In our clinical work we often encounter many patients with thyroid nodules, most of whom do not know much about the disease they are suffering from and often seek treatment in a hurry, which not only increases the cost of treatment, but also delays their condition. In this article, we answer the most frequently asked questions by patients in our clinical work.
1. I usually eat iodized salt, how come I still have thyroid nodules? It is true that most thyroid nodules develop due to iodine deficiency, but a long-term high iodine diet can also stimulate thyroid tissue hyperplasia and nodules by increasing the level of thyroid stimulating hormones in the body. Because iodine is already added to our salt, long-term consumption of seafood with high iodine content, such as kelp, can also easily cause thyroid nodules.
2. Is it better to have a thyroid nodule with or without surgery? This depends on the size of the nodule, the results of the ultrasound examination and the results of the thyroid puncture. Generally speaking, thyroid nodules with a diameter of more than 2 cm need to be analyzed according to the patient’s age, physical condition and other factors, and specific recommendations will be given for surgery or continued observation. Nodules between 1 and 2 cm in diameter can be treated with thyroxine preparations for about six months. If the nodule shrinks or does not continue to grow, surgery can be withheld and followed closely. Nodules less than 1 cm in diameter are generally not treated, but nodules with gravel-like calcification found by ultrasound or papillary hyperplasia or hard texture suspected of cancer found by puncture must be operated regardless of size.
3.Why do benign thyroid nodules easily recur after surgery? Some people need to have two or three operations? The most common benign thyroid nodule in clinical practice is nodular goiter, which is a pathological change of the entire gland from the beginning of the lesion, with epithelial papillary hyperplasia and vascular regeneration leading to nodules due to the gradual expansion of the follicles. In long-standing cases, almost the entire thyroid gland is diseased. Therefore, if the surgical excision is not complete, there is a high risk of residual hyperplastic thyroid tissue and microscopic nodules, and postoperative thyroxine suppressive therapy has limited effect on the residual lesions, so the recurrence rate after surgery is high. Moreover, once recurrence requires reoperation, the risk of surgery is 5 to 10 times higher than that of the initial surgery. In foreign countries, a more aggressive approach is taken to bilateral nodular goiter, with total resection on one side of the main lesion and total or near-total resection on the opposite side; moreover, normal thyroid function can be maintained after surgery with a small dose of thyroxine preparation. The advantages of this procedure are twofold: firstly, it completely avoids recurrence after surgery, and secondly, it avoids the risk and pain of reoperation for patients whose thyroid cancer is confirmed only after surgery. However, total thyroidectomy requires a high level of surgical demand, as it requires complete dissection of the bilateral recurrent laryngeal nerves and parathyroid glands to avoid serious complications. In recent years, our hospital has performed bilateral subtotal thyroidectomy for bilateral diffuse nodular goiter with the consent of the patient, and the results are very satisfactory.
4.Why do I speak normally but feel weak after thyroid nodule surgery? This is mainly because the thyroid nodules are often dissected to avoid damaging the recurrent laryngeal nerve during surgery, which may cause edema of the recurrent laryngeal nerve or affect its blood supply, resulting in the phenomenon of straining to speak. However, this phenomenon will gradually disappear about 3 months after surgery as the edema subsides and the blood supply is restored.
5.Why does numbness in the hands and feet occur some time after thyroid nodule surgery? This is mainly due to the fact that the blood supply to the parathyroid glands is affected or the blood return to the parathyroid glands is blocked due to the necessity of cutting certain blood vessels during surgery for thyroid nodules. Numbness in the hands and feet can often be relieved by appropriate calcium supplements such as Calcium D tablets. This phenomenon will gradually disappear about 2 months after surgery as the blood supply is restored or the bruising subsides.
6.Why is the incision swollen and hard after thyroid nodule surgery? This is actually due to the normal edema reaction of the incision after surgery. Because of the extensive separation of the skin flaps above and below the incision during thyroid nodule surgery, this can easily cause edema in the tissues surrounding the incision. Especially in middle-aged and older women, the incision is easily edematous because the skin is loose and there is more fatty tissue. Patients should not be alarmed by this situation, but the incision will gradually return to flatness as the edema is absorbed within 2 months after surgery.
7. Can thyroid surgery be performed without scarring or with minimal scarring? As people’s living standards improve, the demand for this is getting higher and higher. We can improve our surgical techniques to make the scars smaller and smaller or more concealed. At present, there are several ways to do this: first, small incision surgery, now we can do a 4 cm or even slightly less than 4 cm incision in the neck to complete the routine surgery, you can remove a 5 cm size specimen; second, with the help of endoscopic surgery; third, the implementation of the concept of beauty in surgery. Of course the scars of surgical incisions are not only related to the surgery, but also a very important factor is that a few patients are keloid. Usually after 2-3 years after surgery, the surgical scars will become less and less obvious, and can even be basically invisible in patients with good skin.
8. How to avoid excessive scar growth after surgery for keloid patients? Our practice is (1) to make the surgical incision as small as possible. (2) Adopt intradermal suture technique to reduce the irritation to the skin. (3) Give small doses of radiotherapy or use isotope patches to inhibit the growth of the scar after surgery. (4) Recently, we adopted cosmetic laser treatment in our dermatology department after surgical stitch removal with good results. (5) Special excipients to inhibit the growth of scars are applied after surgery.
9. Why is there a pulling sensation in swallowing and even coughing sometimes after thyroid surgery? This is related to the normal scar contraction reaction after thyroid nodule surgery. This is because, although there is only a line like scar on the neck after thyroid nodule surgery, the actual surgical trauma is much larger than this scar. This scar, like the neck incision, requires a normal scar reaction to recover, during which the scar will contract and pull on the trachea near the scar, causing a pulling sensation when swallowing and even irritating the trachea and causing coughing.
10. What is the purpose of taking thyroid preparations after surgery and how long should I take them? The purpose of taking thyroid preparations after surgery is the following: to correct possible hypothyroidism, to prevent recurrence, and to avoid reoperation. Benign diseases that do not appear hypothyroidism after postoperative follow-up can be discontinued after 3-5 years, but if hypothyroidism appears, the drug may be used for life. Malignant tumors mostly require lifelong medication and control of thyroid stimulating hormone as much as possible below the lower limit of normal, but without the clinical manifestation of hyperthyroidism.
11.What are the side effects of taking thyroxine preparation after surgery? Does long-term use have any effect on the body? The main side effects of taking thyroxine preparations are headache, heartburn and hypertension. There are two types of thyroxine preparations, one is synthesized from animal raw materials, such as thyroxine tablets. This type of drug is not very pure because of more impurities, so it is not easy to control the dose when taking it. The other is synthesized from artificial raw materials, such as eugenol. This kind of drugs because the preparation is more pure, so when taking the dose is easy to grasp. However, no matter what kind of drugs you take, you need to check your thyroid function regularly to avoid excessive doses and drug-related hyperthyroidism. As long as the dosage is appropriate, long-term use of thyroxine preparations will not cause adverse effects on the body. There is no evidence of adverse effects on the fetus when taken by pregnant women, so pregnant women are allowed to take them.
12.What are the precautions for taking thyroxine preparations? It is best to take thyroxine preparations in the early morning after waking up on an empty stomach, and eat breakfast about half an hour after taking the drug, so that the side effects of the drug can be minimized and the efficacy can be best. Also, avoid taking thyroxine preparations together with medications for stomach problems as this may affect the effectiveness of the medication.
13. Besides thyroid preparations, do I need to take other medications for a long time after surgery? Except for permanent parathyroidism after surgery (which is relatively rare), which requires long-term calcium supplements, there is no evidence from the current state of medicine that other medications are beneficial for this type of disease, including the so-called blood-activating herbal preparations on the market. Therefore, if you are approached by someone (medical or non-medical) who is trying to sell you on the need to take a certain drug for a long period of time, be wary of the purpose.
14. What is the purpose of surgery for thyroid nodules? Thyroid nodules are pathologically common as follows: nodular goiter, thyroid adenoma, thyroid cancer, etc. and can transform from anterior to posterior. Long-term growth of thyroid nodules can compress the tracheoesophagus and even fall into the chest, compressing the chest organs. Therefore, the purpose of thyroid surgery is clear: to clarify the diagnosis, to perform a second surgery if necessary, to stop the progression of the disease, to relieve the compression, and to reduce or eliminate the physical pain and psychological burden.
15. Why do some patients still have nodules found during postoperative ultrasound of the thyroid gland? There are several cases of nodules in the post-operative follow-up: (1) the knot tied in the thread to stop bleeding during surgery. (2) There are indeed some very small nodules during surgery, which cannot be detected due to the current level of medicine. (3) The patient has no normal tissue in the thyroid gland, and due to academic disagreement, or the patient and family do not agree to do total thyroidectomy, there may be isoechoic nodules less than 1 cm in the thyroid tissue left behind after surgery. (4) The carelessness or the level of the surgeon cannot be excluded, and some nodules are left behind.
What should I do if a nodule is found in the remnant of the thyroid gland at the postoperative follow-up? If the nodule does not grow within 2-3 years after surgery, no further medical intervention will be required. If the nodule grows gradually, and the first surgery was performed to remove the mass, and the mass grows rapidly and produces or is about to produce symptoms of compression, a second surgery should be considered.
What if a patient who has undergone lobectomy or subtotal thyroidectomy for the first time has a recurrence after surgery? As mentioned earlier, the purpose of surgery is clear: to stop the progression of the disease and to avoid compression of the vital organs by the thyroid swelling. If the scope of the first surgery is large enough, and although the recurrence is not suspected of malignancy after surgery, and there are no symptoms of compression on important organs after hospital examination, we generally recommend not to have a second surgery as much as possible to ensure the patient’s quality of life.
18. Although there is no hoarseness after thyroid surgery, why is there a change in the tone of pronunciation and difficulty in producing high notes? This is because the external branch of the superior laryngeal nerve was damaged during surgery. This symptom can be compensated for in the months after surgery and has little impact on life, so most thyroid surgeons do not pay attention to it. As the standard of living improved, we found that patients continued to question this, so we investigated and found that the rate of damage to the extralaryngeal branch of the superior laryngeal nerve was as high as 15-20%, causing inconvenience to patients’ lives. The patient’s need is the direction of our work, so we began to study how to protect the external branch of the supraglottic nerve during surgery. From what we have done so far, we are avoiding damage to the extralaryngeal branch of the superior laryngeal nerve, and we are trying to reduce the rate of damage to less than 1% by exposing it during surgery and then protecting it rather than dissecting it.
19. Why do some patients develop hoarseness after surgery? What happens afterwards? Most of the hoarseness occurs due to damage to the recurrent laryngeal nerve during surgery, resulting in vocal cord paralysis. If it occurs, the majority of people will be able to compensate for the hoarseness in about six months after the surgery by talking more and exercising appropriately. In order to avoid such complications, there is now a consensus in thyroid surgery in China to dissect or expose and protect the recurrent laryngeal nerve during surgery, and it has been possible to control such complications to less than 1%. Of course, some surgeons do not look for the recurrent laryngeal nerve during surgery. According to the authorities, the injury rate for thyroid surgery without searching for the recurrent laryngeal nerve is 3-10%. If the injury rate is higher than this, the surgeon should reflect on improving his practice. Of course, postoperative recurrence of secondary or multiple surgeries can increase the injury rate significantly or even approach 100%.
What does permanent parathyroidism mean and what can be done after it occurs? Generally, if parathyroid function does not recover six months after surgery and parathyroid hormone is monitored at the hospital at 0.01 (or not measured), it is considered permanent hypoparathyroidism. Permanent hypoparathyroidism is common in patients with total thyroidectomy and bilateral central region clearance. There is no suitable alternative to parathyroid hormone internationally, so permanent hypoparathyroidism cannot be corrected at this time. The patient will gradually tolerate the low blood calcium over time, but lifelong calcium supplementation cannot be changed.