Online Health Chat with Rosemarie Metzger MD

September 29, 2016


Description

Over 20 million Americans have some type of thyroid disorder, suffering from fatigue, sweating, changes in weight and trouble sleeping. Although thyroid conditions can affect anyone, women are five to eight times more likely to have a thyroid disease. Thyroid conditions can include hyperthyroidism, hypothyroidism, thyroid nodules and goiters or thyroid cancer.
The goal of treating a thyroid disorder is to restore normal blood levels of thyroid hormone. Hypothyroidism can be treated with a hormone tablet called levothyroxine. Hyperthyroidism is generally more difficult to treat and could involve drug therapy to block hormone production, radioactive iodine treatment that disables the thyroid, or surgery which removes part or the entire gland.
If your physician recommends surgery, there are several minimally invasive surgery options available such as:

  • Laparoscopic adrenalectomy
  • Robotic adrenalectomy
  • Laparoscopic pancreas surgery
  • Laparoscopic liver radiofrequency thermal ablation
  • Robotic surgery (including adrenalectomies and “scarless” thyroidectomies)

Scarless robotic thyroidectomy is a new surgical option offered in only a few centers across the nation. The procedure removes all or part of the thyroid gland without a neck incision as opposed to the typical 2-6 centimeter scar depending on whether the surgery is minimally invasive. Studies have also shown a significant decrease in incidence of hypocalcemia (low calcium) and less discomfort swallowing in patients who had the robotic thyroidectomy compared to patients who had open thyroid surgery. Ideal candidates for robotic surgery are not overweight, have a smaller thyroid gland, do not have thyroiditis or Grave’s disease, have a single parathyroid adenoma, and have a history of bad wound healing.
Another thyroid condition, thyroid nodules (a growth in the thyroid gland) are seen in about half the adult population. About 90-95% of these growths are benign, painless and can be treated with either a watchful warning or radioactive iodine depending on the severity of the case. However, if the nodules are cancerous or cause suspicious symptoms, surgery may be the best option.


About the Speaker

Rosemarie Metzger, MD is an Endocrine Surgeon with the Department of Endocrine Surgery at Cleveland Clinic Florida. She received her Masters in Public Health from the University of Virginia, and her medical degree from University of Wisconsin Medical School. She completed her residency at University of Virginia Medical Center and her Endocrine Surgery Fellowship at the Cleveland Clinic Foundation in Ohio. Dr. Metzger has specialized expertise in the surgical management of thyroid, parathyroid, and adrenal gland disorders. She utilizes minimally invasive techniques that minimize scarring, including laparoscopy for adrenal surgery.


Let’s Chat About Surgical Options for Thyroid Diseases

Welcome to our Online Health Chat “Surgical Options for Thyroid Diseases" with Rosemarie Metzger MD, MPH, FACS.  We are thrilled to have her here today for this chat. Let’s begin with the questions.

Surgical Options

CeCe: Is a nodulectomy/lumpectomy a possibility in this instance? Thyroid nodule found in 1998. FNA done in 2000 with clusters of benign follicular cells, occasional micro and macro follicles, scattered hurthle cells. Occasional macrophages, no acute inflammation. No nuclear grooves. Synthroid regimen to shrink approximately 2cm nodule. No US done. No shrinkage by palpation. FNA in 2004, similar results. 2016 FNA shows predominance of hurthle cells in absence of significant colloid, only minimal chronic inflammation. No other noticing. Suspicious for HCN. US showed no adenopathy, isthmus normal, size 2.2 x 1.6 x 1.2. 2007 CT scan of neck showed the nodule at about 2 cm. Does a hemithyroidectomy have to be done? Or can a nodulectomy give enough for pathology to determine adenoma or carcinoma? Thank you.

Rosemarie_Metzger,_MD: Typically a lobectomy is done to remove thyroid nodules in order to determine adenoma or carcinoma. Lobectomy is preferred as it is an 'anatomical' resection. Also, should it prove to be a cancer, sometimes a lobectomy alone is enough to treat it. A nodulectomy leaves behind thyroid tissue on the same side where the nodule was making any future surgery on that side more challenging. If it was a cancer, the rest of that side would likely need to be removed and possibly even the other lobe, depending on the diagnosis, etc.

MariaIsabella: What are surgical options for someone with hyperthyroidism?

Rosemarie_Metzger,_MD: It depends on what is causing the hyperthyroidism. Hyperthyroidism is usually from Graves disease or from a nodule (or more than one nodule) that is producing too much thyroid hormone. Graves disease can be treated with either radioactive iodine or with surgical removal of the entire thyroid gland. Some patients are candidates for either treatment, others are better suited for one over the other. For example, patients who have eye changes associated with Graves disease should not have radioactive iodine, they should instead have surgery. For people who have a nodule or more than one nodule (multinodular thyroid) producing too much thyroid hormone, the option is typically surgery. If one nodule is making too much hormone, then surgery to remove the half of the thyroid where that nodule is located can not only cure the hyperthyroidism, but also remove the nodule. There is a chance that no thyroid hormone supplementation would be needed afterwards because half of the thyroid is still there. If there are multiple nodules, on both sides of the thyroid, then removal of the entire thyroid might be necessary. Sometimes radioactive iodine is used to treat these types of nodules, which can stop them from making too much thyroid hormone. However, the nodules can still remain after treatment. For this reason, surgery is often recommended.

Sue_Kessler: Are there any risks when having thyroid surgery?

Rosemarie_Metzger,_MD: There are risks with any type of surgery and thyroid surgery is no exception. Risks common to any surgical procedure include infection or bleeding. The risk of infection after thyroid surgery is very low. The risk of bleeding is higher, and potentially concerning. Bruising or swelling after thyroid surgery can be very common; however, very rapid swelling in the neck, indicating significant bleeding, is a rare but serious complication that can happen after thyroid surgery, which might require an emergency surgery to stop the bleeding.

There is also a risk to the 4 small glands, neighbors to the thyroid gland, called the parathyroid glands. These 4 glands help to regulate the body's calcium level. When doing thyroid surgery, the surgeon works hard to protect these glands and they remain in the neck even after the thyroid is removed. However, they can sometimes be 'stunned' because of the surgery that happened 'right next door' to them and for a while, there can be low levels of calcium in the blood. This may require that you take supplemental calcium pills after surgery until the parathyroid glands 'wake up'.

Lastly, there are two nerves that run behind the thyroid on either side called the recurrent laryngeal nerves. These nerves move the muscles that move the vocal cords. A permanent injury to one of these nerves can therefore effect how the vocal cord moves and this can cause a hoarse voice. This is thankfully a rare event. Sometimes, the swelling and irritation from surgery can affect these nerves for a temporary period of time. This can lead to voice changes that resolve over time as the swelling and inflammation from surgery subside.


Robotic Surgery

JuanJose33: How is the incision for scarless robotic thyroidectomy done so that there is no mark left?

Rosemarie_Metzger,_MD: Robotic thyroid surgery is performed by making an incision under the arm (in the 'armpit' area). A tunnel is then created under your skin all the way over the collarbone to gain access to the neck so the surgery can be performed. Robotic surgery is not scarless.  It’s just that the scar isn't on the neck but under the arm. The scar under the arm is often longer than the scar would be on the neck.

JumpingGillyBean: What’s the difference between robotic surgery and regular surgery? What makes it better if it does?

Rosemarie_Metzger,_MD: Robotic surgery is performed through an incision that is located in the under arm (the 'armpit'). A tunnel is created under the skin, up over the collar bone, and into the neck where surgery is performed. With robotic surgery, the surgeon does not have their own hands inside the body during the surgery. Instead, there are instruments that are attached to the robot that help perform the surgery. The surgeon controls these instruments while sitting at a command station next to the operating table. Robotic surgery is not appropriate for everyone. Some conditions do not lend themselves to be treated via robotic surgery. Also, some patients’ body structure does not lend itself to robotic surgery. Regular surgery is the 'gold standard' of how we do thyroid surgery. There is an incision made in the skin of the lower part of the neck. The surgeon uses hand-held instruments to free the thyroid from its attachments. A major difference between the two is where the scar is located. While everyone is a candidate for 'regular' surgery, not everyone is a candidate for robotic surgery.


Thyroid Disease Symptoms

Puzzled18: Please discuss types of abnormal symptoms conducive to exercising surgical options. Swings between hypothyroidism to hyperthyroidism in 6 month period with high level of antibodies for both Hashimoto’s and Graves disease accompanied by tiny thyroid cysts?

Rosemarie_Metzger,_MD: It sounds like you're battling autoimmune related thyroid function changes. These can sometimes be difficult to manage. If you have Graves disease, then total thyroidectomy is a surgical option for cure. Sometimes, however, Hashimoto's disease can have components of hypo and hyperthyroidism. Unless there is a concerning nodule, or large nodule causing compressive symptoms, surgery is typically not indicated for Hashimoto's. Tiny cysts are quite common and not otherwise concerning.


Medication Therapies For Thyroid Disease

Summergirl: I was diagnosed with Hashimoto’s Thyroiditis in 1996 and taking Synthroid daily. I had a parathyroidectomy in 2010 and upper left and lower right parathyroids were removed. There was a partially exophytic nodule of the lower pole of the right lobe which was removed from my thyroid as well and it was benign. I have a few small subcentimeter reactive lymph nodes found around the thyroid gland on each side, none being worthy of biopsy according to my surgeon. My question to you is how would I know if something is wrong with my thyroid? Symptoms are hard to assess especially since I have angioedema sometimes from my Type 1 Latex Allergy and I blame everything on that allergy when things feel amiss. Will my thyroid eventually stop working completely requiring me to increase Synthroid dosage? Having the latex allergy I am now on high doses of maintenance antihistamines daily and do they have any effect on the absorption of Synthroid? Thank you.

Rosemarie_Metzger,_MD: Your endocrinologist will be able to help monitor your thyroid to determine if your dose of synthroid remains appropriate. It is not uncommon for dosages to need to be adjusted over time. Follow-up ultrasound imaging might also be helpful for monitoring of your thyroid to make sure no new nodules have developed since your surgery.

sejalrama: I wanted to know the pros/cons with treatment of either radioactive iodine vs. medication to treat subclinical hyperthyroidism (due to a nodule). The nodule is very small per the ultrasound. The thyroid scan does show anything remarkable. Which option to treat is safest and is surgical removal advised/safe?

Rosemarie_Metzger,_MD: If the nodule is very small and the thyroid uptake scan does not indicate a 'hot' nodule, then it is unlikely that your very small nodule is contributing to your subclinical hyperthyroidism. Unless it could be better proven that the nodule is the culprit, then surgical removal would not be advised. The need for radioactive iodine vs medical management of subclinical hyperthyroidism can be further discussed with your endocrinologist.


Effects of Epilepsy

blessedx3:Do people with epilepsy have a shortened life span, and will their cognitive function suffer if no further action is taken other than daily medication? My son suffers a lot from short term memory loss, which we believe is a result of the medicine. Would that be regained after surgery?

Camilo_Garcia,_MD:The memory problem that your son has could be either a medication side effect or secondary to the epilepsy itself. Recurrent, uncontrolled seizures can cause cognitive problems including memory decline. People with epilepsy have a shortened life span when compared with the general population. This has been proven to improve after epilepsy surgery. The surgery may improve or decrease the frequency of the seizures, and if successful, may stop the cognitive decline. It also depends on the area of the brain removed.

LNR:Is there a higher rate of Alzheimer's disease in those with epilepsy or in those with epilepsy surgery?

Camilo_Garcia,_MD:Alzheimer's disease is a degenerative disease with a different etiology. However, there are patients with Alzheimer's disease with epilepsy or seizures associated. There is not a higher incidence of Alzheimer’s disease in epilepsy or in patients undergoing epilepsy surgery. There are patients with memory problems related to frequent seizures, but this is not the same as Alzheimer's disease. Memory problems could be secondary to recurrent, uncontrolled seizures, or if the area of the brain resected in surgery is involved in memory processing. I hope this clarifies your question

For Appointments
To make an appointment with Rosemarie Metzger, MD, Endocrine Surgeon or any of the other specialists in the Endocrinology Department at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at my.clevelandclinic.org/florida.

For More Information

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