Why is the thyroid gland important?
The thyroid gland is a butterfly or bow-tie shaped gland that sits in the front of your neck, just below where a man’s Adam’s apple is located and just above your collarbones. The thyroid gland produces hormones that regulate the metabolism of your whole body. Therefore, when the thyroid gland is not functioning properly, people experience symptoms related to the change in their normal metabolism, such as weight changes. Improper functioning of the thyroid gland results in low or high levels of thyroid hormone, also known as hypothyroidism or hyperthyroidism.
What is thyroid disease?
Diseases of the thyroid gland are very common, affecting millions of Americans. The most common thyroid problems are:
- An overactive gland, called hyperthyroidism (e.g., Graves’ disease, toxic adenoma or toxic nodular goiter)
- An underactive gland, called hypothyroidism (e.g., Hashimoto’s thyroiditis)
- Thyroid enlargement due to over activity (as in Graves’ disease) or from under-activity (as in hypothyroidism). An enlarged thyroid gland is often called a goiter.
Patients with a family history of thyroid cancer or who had radiation therapy to the head or neck as children for acne, adenoids, or other reasons are more prone to develop thyroid malignancy.
If you develop significant swelling in your neck or difficulty breathing or swallowing, you should call your surgeon or be seen in the emergency room.
What is a thyroid nodule?
A thyroid nodule is the term used to describe an abnormal growth of thyroid cells that form a lump within the thyroid gland. In most cases, we do not understand why thyroid nodules develop or what causes them to grow or stay the same size. Thyroid nodules are very common and the majority of thyroid nodules are benign (noncancerous). In fact, thyroid nodules are about three times more common in women than men and about 50% of women over age 50 years have a thyroid nodule. Thyroid nodules usually do not cause symptoms or problems in patients, but all thyroid nodules need to be evaluated by a doctor.
What is a goiter?
The term goiter is used to describe a large thyroid gland. Most commonly, a goiter results from multiple thyroid nodules throughout the thyroid gland, which is called a multinodular goiter. Other goiters result from autoimmune lymphocytic infiltration, such as in autoimmune thyroiditis or Hashimoto’s disease.
How are thyroid nodules diagnosed?
Many thyroid nodules are found by a doctor on physical exam or they are found on CT scans that are done for other issues. Occasionally, a patient discovers a lump in their neck while shaving or putting on a necklace. Check out the video below in which a young patient found her right-sided thyroid nodule one morning while looking in the mirror.
How are thyroid nodules evaluated?
Evaluation always begins with a thorough history and physical exam. Thyroid nodules and goiters are often, but not always, able to be felt on physical exam. Once a thyroid nodule is suspected, your doctor will likely order thyroid function studies, in order to ensure that you have a normally functioning thyroid gland, as well as a thyroid ultrasound. Even if a thyroid nodule is found incidentally on a CT scan, a thyroid ultrasound is still obtained because it provides the best and far superior visualization and characterization of the thyroid gland and any nodules present. Thyroid nodules are inspected by ultrasound for the presence of characteristics that may indicate that the nodule is more likely benign or more likely malignant (cancer). Based on the appearance of the nodule, a diagnostic biopsy may be indicated.
When a thyroid nodule is suspected or confirmed, an ENT will also evaluate the function of the vocal cords to ensure that they are working properly. Because the nerves to the vocal cords run behind and against the backside of the thyroid gland, if a thyroid cancer is present and invading a nerve, the vocal cord will then become paralyzed. Therefore, if a vocal cord paralysis is discovered on the same side as a thyroid nodule, the likelihood of a thyroid cancer increases significantly.
In turn, knowing if both vocal cords are working or if one is paralyzed, will then influence a surgical plan. There are many variables that will affect the decision to perform surgery and influence the extent of surgery needed in a particular patient, but in general, if one vocal cord is paralyzed, any surgery must be performed meticulously and with great care to protect the remaining nerve to the functioning vocal cord. It’s also important to note that by evaluating the vocal cord status before surgery, you ensure that the best and most thorough surgery is performed the first time, and you are also able to determine surgical outcomes by evaluating the function of the vocal cords following surgery.
What does ultrasound look for in thyroid nodules?
On thyroid ultrasound, not just the size of the nodule matters. It’s important to note if the nodule is solid, fluid-filled or spongy-appearing, if the margin of the nodule is well-defined or ill-defined, if the nodule is taller than wide, if there are micro- or macro- calcifications present, all of which point to whether or not a diagnostic biopsy should then be performed. As long as the patient is not hyperthyroid, a diagnostic biopsy is then performed of suspicious nodules.
How is a thyroid nodule biopsied?
A biopsy of a thyroid nodule is performed in order to determine if the nodule is benign, malignant, or atypical (indeterminate). The biopsy is most commonly performed by a fine needle aspiration (FNA) using the ultrasound to guide placement of the needle into the nodule in order to obtain appropriate sampling. The cells collected from the biopsy are evaluated under a microscope to determine if they appear normal (benign), unusual (atypical or indeterminate), or malignant. By characterizing a thyroid nodule with ultrasound and sometimes with an US-guided FNA biopsy, a physician can help determine what, if any, surgery is necessary.
What is molecular testing?
When the biopsied thyroid cells are atypical appearing and not obviously normal or cancerous, further testing can be done to evaluate the genes of the cells collected. This further testing is called molecular testing and is very new. Molecular testing is used to identify genetic mutations known to cause thyroid cancer. Therefore, if molecular testing shows a mutation, there is a very high chance that the nodule is cancerous. If the molecular testing does not show a mutation, then there is a very low chance that the nodule is cancerous. To that end, molecular testing is used to guide the decision making with regard to whether or not a patient needs surgery and if they do, the extent of surgery required for cure.
What is the treatment for thyroid nodules?
Depending on the biopsy results and the presence of any associated compressive or other symptoms, surgery may be recommended. Benign nodules do not necessarily require surgery. Repeat ultrasound examinations to ensure stability in the size of the nodule(s) and possible repeat biopsies may be performed if there are no strong indications to remove the thyroid gland at initial discovery of the nodule(s). In the case of a malignant thyroid nodule, surgery to remove all or sometimes half of the thyroid gland would be the best treatment indicated. In other circumstances, the lymph nodes in the neck are also removed if the cancer from the thyroid has spread or is suspected to have spread to the lymph nodes.
Who needs surgery on their thyroid glands?
Not all thyroid abnormalities or thyroid nodules require surgery. Sometimes an overactive thyroid gland or an overactive thyroid nodule may be treated with removal of the entire thyroid gland or removal of the half of the thyroid gland containing the overactive nodule, respectively. Additionally, sometimes an underactive thyroid nodule is removed in the half of the thyroid gland in which it is located, but an underactive thyroid gland is not necessarily an indication for removal of the entire thyroid gland. Patients typically have surgery to remove half or all of the thyroid gland when there are thyroid nodules present that are cancerous or suspicious for cancer. Other reasons that people have surgery to remove all or half of the thyroid gland are when the thyroid nodule(s) or the entire thyroid gland is very large and causes deformity of the neck, trouble swallowing, or throat discomfort, but it’s important to remember that most thyroid nodules do not cause symptoms or problems.
What is HYPERthyroidism?
Hyperthyroidism is an overactive thyroid gland, which results when there is an excess of thyroid hormone being made by the thyroid gland. This means that the body’s metabolism increases or speeds up from the increase in thyroid hormone. When thyroid hormone levels are high, the body’s metabolism increases, which is what results in symptoms of hyperthyroidism. Symptoms of hyperthyroidism include weight loss, difficulty sleeping, an increase in bowel movements and/or looser stools, fast heart rate, thinning of the hair, palpitations or irregular heart beats, hand tremors, anxiety or nervousness, muscle weakness, feeling hot, and increased sweating. Patients usually report an excess of energy initially, but with persistently elevated metabolisms, patients’ bodies become worn out such that patients then report feeling fatigued.
The most common cause of hyperthyroidism is overproduction of thyroid hormone involving the entire gland, not just from a single thyroid nodule. This is called Graves’ disease and it is caused by a patient’s antibodies that attack the thyroid gland. When this happens, the thyroid gland is stimulated erroneously by the antibodies to grow and produce too much thyroid hormone.
Hyperthyroidism can also be caused by just one part of the thyroid gland rather than by the entire gland. In this situation, a thyroid nodule gradually grows and increases in activity to the degree that excess thyroid hormone is produced. This is called a toxic nodule or a toxic multinodular goiter, with toxic referring to the excess of thyroid hormone. That means that someone can have a multinodular goiter without it being toxic; in other words, the thyroid hormone levels are normal or even low in that patient.
Diagnosis of hyperthyroidism is suspected by your physical exam findings and report of symptoms, but is confirmed with lab work that measures the amount of thyroid hormone in your blood. The hormones measured include thyroxine (T4) and triiodothyronine (T3) as well as TSH (thyroid stimulating hormone). In hyperthyroidism, the thyroid hormones T4 and T3 are elevated while TSH is low, all of which signify hyperthyroidism. Further work-up may include additional lab work, imaging or scans of your thyroid gland.
Hyperthyroidism may be temporary and self-limiting or it may be persistent and unremitting. In the case of temporary hyperthyroidism, it is usually a result of thyroiditis, which is inflammation of the thyroid gland causing the release of all of the stored thyroid hormone, but it is not a result of the thyroid gland being overactive. This is referred to as thyrotoxicosis and the cause of the thyroiditis is usually a virus or can be the result of changes occurring after having a baby. Thyrotoxicosis may also result from someone taking too much of thyroid hormone medication. Just like with hypothyroidism, some forms of hyperthyroidism, especially Graves’ disease, runs in families, so it is important to keep this mind if you or your family member is diagnosed with this.
Unlike hypothyroidism, there are many ways to treat hyperthyroidism. The best choice for a given patient is dependent on many things, such as their age, the cause of hyperthyroidism, their other medical problems, and of course, what treatment they prefer or is successful for them. Hyperthyroidism can be treated successfully with medication or with surgery. If you have hyperthyroidism, it is usually most helpful for you to be evaluated by an endocrinologist and by a surgeon who specializes in thyroid surgery in order for you to be able to choose the best possible treatment for you.
Medications used to treat hyperthyroidism include antithyroid medications, such as methimazole or propylthiouracil. These medications can quickly control hyperthyroidism and do not permanently damage the thyroid gland; however, there are potential side effects from these medications. Other patients are treated successfully with a radioactive iodine pill, which selectively damages the thyroid cells that produce thyroid hormone. The cells are damaged over a period of several weeks to several months, resulting in gradual decrease in the thyroid hormone levels as well as a gradual decrease in the size of the thyroid gland or the thyroid nodule(s). Occasionally, patients remain hyperthyroid and they require a second treatment with this medication, but more often, patients become hypothyroid and then require thyroid hormone supplementation.
Other patients are treated successfully with surgery, which entails complete removal of the entire thyroid gland. Patients do best when they are operated on by thyroid surgery specialists. Surgery requires the patient’s hyperthyroid signs and symptoms to be well-controlled prior to the procedure. This requires treatment with a beta-blocker medication and/or a nonradioactive iodine such as Lugol’s iodine solution or supersaturated potassium iodide (SSKI). Whereas beta blockers treat a patient’s symptoms without lowering the thyroid hormone levels, Lugol’s solution treats symptoms and helps to lower thyroid hormone levels before surgery. Beta blockers and Lugol’s iodine solution are used to prevent some of the bothersome symptoms caused by the excess thyroid hormone, while Lugol’s iodine solution has the added benefit of decreasing the blood supply to the thyroid gland, making surgery more straightforward. It is important to have a patient’s hyperthyroidism under control before surgery in order to prevent thyroid storm, which is a very rare, life-threatening condition in which patients with hyperthyroidism suffer from severe thyrotoxicosis. This is usually precipitated by an acute event occurring when the patient’s hyperthyroidism is not controlled with medications, such as from an infection, trauma, pregnancy or surgery anywhere on the body.
Contact Ashford Clinic for an appointment or contact your primary doctor if you have concerns regarding your thyroid gland.
How is a diagnosis made for thyroid disease?
The diagnosis of a thyroid function abnormality or a thyroid mass is made by taking a medical history and a physical examination. In addition, blood tests and imaging studies or fine-needle aspiration may be required. As part of the exam, your doctor will examine your neck and ask you to lift up your chin to make your thyroid gland more prominent. You may be asked to swallow during the examination, which helps to feel the thyroid and any mass in it. Tests your doctor may order include:
- Evaluation of the larynx/vocal cords with a mirror or a fiber optic telescope
- An ultrasound examination of your neck and thyroid
- Blood tests of thyroid function
- A radioactive thyroid scan
- A fine-needle aspiration biopsy
- A chest X-ray
- A CT or MRI scan
Ultrasound evaluation of the thyroid gland is the best way to characterize a thyroid nodule that is found by a physician or found on accident by a CT scan that is done for another problem. Ultrasound evaluation is quick, easy, and is conveniently done in the office. Ultrasound also saves money and does not require radiation exposure to the patient like a CT scan does. Finally, ultrasound also allows a biopsy to be performed under direct visualization. Dr. Beth Ashford performs her own ultrasounds and ultrasound-guided biopsies on the thyroid gland and on other masses found in the head and neck region.
Check out this video of an ultrasound of a normal thyroid gland during which the patient swallows. The swallow is best illustrated by the bright white within the esophagus, or swallowing tube. The neck anatomy, some of which is labeled in the video, is so beautiful and the image quality on ultrasound is ideal.
What treatment may be recommended for thyroid disease?
Treatment for your thyroid disease depends on the nature of your condition. Hypothyroidism treatment includes thyroid hormone replacement pills, the dose of which is tailored to the extent of the thyroid gland’s insufficiency.
Hyperthyroidism can be treated successfully with medication or with surgery. Medications used to treat hyperthyroidism include antithyroid medications, which can quickly control hyperthyroidism and do not permanently damage the thyroid gland; however, there are potential side effects from these medications. Other patients are treated successfully with a radioactive iodine pill, which selectively damages the thyroid cells that produce thyroid hormone. The cells are damaged over a period of several weeks to several months, resulting in gradual decrease in the thyroid hormone levels as well as a gradual decrease in the size of the thyroid gland or the thyroid nodule(s). Occasionally, patients remain hyperthyroid and they require a second treatment with this medication, but more often, patients become hypothyroid and then require thyroid hormone supplementation.
A third treatment option for hyperthyroidism includes the surgical removal of the entire thyroid gland. Surgery requires the patient’s hyperthyroid signs and symptoms to be well-controlled with certain medications prior to the procedure in order to ensure a safe and successful surgery. After surgery, the patient is treated with thyroid hormone replacement therapy.
Goiter or Thyroid Nodule:
If you experience this condition, your doctor will propose a treatment plan based on your physical examination and your test results. He or she may recommend:
An imaging study to determine the size, location, and characteristics of any nodules within the gland. Types of imaging studies include thyroid ultrasound and CT scans.
A fine-needle aspiration (FNA) biopsy is a safe, relatively painless procedure. With this procedure, numbing medication is injected first into the skin. Following the local anesthesia, a hypodermic needle is passed into the thyroid nodule to collect cells from the nodule in question. Several passes with the needle may be required in order to collect enough cells. Ultrasound is typically used to guide the needle into the nodule under direct visualization. There is little pain afterward and essentially no complications from the procedure. This test gives the doctor more information on the nature of the lump in your thyroid gland and may help to differentiate a benign from a malignant or cancerous thyroid mass.
The FNA will show one of three results if enough cells are collected. If the FNA is benign, then the nodule may continue to be observed. If the FNA is suspicious for or positive for cancer, then surgery will be indicated. If the FNA is indeterminate, meaning that the cells seen are not completely normal, but they are not obviously cancerous, further information is needed. A novel diagnostic technique in this “gray area” is the use of molecular markers. By analyzing the genetic make-up of the nodule, any known genetic mutations found in thyroid cancers will be detected. If mutations are detected, then surgery would likely be indicated given that the chance of cancer is higher. If no mutations are detected, then continued observation of the nodule may be recommended.
Thyroid surgery may be required when:
The FNA biopsy is reported as suspicious for or positive for cancer.
The molecular testing of an indeterminate thyroid nodules shows a genetic mutation within that thyroid nodule, which is known to be found in thyroid cancer.
Imaging shows that nodules are getting bigger.
The trachea (windpipe) and/or esophagus (swallowing tube) are compressed because one or both of the thyroid lobes are very large. Usually when this happens, the patient reports difficulty swallowing and pressure on the throat. Rarely do patients experience hoarseness or shortness of breath.
Historically, some thyroid nodules, including some that are malignant, have shown a reduction in size with the administration of thyroid hormone. However, this treatment, known as medical suppression therapy, has proven to be an unreliable treatment method.
What is thyroid surgery?
Thyroid surgery is an operation to remove part or all of the thyroid gland. It is performed in the hospital, and general anesthesia is usually required. Typically, the operation removes the lobe of the thyroid gland containing the lump and possibly the isthmus. A frozen section (immediate microscopic reading) may be used to determine if the rest of the thyroid gland should be removed during the same surgery.
Sometimes, based on the result of the frozen section, the surgeon may decide not to remove any additional thyroid tissue, or proceed to remove the entire thyroid gland, and/or other tissue in the neck. This decision is usually made in the operating room by the surgeon, based on findings at the time of surgery. Your surgeon will discuss these options with you preoperatively.
As an alternative, your surgeon may choose to remove only one lobe and await the final pathology report before deciding if the remaining lobe needs to be removed. There also may be times when the definite microscopic answer cannot be determined until several days after surgery. If a malignancy is identified in this way, your surgeon may recommend that the remaining lobe of the thyroid be removed at a second procedure. If you have specific questions about thyroid surgery, ask your otolaryngologist to answer them in detail.
What happens after thyroid surgery?
During the first 24 hours:
After surgery, you may have a drain (tiny piece of plastic tubing), which prevents fluid and blood from building up in the wound. This is removed after the fluid accumulation has stabilized, usually within 24 hours after surgery. Most patients are discharged later the same day or the next day. Complications are rare but may include:
- Bleeding under the skin that rarely can cause shortness of breath requiring immediate medical evaluation
- A hoarse voice
- Difficulty swallowing
- Numbness of the skin on the neck
- Vocal cord paralysis
- Low blood calcium
Following the procedure, if it is determined that you need to take any medication, your surgeon will discuss this with you prior to your discharge. Medications may include:
- Thyroid hormone replacement
- Calcium and/or vitamin D replacement
Some symptoms may not become evident for two or three days after surgery. If you experience any of the following, call your surgeon or seek medical attention:
- Numbness and tingling around the lips and hands
- Increasing pain
- Wound discharge
- Shortness of breath
If a malignancy is identified, thyroid replacement medication may be withheld for several weeks. This allows a radioactive scan to better detect any remaining microscopic thyroid tissue, or spread of malignant cells to lymph nodes or other sites in the body.
What is HYPOthyroidism?
Hypothyroidism is an underactive thyroid gland, which means that the thyroid gland cannot make enough hormone to maintain the body’s normal metabolism. This means that the body cannot function the way it normally does without enough thyroid hormone. When thyroid hormone levels are low, the body’s metabolism starts to slow down. This means that symptoms of hypothyroidism are a result of the body’s processes slowing down. Symptoms of low thyroid hormone include weight gain, fatigue, constipation, slow heart rate, brittle finger/toe nails, dry skin and hair, possibly thinning of the hair, feeling cold, as well as difficulty thinking, and difficulty with remembering or problems with forgetfulness, among other symptoms. Not everyone has all of the symptoms just mentioned and the severity of symptoms varies from person to person. Because some of the symptoms are vague and some of the symptoms are associated with other problems, the only way to diagnose hypothyroidism for sure is with a simple blood test for TSH or thyroid stimulating hormone. You may also have lab work to investigate if there are antibodies against your thyroid gland causing your hypothyroidism, although it’s important to note that having antibodies against the thyroid gland does not mean you have or will guarantee development of hypothyroidism.
Hypothyroidism may be caused by a wide variety of things. The most common cause is from autoimmune disease, called Hashimoto’s thyroiditis. The second most common cause is from surgical removal of all or part of the thyroid gland. People who have received radiation therapy to the neck to treat cancer are also at risk of developing hypothyroidism. Other less common causes of hypothyroidism include certain medications and too little or too much iodine. There are many other causes of hypothyroidism, which your doctor will evaluate for depending on your history.
Fortunately, hypothyroidism is easily treated, although it cannot be cured. Your doctor can replace your lack of thyroid hormone by giving you a pill to take once a day. This is called levothyroxine or Synthroid. Your symptoms of hypothyroidism will resolve once you are taking the correct dose of the medication and as long as you keep taking it correctly. It is important to note that hypothyroidism can fluctuate, meaning that it can more or less severe over time, or gradually worsen such that your thyroid gland essentially no longer makes any thyroid hormone whatsoever. Therefore, it is important to monitor your thyroid hormone levels and report any new symptoms to your doctor.
It is also important to note that thyroid disease runs in families. That means if someone in your family has thyroid disease, you are more likely to have it, although this is not a guarantee.
If you have concerns that your thyroid gland isn’t working properly, you should contact your doctor or make an appointment with us for an evaluation.