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The one stop information portal for thyroid, neck, and ENT diseases

Thyroid & Parathyroid

This section contains information on the following: 

1. The thyroid gland

2. Thyroid nodule

3. Thyroid mass (goiter)

4. Thyroid cancer

5. Overactive thyroid gland

6. What I should know about thyroid surgery

7. Parathyroid disease and parathyroid surgery

 

1. The thyroid gland

The thyroid is a butterfly-shaped gland located in the midline in the lower part of the neck. A normal gland cannot be seen or felt. It secretes a hormone called thyroxine that regulates sleep, mood, appetite, weight, heart rate, digestion and body metabolism in general.

 

2. Thyroid nodule

A nodule is like a "knot" within the substance of the thyroid gland. It commonly presents itself as a firm swelling in the lower part of the neck that is felt by the patient. However, according to some estimates, if the general adult population is screened by a high resolution ultrasound scan, 70% will have nodules within the gland. 

Reassuringly, the vast majority of thyroid nodules are benign. However 1 in 10 nodules may be due to malignancy. Therefore, once nodules are detected by clinical examination or scan, they need further investigation in the form of a high resolution ultrasound scan and a fine needle aspirate cytology (FNAC). This latter procedure is simple, associated with minimal pain and takes approximately 10 minutes to perform. Results are usually available in a day or two. If both ultrasound and FNAC show reassuring results, no further action is required and the nodule simply needs follow-up. However, if ultrasound and/or FNAC have features of malignancy, surgery is usually required.   

3. Thyroid mass (goiter)

A goiter is a diffuse enlargement of the whole gland which can be readily seen and felt. It is of 2 types- simple goiter and multinodular goiter. The former is commonly seen in younger women and may require an ultrasound and a blood test to check for thyroid hormone status. Surgery is not usually required. The latter needs investigation similar to a thyroid nodule, i.e. ultrasound and FNAC. Depending on the results, the multinodular goiter may simply be observed or treated by removal of the thyroid gland. Indications for surgery include large size causing cosmetic concerns, compressive symptoms such as difficulty swallowing food or breathing problems, extension into the chest, or features of malignancy. 

4. Thyroid cancer

The commonest way in which thyroid cancer presents is in the form of a thyroid nodule. Increasingly these days, it is also picked up by a scan done for some other purpose (incidentaloma). However, as mentioned before, only approximately 1 in 10 thyroid nodules harbour malignancy. Further investigations such as ultrasound and FNAC will clarify the picture. Rarely, thyroid cancer may also present as a neck mass (node). 

Once diagnosed, thyroid cancer typically requires treatment in the form of total thyroidectomy (see below). If there are features suggestive of spread to nearby lymph nodes, selective neck dissection is also indicated. Click here to go to the section on neck dissection and here to know about Dr. M. Dhiwakar's research and journal articles on neck dissection.  A few weeks after surgery, a radio-iodine uptake scan is performed to assess whether there is any remaining tumor activity, and if so, an ablative dose of radio-iodine is given. Life long thyroxine tablet intake and follow-up are required. 

Nevertheless, thyroid cancer that is treated by experts has an excellent prognosis, with long term cure rates exceeding 90%. This holds true even for tumors that have spread to nearby lymph nodes.  

5. Overactive thyroid gland

An overactive thyroid gland produces excess thyroxine hormone that causes sweating, tremor of hands and fingers, inability to sleep and anxiety/panic attacks. This condition is usually treated with medications. If the overactivity is not controlled with tablets, total thyroidectomy is indicated. 

6. What I should know about thyroid surgery 

Thyroid surgery in expert hands is a safe procedure. Hemithyroidectomy involves removal of one-half of the thyroid gland. This procedure is generally indicated for suspicious nodules that involve one lobe of the gland. The thyroid lobe needs to be dissected off the deeper-lying recurrent laryngeal nerve. Injury to the nerve can result in voice change. However, in experienced and expert hands utilizing modern, meticulous operating techniques, the risk of permanent injury to the nerve is exceedingly low. Patients go home a day or two following surgery.

Total thyroidectomy involves removal of the whole thyroid gland and is a safe procedure in expert hands. Common indications are malignancy, large multinodular goiter and an overactive thyroid gland that is not controlled with medications. Once again, the risk of permanent voice change is exceedingly low. However, as the whole gland is removed, life long thyroxine tablet intake (one a day) is necessary. Also while removing the thyroid gland, all 4 parathyroid glands (regulators of blood calcium levels - see below) are meticulously identified and preserved along with their blood supply. However, due to their small size and delicate blood supply, there is a small chance they may be "stunned" and stop functioning temporarily. If this happens, short term calcium and vitamin D supplements may be necessary. When total thyroidectomy is done expertly, the need for life long calcium tablet intake should be rare. Patients can expect to go home in a day or two.

Another important question that comes up with thyroid surgery is regarding the scar. The incision (cut) is usually placed in a skin crease. This disguises the scar and hence the wound heals very well with minimal scarring. Given time, the scar becomes barely noticeable. In many situations, especially for a small lobe or nodule, a highly cosmetic, "mini-incision" that measures 4 cm or less can be performed and the gland safely removed. This minimally invasive approach gives an even better cosmetic outcome.

7. Parathyroid disease and parathyroid surgery

There are 4 parathyroid glands closely applied to the undersurface of the thyroid gland. They secrete a hormone called parathormone that regulates calcium levels in the body which is important for normal growth and body functions. Overactive glands (primary hyperparathyroidism) produce excess parathormone that results in high calcium levels. While this can cause tiredness, fatigue, loss of appetite, bone pain, depression or excess thirst, hyperparathyroidism can often be silent. It is detected by routine blood tests that includes serum calcium levels. Other necessary tests include blood parathormone (PTH) levels which are usually high and 24 hour urine calcium. 

Primary hyperparathyroidism is usually caused by excess hormone secretion by a single enlarged gland (single adenoma). Surgical removal of this adenoma results in cure. The traditional approach involves exploring all 4 glands to find the abnormally enlarged one. However, with the advent of radionuclear scans such as sestamibi, the adenoma can be localized preoperatively, and hence a smaller incision is often adequate to target and remove it. This is yet another example of a minimally invasive approach.  

Secondary hyperparathyroidism is usually caused by renal failure. A low serum calcium level prompts all 4 parathyroid glands to hypertrophy (become fleshy) and secrete high levels of parathormone. This condition can be resolved by correcting the low calcium levels. Sometimes the condition persists despite correcting calcium levels. In such a scenario, removal of 3-and-a-half parathyroid glands may be necessary.