Keith Forwith

Innovative Thyroid Surgeon

FNA is the best way to determine without a surgical procedure whether a nodule is benign or cancerous. It is done in the office setting under ultrasound guidance. Here are several things to be aware of:

This visit can also be effectively done via Telemedicine, which provides at home or work convenience.

The American Thyroid Association recommends using the Bethesda system for reporting the findings of an FNA biopsy. There are six different categories:

Category 1

Nondiagnostic: This indicates an insufficient sample from the FNA procedure and repeat FNA is indicated.

Category 2

Benign nodules: This indicates that the pathologist saw normal thyroid cells and nothing unusual or atypical was seen in the sampling.

Categories 3 and 4

Atypical or suspicious indeterminant: This category means that abnormal cells were seen but the characteristics seen were not distinct enough to determine whether the lesion was benign or cancerous.

Category 5

Suspicious for cancer: The pathologist saw very unusual cells matching many of the criteria for thyroid cancer but is not saying with 100% certainty that the thyroid has cancer. This category is highly dependent upon the pathologist reading the cytology. Many pathologists will use this category even if they are completely convinced of the presence of thyroid cancer.

Category 6

Malignant thyroid cancer is present in the cells and the cytology reading is clear that this is the case.

What is a thyroidectomy?

Thyroidectomy is the surgical removal of all or a portion of the thyroid gland. It is most commonly performed because of a tumor or nodule within the thyroid gland. Typically, a fine needle aspiration biopsy has been performed to aid in preoperative planning. An ultrasound by the performing surgeon provides a roadmap and is part of a comprehensive pre-operative work up. Even if you have had a prior ultrasound, there’s no replacement for the information learned from an ultrasound in an expert surgeon’s hands.

How is thyroidectomy performed?

Thyroidectomy is performed under general anesthesia as an outpatient procedure in most cases where only half the thyroid is to be removed. In most cases where the entire thyroid is removed, an overnight hospital stay would be expected. In some cases, total thyroidectomy may be performed safely as an outpatient. Every case is different so talk over your options with your surgeon.

Isn’t Staying In The Hospital Better?

While sometimes there are good reasons to keep patients overnight, generally outpatient operations are preferred. First, there is a safety factor – hospital acquired infections usually only occur in patients spending the night or several days. Infection risks are decreased with shorter stays and especially with no overnight stay. Second, patients generally sleep better in their own beds without the distractions and interruptions of a typical hospital stay. No nurse will wake you up take your vitals at 4 am if you’re at home! Good sleep is important for your body to make a quick and uneventful recovery. This is usually better in the familiar environment of home. Finally, there’s a huge cost difference and outpatient surgery doesn’t waste valuable healthcare dollars.

How long will surgery take?

Most hemi-thyroidectomies take 40-50 minutes in my hands. A total thyroidectomy is generally 1-2 hours, depending on the complexity. If more involved surgery, like central compartment neck dissection for cancer is needed, this adds to the operative time. While meticulous surgical technique and experience lead to shorter operative times, I will take as much time as needed to ensure the best outcome for each individual patient.

What are the risks associated with thyroidectomy?

The major concern of this procedure is in preserving the laryngeal nerves and parathyroid glands. The laryngeal nerves control the muscles for the voice box. During thyroidectomy these nerves are monitored with a computer and meticulous dissection is performed to preserve them. Despite all precautions, permanent or temporary injury can occur. Most often, weakness of a nerve is a temporary condition. In some instances, especially cancer, the disease process itself can irreversibly injure these nerves. Rates of injury are reported in the scientific literature anywhere from 5% for experienced, high volume surgeons to over 20% for low volume surgeons who perform thyroidectomy on an occasional basis. In my experience, permanent injury rate is less than 1% in my 20+ year experience.
Parathyroid glands sit just on the backside of the thyroid gland and regulate calcium levels in the body by the production of parathyroid hormone (PTH). During surgery these glands can be removed, damaged or shocked – leading to a drop in PTH levels. A PTH level that is too low will lead to low calcium levels in the blood. Temporary or permanent problems can occur requiring treatment – usually with a combination of vitamin D and oral calcium. Protecting and preserving these important parathyroid glands is one of the challenges of thyroid surgery. Like nerve injury, rates of parathyroid injury are relative to the experience and volume of the surgeon performing the case.

Other risks include those which are common to any operation. Infection, bleeding and the risks of anesthesia would fall in this category. Because the neck, and thyroid in particular, have a very rich blood supply – infection is rarely seen. In the few cases I’ve seen, the patient’s blood sugar is usually out of control from poor diabetes management. So, diabetics need proper control to avoid this unusual complication. Hematoma, or bleeding in the surgical site, is rare but accounts for the third most common complication of thyroidectomy. This presents as a rapid swelling in the operated area and if this is suspected, the surgeon should be notified immediately!

Are there alternatives to surgery?

There are no non-surgical interventions for thyroid cancer which even come close to the success rate of surgery. Radioactive iodine is an additional therapy that may be used, but never as a substitute for patients that can have surgery. In cases of high-grade cancer, radiation therapy may be employed as additional treatment but not as a primary treatment. In cases of low-grade cancer and benign tumors surgical excision is usually the only treatment needed.

After Surgery

Will I Be in Pain?

Post-operative pain is usually mild to moderate and readily controlled with medications. Most patients will have been off their pain medicine for several days by the time we remove the stitches one week later. Because we usually don’t have to cut any major muscle, recovery is quite rapid. Discomfort when swallowing is common but improves quickly after surgery. Rarely does this limit a patient’s ability to eat and drink. Most throat soreness is a result of the breathing tube used during the operation.

Recently there has been a trend towards shorter and shorter incisions which sounds like a desirable outcome from thyroid surgery. However, sometimes small incisions can be highly visible because of the degree of scarring. The amount of tension that is put on the incision if the incision is made too small can result in prominent scarring. There are several examples of celebrities who have had mini incisions and yet you can see a small worm-like scar in the middle of the neck easily from across the room. In thyroid surgery, most patients desire a less noticeable scar and so care must be taken not to put the incision under excess tension during the surgery. This reduces scarring and noticeability in the end. A short scar is nothing to be proud of if it’s highly visible. I became sensitive to this when I was in college. When I was a sophomore and had no medical knowledge or insight, I had a lymph node removed from my neck. Thankfully, it turned out benign, but I was left with a highly visible, short scar. I was surprised at how often people asked about that scar. I was often shocked when people I just met would ask me why I had my surgery. While my lymph node surgery wasn’t a secret, I was often put off by people asking about it so often. I certainly would have liked a more meticulous and careful surgeon. On the positive side, that scar has given me great motivation to perfect my craft and I’m sure has made me a much better surgeon. So, perhaps I should thank that careless general surgeon who set me on this path!

One of the unfortunate consequences of surgery is a scar on the neck. However, there are a couple of options which can minimize or completely eliminate the scar from thyroidectomy. Certainly, one of the more exciting developments over the past couple of years has been the development of a transoral approach to thyroidectomy which leaves no visible scar on the neck. This is an excellent option for patients who scar badly, form keloids, or just want to avoid the cosmetic consequences of a neck scar. Not everyone is a candidate for a transoral approach, but for those that are, it is an excellent option to consider. In the traditional approach, there would always be a scar left on the neck. In recent years, there has been a move towards a minimally invasive approach that leaves a shorter scar, however, some of these shorter scars are highly visible. In my practice what I have found is patients typically want a less noticeable scar. Achieving a less noticeable scar that looks natural and appears like a neck crease would be far less noticeable to both patients and others. Achieving a good scar outcome involves multiple aspects all throughout the surgery. Stretching and injury of the incision edges leads to worse scarring postoperatively. And of course, the closure technique is extremely important as well. A natural looking scar looks like a neck crease and after just a few weeks of healing can appear nearly unnoticeable to the casual observer. There are multiple interventions that can improve scar outcome and we monitor our patients very carefully to see that their scars are healing well and will fade over time. When considering a thyroid surgeon, certainly the scar outcome is an easy thing to evaluate. We routinely provide patients pictures and examples of what to expect from our thyroid surgeries. If you Google thyroid scars, you will see some ghastly examples of poorly done surgery. Don’t be alarmed by these awful pictures! Outcomes can be much better if you choose your surgeon wisely. If a surgeon doesn’t have pictures to show you or refuses to show you pictures, then move on and find a better surgeon!

Pain: expect some mild to moderate pain after surgery. Use the prescribed pain medicine, which may be changed to Tylenol as pain subsides (usually 24-48 hours).

Diet: Patients may resume a regular diet as soon as they recover from anesthesia. Some sore throat may be present from the breathing tube being inserted during surgery.

Fever: Call for fever in excess of 102 degrees that does not respond to Tylenol. The main reason for fever after surgery is failure to clear secretions from the lungs due to inactivity.

Strenuous Activities: should be avoided for 10 days. This especially includes bending, lifting, or any activity that raises the blood pressure.

Bandage: There is a clear bandage called Tegaderm on the neck – shower normally while this is in place. It should be removed 48 hours after surgery, or sooner if any redness develops on the neck skin (this is irritation from the adhesive).

Removal: After removal of the clear dressing, white steristrips will be seen. These need to stay dry! Cover them with a dry wash cloth or towel while showering or bathing. These strips will be removed in my office one week after surgery.

Do Not Smoke: or be exposed to second hand smoke for two weeks. Smoke is highly irritating to healing tissue.

Sleep: Keep the head elevated while reclining and sleeping for 24-48 hours.

Ice bag: You may apply a lightweight ice bag to the neck intermittently for the first 24 hours. This can be comforting but not absolutely required.

Don’t Take: Aspirin, aspirin containing products, ibuprofen (Motrin, Advil, etc), naproxen (Alleve) or blood thinning medications for at least two weeks following surgery.

Bleeding: If bleeding is heavy, call the doctor’s office.

Nausea: nausea medication may be used 30-45 minutes prior to pain medicine to avoid the nausea side effect that some patients experience with narcotics.

Contact Sports: or other possibilities of neck trauma should be avoided for at least 10 days. Expect the neck to be sore to the touch for several weeks.

Call the Office: for any numbness or tingling around the mouth, in the hands, fingers, feet or toes. This can sometimes be a sign of low calcium. Click here for more information. Click here for information about thyroid scar care.

There are some unique challenges to thyroid surgery, mainly related to the structures that surround the thyroid. There is a delicate nerve called the recurrent laryngeal nerve (RLN) which runs behind the thyroid and goes to the voice box. If this nerve is stretched, injured or damaged during surgery then hoarseness or breathiness of the voice can result. The rate of injury in this surgery is directly related to the amount of experience that the surgeon has. Recently the American Thyroid Association cited a problem in that over 80% of thyroid operations were being performed by low- or intermediate-volume surgeons. What they noted was that low-volume and intermediate-volume surgeons had higher complication rates than high-volume surgeons. They broke down the experience of these different types of surgeons according to the number of surgeries they did each year. Low-volume surgeons perform less than 10 cases per year, sometimes only 1 or 2 cases per year. An intermediate surgeon would perform between 10 and 100 cases per year, whereas a high-volume surgeon does an excess of 100 cases per year. Their data shows that high-volume surgeons (who clearly have more experience in doing this delicate operation) have lower rates of complications. They cited overall complication rates for experienced high-volume surgeons at 7.5%. This is substantially higher than my own experience but not as surprising as what you see when you look at intermittent-volume surgeons who the ATA states have a 13.4% complication rate. Even worse, low-volume surgeons have complication rates as high as 18.9%. This is from a statistically significant study put out by the Healthcare Utilization Project nationwide inpatient sampling incorporating over 6,000 surgeons in the study. The ATA concluded from this data that patients should be referred to high-volume thyroid surgeons, particularly if the case is considered to be extensive or complex. They also noted that even high-volume surgeons have a higher rate of complications when a total thyroidectomy is performed vs. a more limited lobectomy. They did cite that high-volume surgeons saw their rates of complications go from 7.5% for lobectomy to 14.5% for total thyroidectomy. Still, experience matters here as low-volume surgeons saw complication rates of 11.8% rise to 24% for total thyroidectomies. The bottom line from all this data is that the amount of surgeries that are done is critical in developing techniques which are meticulous and are more likely to avoid injury to delicate structures such as the recurrent laryngeal nerve and the parathyroid glands. The experience the surgeon has determines the risk of injury that you face if you need thyroid surgery, so choose wisely!

I am very conservative in my recommendations for surgery. I follow this simple rule: would I encourage my wife, child, parent, or friend to have the surgery under the same conditions? I sleep well at night because I never forget this very simple guideline: treat patients as though they are family and everyone you care about is watching!

So, if I’m doing my job right, an expert second opinion will only make me look good and provide reassurance to the patient and family. If’ I’m offended by a second opinion – then I’m not following the simple rule stated above. I encourage my family and friends to get second opinions for major surgery.

As a high-volume thyroid surgeon at this point in my career, most cases seem routine to me. But surgery is never routine to the patient. Each surgery is likely the first for the patient and a lot is on the line! The best outcomes are with the first surgery. Complications and completeness of resection matter, especially to cancer outcomes. While I strive to reduce complications to the lowest possible rates, there is still risk with every surgery. A thorough and honest discussion is part of every pre-operative counseling visit. In my field of expertise, it’s literally the patient’s neck on the line!

Non-Diagnostic FNA

When an FNA biopsy is done and a nondiagnostic biopsy is returned, the FNA should usually be repeated. If it was a clear indication for a biopsy the first time, then a nondiagnostic result would mean that the patient is still in need of an accurate fine needle aspiration. The process of obtaining an FNA does generate inflammation within the gland of the thyroid and so repeat FNA should be delayed for a time which allows for a resolution of the inflammation. This helps to avoid conflicting biopsy results and increases the accuracy of the subsequent biopsy.

Indeterminate FNA

The other situation where a repeat FNA is often considered is in the face of an indeterminant result. While some people advocate for repeat FNA, this should be done with caution. Not all nodules contain uniform and homogeneous populations of cells. It is possible for a repeat FNA to pull out benign cells that are unlike the unusual cells that were seen on the first sampling. While this may appear reassuring for the patient that benign cells were seen, there is still a concern about the abnormal cells that were sampled during the first FNA. The better reason to consider a repeat FNA for indeterminant results is if molecular testing could be used to help further stratify the risk of cancer in a particular lesion. Molecular testing has added a significant degree of certainty to the indeterminant category and can be reassuring for increased probability of benign disease. Its use has obviated the need for surgical biopsy in many cases. Molecular testing is certainly an evolving area within the thyroid nodule evaluation, and it is critical that the performing surgeon understand the nuances of molecular testing and when it is appropriate to be used. Not all indeterminant lesions should undergo molecular testing and not all patients require this expensive testing. New advances in this area are coming at a rapid pace, so make sure your doctor has extensive knowledge and has kept up with the available molecular tests.

The evaluation for a thyroid nodule in a pregnant patient is pretty much the same as that for nonpregnant women. If the pregnant woman has a normal TSH or is hypothyroid then a fine needle aspiration can be done in the routine way. Fine needle aspiration does not present any risk to the developing baby. If the TSH is below normal range, the fine needle aspiration is typically deferred until after pregnancy and sometimes even after the cessation of lactation. Thyroid uptake scans are not recommended for evaluation during pregnancy or lactation. If a nodule is proven to be thyroid cancer, then the decision making needs to be done in close conjunction with the surgeon. If the thyroid cancer does not appear to be aggressive, then waiting until after delivery for surgical removal is likely to be the recommendation. If surgery is required because of an aggressive growing thyroid cancer during pregnancy, the ideal time to perform that is in the second trimester. The first trimester induction of anesthesia puts the patient at risk for developmental abnormalities. These risks are much lower in the second trimester. Third trimester operations have the risk of inducing premature labor. So, second trimester is the ideal time if the surgery cannot be delayed until after delivery. If thyroid cancer treatment is delayed on the suspicion or confirmation of thyroid cancer, then the TSH should be kept at low range, typically .1 to 1.0 for the duration of the pregnancy. As with all thyroid surgery, an experienced thyroid surgeon can reduce the inherent risks. As time under anesthesia is an important risk factor in pregnant women, a high-volume thyroid surgeon can more efficiently perform a thyroidectomy and reduce anesthesia time for the operation. Higher risk thyroidectomies, such as in a pregnant patient, should not be done by anyone other than a high-volume, experienced thyroid surgeon! Check out this advice on choosing a thyroid surgeon!

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