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Surgery

1. Why do some patients continue to have dysphasia (swallowing discomfort) and/or neck discomfort including tightness or breathing difficulty many months after their thyroidectomy surgery?

   Ng (May 1/11)

   Feeling tightness and sensation of dysphagia after thyroidectomy is not uncommon. In some situations, it may last up to one year. I have never encountered situations where further surgery is needed. Almost all patients' symptoms resolved spontaneously. The cause is likely due to scarring and inflammatory changes in the tissues around the thyroid bed. Since it is also in close proximity to the esophagus, some constriction of esophageal muscles at that level can also occur, causing the symptoms of dysphagia.
   
   Rosen (May 1/11)

   You appear to be describing postoperative side effects that are not uncommon, which I have ascribed to post op tissue swelling.  Unless there has been an injury to nerve, these symptoms  are temporary and invariably resolve with time.  There is an individual aspect to these symptoms so that some patients  seem more distressd than others.  Positive reassurance helps  the patient  overcome these symptoms.  They are usually not a long term problem.  Indeed thyroidectomy patients usually have a much easier time than most other surgical procedures.

2. Should central neck dissections be included with all thyroidectomy surgeries?

   Rosen (April 1/11)

   Recently the concept of a central neck dissection(CND) has been articulated as an entity and earned discussion as a “new procedure “In actuality I and other experienced surgeons included this maneuver as part of a  thyroidectomy for thyroid cancer and looked upon the procedure as standard.  I obviously agree with this procedure since it may remove additional malignant material and alert one for enhanced surveillance.  I even did further nodal sampling.  It is difficult to ascribe a survival benefit for this procedure but that has been an issue with  nodal involvement on a historical basis.  Some have described increased parathyroid and vocal morbidity with CND but I did not experience this and it is avoidable with appropriate care
   
   Ng (April 1/11)

   I  agree with prophylactic neck dissection. I also routinely request a detailed preoperative ultrasound of the neck to assess the lymph node status in the central neck compartment. For head and neck surgeons with experience in thyroid surgery and neck dissection, the complication rate is very low. Removal of metastatic lymph nodes allows better control of disease with other treatment modalities such as post surgery radioactive iodine therapy.
    

3. What are the effects of a patient being obese or morbidly obese on thyroidectomy surgery?

   Rosen (April 1/10)

   While obesity is an adverse factor for the surgical patient, it is less apparent in the patient requiring thyroid or parathyroid surgery in comparison to abdominal surgery in particular. Obesity may have associated problems-such as diabetes, or hypertension-that may complicate surgical care. Obesity may interfere as well with demonstration of anatomical features . However in the main the obesity factor can be well overcome in thyroid procedures. The post op convalescence is benign where post op problems in cough and consequent atelectasis of the lung are really minimized. The obese patient can in contrast to abdominal surgery do well with thyroid surgery but generally it is better to be slim for more than one reason.
   
   Ng (April 1/10)

   Obesity will make the surgery more difficult due to the neck position usually. So if the neck is thick and short, and lack of neck extension to allow proper exposure of the neck and the thyroid bed, access will be more difficult. The amount of thyroid tissues removed is the same. If the access if difficult, then the surgery will take longer but surgeons will still make sure the parathyroid glands are preserved. Recovery may be longer due to the fact that obese or morbidly obese individuals are likely to have other medical conditions that delay recovery.
   
   
    

4. Can thyroid cancer cells `escape' from the aspirate sample during a Fine Needle Aspiration procedure and be deposited in surrounding tissue?

   Ng  (Feb 1/10)

   The risk of contamination of the field with cancer cells from needle aspirate is nearly non existent. Even so, the likelihood of a new growth due to new deposit is exceedingly low. Needle biopsy is routinely performed and significant secondary deposit has not been demonstrated.

    

   Rosen (Feb 1/10)

   The concern for implantation of thyroid cancer cells with FNAB has been a talking point from the very beginning of needle biopsies. That is how thyroid ultrasonoogaphy was initiated by ourselves (at Mt. Sinai). We wished to differentiate solid (possibly cancer) from cysts(always benign) in order to avoid implanting ca. That was fallacious thinking. Cysts can also show cancer. There is much experience to indicate the implantation of cancer by FNAB is not a real concern. In all my experience with about 2000 cases of cancer I cannot recall any patient who showed this problem. Rare cases of implantation have been reported with anaplastic cancer and that has not been numerous. FNAB has led to the early diagnosis and treatment of thyroid cancer which is still the best factor in cure.

5. Details about Lymph Nodes

   Ng (Feb 1/09)

   We know that lymph nodes in the neck help fight infections. How does this process work?
   
   The lymph node is the site where the lymphocytes are gathered. Lymphocytes are white blood cells (there are several types having different functions) that kill bacteria or remove foreign bodies that enter into our body. Lymph nodes (or chains of lymph nodes) are like regional filtration systems that collect and screen the lymphatic fluid that passes through them and help to filter out the offending substances, for example, cancer cells.
   
   Although it seems counterintuitive, some patients report having fewer infections (such as colds and viruses) after having central compartment or modified neck dissections. Is there any explanation for this?
   
   Removing the diseased lymph nodes (cancerous lymph nodes) in the central neck compartment (or other part of the neck) should not affect the body's remaining lymphatic system and therefore should have no impact on the rate of infections.
   
   Others report having "reactive" nodes (nodes that swell up easily). Is there a relationship between the number of neck lymph nodes one has, and the ability to fight respiratory infections and/or have reactive nodes?
   
   There are many thousands of lymph nodes in our body. A normal and healthy individual will have many reactive lymph nodes to fight infection and these lymph nodes will resume their normal state when the infection is over. If a person's immune system is compromised, then the ability to form "reactive lymph nodes" can be compromised but there is no study to correlate the number of reactive lymph nodes on the ability to fight infection.

6. Is it okay for thyroid cancer patients to have their necks massaged either with or without known disease?

   Ezzat (Oct '09)
   There is no reason to believe nor is there direct evidence that massage will affect cancer cell growth.
   
   Cheng (Oct '09)
   There is no evidence that deep massage can release cancer cells. Patients with or without thyroid cancer can safely undergo deep massage of the neck if needed for other reasons.
   
    

7. After a person has had a thyroidectomy surgery, for what period of time should they refrain from doing heavy lifting? How much lifting is allowed?

   Ezzat (Sept 1/09)
   This depends on whether neck node dissection was or was not performed. In the absence of neck node dissection, most neck muscles are not affected and hence no specific limitations are warranted. In situations where the lymph nodes are dissected and the neck muscles (sternomastoids) are surgically manipulated, then at least 6 weeks of healing should be allowed. The use of blood thinners or other medications may also play a role. Always consult with your surgeon regarding further precautions following your operation.

   Rosen (Sept 1/09)
   Lifting heavy objects is usually not a question that affects a thyroidectomy patients' thinking as opposed to abdominal surgery or hernia surgery where exertion may be a definite factor in problems with wound healing. This is not the case for thyroidectomy wound healing. Patients defer heavy lifting to a time when they feel their general health and vigor is restored which is usually 3-4 weeks with lots of variation. Lifting heavy objects does not usually include infants. Again wound healing is not so much the issue as opposed to patient's sense of well-being.
   
   
   
    

8. Can after-effects of surgery such as scar tissue, cause dizziness and/or difficulty swallowing? Can this effect be caused by enlarged lymph nodes?

   Rosen (Sept 1/08)

   I have not encountered nodes or a surgical scar causing dizziness. External Radiation applied to the esophagus can definitely cause scarring which can contract the lumen of the esophagus and be responsible for significant swallowing problems which may require corrective measures. I think the nature of the "scarring" may be varied and operative in symptom explanation.
   
   Ng (Sept 1/08)

   Generally, no. However, if the lymph node is significantly enlarged and causes significant compression of the carotid artery, there is a possibility of reduced blood flow to the brain and hence some risk of cerebral ischemia. One would also be concerned about developing a stroke due to lack of blood flow to the brain.
   
   It is rare to see significant scar tissue formation around the carotid and cause compression and dizziness. However, scarring can be significant if the neck is radiated.
   
   Yes, scarring of tissues around the thyroid bed and therefore around the esophagus after surgery is thought to be one of the main reasons for causing symptoms of dysphagia; ie. swallowing difficulty. Generally, scarring can also cause contracture and stiffness of the neck. If there are enlarged lymph nodes and invasion of esophagus, then patients may experience swallowing problems
    

9. Is the healing process of scars following a thyroidectomy incision improved with the use of creams and/or lotions?

   Ng (Jan 1/09)

   It has been shown that vitamin E cream has some impact on reducing scar and keloid formation. However, conclusive and larger scale studies are still lacking. The formation of keloid or unpleasant scar depends on many factors such as skin type, post surgery infection, ethnic background (eg. more likely to form keloid in darker skin individuals) such that a universal solution to improve scar is difficult.
   
   Is one cream superior to another and if so, why?
   
   There are no conclusive reports to suggest one type of scar management solution is better than the others. Silicon patch and steroid injection seems to have the most consistent and reliable outcome. Meticulous skin incision handling and post operative incision wound care play an important part in having a better scar outcome.
   
   Is the healing dynamic primarily related to processes inherit in individual patients regardless of lotions used, and if so, what are those processes?
   
   Yes. The healing process depends on many factors including peri-operative (e.g. skin incision retraction during the procedure) and post-operative conditions (infection and reaction to suture materials, etc) as well as individual patients' skin types.

10. Can One Improve Incision Healing?

    Rosen (Dec 1/05)

    Referring to thyroidectomy incisions, surgeons are quite aware that the incision is uppermost in patients' minds particularly since the majority of patients are young women.

    The incision is usually placed in a normal skin crease and can be 2 to 3 inches long depending on the patient's body build and the size of the thyroid tumour. Usually the incision heals well with difficulty in recognizing scar afterwards depending on the individual. The patient is monitored for good wound healing after. Sutures are removed early on. Sometimes sutures are placed beneath the skin and do not require removal as they dissolve on their own.

    Surgeons look at the wounds to detect infection or keloid (overgrowth of the wound) or discoloration.

    For infection antibiotics are used.

    To facilitate good wound healing, steroid or Vitamin E ointment may be prescribed.

    Where a keloid has become established, steroid injections, laser therapy or silicone patches can be prescribed or surgical re section may be required.

    Patients vary in their individual ability in wound healing. Patients should avoid irritating their incisions (fingering their incision, overexposing it to the sun light) and accept the fact that incisions improve with time and that improvement again is an individual matter. Makeup can be applied to the healed incision and it is best to discuss this with the surgeon.

    Most patients wind up with an excellent cosmetic effect to the point that it is not noticeable. Some work is being done to on surgery through an incision away from the neck or through a scope but this is not standard practice.

    (In regards to a specific case, Dr. Rosen said) modified neck dissection varies in extent depending on the extent of nodal involvement requiring appropriate dissection of affected tissue. Being upright facilitates lymphatic drainage and is the usual posture people pursue. After 4 years it is unlikely that there will be a marked difference in facial swelling. As a rule the cosmetic result of a modified radical neck dissection, even where swelling persists, is usually good. It may be less noticeable to others than to you. There should be some comfort in knowing that your neck surgery presumably dealt with significant lymph node metastases from thyroid cancer and that you are well 4 years later with a concern only for facial swelling.

    Rosen (Apr 1/06)

    Thyroidectomy incision reaction is an individual matter to a great degree. The vast majority do cosmetically well without any assistance. For those who show a problem, time is of great benefit and improvement can continue for years.

    Initially I prescribe cortisone ointments particularly if there is some inflammatory look to the incision. I have no objection to Vitamin E ointments. The use of silicone mats available as band aids is also helpful. For keloid incisions kenalog injections into the wound may help and even surgery can be used. Please understand that these are general recommendations and specific problems must be assessed on an individual basis. Dermatologists, plastic surgeons, and the individual's surgeon can provide solutions to wound problems.

11. Under what circumstances is a drain required during and after a thyroidectomy surgery?

    Rosen (Dec 1/09)

    There is a great deal of individual surgeon variation in this practice. Most, including myself, used a drain which presumably: 1) decreases chances of fluids/hematoma collection; need for its aspiration which can lead to infection; gives a better cosmetic result, 2) signals evidence of bleeding and focuses attention to this situation.
    
    The drain is usually removed on the first post-op day if all is well.
    
    Possible side effects of using a drain include: 1) increased patient morbidity in removing it; 2) possible introduction of infection and 3) mechanical problems such as drain loss within wound.
    
    I favoured a fine drain to negative suction which was easily removed on the first post-op day with little patient discomfort

12. What factors help a doctor and patient decide whether he/she should have thyroidectomy surgery in cases where the FNAB is inconclusive? How does one decide on a partial or total under such circumstances?

    Rosen (Sept 1/08)

    I personally prefer following a patient with repeat FNABs. In lesions over 1cm, a cytology report should be forthcoming. The factors influencing surgery would be to include a) pressure symptoms, b) history of definite radiation to the neck and c) serious patient anxiety. Generally, I favour clinical followup.
     

    Ng (Sept 1/08)

    It depends on many factors. If the patient comes from a high risk group, ie history of radiation to the head and neck areas, or family history of thyroid cancer, the patient should seriously consider removing the tumour. If the inconclusive cytology suggests some "abnormal" or "higher risks" features while being inconclusive, the patient should discuss it with the surgeon and consider definitive treatment of surgery. If the patient is low risk group and asymptomatic, repeating the cytology in a regular interval (six months) is not unreasonable as long as it is properly monitored.
    
    Also, if the patient cannot accept the potential general risk of cancer for thyroid nodules (around 5 to 10%) and is having difficulty accepting the fact that they have to repeat the FNA every 12 months, then surgical removal is a good option to alleviate persistent anxiety. Patient must remember that FNA can also be false negative. There is also a risk that cancer develops after FNA even though it is benign. So if the patient has significant anxiety around this issue, removing the tumour is not unreasonable.
    
    For a small single and isolated benign tumour affecting only one lobe of the thyroid, it is safe to consider partial thyroidectomy. However, if there is significant risk of cancer (ie. high risk group) and both lobes have tumour nodules and if it is in the hands of an experienced surgeon who perform many thyroid surgery, total thyroidectomy is a good and recommended option and is safe in most situations. Again, the surgeon should discuss the individual case with the patient to determine what is best for the patient.
     

13. Is there any data to suggest the predictability of FNAB in regards to thyroid cancer?

    Ng (June 1/09)

    Generally, the accuracy of FNAB is in the range of 70 to 90%. However, when the FNAB indicates cancer, the probability of final cancer diagnosis is very high.
    
    What is the ratio of negative, positive and inconclusive/indeterminate results overall?
    
    Majority of FNAB is likely negative as benign thyroid nodules are common. There is no published data on ratio of negative/positive/inconclusive/indeterminate results. The ratio will vary in different physicians practices or centres where the FNAB is performed.
    
    How often is one result found in FNAB and a conflicting result found in pathology, especially in regards to cancerous vs. benign, or the reverse?
    
    If the cytology result is cancer, the chance of finding malignancy in final pathology is high. Generally, the accuracy rate is in the range of 70 to 90%. Therefore, conflicting results can be found in 10 to 30% of cases.
    
    Are there factors that make the predictability vary from one lab to another, or one clinician to another, or one technique to another?
    
    Common factors that can affect the FNAB results include: performance skill of the physician (e.g. not properly sampling the right nodules; failure to aspirate adequate samples); reading errors/interpretation of the cytological slides in the lab by the cytopathologists.
    
    For example, is there a higher predictability with ultrasound guided needle biopsy?
    
    Ultrasound guided needle biopsy significantly improve localization of nodules and help to identify critical areas within nodules for aspiration. Therefore, ultrasound guided fine needle aspiration biopsy is the preferred method when available.