Endocrine Head & Neck Surgery
Stanford Head & Neck Center
Hyperthyroidism/Grave's Disease & Treatments
What is Hyperthyroidism?
Hyperthyroidism means overactivity of the thyroid gland, resulting in too much thyroid hormone in the bloodstream. Hyperthyroidisim can result from autoimmune thyroid disease, toxic nodular goiter, solitary toxic nodule, or excess thyroid hormone intake. In patients with hyperthyroidism, too much thyroid hormone in the blood stream results in a variety of problems, including: palpitations, increased sweating, irritability, nervousness, tremor, weakness, unintentional weight loss, and insomnia. Patients who suffer from hyperthyroidism caused by the Graves’ disease may experience a change in the appearance, comfort, and alignment of the eyes.
A diagnosis of hyperthyroidism is made when a blood test shows high levels of thyroid hormones and very low levels of thyroid-stimulating hormones (TSH), which is produced by the pituitary gland. When there are excessive levels of thyroid hormones in the bloodstream, the body’s normal feedback mechanism turns off the pituitary gland’s production of TSH, resulting in very low TSH levels.
The most common cause of hyperthyroidism is Graves’ disease, a condition marked by enlargement of the thyroid (also known as “goiter”), a bulging appearance to the eyes (“ophthalmopathy”), and sometimes changes to the skin along the legs.
Other causes of hyperthyroidism include Toxic Nodular Goiter, when multiple nodules in the thyroid produce too much thyroid hormone, and a Solitary Toxic Nodule, in which a single thyroid nodule produces excessive thyroid hormones, and Hashimoto’s thyroiditis, another type of autoimmune thyroid disease. In cases of Toxic Nodular Goiter, significant enlargement of the thyroid can occur, causing the enlarged mass to press on surrounding structures, which can cause swallowing and breathing problems.
Patients diagnosed with hyperthyroidism are first evaluated and treated by endocrinologists, specialists in treating medical thyroid issues. The endocrinologist may order additional testing for hyperthyroidism, which may include a nuclear medicine scan. The endocrinologist will often prescribe medication to help control the hyperthyroidism, while helping determine the best long-term plan of action.
Patients with hyperthyroidism are always initially treated with antithyroid drugs (methimazole and/or PTU), which inhibit thyroid hormone production by the thyroid gland. Although very effective, antithyroid medications are often needed for long periods of time to achieve remission and have some risk of mild to severe side effects. Sometimes beta-blockers are also prescribed to initially control the symptoms related to hyperthyroidism.
More definitive treatment options for hyperthyroidism include radioactive iodine therapy or surgery.
Radioactive iodine therapy is used to destroy thyroid tissue and can be effective in achieving a cure for some patients with hyperthyroidism. Patients with eye findings in Graves’ disease and those with compression symptoms are often not candidates for this treatment.
Surgical treatment for hyperthyroidism may be considered if there are co-existing thyroid enlargement nodules, known eye disease, and/or a preference to avoid radioactive iodine. In patients with Graves’ disease or Toxic Nodular Goiter, the entire thyroid gland is usually removed. In patients with a Toxic Solitary Nodule, the surgeon usually removes half of the thyroid.
Thyroid surgeons at Stanford have extensive experience and expertise in the surgical management of hyperthyroidism from the causes described. Using the latest surgical techniques including monitoring of the recurrent laryngeal nerve, surgeons can safely and thoroughly remove either the entire gland or a portion of the thyroid to achieve a permanent cure of hyperthyroidism.
As with any surgical procedure, there are risks involved. There is a risk of bleeding, but this is very low. The average blood loss is less than an ounce. The risk of infection is so low that antibiotics are not routinely used. There is also a very low risk of injury to important nerves in the neck, called laryngeal nerves. These nerves control the muscles of the vocal cords. Injury to these nerves could affect your voice. The parathyroid glands are located near the thyroid gland and may be injured during thyroid surgery. This can result in a drop in blood calcium levels. There is also a small risk associated with anesthesia. However, the relative risk of complications is very low and is usually outweighed by the potential benefits of having the surgery. Your surgeon will go over this information with you and answer any questions you might have.
If you take aspirin or nonsteroidal anti-inflammatory agents (such as ibuprofen), you should stop taking these one week before surgery. If you take prescription blood thinners (anticoagulants such as Coumadin or Plavix) please discuss the discontinuation plan and possible “bridging” plan for anticoagulation with your prescribing doctor as well as your surgeon. The night before surgery, do not have anything to eat or drink after midnight. Get a good night’s sleep.
What will Happen in Surgery?
You will be given general anesthesia to put you to sleep. You are positioned with special pillows under your neck to tilt your head back. An incision is made at the base of your neck and is about two to three inches long. Using magnifying lenses, the surgeon locates the thyroid gland and associated structures and all or part of the thyroid is removed. In some cases additional surgery will involve removal of lymph nodes and other structures. The incision is stitched closed and is then covered with a small dressing. The operation generally lasts from two to three hours. If neck dissection (lymph node removal) is required, additional itme will be needed. After surgery, you will go to the recovery room where you will be monitored closely and cared for as you recover from the anesthesia.
The evening after surgery you will be able to eat dinner. You may have a sore throat. Pain medicine will be available but may not be necessary. You will have a dressing on your neck which should be removed the day after surgery. The head of your bed will be raised to help minimize swelling. You may have an intravenous line to give you fluids until you are eating and drinking at a normal rate. You may have routine blood tests.
Usually, you may shower the day after surgery. If a drain was present, you may shower 24 hours after the drain is removed. Try to keep the neck area as dry as possible and pat dry after showering. Your stitches will be removed in the office about a week after surgery. Infection is extremely rare. If you notice any redness or drainage from the incision contact your surgeon. After the stitches are removed, the most important thing you can do to improve the appearance of your scar is to protect it with sunscreen that has a sun protection factor (SPF) of 30 for an entire year. During the year your scar may become raised or red, but will almost always fade into a thin line which will be less noticeable.
Transoral (scarless) thyroidectomy
Why Scarless Thyroidectomy?
Traditional thyroid surgery is performed through an incision in the neck that leaves a visible scar. Recent improvements in technology and instrumentation have allowed for the removal of the thyroid gland through small incisions inside in the lower lip. This is the only thyroidectomy procedure that leaves no external scar – no one will know you had thyroid surgery! This minimally invasive approach is an ideal option for patients with tendencies for keloid or unsightly scarring, or who would rather not bear a constant reminder of their surgery.
1. The transoral endoscopic vestibular approach to thyroidectomy allows for removal of part or all of the thyroid gland through 3 small incisions inside the lower lip.
2. The instruments are passed through these incisions and tunneled underneath the skin to the neck.
3. High definition cameras provide sharp and magnified images that permit the surgeon to work with the utmost precision and protect vital structures.
When surgery is finished, you awake with dissolvable stitches and no scar on the neck.
Am I a Candidate?
Patients needing thyroid or parathyroid surgery may be eligible for a scarless approach. Ideal candidates usually have one of the following:
- Small thyroid cancers (<2cm) with no spread to lymph nodes
- Benign or indeterminate thyroid nodules
- An overactive parathyroid gland causing hyperparathyroidism
- Select patients with Graves’ disease or goiter
We want you to have the best possible outcome, and are very thoughtful in offering this approach to our patients. We evaluate each person thoroughly and will discuss candidacy with you during your appointment.
What to Expect After Surgery
The 3 small incisions inside the mouth are closed with dissolvable stitches that do not need to be removed. Typically, patients are allowed to go home either the same day, or the day after surgery. You will be provided with a dressing to wear under the chin and instructions on neck exercises to prevent stiffness. Swelling and bruising of the lower lip and chin are common and usually resolve within 7-10 days. Soft foods are recommended for the first 2 days, then you may resume your normal diet. It is important to keep your mouth clean between meals.