Endocrine Head & Neck Surgery

Stanford Head & Neck Center

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Thyroid Nodules & Treatments

What are Thyroid Nodules?

Thyroid nodules are either benign (noncancerous) or malignant (cancerous) growths within the thyroid gland. Thyroid nodules are very common, occurring in 15-65% of people of all ages. They occur in both women and men but are more common in women (50% of women ages 50 or older have had a thyroid nodule). 

Usually patients or their physicians first notice thyroid nodules during a routine exam of the neck area; sometimes they are found incidentally during a radiologic examination of the neck (such as a CT scan, X-ray, MRI or ultrasound) ordered to investigate another condition— such as a carotid artery ultrasound or perhaps a CT scan of the spine for neck pain or car accident. Although the vast majority of thyroid nodules are benign, approximately 5-10% of thyroid nodules are cancerous. In general, a thyroid nodule is considered “significant” if it is 1 cm or larger and/or has suspicious features on ultrasound.

People with thyroid nodules may have normal thyroid function, and people with hormonal dysfunction of the thyroid gland may not have nodules. The structure and the function of the thyroid gland are often independent. Some thyroid nodules require surgical management. Occasionally thyroid nodules produce excess thyroid hormone (causing hyperthyroidism) that may be treated by surgical removal of part or all of the thyroid gland. Large benign thyroid nodules may cause pressure symptoms on the throat, windpipe, or neck muscles, and can contribute to the formation of goiter; symptoms may be relieved by surgery to remove the goiter. Lastly, some thyroid nodules are atypical enough that standard diagnostic measures are notable to eliminate of the possibility of cancer; such nodules may need to be surgically removed to reach a diagnosis.

Diagnosis

The typical workup for thyroid nodules includes an initial ultrasound, blood tests to assess thyroid function or inflammation, and, for nodules that are big enough to be potentially harmful and/or that appear suspicious on ultrasound, a fine needle biopsy.

If the nodule cannot be felt during the office physical exam, an ultrasound-guided fine needle biopsy will be performed by the surgeon, endocrinologist, or radiologist who will localize the nodule and obtain a sample of the nodule using a thin needle. These biopsies help the physician gain a better understanding of the cytology (cell make-up) of the nodule and help to determine whether surgery is needed. These studies may be performed in the office, in the Radiology Department or in the Pathology Department. The results are analyzed by the Cytopathology experts at Stanford.

Ultrasonography of the thyroid

At the conclusion of this workup, surgeons on the Stanford Thyroid and Parathyroid Surgery team will determine if surgery is recommended and if so, the extent of surgery needed. Surgery may include removing one side of the thyroid (thyroid lobectomy) or the entire thyroid (total thyroidectomy), and it may also include removal of affected lymph nodes in the neck around the thyroid (neck dissection).For thyroid nodules that are either suspicious for cancer or show definite evidence of thyroid cancer, thyroid surgery is generally the recommended treatment. The surgeon will individualize the treatment plan after a thorough review of all the data.

Thyroid Ultrasound Images

Treatment

There is no routine medical treatment for thyroid nodules. If thyroid hormone levels are deficient, a supplement of thyroid hormone may be prescribed. If hyperthyroidism is detected, then there may be medications that help control the hyperthyroidism while a definitive plan is being worked out. If thyroid function is normal, a recommendation for the management of the thyroid nodule is made from a structural or anatomic standpoint. If a decision is made that the thyroid nodule needs to be removed, surgical treatment is generally recommended.

Scarless Thyroidectomy

Typically surgery is performed through a small incision at the lower front part of the neck and involves removal of one lobe of the thyroid or the entire thyroid gland. The surgery usually takes 2-3 hours, and most patients are watched carefully in the hospital overnight. The pain is often minimal, and most patients take about 7 days off from work to recuperate. 

Some patients will need to take thyroid replacement medication long-term after surgery. This medication promotes normal thyroid function and normal metabolism after surgery to, so that patients are able to return to normal after surgery. Additionally, if there is evidence of cancer, some patients may require the administration of postoperative radioactive iodine treatment. The thyroid surgeon and medical endocrinologist will communicate and make a decision together after surgery regarding these potential postoperative interventions.

An important risk to consider with any type of thyroid surgery is the potential loss of voice, swallowing and sometimes breathing function. Surgeon experience and measures taken to preserve the nerves in this complex area are imperative to a good outcome. These measures include preoperative laryngeal exam, intraoperative nerve monitoring, and postoperative laryngeal exam with rehabilitation if necessary. Physicians in the Stanford Thyroid and Parathyroid Surgery program are committed to the recognition of the importance of voice and its preservation as patients are evaluated and treated surgically for thyroid nodularity.

Another risk of surgery is a potential compromise of parathyroid function. The parathyroid glands are very small glands that sit at the periphery of the thyroid gland and should be handled carefully during thyroid surgery, as they have an important role in calcium metabolism.  Surgeons at Stanford are knowledgeable in  parathyroid anatomy and preservation. Occasionally patients experience a temporary loss of parathyroid function from surgical manipulation. These patients may require short-term supplementation with calcium pills until the function of these glands recovers.

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.

 

 

Treatment for Benign Nodules

Radiofrequency Ablation (RFA)

What is Radiofrequency Ablation?

Radiofrequency ablation is a treatment that relies on heat to eliminate tissue. It has been used to treat tumors in the lung, liver, kidney, bone, and now the thyroid!

The treatment requires ultrasound for guidance, so it is important that your surgeon has expertise in ultrasound imaging and using this technology for procedures. A thin probe the size of a needle is inserted through the skin and into the target nodule. A machine then delivers an electrical current to the tip of the probe, which heats up and destroys the surrounding tissue. This results in gradual shrinkage of the thyroid nodule.

 

Ablation or Surgery?

The traditional treatment for a symptomatic thyroid nodule is a thyroid lobectomy. This results in complete removal of the nodule and some of the surrounding thyroid tissue. There is no tissue removed during radiofrequency ablation. Instead, the nodule is destroyed by heat, which leads to a significant decrease in size over time, such that it is no longer noticeable or causing symptoms.

For the right patient, radiofrequency ablation has some advantages over surgery. It is an outpatient procedure and can be done in the office under local anesthesia. It does not require an incision. Normal thyroid tissue surrounding nodules is preserved and results in significantly lower likelihood of needing thyroid hormone supplementation. This also means nodules on both sides of the thyroid may be treated without risking hypothyroidism. Typically, only requires one treatment is needed, but ablation can certainly be repeated if indicated.

 

What to Expect During and After the Procedure?

Before starting the treatment, your surgeon will apply local anesthesia around the thyroid gland and surrounding tissue to ensure a comfortable procedure. Once this has taken effect, the radiofrequency probe is inserted into the target nodule. Under constant ultrasound guidance, it is moved back and forth within the nodule to ensure ablation of the intended tissue while avoiding important structures. Typically, this requires only one point of entry in the skin. For very large nodules, two different sites may be required.

The total time of the treatment will depend on the size and number of the nodule(s), but typically lasts between 30 and 45 minutes. A bandage will be applied to the skin and you may return home afterward. You may experience soreness at the treatment site and can take over-the-counter pain medication. Local swelling can be expected in the first days after the procedure, followed by steady decrease in nodule size over the next few weeks to months.

 

Am I a Candidate?

Radiofrequency ablation is ideal for patients with benign thyroid nodules. Many nodules do not require intervention, but when they are causing discomfort or pressure, distorting appearance, or exhibiting growth, treatment may be indicated. Prior to offering this procedure, your surgeon will confirm the target nodule is benign, and a complete neck and thyroid ultrasound will be performed to ensure it is in a location that can be treated safely and effectively.