Q&A

It is important for you to know the right questions to ask at your visit with a surgeon. First and foremost, we believe the experience of the surgeon is directly related to the risks of thyroid and parathyroid operations. Please ask your surgeon how many thyroid and parathyroid surgeries they perform weekly. It is well known in surgery the higher number of thyroid and parathyroid surgeries done by a surgeon results in fewer complications, with usually 100 of these cases per year being a minimum needed to be considered “high-volume”.

Other questions to ask your surgeon

• Ask your surgeon if they are sending thyroid biopsies for genetic testing! See our genetic section on the home page to find out why this is so important! This is the most important question to ask your surgeon!!! Also, please ask if they use numbing medicine during the biopsy as these can be uncomfortable with out it. At Austin Thyroid and Parathyroid Surgeons, we take the time to use local anesthesia or numbing medicine for the skin to make it as painless as possible. If they do not take the time to use local anesthesia, we will!
  Do they concentrate on only thyroid and parathyroid operations or do they spend time doing many other types of surgeries, such as abdominal cases, breast surgery, or bariatric operations?
• It is also imperative to ask the surgeon how many complications from neck dissections for thyroid cancer surgeries that they have had in the past…ask about hematomas (bleeding in the neck after surgery), need for tracheostomy (breathing tube placed surgically after thyroid surgery), thoracic duct (lymph node injury which requires drains and multiple days in the hospital), nerve injuries (including the nerve innervating the lip), vocal cord injury. Take note if the surgeon tells you that you will likely be in the hospital for more than one night for thyroid surgery (even with a neck dissection)…this is a concern since patients that are doing very well after surgery can go home earlier. All of our patients go home within 24 hours of their operation! Austin Thyroid Surgeons has NOT had any of these complications! We are tracking our data, ask for this when you see a surgeon!
• If a patient has thyroid cancer, ask the surgeon which lymph node levels they will be removing at the time of the cancer operation. There are actually 7 different levels of lymph nodes on each side of the neck, so that means 14 total in the entire neck. It is important for your surgeon to know which levels on which side may need surgery and when it is appropriate to operate on them.
• Do they try to preserve as much of the thyroid gland as possible? The vast majority of thyroid cancers are not aggressive and only require partial or hemi-thyroidectomy. If your surgeon is recommending total thyroid removal, please get a second opinion from our team. This is NOT indicated in most patients, even with thyroid cancers.
• How many thyroid and parathyroid surgeries do they do per week? per month? per year? It’s important to know that complication rates are directly related to surgical volume! Austin Thyroid and Parathyroid Surgeons perform on average 10 thyroid and parathyroid cases per week, that is over several hundred per year!
• Please find out how long you will be under anesthesia, this is extremely important as there are risks associated with prolonged general anesthesia.

Thyroid nodules (growths in the thyroid gland) are extremely common. The majority of these lesions are benign (not cancer). However, the thyroid gland can develop nodules or lesions that may require removal by a thyroid surgeon. Some of these nodules can be cancerous and need to be removed. To evaluate if a nodule could be cancerous, we often recommend an FNA (Fine Needle Aspiration) biopsy. If an FNA biopsy reveals benign tissue, patients can be followed conservatively (without thyroid surgery). At times, patients may experience symptoms from even benign nodules. These symptoms can include difficulty swallowing or breathing, a choking sensation, or the feeling that something is stuck in their throat. On occasion, patients can have voice hoarseness as a thyroid nodule or goiter enlarges and begins to push on the windpipe, vocal cords, or esophagus. We refer to these as compressive symptoms and these symptoms may become severe enough that we recommend surgery.

The parathyroid glands are not related to thyroid function at all. The name “para” thyroid simply comes from the fact that they are near the thyroid gland and share some of the same blood supply as the thyroid. They are primarily involved with regulating calcium levels in the body. Whereas the thyroid gland is important for metabolism and can affect the function of all organ systems in the body. At times, the parathyroid glands can grow and produce too much parathyroid hormone (PTH) in the body. This overproduction inappropriately pulls calcium out of the bone and puts it into the blood stream. This can cause patients to have a number of symptoms such as lethargy, problems with concentration, memory loss, depression, high blood pressure, heart problems, kidney stones, and osteoporosis. The presence of some of these symptoms combined with either an elevated PTH and/or calcium level means that a patient may require parathyroid surgery. At times, patients have a normal calcium level and an elevated parathyroid hormone level. Other times, patients can have an elevated calcium level and normal parathyroid hormone levels. Both of these groups of patients still have primary hyperparathyroidism and will require parathyroid surgery. In my experience, patients feel much better after parathyroid surgery to remove their abnormal gland or glands. Many patients have told me it was “life changing” for them, giving them an increased energy level and improved cognitive function.

An FNA biopsy or fine needle aspiration is a sample of tissue that is obtained with a very small needle taken using ultrasound guidance that the pathologist can evaluate.

A neck ultrasound is a radiologic examination of the neck that uses sound waves (not radiation) to evaluate the size of the thyroid and the presence of nodules or lymph nodes in the region of the thyroid. A thyroid ultrasound is painless, noninvasive, and inexpensive. If they are enlarged, parathyroid glands can also be seen on an ultrasound. Typically, thyroid nodules over 1 cm need to be biopsied to ensure that they are benign. Certain nodules like cystic (fluid filled) lesions are almost always benign and can be followed without surgery. These cystic nodules can be aspirated (drained) to decrease size if they are causing any symptoms such as compression or pain. They may need a FNA biopsy if they are complex (have solid and cystic areas). Lymph nodes that appear suspicious with areas of calcifications, loss of normal appearance, enlargement, or increased blood supply may also need a biopsy.

Thyroid and parathyroid surgeons might order this scan or X-ray to help identify abnormal or enlarged parathyroid glands. It is not used for diagnosing hyperparathyroidism, but mainly for surgical planning, and is accurate in about 80% of cases. The thyroid and parathyroid glands have a strong affinity for the sestamibi(radiotracer) that is injected and with time the thyroid loses or washes out the sestamibi. The parathyroid glands hold onto the tracer longer, especially if they are enlarged or abnormal. Over a span of about 2 hours, photos or X-rays are taken to evaluate the patient for parathyroid disease. It is also helpful in identifying ectopic parathyroid glands or those that are not in the normal anatomic positions. Some of these glands can even be in the chest, upper neck, or next to the esophagus.

If a parathyroid or sestamibi scan is normal, it does not mean that a patient does not have a parathyroid problem. Thyroid nodules, thyroid cancers, and Hashimoto’s thyroiditis can all cause a scan to be inaccurate or not show the abnormal parathyroid gland. Some may also have multiple (more than one) abnormal parathyroid glands occurring in 15%-20% of patients with hyperparathyroidism. Also, if a patient has had prior thyroid or parathyroid surgery, their scan can be negative. Finally, the patients with small abnormal parathyroid glands cannot always be seen on X-ray.

This is a sestamibi scan with single photon emission computed tomography (SPECT), or basically a CT scan of the neck using sestamibi tracer also. A 4D CT scan of the neck is a detailed computed tomography with use of IV contrast or dye with the 4th dimension being time. It can help identify a lymph node from a parathyroid gland by monitoring blood flow in real time.

This test can confirm primary hyperparathyroidism from a rare inherited disorder known as Benign Familial Hypocalciuric Hypercalcemia or BFHH. Patients with this disorder have a long history of high blood calcium levels and a family history of elevated calcium levels. It is important to rule this out as these patients do not benefit from surgery. Patients with high 24-hour urine calcium levels (>100 mg/day) have primary hyperparathyroidism and those with low urine calcium levels (‹100 mg/day) have BFHH.

There are 2 main risks of thyroid and parathyroid surgery that a surgeon should discuss with any patient that is preparing for a thyroid or parathyroid operation.

The risk of permanent recurrent laryngeal nerve injury is approximately 1% in the hands of experienced thyroid or parathyroid surgeons. This type of injury causes hoarseness of the voice and can be temporary or permanent. Temporary hoarseness occurs about 20% of the time and takes anywhere from a few days to several months to resolve completely. There is also a risk of injury to the external branch of the superior laryngeal nerve that can result in loss of tone in the voice or inability to yell or sing.

Another risk of thyroid surgery is injury to or inadvertent removal of normal parathyroid glands. In the hands of an experienced thyroid or parathyroid surgeon, that risk is about 2% or less. The parathyroid glands control calcium metabolism in the body, which can lead to problems with muscle contraction. This type of complication can be temporary or permanent. If this occurs, patients can become hypocalcemic (low blood calcium levels) and may require daily calcium supplements.

To an inexperienced surgeon, parathyroid glands can be very difficult to differentiate from the surrounding tissue. The way the parathyroid gland feels to touch and looks under magnification is critical in differentiating parathyroid tissue from its surrounding tissue. Normal parathyroid glands must be preserved and not removed as inadvertent removal can require life-long daily calcium supplementation.

A temporary drop in the calcium level is not uncommon after thyroid and parathyroid surgeries. Symptoms can include tingling or numbness in the fingers, toes, or around the mouth. These symptoms result from increased neuromuscular irritability. In more severe cases, patients can experience muscle spasms, muscle aches or stiffness. If any of these symptoms occur, one should contact their thyroid surgeon or parathyroid doctor immediately.

I recommend that all of my patients having a total thyroidectomy or parathyroid surgery take calcium by mouth daily for approximately one week after their thyroid or parathyroid surgery. Usually, I ask them to take Tums or any calcium pill (750-1000 mg every 8 hours). This helps to prevent the symptoms of low calcium that can occur after any thyroid or parathyroid surgery. At times, thyroid surgeons will also prescribe Rocaltrol (calcitriol), a prescription form of vitamin D that helps with calcium absorption in the intestine.

For the first 24-48 hours after surgery, ice packs are recommended to the neck wound and limitation of heavy lifting or exercise for about 5 days. Our patients may resume normal daily activity the day after surgery if there are no issues. We allow our patients to shower the next day and get the wound wet. If the patient has steri-strips (white strips) placed on the wound, these usually stay in place until the postoperative visit with me at about 10-14 days. We will remove these strips at that visit. Some patients have Dermabond (surgical glue) placed on the wound and this will usually stay on for 2-3 weeks. After the postoperative visit, we recommend daily sunscreen application to the wound every morning for 6 months. Zinc oxide is preferred. The other option is to avoid sun exposure, but many find that nearly impossible in the beautiful city of Austin, Texas! In the evening, a scar prevention cream (such as Mederma or any generic equivalent) can be applied to prevent further scar formation. We also recommend daily multi-vitamins as they will assist with wound healing and scar prevention.

Thyroid replacement hormone can be started within a few weeks after a patient has had the entire thyroid gland removed. Typically, an endocrinologist, primary care physician or ob-gyn doctor will monitor thyroid hormone levels and prescribe thyroid hormone replacement as needed. If only half of a patient’s thyroid is removed, the patient will need thyroid function tests performed about 6-8 weeks after their thyroid surgery or earlier if they are experiencing symptoms of hypothyroidism (low thyroid). Approximately 80% of our patients don’t require thyroid replacement hormone after a partial thyroidectomy or thyroid lobectomy.

Thyroid replacement hormone is completely safe and important to take if one is pregnant or trying to become pregnant. Thyroid hormone is essential for proper fetal thyroid development as it crosses over the placenta to the baby. Adequate thyroid hormone levels are most critical during the early weeks of gestation, but a patient’s thyroid hormone requirements can often increase as the pregnancy progresses or if the patient is pregnant with multiples. Patients need to let their doctors know that they are taking thyroid replacement at the initial visit so that their thyroid levels can be followed regularly and their dosage of medication adjusted as needed to ensure a healthy pregnancy.

Thyroid cancer is primarily treated with surgery. At times, radioactive iodine is needed after a thyroid operation. Most times, an endocrinologist and the thyroid surgeon determine whether a patient needs radioactive iodine by evaluation of the pathology report. Radioactive iodine can be recommended for certain patients depending on the size of the thyroid tumor or if the patient has extensive disease involving lymph nodes or growth beyond the thyroid gland. This treatment is given in a pill form several weeks after thyroid surgery and does require specific protocols on administration. Radioactive iodine will kill any remaining microscopic thyroid cells in the body that might be remaining.

If a patient is diagnosed with thyroid cancer, long-term surveillance is essential. Patients with thyroid cancer are typically followed at least yearly with ultrasounds, thyroglobulin, and thyroid stimulating hormone (TSH) levels. The main treatment for thyroid cancer is SURGERY, but sometimes a patient will require radioactive iodine to burn tiny thyroid cancer cells that might still be present in the body. This radiation treatment is actually offered in a pill that the patient swallows. After the entire thyroid and lymph nodes nearby are removed, a patient must be on thyroid replacement hormone for life to maintain their normal metabolism. The goal of this medical therapy for thyroid cancer patients is to keep the TSH very low or suppressed so that the thyroid cancer does not return or keep the few cancer cells that may be still in the body from growing or dividing. We follow thyroglobulin levels as a marker for possible thyroid cancer recurrence.

Genetic testing is one of the newest tests that can be performed on thyroid nodules. It is important since it can help determine whether a nodule in the thyroid is at risk for being a cancer. Many FNA (fine needle aspirate) biopsies come back with follicular cells that are the normal cells that make up the normal thyroid gland. Sometimes it is impossible for any pathologist to tell the difference between benign or cancerous follicular cells. This is how the genetic test on the FNA cells becomes key. If the FNA biopsy with the gene test comes back benign (and other things such as the ultrasound, exam, and family history are not suspicious for a cancer), then normally a patient would NOT need to have thyroid surgery or removal of a portion of the thyroid gland. This is what happens the majority of the time when such testing is done.

In the past, patients who had follicular cells on an FNA biopsy were advised to have their thyroid removed, since the pathologist would not be able to definitively rule out cancer. Now some of these same patients can be safely followed without surgery, and instead doing close follow up with physical exams and neck ultrasounds by their thyroid surgeon or endocrinologist. However, not all surgeons perform this type of biopsy so it is very important to ask your surgeon if they do the genetic testing for thyroid nodules (such as the AFIRMA biopsy).

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Thyroid Ablation is the process of injecting thyroid cysts nodules with alcohol to actually kill the cells that are creating the nodules. It is usually done using a neck ultrasound and a small needle in the clinic. Ablation can also be done using laser machines or other electrical energy equipment. There are certain scenarios where smaller benign nodules or cysts are candidates for ablation techniques instead of surgical removal. Observation of these same nodules without any intervention can also be an option, so it is important to discuss all of the options with your endocrinologist and endocrine surgeon. There may be a time in the future when ablation techniques become a standard treatment approach for many nodules, although we are not there yet.

Your thyroid has 2 lobes, one on the left and one on the right, and they are usually symmetric. A normal thyroid gland appears uniform throughout, with all of the areas appearing to have the same color and density on the ultrasound screen. If the ultrasound does not appear uniform then it may be that there are nodules present in the gland. The majority of thyroid nodules are benign, and they can appear as solid, cystic (fluid filled) or complex (combination of solid and cystic). These nodules can have smooth (less suspicious) or irregular borders (more suspicious), and these characteristics along with others help your doctors determine if a nodule needs to be biopsied.

Obtaining a thyroid ultrasound before any surgery is recommended by the ATA (American Thyroid Association) as an integral part of patient care, which includes determining the extent of disease present and best type of surgery that is needed.

In patients with PTC (papillary thyroid cancer) there is a risk of lymph node cancers as high as 30-50% at the time the diagnosis is made. These lymph nodes are measured best and assessed with neck ultrasound before surgery. It has been shown that recognizing neck lymph nodes with cancer before surgery and then treating with an appropriate operative resection lowers the risk of local recurrence (cancer coming back). It is the most effective means to decrease disease recurrence long term.

A neck ultrasound can help locate an abnormal parathyroid gland or even multiple glands. Locating these glands before any surgery is done can be helpful to the surgeon, and even allow for a more “minimally invasive” surgery if approporiate (a small scar surgery).

Also, approximately 2/3rd of patients with parathyroid disease will also have thyroid nodules at the same time. It is important to address both the thyroid and parathyroid before any neck operation, as there is a chance necessary surgery may be done on both glands during the same operation. Dr. Brady and Dr. Sabra both perform preoperative neck ultrasounds when appropriate during the initial clinic visit.