HEAD AND NECK

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The thyroid is an endocrine gland which, because of the hormones it produces, plays a central role in the metabolism of the human body. It is a surface organ right under the skin of the neck and it is easily affected by dietary habits, heredity, even the radiation of the environment. Due to all the above, we easily understand that the diseases of the thyroid are quite often, their symptoms vary and this gland is often held responsible for the various health problems we suffer. At times, we also tend to wrongly blame the thyroid for our stress attacks, our predisposition to obesity or hair loss, even our psychological condition, submitting, in this way, ourselves to unnecessary treatment and operations.

The problems of the thyroid gland should not be treated the way other neck masses are, and this because of the functional character of the gland at hand. Any disorders of the thyroid should be examined and treated by the endocrinologist. He/she, after thorough diagnosis, will decide about the right treatment, if, that is, this will be simple medication or surgery. The cases, for which surgery is considered the necessary way to treat the problem, are undertaken by the head and neck surgeon.

As it was mentioned above, the decision for surgical treatment is taken by the endocrinologist. These cases have to do with the function, the size and the composition of the gland. Thus, the patient will inevitably undergo surgery in the case of severe hyperthyroidism which does not respond to medication. Also, when the gland has become enlarged, the so called bronchocele or goiter, and it causes a feeling of pressure in the trachea or obvious deformity in the neck. However, the most important indication for a thyroidectomy is diagnosis of cancer in the gland, any strong suspension for its existence or any increasing possibility of transformation of a benign thyroidal lesion to malignant.

Even though the investigation of the thyroid is the subject of the endocrinologist we will briefly refer to the most important diagnostic examinations. First and foremost the biochemical tests. Based on the results of these tests the endocrinologist will decide on the functionality of the gland is, the function of other endocrine glands which interact with the thyroid, antibodies indicative of inflammatory conditions of the gland, or indicators which may be related to a malignant degeneration of a parenchymatous focus. Unfortunately, normal values in all these examinations do not exclude the possibility of malignancy, and in various cases, further study is required.

One of the most important, fast and painless tests is the ultrasound study. With the ultrasound, the radiologist will inform us about the size of the gland, the homogeneity of its composition, the presence and the consistency of the nodules, the calcium deposits etc. The diagnostic accuracy of the ultrasound has substantially improved in recent years and, in the right hands, can be used to identify and characterize alterations as accurately as those given by any histological study. It is proper to apply the ultrasound study to the whole neck. In this way the doctor can identify possible swelling in the lymph glands which may be connected to a problem in the thyroid. In most cases, it is necessary to supplement the ultrasound study with FNA for sample acquisition for biopsy. However, it is advisable first to complete the rest, not surgical, checkups.

The next, therefore, examination is the scintigraphy of the gland. Practically, it is a photographic representation of functional (warm) and non-functional (cold) areas of the gland. The significance of the scintigraphy lies on the fact that, statistically, the cold areas are more possible to contain foci of malignance compared to the warm ones. The scintigraphy findings, however, will be examined based on the ultrasound findings. Thus, a cystic nodule will appear as a cold area in the scintigraphy, without, however, having any particular clinical significance. Hence, the ultrasound must come first.

We have already mentioned that the swelling of the thyroid is not treated like the rest of the neck masses. Therefore, a CT is rarely necessary. These cases have to do with possible extension of the gland behind the chest (the so called plunging goiter), or around the trachea, the investigation for lymphatic swellings in the mediastinum, the examination of the relation between the large swellings in the lymph glands and the large blood vessels of the neck. In the rest of the cases, the ultrasound has provided sufficient information.

The cytologic examination of the material after the FNA is perhaps the final diagnostic test. Totally safe and almost painless, it is the only examination which can give us the tissue identity of the swelling under study. But like all previous examinations, this also has its own limitations. If the result of the FNA is compatible with, or at lease indicative of malignancy, then it has to be given serious consideration. If, however, the result is compatible with a benign alteration of the gland, this unfortunately does not exclude the possibility of a malignant focus, or its degeneration towards malignancy. And the larger the nodule under FNA the larger the probability. In any case, the FNA is a very important examination. If the mass we want to subject to FNA is not palpable, the puncture should be supported by ultrasound control.

None of the above investigations is purely diagnostic, with the possible exception of the FNA. In order to decide on the kind of medical treatment, we have to take into consideration the history of the patients, their age and sex, the existence of hereditary predisposition, and the general condition of their health. To suggest that our patient should undergo surgical removal of the thyroid, we need to consider and “weigh” all of the above. In general, we should consider as aggravating factors any appearance of nodes at very old ages, the male sex, the solitary nodule in contrast with the multinodular goiter, the cold in contrast with the warm nodules, and the firm in contrast with the cystic ones. However, in all cases, it is important to create a sense of optimism to our patients, assuring them that their problem, even when malignant, can be treated successfully, and in most cases, for life. If the case of malignancy is not sufficiently established, the endocrinologist will prescribe medication for the regression of the nodules and re-examination after a period of three to six months. The duration of the lesions does not unfortunately mean that the patient will not have to undergo regular checkups.

The surgical removal of the thyroid is delicate and with potentially unpleasant complications. Our suggestion, therefore, for thyroidectomy has to be well beyond doubt and our experience in neck operations rather extensive. The operation is done under total anesthesia and requires 24-hour hospitalization. In the overwhelming majority of the cases, we perform total thyroidectomy. The reasons are that, many times thyroid cancer has multiple foci, radioactive iodine uptake and substitution therapy in general are hindered by the presence of gland remnants, and the cases of revision surgery are quite more difficult and are accompanied by a higher frequency of complications. In some cases, when there are swollen tracheal lymph glands, the operation is extended to the rest of the neck, in order to practice unilateral or, possibly, bilateral removal of the lymph glands.

The thyroid surgery would be relatively simple if there were not present the laryngeal nerves, the nerves which move the vocal chords. The gland should be removed after the laryngeal nerves are dissected and recognized. In this attempt of ours, in addition to our experience, we have as our weapon the nerve monitoring. This piece of equipment informs us about any harm done to the nerves during the operation. Another difficulty of this operation is due to the presence of the parathyroid glands. These glands control the concentration of calcium in the blood, are in contact with the thyroid gland and they have to be recognized and kept intact before removal of the thyroid. In any case, the percentages of these complications are rather low and they do not justify any delay to the decision for removal of the thyroid when there are enough reasons for such an operation.

In recent years, effort has been made to improve other methods of removing the thyroid, avoiding neck incision. The most successful attempts combine robotic technology with the use of endoscopes. For the time being however, they are mostly experimental, using rather extensive incisions on other parts of the body and they often end up removing individual nodules of the gland, something like an extensive biopsy, that is. The post-surgical symphyses, which end in the area of the gland, make it difficult to operate again, although such operations are often necessary for those patients. For these reasons, these attempts are not yet widely approved, despite the availability of robotic technology in many hospitals.

After the operation, the gland is sent for histological examination. If a serious malignance focus is found, the endocrinologist subjects the patient to a scintigraphy examination, in order to check the depth of the removal and then to prescribe treatment with radioactive iodine for the removal of any remnants of the thyroid tissue. If, on the other hand, the results of the histological testing are compatible with a benign lesion, then the endocrinologist begins the so called substitution therapy. He/she administers, that is, to the patient the hormone produced by the thyroid before its removal.

The thyroidectomy is the most common operation in the area of the neck. The patient has to be subjected to such an operation only if there are sufficient reasons and the surgeon has to show extreme caution, in order to improve the condition of the patient rather than aggravate it.