Great catching up with endocrine friends at AACE meeting 2017 in Austin, Tx with Drs Lindsay Harrison and Tira Chaicha-BromRead more →
YES! She will ALWAYS look at all four glands, but remove only the abnormal parathyroid adenoma. The reason to look at all four glands is that up to 15% of patients can have “double adenomas” or more than one abnormal parathyroid gland. If other glands appear abnormal, Dr. Brady will perform a biopsy of them and send the sample to the pathologist. If the intraoperative pathology confirms hypercellular (too many cells) parathyroid tissue, she will remove the gland. If not, Dr Brady will preserve it.
Thyroid nodules (growths in the thyroid gland) are extremely common. The majority of these lesions are benign (not cancer). However, the thyroid gland can develop nodules or lesions that may require removal by a thyroid surgeon. Some of these nodules can be cancerous and need to be removed. To evaluate if a nodule could be cancerous, we often recommend an FNA (Fine Needle Aspiration) biopsy. If an FNA biopsy reveals benign tissue, patients can be followed conservatively (without thyroid surgery). At times, patients may experience symptoms from even benign nodules. These symptoms can include difficulty swallowing or breathing, a choking sensation, or the feeling that something is stuck in their throat. On occasion, patients can have voice hoarseness as a thyroid nodule or goiter enlarges and begins to push on the windpipe, vocal cords, or esophagus. We refer to these as compressive symptoms and these symptoms may become severe enough that we recommend surgery.
The parathyroid glands are not related to thyroid function at all. The name “para” thyroid simply comes from the fact that they are near the thyroid gland and share some of the same blood supply as the thyroid. They are primarily involved with regulating calcium levels in the body. Whereas the thyroid gland is important for metabolism and can affect the function of all organ systems in the body. At times, the parathyroid glands can grow and produce too much parathyroid hormone (PTH) in the body. This overproduction inappropriately pulls calcium out of the bone and puts it into the blood stream. This can cause patients to have a number of symptoms such as lethargy, problems with concentration, memory loss, depression, high blood pressure, heart problems, kidney stones, and osteoporosis. The presence of some of these symptoms combined with either an elevated PTH and/or calcium level means that a patient may require parathyroid surgery. At times, patients have a normal calcium level and an elevated parathyroid hormone level. Other times, patients can have an elevated calcium level and normal parathyroid hormone levels. Both of these groups of patients still have primary hyperparathyroidism and will require parathyroid surgery. In my experience, patients feel much better after parathyroid surgery to remove their abnormal gland or glands. Many patients have told me it was “life changing” for them, giving them an increased energy level and improved cognitive function.
An FNA biopsy or fine needle aspiration is a sample of tissue that is obtained with a very small needle taken using ultrasound guidance that the pathologist can evaluate. Dr. Brady, local thyroid and parathyroid surgeon in the Austin area, performs these if indicated in her office at the initial consultation with her thyroid and parathyroid patients. After identifying the lesion or lesions to be sampled, she will prep or clean the skin on the neck and inject some local anesthetic or numbing medicine. With the ultrasound guiding her, Dr. Brady advances the needle in the numb area into the nodule that needs to be sampled. She then prepares several slides for the pathologist to study under the microscope. This procedure is extremely important for determining if thyroid nodules are benign (non-cancerous) or malignant (cancerous). Dr. Brady usually takes 10-15 minutes to perform these biopsies. The FNA biopsy is helpful in sampling lymph nodes for metastatic disease also. The patient can go back to work and drive home after the procedure. Dr. Brady will recommend ice packs to be used for minimizing swelling and soreness after the biopsy. Within 48-72 hours, she will obtain a result from the pathologist and will call the patient with results and a plan for the patient.
Usually any thyroid nodule that measures 1cm or greater needs an FNA biopsy to ensure it is benign and can be followed without a thyroid surgery. If a nodule has suspicious features such as increased blood supply, irregular borders, calcifications, signs of enlargement or the patient has a history of radiation exposure to the neck, Dr. Brady, one of Austin’s finest local thyroid and parathyroid surgeon, always recommends an FNA biopsy. In these cases a biopsy is required even if the nodule is less than 1cm. Another group of patients that will likely need an FNA biopsy of thyroid nodules are those with a personal history of any cancer or family history of thyroid cancer. It is rare, but some other types of cancer can metastasize to the thyroid gland with the most common being kidney, breast, lung, gastrointestinal tract or melanoma.
A neck ultrasound is a radiologic examination of the neck that uses sound waves (not radiation) to evaluate the size of the thyroid and the presence of nodules or lymph nodes in the region of the thyroid. A thyroid ultrasound is painless, noninvasive, and inexpensive. If they are enlarged, parathyroid glands can also be seen on an ultrasound. Typically, thyroid nodules over 1 cm need to be biopsied to ensure that they are benign. Certain nodules like cystic (fluid filled) lesions are almost always benign and can be followed without surgery. These cystic nodules can be aspirated (drained) to decrease size if they are causing any symptoms such as compression or pain. They may need a FNA biopsy if they are complex (have solid and cystic areas). Lymph nodes that appear suspicious with areas of calcifications, loss of normal appearance, enlargement, or increased blood supply may also need a biopsy.
Thyroid and parathyroid surgeons might order this scan or X-ray to help identify abnormal or enlarged parathyroid glands. It is not used for diagnosing hyperparathyroidism, but mainly for surgical planning, and is accurate in about 80% of cases. The thyroid and parathyroid glands have a strong affinity for the sestamibi(radiotracer) that is injected and with time the thyroid loses or washes out the sestamibi. The parathyroid glands hold onto the tracer longer, especially if they are enlarged or abnormal. Over a span of about 2 hours, photos or X-rays are taken to evaluate the patient for parathyroid disease. This helps determine which of the 4 parathyroid glands is hypercellular or enlarged. When a single gland is identified on the parathyroid scan, Dr. Brady, with 10 years of experience in the Austin area, offers the MIP (minimally invasive parathyroidectomy) for patients and it is done on an outpatient basis. It is also helpful in identifying ectopic parathyroid glands or those that are not in the normal anatomic positions. Some of these glands can even be in the chest, upper neck, or next to the esophagus.
If a parathyroid or sestamibi scan is normal, it does not mean that a patient does not have a parathyroid problem. Thyroid nodules, thyroid cancers, and Hashimoto’s thyroiditis can all cause a scan to be inaccurate or not show the abnormal parathyroid gland. Some may also have multiple (more than one) abnormal parathyroid glands occurring in 15%-20% of patients with hyperparathyroidism. Also, if a patient has had prior thyroid or parathyroid surgery, their scan can be negative. Finally, the patients with small abnormal parathyroid glands cannot always be seen on X-ray.
This is a sestamibi scan with single photon emission computed tomography (SPECT), or basically a CT scan of the neck using sestamibi tracer also. A 4D CT scan of the neck is a detailed computed tomography with use of IV contrast or dye with the 4th dimension being time. It can help identify a lymph node from a parathyroid gland by monitoring blood flow in real time.
This test can confirm primary hyperparathyroidism from a rare inherited disorder known as Benign Familial Hypocalciuric Hypercalcemia or BFHH. Patients with this disorder have a long history of high blood calcium levels and a family history of elevated calcium levels. It is important to rule this out as these patients do not benefit from surgery. Patients with high 24-hour urine calcium levels (>100 mg/day) have primary hyperparathyroidism and those with low urine calcium levels (‹100 mg/day) have BFHH.
This depends on the skill of the thyroid surgeon, the type of surgery being performed, and the severity of the disease. In the hands of an experienced surgeon like Dr. Brady, a thyroid lobectomy (partial thyroid removal) typically takes about 45 minutes to one hour. A total thyroidectomy can take about 45 minutes to 90 minutes depending on the degree of difficulty of the operation and whether lymph nodes are removed at the same time. Minimally invasive parathyroidectomy (MIP) is shorter, usually lasting only about 20 minutes if the diseased gland is localized or slightly longer if Dr. Brady needs to visualize and evaluate all 4 glands. At times, parathyroid surgeries can last longer, especially for reoperations or if the diseased gland is not in the suspected location. All of these surgeries require a general anesthetic, meaning that a patient is given a sedative to put them to sleep. A breathing tube is placed by an anesthesiologist, who monitors the patient throughout the procedure. Patients typically spend 1-2 hours in the recovery room and then will be either discharged home or admitted overnight to the hospital. The great majority of patients undergoing a partial thyroid removal or parathyroid surgery do not have to stay in the hospital overnight. If a patient has a total thyroidectomy, Dr. Brady will determine whether they require a hospital stay. Many patients having a total thyroidectomy have been able to go home on the same day as surgery, therefore avoiding an overnight hospital stay.
This type of parathyroid surgery involves an injection with a radioactive substance called sestamibi (radioisotope technetium-99m) by the radiology department before surgery. The sestamibi tracer will be taken up quickly by the thyroid and parathyroid glands. Over time, the thyroid loses or clears the tracer before the parathyroid glands. If a patient has an enlarged parathyroid gland, it will hold onto the sestamibi even longer and therefore can be picked up by a probe in the operating room. Once the enlarged parathyroid is removed, Dr. Brady can get a count (or level) of radioactivity compared to background tissue. It can help thyroid surgeons detect locations of parathyroid lesions that may be hard to find. For example, if a patient requires a reoperation for a failed parathyroid surgery or if the parathyroid gland is found to be ectopic (not in its normal anatomic location), this type of procedure is extremely helpful. Dr. Brady, who specializes in thyroid and parathyroid operations, uses this type of injection selectively as it is may not be needed in straightforward cases where the adenoma is seen well on parathyroid scan prior to surgery. It can carry an added cost to the patient and their procedure.
Neck surgery in general is considered to be minimally painful. That being said, Dr. Brady injects local anesthesia for every patient to ensure adequate pain control after thyroid and parathyroid surgery. She also prescribes pain and nausea medications to use at home as needed. Additionally, It is fine to take Tylenol, Motrin, or ibuprofen postoperatively to improve comfort and decrease inflammation.
There are 2 main risks of thyroid and parathyroid surgery that a surgeon should discuss with any patient that is preparing for a thyroid or parathyroid operation.
The risk of permanent recurrent laryngeal nerve injury is approximately 1% in the hands of an experienced thyroid or parathyroid surgeon like Dr. Brady. This type of injury causes hoarseness of the voice and can be temporary or permanent. Temporary hoarseness occurs about 20% of the time and takes anywhere from a few days to several months to resolve completely. There is also a risk of injury to the external branch of the superior laryngeal nerve that can result in loss of tone in the voice or inability to yell or sing. Dr. Brady uses a nerve monitoring system to identify, protect, and evaluate these nerves during every thyroid and parathyroid operation.
Another risk of thyroid surgery is injury to or inadvertent removal of normal parathyroid glands. In the hands of an experienced thyroid or parathyroid surgeon, that risk is about 2% or less. The parathyroid glands control calcium metabolism in the body, which can lead to problems with muscle contraction. This type of complication can be temporary or permanent. If this occurs, patients can become hypocalcemic (low blood calcium levels) and may require daily calcium supplements.
To an inexperienced surgeon, parathyroid glands can be very difficult to differentiate from the surrounding tissue. The way the parathyroid gland feels to touch and looks under magnification is critical in differentiating parathyroid tissue from its surrounding tissue. This is where Dr. Brady’s years of experience and expertise become critical to the success of the operation. Having done hundreds of thyroid and parathyroid surgeries over the past 10 years in practice in Austin Texas have given her the ability to identify subtle differences between parathyroid tissue and its surrounding tissues, such as fat or lymph nodes. She also routinely takes the specimen to the pathology department and looks under the microscope with the pathologist to ensure adequate and successful surgery is done. Normal parathyroid glands must be preserved and not removed as inadvertent removal can require life-long daily calcium supplementation.
A temporary drop in the calcium level is not uncommon after thyroid and parathyroid surgeries. Symptoms can include tingling or numbness in the fingers, toes, or around the mouth. These symptoms result from increased neuromuscular irritability. In more severe cases, patients can experience muscle spasms, muscle aches or stiffness. If any of these symptoms occur, one should contact their thyroid surgeon or parathyroid doctor immediately.
I recommend that all of my patients having a total thyroidectomy or parathyroid surgery take calcium by mouth daily for approximately one week after their thyroid or parathyroid surgery. Usually, I ask them to take Tums or any calcium pill (750-1000 mg every 8 hours). This helps to prevent the symptoms of low calcium that can occur after any thyroid or parathyroid surgery. At times, thyroid surgeons will also prescribe Rocaltrol (calcitriol), a prescription form of vitamin D that helps with calcium absorption in the intestine.
For the majority of Dr. Brady’s surgeries, she prefers the minimally invasive approach. Dr. Brady takes her patients’ surgeries very seriously, and on occasion, she teams up with Dr. Jennifer Walden, a renown plastic surgeon in Austin, Texas. Thyroid and parathyroid surgery should never compromised by the incision length. At times, depending on the size of the thyroid or parathyroid, she may have to enlarge the incision slightly to perform safe surgery. Her standard thyroid lobectomy or complete thyroidectomy incision is 4 cm or less. That is less than 2 inches. The incision for minimally invasive parathyroidectomy is 2 cm or less, smaller than 1 inch. Dr. Brady ALWAYS hides the incision in a natural skin fold of the neck so that the scar is barely visible once it is healed. She has performed a number of reoperations on the neck in patients with disease recurrence after unsuccessful surgery performed by other parathyroid doctors. She will typically use the same incision site and revise it to improve patient’s cosmetic outcome.
For the first 24-48 hours after surgery, I recommend ice packs to the neck wound and limitation of heavy lifting or exercise for about 5 days. My patients may resume normal daily activity the day after surgery if there are no issues. I allow my patients to shower the next day and get the wound wet. If the patient has steri-strips (white strips) placed on the wound, these usually stay in place until the postoperative visit with me at about 10-14 days. I will remove these strips at that visit. Some patients have Dermabond (surgical glue) placed on the wound and this will usually stay on for 2-3 weeks. After the postoperative visit, I recommend daily sunscreen application to the wound every morning for 6 months. Zinc oxide is preferred. The other option is to avoid sun exposure, but many find that nearly impossible in the beautiful city of Austin, Texas! In the evening, a scar prevention cream (such as Mederma or any generic equivalent) can be applied to prevent further scar formation. I also recommend daily multi-vitamins as they will assist with wound healing and scar prevention.
Thyroid replacement hormone can be started within a few weeks after a patient has had the entire thyroid gland removed. Typically, an endocrinologist, primary care physician or ob-gyn doctor will monitor thyroid hormone levels and prescribe thyroid hormone replacement as needed. If only half of a patient’s thyroid is removed, the patient will need thyroid function tests performed about 6-8 weeks after their thyroid surgery or earlier if they are experiencing symptoms of hypothyroidism (low thyroid). Approximately 80% of my patients don’t require thyroid replacement hormone after a partial thyroidectomy or thyroid lobectomy.
Thyroid replacement hormone is completely safe and important to take if one is pregnant or trying to become pregnant. Thyroid hormone is essential for proper fetal thyroid development as it crosses over the placenta to the baby. Adequate thyroid hormone levels are most critical during the early weeks of gestation, but a patient’s thyroid hormone requirements can often increase as the pregnancy progresses or if the patient is pregnant with multiples. Patients need to let their doctors know that they are taking thyroid replacement at the initial visit so that their thyroid levels can be followed regularly and their dosage of medication adjusted as needed to ensure a healthy pregnancy.
Patients do very well after thyroid surgery and usually don’t need to take thyroid hormone unless the entire thyroid gland is removed. Usually a patient has their thyroid function checked several weeks after the operation to ensure that the remaining thyroid is producing adequate amounts of thyroid hormone for the body. Depending on their thyroid levels and how they are feeling, patients may need extra thyroid hormone. In my experience, patients that are followed by their physicians regularly do not experience any weight gain or other symptoms of hypothyroidism (low thyroid). If a patient has complete removal of the thyroid gland, they will be required to take a thyroid pill everyday to maintain their metabolism. Those diagnosed with thyroid cancer typically have excellent long-term survivals rates of 97-98%.
Thyroid cancer is primarily treated with surgery. At times, radioactive iodine is needed after a thyroid operation. Most times, an endocrinologist and the thyroid surgeon determine whether a patient needs radioactive iodine by evaluation of the pathology report. Radioactive iodine can be recommended for certain patients depending on the size of the thyroid tumor or if the patient has extensive disease involving lymph nodes or growth beyond the thyroid gland. This treatment is given in a pill form several weeks after thyroid surgery and does require specific protocols on administration. Radioactive iodine will kill any remaining microscopic thyroid cells in the body that might be remaining.
An oncologist is not necessary with a diagnosis of thyroid cancer and this type of caner is not sensitive to chemotherapy. Typically an endocrinologist and an endocrine surgeon follow a thyroid cancer patient over the long term. They will see the patient regularly and obtain thyroid ultrasounds and blood work to make sure the thyroid cancer has not recurred or come back. One blood test they follow is a thyroglobulin level (a test for thyroid tissue present in the body.) After a complete thyroidectomy and lymph node excision, the thyroglobulin level should be zero since there is no longer thyroid tissue in the body. If the number increases, the thyroid surgeon or endocrinologist will obtain a thyroid ultrasound and thyroid scan to look in the body for where the thyroid tissue or cancer has come back. If it comes back in lymph nodes in the lateral neck (most common scenario), the patient will need a lateral neck dissection and Dr. Brady, local thyroid and parathyroid surgeon in the Austin area, can perform this surgery to remove the lymph nodes in this area.
Laryngoscopy is a procedure where a doctor inserts a scope into the patient’s nose and advances it into the back of the throat to visualize the vocal cords. This can be done in the office or the operating room. Dr. Brady does not believe every thyroid patient needs a direct laryngoscopy and she only recommends this procedure to certain thyroid patients as it is an added cost and can be uncomfortable for the patient. The patients that would need laryngoscopy are those that have had prior thyroid, parathyroid or other neck surgery. Also, patients that have recent hoarseness from enlarging thyroid nodules or an aggressive thyroid cancer need laryngoscopy. Recent data out of Japan was presented at the American Association of Endocrine Surgeons meeting in 2014 demonstrating that ultrasound can be used to visualize the cords accurately and without any added cost or discomfort to the patient. This can be done when a thyroid patient is seeing Dr. Brady for the first time in the office.
Dr. Brady will order certain lab levels on every thyroid and parathyroid patient. The reason for this is that these patients commonly have problems with both organs. She feels that if they have problems with both, these can both be addressed in the same operation. The labs that she checks routinely are calcium levels, parathyroid hormone (PTH) level, thyroid stimulating hormone (TSH) level, free T4 (thyroxine) level, and a vitamin D level.
If a patient is diagnosed with thyroid cancer, long-term surveillance is essential. Patients with thyroid cancer are typically followed at least yearly with ultrasounds, thyroglobulin, and thyroid stimulating hormone (TSH) levels. The main treatment for thyroid cancer is SURGERY, but sometimes a patient will require radioactive iodine to burn tiny thyroid cancer cells that might still be present in the body. This radiation treatment is actually offered in a pill that the patient swallows. After the entire thyroid and lymph nodes nearby are removed, a patient must be on thyroid replacement hormone for life to maintain their normal metabolism. The goal of this medical therapy for thyroid cancer patients is to keep the TSH very low or suppressed so that the thyroid cancer does not return or keep the few cancer cells that may be still in the body from growing or dividing. We follow thyroglobulin levels as a marker for possible thyroid cancer recurrence.
Dr. Brady was one of 10 general surgeons listed as a Top Doctor in the September 2015 issue of Austin Monthly magazine.Read more →