THYROIDECTOMY AND PARATHYROIDECTOMY

The thyroid gland is a gland in the neck that produces a hormone called thyroxine that helps to control metabolism. If too little hormone is produced you may have symptoms of fatigue, weight gain, hair loss, depression, swelling, and constipation (myxedema). In children, this can lead to delayed growth. If too much is produced you can have symptoms of weight loss, racing heart rate, heat intolerance, overactive, bulging eyes and difficulty sleeping (thyrotoxicosis). Occasionally, the gland can become lumpy and bumpy by developing nodules. These nodules can be concerning for the development of thyroid cancer and often need to be evaluated. They can also cause symptoms of problems swallowing, hoarseness, pain, sleep apnea and cosmetic prominence of the neck. They are typically identified by your primary care doctor leading to a referral to ENT.

Alternatively, parathyroid glands control your calcium metabolism. When overactive they can lead to depression, kidney stones, constipation, bone pain, and even kidney disease. Additionally, overactive parathyroid glands can cause hair loss, hypertension and even heart disease. They are only typically underactive after surgery. The patient with parathyroid problems is typically identified on routine blood testing noting an elevated calcium level, prompting evaluation with a parathyroid hormone level. Often the patient is surprised to hear they have an issue with their parathyroids as they are often asymptomatic, making this a silent disease at time. Their parathyroid levels need to be carefully evaluated as a patient's Vitamin D level can sometimes skew this finding. Also, some patients have a naturally abnormal set point level of the parathyroids called familial hypercalcemic hypocalcuria. This needs to be watched for. Lastly, parathyroid problems can occur in chronic renal failure patients due to their kidney failure.

When is surgery indicated?

When a patient has a finding of a thyroid nodule, they are typically referred for evaluation. For isolated nodules, we are concerned when certain risk factors are present such as a family history of thyroid cancer, radiation exposure, weight loss, vocal cord paralysis, other lumps and bumps of the neck or unidentified pulmonary nodules. The nodule is often evaluated with a fine needle aspiration biopsy or FNAB. Additionally, the patient will require an ultrasound and thyroid laboratories as a part of their evaluation. If the patient has thyrotoxicosis, they will need management by endocrinology in addition to the thyroid surgeon. In fact, endocrinology evaluation is always a nice addition to the team. Once a needle biopsy is performed one of 4 results often return including: benign, suspicious, malignant or indeterminate. A needle biopsy is a lot like reaching into a lady's purse and finding keys, lipstick, and wallet and calling it a purse based upon these contents. So it is a piece of information but not always a diagnosis. Because of this, the patient may require surgery to either remove a biopsy consistent with cancer or to find out more about a nodule for appropriate treatment. After a general picture of the nodule is made, a decision based upon evidence and risk factors is made regarding surgery. Dr. Kelsch will discuss these indications. As with any discussion of surgery there are risk factors and possible complications including, bleeding, infection, scarring, hematoma, hoarseness, permanent low thyroid level, permanent low calcium levels and long term need for calcium oral supplementation. Prior to surgery, there will be preoperative preparation.

What is expected prior to surgery?

Preoperatively we will need to make sure you are healthy enough to undergo surgery. This will often include an EKG, bloodwork or evaluation by your primary care doctor. They are a part of the team after all. The night before surgery you cannot eat or drink after midnight. As well, all blood thinning medication must be stopped 1 week prior to surgery and a list of these is often provided.

What happens during surgery?

You will be placed under anesthesia by an anesthesiologist. Most patients only remember waking up after the surgery and a sense of fullness or dull pain in the neck. Occasionally, you can wake up hoarse or have some swelling. During surgery, half or the whole thyroid gland is removed through a small incision approximately 4-6 cm in length. If parathyroid gland surgery is performed, only those glands involved will be removed. Dr. Kelsch typically has an assistant help him with this and they will likely meet you before surgery. During surgery, we identify your vocal cord nerve, the carotid artery, the parathyroid glands, and the windpipe. Intraoperatively, we often employ the help of a pathologist to look at the gland while your asleep and help to identify the extent of disease. You will wake up in the post-anesthesia care unit where a nurse will help you recover. Typically, patients will stay overnight after surgery. Overnight we will observe for drops in your calcium or the development of bruising or swelling. IF there are any problems, Dr. Kelsch will be quickly available. Typically patients go home the next day. Occasionally, they have to stay 2-3 days.

What if cancer is found?

Based on the pathology, further options may be offered for the care of your thyroid problem. This may include consultation with endocrinology and even postoperative radioactive iodine ablation of the thyroid. The thyroid is unique in that it uses iodine for the production of its hormone, a lot of it! If thyroid cancer is found, we can use this against any remaining thyroid cancer cells by sending a radioactively targeted chemical to kill those cells somewhat selectively. This is not indicated for all thyroid cancers but will be discussed if indicated. This will require the help of an endocrinologist requiring a consult.

What about parathyroid surgery?

Parathyroid surgery is more focused on calcium management than cancer typically. Your calcium levels will be followed after surgery and markers of calcium production usually confirm a successful surgery. Prior to surgery, you will be injected with a blue dye and possibly even radioactive markers to help identify the parathyroid. Preoperative scans called sestamibi SPECT scans are often needed as well as blood work to identify the abnormal gland. There are typically 4 glands and usually, only 1 or 2 may be involved. So localizing the right gland is very important. Dr. Kelsch will evaluate your unique anatomy and parathyroid issue to tailor a specific approach to your problem. Recovery tends to be quick and surgery is often minimally invasive.