Thyroid Lumps and Disorders

Overview

The thyroid is a butterfly-shaped gland in the middle of the neck, located below the larynx (voice box) and above the clavicles (collarbones). Thyroid nodules are round or oval-shaped areas within the thyroid that can be caused by a number of conditions, most of which are not serious.

WHAT DOES THE THYROID DO?

The thyroid produces two hormones, triidodothyronine (T3) and thyroxine (T4), which regulate how the body uses and stores energy. Thyroid function is controlled by a gland located just below the brain, known as the pituitary. The pituitary produces thyroid stimulating hormone (TSH), which stimulates the thyroid to produce T3 and T4.

Thyroid nodules are very common; up to half of all people have at least one thyroid nodule, although most do not know about it. Thyroid nodules can be caused by many different conditions. Reassuringly, about 95 percent of all thyroid nodules are caused by benign (non-cancerous) conditions.

The medical history and physical exam are important parts of the evaluation for thyroid problems. The doctor will focus on eye, skin, cardiac and neurologic findings.

Blood tests

Thyroid-stimulating hormone (TSH): In most cases, this is the single most useful test we do in our clinic to diagnose thyroid disease. When there is an excess of thyroid hormone in the blood, as in hyperthyroidism, the TSH is low. When there is too little thyroid hormone, as in hypothyroidism, the TSH is high.
Free (T4): T4 is one of the thyroid hormones. High T4 may indicate hyperthyroidism. Low T4 may indicate hypothyroidism.
Triiodothyronine (T3): T3 is another one of the thyroid hormones. High T3 may indicate hyperthyroidism. Low T3 may indicate hypothyroidism.
Fine needle aspiration

If the TSH level is normal, then the next step is the fine needle aspiration (FNA). FNA uses a thin needle to remove small tissue samples from the thyroid nodule. The tissue is sent to a labortory to be examined under a microscope.

Fine-needle aspiration biopsy can be performed in our clinic under a local anesthetic (numbing medicine). You may feel mild discomfort as the anesthesia is injected, but you will not feel pain during the biopsy. This test is accurate in identifying cancer in a suspicious thyroid nodule.

The results of the biopsy can be one of the following:

Benign (noncancerous)
Malignant (cancer)
Indeterminant or suspicious
Thyroid Scan

Thyroid scan: For this test, a small amount of radioactive iodine is injected into the blood, and then an x-ray image of the thyroid is taken. Increased uptake of the radioactive material in the thyroid gland indicates hyperthyroidism, while decreased uptake is present in hypothyroidism. This test will not be done on pregnant women.
Thyroid ultrasound: This exam helps to differentiate between different types of nodules of the thyroid gland.
Thyroid Surgery

Thyroid surgery is used for patients who have a variety of thyroid conditions, including both cancerous and benign (non-cancerous) thyroid nodules, large thyroid glands (goiters), and overactive thyroid glands.

There are several thyroid operations that our consultant may perform, including:

Hemi-thyroidectomy – removing half of the thyroid gland
Total thyroidectomy, which removes all identifiable thyroid tissue
Our consultant will usually perform a hemi-thyroidectomy first. During the surgery (intra-operative), a quick analysis of the thyroid specimen would be inspected by a pathologist (a frozen section) at the operating theatre, while the patient is still asleep under anaesthesia. Based on the frozen section, our consultant would determine whether the tumor is benign (not cancerous) or malignant (cancerous). If the tumor is found cancerous, then a total thyroidectomy would be performed.

There are specific indications for each of these operations.

What can I expect once I decide to proceed with surgery?

Once you have decided to proceed with surgery, you will be scheduled for your pre-op evaluation. You should have nothing to eat or drink 6 hours before the surgery. The surgery usually takes 2-2½ hours, after which time you will slowly wake up in the recovery room. There may be a surgical drain in the incision in your neck (which will be removed the morning after the surgery).

Once you are fully awake, you will be moved to a bed in a hospital room where you will be able to eat and drink as you wish. Most of our patients having thyroid operations are hospitalized for about 24 hours and can be discharged on the morning following the operation.

Normal activity can begin on the first postoperative day. Vigorous sports, such as swimming, and activities that include heavy lifting should be delayed for at least ten days.

Will I be normal after surgery?

Yes. Once you have recovered from the effects of thyroid surgery, you will usually be able to doing anything that you could do prior to surgery.

In Another Case Study

A 42 year old woman noticed a growth in her neck that has been growing steadily for 3 months.

She went for Ultrasound thyroid scan which shows a left thyroid mass that is mixed, i.e. containing both cystic and solid components.

Thyroid ultrasound scan report:

• Mixed left thyroid mass measuring 4.1 cm in diameter with cystic and solid components identified.
• No calcification seen.
• The mass is solitary and is not a part of multinodular thyroid disease.
• Normal right thyroid gland.
• No cervical lymph node enlargement.

• Horizontal incision made along a skin crease low in the neck.
• When the wound heals, the scar will become nearly invisible.

• Skin flaps are raised in the sub-platysmal plane, i.e. deep to the platysma muscle.
• Surgery must be bloodless & dry in order to facilitate good visualization of the tissues.
• The skin flap has to reach the larynx above, and the sternal notch below.
• Notice the anterior jugular veins in the operative field.

• The strap muscles are separated longitudinally to expose the thyroid gland.
• Blood vessels must be preserved to avoid unneckessary bleeding.
• Good surgery must be clean, dry, and bloodless.

• The left thyroid mass is exposed.
• It is carefully dissected out without injuring the recurrent laryngeal nerve, parathyroid glands, and blood vessels.