General Information
The word thyroid comes from the Greek word thyros, which means “shield.” The thyroid gland is a butterfly-shaped gland in the lower portion of your neck. It is situated in the front of the neck, below the skin and muscle layers. It sits where a bowtie on a man would sit. The butterfly wings are the left and right thyroid lobes that wrap around the trachea.
 The function of the thyroid is to make thyroid hormones. There are two hormones (T3 and T4). These hormones help regulate your body's metabolism and they affect many organ systems in your body.
Symptoms/Diagnosis
Common Thyroid Problems
The thyroid gland is prone to multiple problems, some of which are extremely common. Several of the problems are explained below.
Goiter – A thyroid goiter refers to a benign (non-cancerous) enlargement of the thyroid gland. A goiters is usually left alone unless it causes problems. Some problems that could merit surgical removal of a goiter are: compression of the airway, unsightly mass on the front of the neck, or the presence of so many lumps that it is impossible to rule out cancer.
Hyperthyroidism – Hyperthyroidism means too much thyroid hormone is being made by your thyroid gland. This happens for a variety of reasons. Current methods used for treating a hyperthyroid patient are radioactive iodine, anti-thyroid drugs, or surgery. Each method has advantages and disadvantages. In North America, surgery is the least common treatment selected for hyperthyroidism. Symptoms of hyperthyroidism include
- Sweating / Always hot
- Tremor
- Weight loss/Anorexia
- Diarrhea
- Lower extremity swelling
- Insomnia
- Visual disturbances
- Malaise/fatigue
- Thirsty/ frequent urinating
Hypothyroidism – Hypothyroidism means too little thyroid hormone is being made by the thyroid gland. This is a common problem. There are multiple causes. Surgery is usually not an issue. The following are symptoms of hypothyroidism.
- Cold intolerance
- Weight gain
- Decreased concentration
- Depression
- Myalgias
- Constipation
Thyroiditis – Thyroiditis is an inflammatory process within the thyroid gland. Thyroiditis can present a number of symptoms such as fever and pain, but it can also appear as subtle findings that are related to either hypo or hyper-thyroidism. There are a number of causes, some more common than others.
Thyroid nodules and thyroid cancer are two of the most common conditions that lead to consideration of surgery on the thyroid gland. Each of these is explained more fully below:
Thyroid Nodules
Thyroid nodules are more common as one gets older. They are also more common in females. Nearly 25 percent of people walking around have thyroid nodules.
Ninety-five percent of solitary thyroid nodules are benign. That means that only five percent of thyroid nodules are malignant. If you have more than one nodule, then the “dominant” or larger nodule is biopsied. If a nodule is found to be malignant, or has features suggestive of malignancy, then the recommendation is to remove the thyroid. (See thyroid cancer.)
Benign nodules are usually watched without doing an operation. Exceptions to this rule are the following:
History of radiation exposure.
Many people have had radiation exposure for a variety of reasons. For example, acne used to be treated with radiation. If there is a history of radiation exposure (no matter how long ago) and you have a thyroid nodule, it is strongly recommended that you have your thyroid completely removed because of the increased chance of cancer.
Multiple Nodular Goiter.
This is a benign condition where you have a large thyroid gland that has many nodules. If there are so many nodules that observing these nodules would be too difficult, then we would remove your thyroid.
Thyroid Cancer
There are four different types of cancer. Eighty percent of thyroid cancers are either papillary or follicular. These two cancers are usually pretty well behaved and are not too aggressive. Overall, the prognosis of these cancers is quite good.
Note: The amount of thyroid to remove with a diagnosis of cancer is controversial and therefore the treatments can vary from surgeon to surgeon. The treatments mentioned in this text are our group's preferred method of treatment.
Papillary Cancer
The treatment for both papillary and follicular cancer is a total thyroidectomy. This is the total removal of your thyroid gland. After the gland is removed, very little is done for four to six weeks. During this time, you will become very hypothyroid. You will then have a body scan looking for any residual thyroid cells. Any thyroid cells that remain are obliterated using radioactive iodine, which is painless. You will then have regular blood draws to follow certain levels in your blood to make sure there is no tumor recurrence. If your levels were to rise, you would require more body scans to see if the tumor has spread to other parts of your body.
Follicular Cancer
The treatment for both papillary and follicular cancer is a total thyroidectomy. This is the total removal of your thyroid gland. After the gland is removed, very little is done for four to six weeks. During this time, you will become very hypothyroid. You will then have a body scan looking for any residual thyroid cells. Any thyroid cells that remain are obliterated using (painless) radioactive iodine. You will then have regular blood draws to follow certain levels in your blood to make sure there is no tumor recurrence. If your levels were to rise, you would require more body scans to see if the tumor has spread to other parts of your body.
Medullary Cancer
This very aggressive cancer has no effective treatment other than surgery. In about 80 percent of cases it occurs sporadically; however, in 20 percent there is a strong genetic component. Making sure that the genetic component is ruled out is very important. This has strong implications for your family.
Anaplastic
This is also a very aggressive cancer. Many times treatment cannot be offered because the cancer has spread too far.
What Causes Thyroid cancer?
Doctors do not know what causes most cases of thyroid cancer. However, doctors and scientists have observed that thyroid cancer affects women two to three times as often as men and occurs more frequently in whites than in blacks. Scientists do not fully understand the reasons for these patterns.
One known risk factor is exposure to radiation during childhood. Before doctors knew of its dangers, radiation therapy was used to treat acne and to reduce swelling and infection in organs such as the thymus, tonsils, and lymph nodes. People who received radiation to the head and neck as children have a higher- than-average risk of developing thyroid cancer many years later.
Early Detection
The National Cancer Institute recommends that anyone who received radiation to the head or neck in childhood be examined by a doctor every 1 to 2 years. Also, people should see a doctor if they have a family member with medullary thyroid cancer. The most important part of a checkup is the careful examination of the neck, feeling for lumps in the thyroid and enlargement of nearby lymph nodes. A thyroid ultrasound should be performed.
Thyroid Cancer Symptoms
The most common symptom of thyroid cancer is a lump, or nodule, that can be felt in the neck. Other symptoms are rare. Pain is seldom an early warning sign of thyroid cancer. However, a few patients have a tight or full feeling in the neck, difficulty breathing or swallowing, hoarseness, or swollen lymph nodes. These symptoms can be caused by thyroid cancer or by other, less serious problems. If a person is experiencing the following symptoms, you should see a doctor.
- Ear pain
- Trouble swallowing
- Neck pain/enlargement
- Neck mass
- Shortness of breath
- Hoarseness
Ultrasound
Ultrasound is the use of harmless sound waves to look at your neck. It is part of a thorough physical exam. By using the ultrasound, we are able to appreciate and “see” many things that would otherwise not be appreciated. For example, many nodules or cysts that cannot be palpated during physical exam can be seen by ultrasound. We are able to “see” irregularities in the thyroid and determine if they are solid or cystic – even if they are only a couple of millimeters in size.
Ultrasound alone cannot be used to differentiate benign from malignant nodules. One needs an FNA (see FNA) to establish if a nodule is malignant.
“Hot” or “cold” nodules
This refers to how a nodule may look on a radiology study called a thyroid scan. These are not performed very often. It was much more popular to perform these scans many years ago.
A “hot” nodule refers to an area of the thyroid that is overactive compared to the remaining thyroid. It almost always is benign.
A “cold” nodule refers to an area of the thyroid that is NOT absorbing iodine as efficiently as the remaining gland. Cold nodules can be malignant in approximately 5 percent of cases.
Evaluating thyroid nodules should always include history and examination by a physician. An ultrasound of your neck by your surgeon is also part of the physical exam.
What is FNA?
FNA of the thyroid is a safe, inexpensive, and effective way to help distinguish a benign from a malignant nodule. It is often the first diagnostic test performed. FNA stands for Fine Needle Aspiration.
A very small needle is inserted under the guidance of the ultrasound machine directly into your thyroid where the suspicious nodule or cyst is located. Thyroid material is removed and then examined under a microscope by a pathologist. This usually, but not always, can provide information regarding the suspicious area.
Physician’s exams, laboratory tests and radiology scans are helpful, but the best test to differentiate a benign from cancerous thyroid nodules is an FNA done using ultrasound guidance.
There are four types of results after an FNA.
Benign
Benign is benign. Usually this means that no further treatment is necessary. Often times you will need to come back in 6-12 months to make sure that the area stays benign and has not changed.
Malignant
Usually this means that surgical removal of your thyroid is recommended. (See thyroid cancer.)
Suspicious
This may vary from case to case. This also depends on the reason why the biopsy was done. There are cases where an FNA cannot distinguish a cancer from a benign lesion. In these particular cases, surgery of part of your thyroid is recommended to ensure that we do not miss a cancer.
Nondiagnostic
Usually this means that you will need another FNA performed because the sample was not good enough for the pathologist to make a diagnosis.
Treatment
After some or all of your thyroid has been removed, you will spend one night in the hospital. During this time you will be able to walk around, eat dinner, and be with your family. While in the hospital, labs will be checked to make sure that your calcium level is still the same and that your parathyroid glands were not injured.
The following morning you will be seen by your surgeon who will look at your incision and make sure that your voice is OK. Then you are discharged from the hospital. When you go home, there are few restrictions. We ask that you not drive your car for several days. The reason is that we do not want you moving your neck quickly from side to side until the incision has had a chance to heal. You can drive when you have been off narcotics for 48 hours.
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