Head & Neck Surgery - Thyroid & Parathyroid




Head & Neck Wound Care
Thyroid Questionnaire
Thyroid & Parathyroid Surgery

Thyroid Nodules

Head and Neck Surgery The thyroid gland is a butterfly-shaped gland located in the low anterior neck. It produces thyroid hormone, which helps to regulate the body’s metabolism. The functional capacity of the thyroid is measured by blood tests. Excessive production of thyroid hormone (hyperthyroidism) can cause palpitations, tremors, weight loss, and heat intolerance. Conversely, an under-active thyroid gland (hypothyroidism) can result in fatigue, weight gain, and cold intolerance.

A thyroid nodule is a growth in the thyroid gland. Thyroid nodules are extremely common, and may be solitary or multiple (multinodular goiter). It is estimated that approximately 5-10% of the population has a palpable thyroid nodule, and between 30-85% have tiny thyroid nodules that are too small to palpate.

In most people with thyroid nodules, the gland produces a normal level of thyroid hormone (euthyroid state). Statistically, approximately 5-10% of nodules are cancerous. Some patients have findings that increase the risk of malignancy. A history of exposure to ionizing radiation to the neck is such a risk factor, as is a family history of thyroid cancer. Hoarseness, lymph node enlargement, and fixation of the nodule can also increase the risk of malignancy. Fortunately, the vast majority of thyroid cancers are treatable and carry an excellent prognosis.

Most thyroid nodules do not require surgery. The primary indications for thyroidectomy are suspicion of cancer, large size, substernal location (nodules that grow inferiorly into the chest), or symptoms (throat pressure, difficulty swallowing, respiratory distress, or cosmetic disfigurement from a visible goiter). Over-functioning nodules are sometimes best treated by surgery, as well.

The most important tests to evaluate a thyroid nodule are a TSH level (a blood test that evaluates the function of the gland) and a fine needle aspiration (FNA) biopsy to evaluate the nodule for malignancy. Although FNA is highly accurate, it is not 100% accurate in making a diagnosis. FNA is usually performed in our office, but for smaller nodules and others that are difficult to palpate, the biopsy is done by the radiologists under ultrasound guidance. There are some types of thyroid nodules (follicular tumors) where FNA cannot distinguish benign from malignant nodules- these nodules are usually best managed by thyroidectomy.

Thyroid Surgery (Thyroidectomy)

Thyroid operations can be divided into several categories, including a unilateral lobectomy (“one-sided” removal of the thyroid gland), total thyroidectomy (removal of both sides of the thyroid gland), or variations in which all of one side of the gland and part of the other side of the gland are removed.

Hospital Course

Patients who have a unilateral (one-sided) thyroidectomy will usually spend one night in the hospital, have their drain removed on the morning after their surgery, and go home with or without a wrap-like pressure dressing in place around the neck.

On the day after your discharge, please remove the pressure wrap around your neck if not already done so using a pair of large scissors, or alternatively the wrap may be “unwound” from the neck after any adhesive tape holding the dressing in place has been removed. You will see a semicircular or curved incision just above the breastbone, which will be your thyroidectomy surgical incision site. See Head and Neck Wound Care handout for specific instructions.

Patients having a total or subtotal thyroidectomy (operation on both sides of the gland) will usually spend two nights in the hospital in order that their calcium levels are monitored closely, as low calcium levels are a complication seen only with the more comprehensive removal of thyroid tissue. Total and subtotal thyroidectomy patients will usually also have a pressure wrap placed around the neck, but it is usually removed prior to discharge from the hospital. Unless instructed otherwise by your surgeon, the neck wound may be left open to the air.

Medication

Patients will usually be given a prescription for pain medicine, which is to be used as needed. In some cases, you will be also sent home with either a new or continuing prescription for Synthroid, levothyroxine, or Cytomel (thyroid replacement or suppression medication) and this must be used on a regular daily basis at the dose prescribed by your doctor. Calcium and Vitamin D supplements are sometimes prescribed as well.

Complications

Many patients notice a subtle change in their voice quality for the first few weeks postoperatively. Although trauma to the nerves supplying the vocal cords on one or both sides of the voice box may occur during thyroidectomy, frank hoarseness or trouble swallowing is a very rare complication. If you have any questions regarding the fact that your voice may be excessively hoarse or raspy, or if you are experiencing any type of coughing or choking when you attempt to swallow, please call our office immediately.

For patients undergoing a total or subtotal thyroidectomy, normal calcium levels the first several days while hospitalized do not always predict stable blood calcium levels. Occasionally, patients have significant dips in their blood calcium levels after their discharge from the hospital due to manipulating or “bruising” of the parathyroid glands. The symptoms of low calcium would include tingling around the mouth or in the hands or feet, generalized weakness, or feelings of the heart exhibiting an abnormal rate or irregular beat. If any of these symptoms occur, please call our office immediately.

A potentially serious or life-threatening complication of thyroidectomy, which can occur rather abruptly, is formation of a hematoma from a bleeding blood vessel or other area deep in the neck tissues. If you would at any point feel that there has been an abrupt swelling or outward displacement of the wound area in the lower neck, or if the neck wound suddenly starts exhibiting more tenderness, redness, or bogginess than you would expect, you need to contact our office immediately. If any shortness of breath would begin to develop, you are directed to proceed to the emergency room at the hospital where your surgery was performed as quickly as possible.

Facial Nerve Monitoring - (ear and parotid surgery) laryngeal nerve (thyroid and parathyroid)

Facial nerve injury is a devastating surgical complication. It can produce severe changes in facial appearance, expose the eye to infection and complications that can comprimise vision, and cause drooling and changes in vocal quality.

Patients who have had severe facial nerve injurycan have lowered self-image and loss of self-confidence and self-esteem. Many have reported boughts of depression. These issues can affect both patients work life and social interactions.

NIM-Response® 2.0
Nerve Integrity Monitoring System

A new level of sensitivity and convenience in nerve monitoring

Monitoring of the facial nerve continuously evaluates the activity in the monitored facial muscles. Both a graphic signal, which can be seen on a screen, and an sound signal, which can be heard throughout the procedure room, are generated.

Skin Cancer Removal

The three ways that cancer spreads in the body are:

  • Through tissue. Cancer invades the surrounding normal tissue.
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

Fine Needle Aspiration Biopsy

Fine needle aspiration is a technique that allows a biopsy of various bumps and lumps. It allows your otolaryngologist to retrieve enough tissue for microscopic analysis and thus make an accurate diagnosis of a number of problems, such as inflammation or even cancer.

Why Is It Important?

A mass or lump sometimes indicates a serious problem, such as a growth or cancer*. While this is not always the case, the presence of a mass may require FNA for diagnosis. Your age, sex and habits, such as smoking and drinking, are also important factors that help diagnosis of a mass. Symptoms of ear pain, increased difficulty swallowing, weight loss or a history of familial thyroid disorder or of previous skin cancer (squamous cell carcinoma) may be important as well.

  • When found early, most cancers in the head and neck can be cured with relatively little difficulty. Cure rates for these cancers are greatly improved if people seek medical advice as soon as possible. So play it safe. If you have a lump in your head and neck area, see your doctor right away.

What Are Some Areas That Can Be Biopsied In This Fashion?

FNA is generally used for diagnosis in areas such as the neck lymph nodes or for cysts in the neck. The parotid gland (the mumps gland), thyroid gland and other areas inside the mouth or throat can be aspirated as well. Virtually any lump or bump that can be felt (palpated) can be biopsied using the FNA technique.

FNA Is Used To Diagnose Masses In:

  • Enlarged neck lymph nodes
  • Parotid gland
  • Thyroid gland
  • Neck cysts
  • Inside the mouth
  • Any lump that can be felt

How Is It Done?

Your doctor will insert a small needle into the mass. Negative pressure is created in the syringe, and as a result of this pressure difference between the syringe and the mass, cellular material can be drawn into the syringe. The needle is moved in a to-and-fro fashion, obtaining enough material to examine under a microscope and make a diagnosis. The procedure is usually repeated several times to insure adequate sampling of the lump. This procedure is quite accurate and frequently prevents the patient from having an open surgical biopsy, which is more painful and costly.

The procedure generally does not require anesthesia, yet your doctor usually injects a small amount of local anesthetic into the skin. It is slightly more uncomfortable than drawing blood from the arm for laboratory testing. In fact, the needle used for FNA is smaller than that used for drawing blood. Although not painless, any discomfort associated with FNA is usually minimal.

What Are The Complications Of This Procedure?

No medical procedure is without risks. Due to the small size of the needle, the chance of spreading a cancer or finding cancer in the needle path is very small. Other complications are rare; the most common is bleeding. If bleeding occurs at all, it is generally seen as a small bruise. Patients who take aspirin, Advil or blood thinners, such as Coumadin, are more at risk to bleed. However, the risk is minimal. Infection is rarely seen.

Tracheostomy

A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube.

A tracheostomy may be done if you have:

  • A large object blocking the airway
  • An inherited abnormality of the larynx or trachea
  • Breathed in harmful material such as smoke, steam, or other toxic gases
  • Cancer of the neck, which can affect breathing
  • Breathed in harmful material such as smoke or steam
  • Paralysis of the muscles that affect swallowing
  • Severe neck or mouth injuries

If the tracheostomy is temporary, the tube will eventually be removed. Healing will occur quickly, leaving a minimal scar.

Occasionally a stricture, or tightening, of the trachea may develop, which may affect breathing.

If the tracheostomy tube is permanent, the hole remains open and may require surgical closure when no longer needed.

Most patients require 1 to 3 days to adapt to breathing through a tracheostomy tube. It will take some time to learn how to communicate with others. Initially, it may be impossible for the patient to talk or make sounds.

After training and practice, most patients can learn to talk with a tracheostomy tube. Patients or family members learn how to take care of the tracheostomy during the hospital stay. Home-care service may also be available.

Normal lifestyles are encouraged and most activities can be resumed. When outside, a loose covering (a scarf or other protection) for the tracheostomy stoma (hole) is recommended. Patients must adhere to other safety precautions regarding exposure to water, aerosols, powder, or food particles as well.

Laryngectomy

Laryngectomy is surgery to remove the larynx (voice box) in your throat. All or part of the larynx may be removed in a laryngectomy.

Total laryngectomy is major surgery that is done in the hospital. Before surgery you will receive general anesthesia. This will make you unconscious and unable to feel pain.

In a total laryngectomy, first your surgeon will make an incision (cut) in your neck to open up the area. Important parts of this surgery are:

  • Your surgeon may remove the lymph nodes.

  • Your surgeon may do a tracheoesophageal puncture (TEP). A TEP is a small hole made in your trachea (wind pipe) and esophagus (the tube that moves food from your throat to your stomach). Your surgeon will place a small prosthesis (a man-made part) into this opening. The prosthesis will allow you to speak after your voice box has been removed.

  • Your surgeon will remove your larynx and the tissues around it.

  • Your surgeon will make an opening in your trachea and a hole in front of your neck. Your trachea will be brought up and attached to this hole. The hole is called a stoma. After surgery you will breathe through your stoma. It will never be removed.

  • Your muscles and skin will be closed with stitches or clips. You may have tubes coming from your wound for a while after surgery.

There are many less invasive surgeries to remove part of the larynx.

  • These may work for some people. The surgery you have may depend on how much your cancer has spread and what type of cancer you have.

  • The names of some of these less invasive procedures are endoscopic (or transoral resection), vertical partial laryngectomy, horizontal or supraglottic partial laryngectomy, and supracricoid partial laryngectomy.
Part of your pharynx may be removed in a total laryngectomy. Your pharynx is the tube air moves through from your nose. It connects with your larynx. The surgery takes 5 to 9 hours.

Usually laryngectomy is done to treat cancer of the larynx. It is also done to treat:

  • Severe trauma, such as a gunshot wound or other physical injury.
  • Severe damage to the larynx from radiation treatment. This is called radiation necrosis.

You will have many doctor visits and medical tests before you have surgery. Some of these are:

  • A complete physical exam and blood tests
  • A visit with a speech therapist and a swallowing therapist to prepare for changes after surgery
  • Nutritional counseling
  • Stop-smoking counseling, if you are a smoker and have not quit

Always tell your doctor or nurse:

  • If you are or could be pregnant
  • What drugs you are taking, even drugs, supplements, or herbs you bought without a prescription
  • If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day

During the days before your surgery:

  • You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), clopidogrel (Plavix), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot.
  • Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

  • You will be asked not to drink or eat anything after midnight the night before your surgery.
  • Take your drugs your doctor told you to take with a small sip of water.
  • Your doctor or nurse will tell you when to arrive at the hospital.

You will need to stay in the hospital for several days after surgery.

After the procedure, you will be groggy and will not be able to speak. An oxygen mask will be on your stoma. It’s important to keep your head raised, rest a lot, and move your legs from time to time to improve blood flow. Keeping blood moving reduces your risk of getting a blood clot.

You can use warm compresses to reduce pain around your incision. Your nurse will give you pain medicine.

You will receive nutrition through an IV (a tube that goes into a vein) and tube feedings. Tube feedings are given through a tube that goes through your stoma and into your esophagus (swallowing tube).

You may be allowed to swallow food as soon as 2 to 3 days after surgery. But, it is more common to wait 5 to 7 days after your surgery to start eating through your mouth.

Your trachea drain will be removed in 2 to 3 days. You will be taught how to care for your tracheostomy tube and stoma. You will learn how to safely shower or swim. You must be careful not to let water enter through your stoma.

Speech rehabilitation with a speech therapist will help you relearn how to speak.

You will need to avoid heavy lifting or strenuous activity for about 6 weeks. You may slowly resume your normal, light activities.

Follow up with your doctor as often as your doctor says you need to.

Your wounds will take about 2 to 3 weeks to heal. You can expect full recovery in about a month. Many times, removal of the larynx will take out all the cancer or injured material. People learn how to change their lifestyle and live without their voice box.

 

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