice production. This is usually due to a form of laryngitis
following irritation by the anaesthetic tube and as such will also
disappear in a few weeks or even months time. While an injury of
the recurrent nerve can cause hoarseness or weakness of the voice,
this is an unusual event and should be completely avoidable. Occasionally
with cancerous conditions, the recurrent nerve is destroyed by the
cancer, and its loss is unavoidable if one is to completely remove
the malignancy.
Where most of the thyroid gland is
removed, the occurrence of a low calcium state following such surgery
is not uncommon and is easily treated by calcium supplement. This
is usually self-correcting although it may take a few weeks or months
before the calcium state returns to normal and pills are no longer
necessary. Occasionally calcium pills must be taken on a permanent
basis, and this is particularly true of extensive cancers of the
thyroid gland that discourage excessive manipulation of the gland.
It is due to damage to the parathyroid glands during surgery.
The incision as a rule heals very
nicely and is cosmetically very acceptable. An undue thickening
or keloid formation can occur in people of Oriental or Black origin
or in the adolescent state. These can be treated with cortisone
injection which is usually effective in improvement.
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Postoperative
Treatment
Following surgery, it is recommended
that patients take thyroid replacement even if only a small portion
of the thyroid gland requires treatment. This protects the patient
from underfunction of the thyroid gland and the occurrence of tumours
in residual thyroid gland or tumour-like enlargement.
If a patients' problem is that of
a cancer, he may require treatment with radioactive iodine and even
external x-ray treatment to the neck. This depends on the final
report of the tissue examined by a doctor called a pathologist.
The patient's doctor should make recommendations regarding such
treatment.
It is important that all patients
undergoing thyroidectomy be seen at least twice a year to have their
thyroid function tests checked.
Taking a thyroid pill is a simple
matter and does not require complicated control. Patients with malignancy
may be seen more often and require ultrasound examinations of the
neck and thyroglobulin tests to detect possible recurrence of cancer.
If the levels of calcium were made permanently low, then calcium
and Vitamin D must be administered and monitored.
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Operative
Results
Patients undergoing thyroidectomy
usually recover quickly and well with little to show as a rule for
their operative experience. The side effects of the surgery should
be minimal, and it is best to ensure that the surgeon selected for
the operation is someone who is experienced or educated in thyroid
surgery. The treatment of malignancy by surgery in particular is
exceptionally effective, and the cure rate is exceptionally high.
Patients should enjoy a sense of good health and vigour following
their recovery from thyroid surgery. |
Written
by Irving B. Rosen, MD, FRCS(C), FACS, Associate Professor Department
of Surgery, University of Toronto, Mount Sinai Hospital, Toronto.
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printed version of this Health Guide is available to health care
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Production of
the printed version of this Health Guide was made possible through
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herein are solely those of the authors and do not necessarily represent
the official policy of Health Canada. |
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