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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:

Tell your doctor about any medications you are on. While patients on blood thinners may have excessive bruising from the procedure, blood thinning medications do not typically need to be stopped prior to the biopsy. Ask your doctor specifically whether these medications should be withheld. In most cases, this is typically not necessary.
You do not need to refrain from eating or drinking normally prior to the procedure.
After the procedure, you should be able to go back to your normal daily activities with no restrictions.
You should wear clothes that allow for the doctor to easily access the low part of the neck where the thyroid resides. Turtlenecks or high riding sweaters are not ideal. Many types of physicians perform FNA biopsies including endocrinologists, internists, pathologists, radiologists, and other physicians who have learned to perform an FNA. However, quality of the FNA is highly determined by the person taking the sample. As a thyroid surgeon, no one is more interested in an accurate diagnosis than I am and that is why I prefer to do my own needle biopsies to ensure that we get the best possible results!
The fine needle aspiration uses a very small needle that is typically much smaller than the one that is used to draw blood. There is minimal swelling, aching, or bruising in patients who are not on blood thinners.
Ask if you will be adequately numbed! While some people do not use numbing anesthesia prior to biopsy, I have found through my own experience and the experience of thousands of patients that people are way more comfortable if we do a very short injection and give adequate time for anesthetic effect. I cannot think of a single patient who would want to repeat a non-anesthetized FNA.
The optimal position for the FNA is lying down on the back with the neck slightly extended. A pillow is typically placed under the shoulder blades to fully expose the thyroid and allow for optimal biopsy.
After you are numb, the needle will be inserted, but typically patients do not feel the needle penetrating the skin. Breathing normally during the procedure helps to alleviate anxiety and as the thyroid moves up and down with swallowing and talking, typically we would ask you not to swallow or talk while we are taking the samples.
While the whole procedure may take 30-45 minutes, the needle stick portion of it only lasts a few seconds and involves just an odd pressure sensation when being performed.
After the procedure, the numbing medicine often can do some unusual things when it wears off. It is not unusual for people to get a pins and needles type sensation that can be felt in the ear or in the jaw. This is a referred sensation and it happens because of a nerve from the area of the neck hooking up in the same part of the brain as a nerve from the jaw or ear. This goes away as the medicine wears off and is no cause for concern.
Our FNA samples are sent to one of the most experienced labs in the country. There are quality differences in cytology readings and experience is critical for proper test results. This typically takes about a week to get results back. If molecular testing is indicated, this can delay results for up to three to four weeks.
While some doctors may give results over the phone, I do not find this to be a good practice. The purpose of sitting down with the patient to review the results is to go over best treatment advice and recommendations. This is true regardless of whether the biopsy is benign or cancerous. This is an excellent visit to bring a friend, spouse, or trusted companion as two sets of ears are often better at listening than just one.

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!

Keith Forwith