Thyroid Diseases and Thyroid Surgery: Diagnosis, Treatment and the Surgical Process

Main Keywords: thyroid diseases, thyroid nodule, thyroid surgery, thyroidectomy, thyroid cancer, goiter, goiter surgery

Supporting Keywords: thyroid nodule symptoms, thyroid nodule treatment, when does a thyroid nodule need surgery, thyroid biopsy, fine needle aspiration biopsy, Bethesda classification, multinodular goiter, Graves’ disease, thyroid cancer surgery, papillary thyroid cancer, total thyroidectomy, thyroid lobectomy, thyroid surgery risks, hoarseness after thyroid surgery, low calcium after thyroid surgery, recovery after thyroid surgery, nerve monitoring in thyroid surgery

Thyroid diseases are very common conditions that can affect the function or the structure of the thyroid gland. Thyroid nodules, goiter, hyperthyroidism, Graves’ disease and thyroid cancer are the main ones.

The great majority of thyroid diseases do not require surgery. However, thyroid surgery may come onto the agenda when there is suspicion of cancer in a thyroid nodule, thyroid cancer, a large goiter, compressive symptoms or certain cases of hyperthyroidism.

The aim of thyroid surgery is to remove the diseased thyroid tissue appropriately while protecting, in particular, the nerves that control the vocal cords and the parathyroid glands.

What Is the Thyroid Gland and What Does It Do?

The thyroid gland is a butterfly-shaped organ located at the front of the neck, in front of the windpipe.

The hormones produced by the thyroid gland influence many physiological processes — above all metabolism, but also heart rate, body temperature and energy use.

When the thyroid gland produces more hormone than normal, this is called hyperthyroidism; when it produces too little, hypothyroidism. Enlargement of the thyroid gland is generally referred to as goiter.

What Are the Most Common Thyroid Diseases?

Thyroid diseases cover a very wide group. The conditions of particular importance from a general surgery perspective are:

Thyroid nodules

Multinodular goiter

Graves’ disease

Toxic nodular goiter

Thyroid cancers

Large or compressive goiters

Depending on the type of thyroid disease, one of the following may be chosen: observation alone, medication, radioactive iodine treatment or surgical treatment.

What Is a Thyroid Nodule?

A thyroid nodule is a growth that forms within the thyroid gland and shows different characteristics from the rest of the gland.

Thyroid nodules are very common and the great majority are benign. Finding a nodule in the thyroid gland therefore does not directly mean cancer.

However, since some nodules can carry a risk of thyroid cancer, the ultrasound features of the nodule and, when necessary, the biopsy results must be evaluated.

What Are the Symptoms of a Thyroid Nodule?

A significant proportion of thyroid nodules cause no complaints at all and are discovered incidentally during an ultrasound performed for another reason.

With larger nodules or in the presence of goiter, complaints such as:

Swelling in the neck,

A feeling of pressure in the neck,

Difficulty swallowing,

Difficulty breathing,

Voice changes

can occur.

If the thyroid nodule produces hormone, symptoms of hyperthyroidism such as palpitations, sweating, weight loss and trembling hands may be seen.

Is a Thyroid Nodule Cancer?

No. Most thyroid nodules are not cancer.

That said, it is important to determine which nodules need to be investigated for cancer.

On thyroid ultrasound, not only the size of the nodule but also its structure, borders, calcification pattern and other ultrasound features are evaluated. Fine needle aspiration biopsy (FNAB) can be performed on nodules where this is considered necessary.

What Is a Thyroid Biopsy?

Fine needle aspiration biopsy of the thyroid is the procedure of taking a cell sample from a thyroid nodule with a thin needle. It is usually performed under ultrasound guidance.

The sample is examined by a pathologist and the results are usually reported using the Bethesda classification.

Alongside the biopsy result, the ultrasound features of the nodule, its size, the patient’s history and other clinical findings are evaluated together to decide on follow-up or treatment.

What Is a Goiter?

A goiter is an enlargement of the thyroid gland beyond its normal size.

The entire thyroid gland may enlarge, or it may contain multiple nodules. The latter is called a multinodular goiter.

A goiter does not always require surgery. However, surgical treatment can be considered in situations such as pressure on the windpipe or esophagus due to marked enlargement of the gland, visible swelling in the neck, the presence of suspicious nodules or hormone excess.

What Is Graves’ Disease?

Graves’ disease is an autoimmune condition in which the immune system affects the thyroid gland and causes excessive production of thyroid hormone.

Depending on the patient’s characteristics, treatment options include medication, radioactive iodine or surgery.

Thyroid surgery may be preferred in Graves’ disease in cases of large goiter, compressive symptoms, a suspicious nodule or certain special clinical situations.

What Is Thyroid Cancer?

Thyroid cancer is the general term for malignant tumors that develop from the cells of the thyroid gland.

There are different types of thyroid cancer. The most common type is papillary thyroid cancer.

Other main types are:

Follicular thyroid cancer

Medullary thyroid cancer

Anaplastic thyroid cancer

The biological behavior and treatment of these cancer types differ from one another. In a significant proportion of papillary thyroid cancers in particular, successful outcomes can be achieved with appropriate treatment.

What Are the Symptoms of Thyroid Cancer?

Thyroid cancer may cause no symptoms in the early period. One of the most common findings is a nodule detected in the thyroid gland or the neck.

In some patients, symptoms such as:

A growing lump in the neck,

Enlarged lymph nodes in the neck,

Voice changes,

Difficulty swallowing,

A feeling of pressure in the neck

may be seen.

The presence of these symptoms does not by itself mean thyroid cancer, but it does require evaluation.

When Does a Thyroid Nodule Require Surgery?

Not every thyroid nodule needs to be operated on.

Thyroid surgery may come onto the agenda particularly in the following situations:

A diagnosis of thyroid cancer,

Suspicion of cancer on biopsy,

Compressive symptoms caused by a large nodule or goiter,

Certain large or progressively growing nodules,

Certain toxic nodules and cases of hyperthyroidism,

Graves’ disease in which surgical treatment is preferred,

Other patient-specific clinical reasons.

The decision for surgery is not made based on the size of the nodule alone. Ultrasound, the biopsy result, thyroid function and the patient’s clinical characteristics are evaluated together.

How Is Thyroid Surgery Performed?

Thyroid surgery is a procedure performed under general anesthesia. The thyroid gland is reached through an incision in the lower front part of the neck.

Depending on the type of disease, one lobe of the thyroid gland or the entire gland may be removed. Removal of one side of the thyroid gland is called a lobectomy; removal of the entire gland is called a total thyroidectomy.

Which operation is appropriate is decided according to the type and extent of the disease.

Is the Entire Thyroid Gland Removed?

Not every thyroid operation requires removal of the entire gland.

For some unilateral nodules or certain thyroid tumors with suitable features, removing only one lobe of the thyroid gland may be sufficient. In multinodular goiter, Graves’ disease or some thyroid cancers, a total thyroidectomy may be preferred.

The extent of the operation is therefore determined individually for each patient.

Are Lymph Nodes Removed in Thyroid Cancer?

Not every thyroid cancer operation requires removal of the lymph nodes in the neck.

Neck lymph node dissection can be performed in the patients who need it, based on the type and extent of the thyroid cancer and the state of the lymph nodes in the neck.

Pre-operative ultrasound is particularly important in this respect.

What Are the Risks of Thyroid Surgery?

As with any surgical procedure, thyroid surgery carries certain risks.

Important risks specific to thyroid surgery include:

Bleeding,

Voice changes due to the involvement of the nerves that control the vocal cords,

Low calcium levels due to the involvement of the parathyroid glands,

Infection.

The level of risk can vary according to the extent of the operation, the characteristics of the disease and patient-related factors.

What Is Nerve Monitoring in Thyroid Surgery?

Immediately adjacent to the thyroid gland lie important nerves that move the vocal cords. Identifying and preserving these nerves anatomically is one of the fundamental principles of thyroid surgery.

Nerve monitoring is a technology that helps assess the function of the nerve during the operation.

Nerve monitoring does not replace the surgeon’s anatomical dissection; it is an auxiliary method that provides additional functional information during surgery.

Can Thyroid Surgery Cause Hoarseness?

Some patients may experience temporary voice changes after thyroid surgery. If the nerves that move the vocal cords are affected, more noticeable voice problems can occur.

Whether a voice change is temporary or permanent depends on the characteristics of the operation and the condition of the nerve. Persistent, noticeable hoarseness after surgery should be evaluated appropriately.

Why Does Calcium Drop After Thyroid Surgery?

Behind the thyroid gland lie small glands called the parathyroid glands. These glands play an important role in the body’s calcium balance.

Particularly after a total thyroidectomy, blood calcium levels can fall due to temporary disturbance of the parathyroid glands. This can cause symptoms such as numbness and tingling around the mouth or in the fingers.

Calcium and vitamin D supplements can be given to the patients who need them.

Recovery After Thyroid Surgery

The length of hospital stay after thyroid surgery can vary according to the extent of the operation and the patient’s clinical condition.

In the early post-operative period, mild neck pain, throat discomfort or tenderness when swallowing may occur. Patients can gradually return to their daily activities.

Patients who have had a total thyroidectomy require thyroid hormone therapy to replace the thyroid hormone. In patients operated on for thyroid cancer, additional treatment and follow-up can be planned according to the pathology result.

Does Thyroid Surgery Leave a Scar?

In classic thyroid surgery, a horizontal incision is made in the lower front part of the neck.

The surgical incision is planned to follow the natural skin lines of the neck as far as possible. How the scar looks over time depends on the individual’s wound healing characteristics.

How Is the Right Treatment for Thyroid Disease Determined?

Not every patient found to have a thyroid nodule or goiter needs surgery.

In the treatment decision, the following are evaluated together:

Thyroid ultrasound,

Thyroid hormone tests,

Thyroid biopsy when needed,

The Bethesda result of the biopsy,

The size and features of the nodule,

Compressive symptoms,

The patient’s age and clinical characteristics.

The aim is not only to treat the disease but to avoid unnecessary thyroid operations while correctly identifying the patients who do need surgery.

Frequently Asked Questions

Is a thyroid nodule cancer?

No. The great majority of thyroid nodules are benign. Ultrasound and, when necessary, fine needle biopsy are used to assess the risk of cancer.

At what size (cm) does a thyroid nodule require surgery?

The decision for thyroid surgery is not based on the size of the nodule alone. Ultrasound features, the biopsy result, growth, compressive symptoms and the patient’s clinical characteristics are evaluated together.

What happens if a thyroid biopsy shows cancer?

Treatment is planned according to the type, size and extent of the cancer. Thyroid surgery can be performed in suitable patients.

Is the entire thyroid removed in thyroid surgery?

Not always. In some patients a lobectomy is sufficient, while some diseases may require a total thyroidectomy.

Do you have to take medication for life after thyroid surgery?

If the entire thyroid gland has been removed, hormone therapy is required to replace the thyroid hormone. After a lobectomy, hormone therapy may not be needed in every patient.

Does your voice change after thyroid surgery?

Temporary voice changes can occur. Involvement of the nerves that move the vocal cords is one of the important risks of thyroid surgery.

Does calcium drop after thyroid surgery?

Temporary low calcium can occur, particularly after a total thyroidectomy. Permanent problems are rarer.

Can thyroid cancer be completely cured?

It depends on the type of thyroid cancer and the stage of the disease. In a significant proportion of the commonly seen differentiated thyroid cancers in particular, successful outcomes can be achieved with appropriate treatment.

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