Thyroid / Head and Neck

Diseases of the thyroid glands are common – It is estimated 1 in 20 patients will have a thyroid nodule that is palpable.

Thyroid nodules are approximately more common in women than in men.

Most thyroid nodules are benign and an accurate assessment will usually require an ultrasound scan and a needle biopsy along with a thyroid function test.

Lady with a 10cm thyroid lump that turned out to be cancerous (papillary thyroid carcinoma)

Lady with a 10cm thyroid lump that turned out to be cancerous
(papillary thyroid carcinoma)

Young lady with a small central lump that turned out to be benign (follicular adenoma)

Young lady with a small central lump that turned out to be benign (follicular adenoma)

A total thyroidectomy done for a patient with compressive (swallowing) symptoms from a multinodular goitre that measured 16cm across.

A total thyroidectomy done for a patient with compressive (swallowing) symptoms from a multinodular goitre that measured 16cm across.

There are several surgical approaches to remove a thyroid lump.

The conventional way usually involves a skin crease incision along the anterior aspect of the neck to access the lump. This scar usually heals well if proper precautions are taken perioperatively.

 

Minimally Invasive Video Assisted Thyroid Surgery (MIVAT)

 Several minimally invasive approaches exist to remove the lump. An example of a minimally invasive video assisted thyroid surgery is shown below.

Typical appearance of scar via a conventional approach 1 week after surgery. Length is typically 5cm in length

Typical appearance of scar via a conventional approach 1 week after surgery. Length is typically 5cm in length

Surgery via a Minimally Invasive Video Assisted Thyroid Surgery. 2.5cm scar healing 1 month after surgery

Surgery via a Minimally Invasive Video Assisted Thyroid Surgery.
2.5cm scar healing 1 month after surgery

A thyroid scar 5cm in length that has healed 1 year after surgery

A thyroid scar 5cm in length that has healed 1 year after surgery

There are several other approaches available including robotic thyroid surgery and even transoral thyroid surgery. A thorough evaluation will be necessary to decide on the best approaches for the patient.

 

Personal Philosophy

Patient safety is of utmost importance and complete removal of a suspected thyroid cancer with clear margins is the priority in choosing the appropriate surgical approach. The American Thyroid Association guidelines is very useful in directing the management of patients with thyroid nodules. 

 

Article in Business Times : 3rd December 2016

“Tackling thyroid gland conditions the right way”

“Tackling thyroid gland conditions the right way”

 

Lumps in the neck are common and the cause is usually benign. However, the lump may be the presentation of more serious disease, eg malignancy or chronic infection and so a thorough assessment and diagnosis are essential. If there is any doubt as to the cause, then the patient should be investigated further either with imaging or a needle biopsy. Patients over the age of 40 are more likely to have a neoplastic cause. Inflammatory, congenital and traumatic causes are more common in younger patients but neoplasm should still be borne in mind.

Investigations that may be helpful to evaluate a neck lump:

  1. Blood tests (e.g. thyroid function test)
  2. Fine needle biopsy (e.g. thyroid, salivary, lymph nodes)
  3. Punch biopsy (e.g. tumours in the nose, mouth or throat)
  4. Lymph node biopsy
  5. X ray, CT, MRI scans or PET scans
  6. Examination under anaesthesia and biopsy (e.g. tumours behind the tongue, lower throat and larynx)

 

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Patient with a right branchial cleft cyst going for surgery

Branchial cleft cyst specimen

Branchial cleft cyst specimen

Submandibular calculus (stone) that was causing sialoadenitis (infection).

Submandibular calculus (stone) that was causing sialoadenitis (infection). 

Young lady with a large parotid tumor.

Young lady with a large parotid tumor. 

 

Sialoendoscopy is a minimally invasive technique that allows for salivary gland surgery for the safe and effective treatment of obstructive salivary gland disorders (eg stones) and other conditions of the salivary glands. During sialoendoscopy a small endoscope is placed into the salivary glands through the salivary ducts that empty into the mouth. Sialoendoscopy is an efficient yet simple mode of treatment for major salivary gland obstructions, strictures and sialoliths(salivary stones).

CT scan showing 2 stones along wharton’s duct.

CT scan showing 2 stones along wharton’s duct.

The same patient undergoing stone removal via sialendoscopy rather than an external approach which will require a neck incision to remove the submandibular gland.

The same patient undergoing stone removal via sialendoscopy rather than an external approach which will require a neck incision to remove the submandibular gland.

 

There are around 300 lymph nodes in the head and neck region. Most cannot be felt unless they are enlarged. 95% of causes of enlargement are benign and are usually due to an upper respiratory tract infection. 5% of the time we worry about malignancy (cancer) or tuberculosis.

Picture of patient with a supraclavicular lymph node enlargement. Subsequent excision biopsy revealed this to be due to tuberculosis

Picture of patient with a supraclavicular lymph node enlargement. Subsequent excision biopsy revealed this to be due to tuberculosis

A thyroglossal duct cyst is a pocket in the front part of neck that is filled with fluid. A child is born with this cyst. It is formed from leftover tissue from the development of the thyroid gland when an embryo was forming. The thyroid gland is located in the front of the neck. This has to be investigated frequently with imaging (either ultrasound scan or CT scan) to visualise the location and to ensure it is not the only source of thyroid hormone production in the body. Also a fine needle aspiration cytology can be performed to ensure there is no malignancy.

A thyroglossal duct cyst commonly presents with a central neck mass that moves with swallowing and tongue protrusion.

A thyroglossal duct cyst commonly presents with a central neck mass that moves with swallowing and tongue protrusion.

Ultrasound scan of thyroglossal duct cyst

Ultrasound scan of thyroglossal duct cyst

CT scan showing a 1.3cm thyroglossal duct cyst

CT scan showing a 1.3cm thyroglossal duct cyst

Specimen of thyroglossal duct cyst. The removal involves a Sistrunk operation that involves not only removal of the cyst but also the central portion of hyoid bone to minimize the chance of recurrence.

Specimen of thyroglossal duct cyst. The removal involves a Sistrunk operation that involves not only removal of the cyst but also the central portion of hyoid bone to minimize the chance of recurrence.

 

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