THYROID SURGERY SINGAPORE

What is the thyroid? How important is it for my health?

The thyroid gland is a butterfly-shaped endocrine organ located in the lower front portion of the neck. The thyroid primarily produces thyroxine hormone which is secreted into the bloodstream and carried to the rest of the body. Thyroxine contributes to the body’s metabolism such as keeping the body warm and keeping the brain, heart, muscles, and other vital organs working as they should.

What tests are needed for thyroid problems in Singapore?

In general, thyroid diseases can be divided into 2 broad categories:

  • Over- or under-production of thyroid hormone
  • Overgrowth of the gland or the formation of tumor thyroid nodules

Patients with over-production of thyroid hormone or hyperthyroidism may experience symptoms such as increased heart rate, sweatiness, significant weight loss, mood changes, irregular menses, just to name a few. Conversely, patients with under-production of thyroid hormone or hypothyroidism may experience symptoms such as significant lethargy, weight gain, mind ‘fog’ and mood changes.

If you are diagnosed with the first category of disease, your doctor would have ordered a panel of blood tests called thyroid function test (TFT) and you may be prescribed medications to lower or raise the thyroid hormone level. Subsequently, you may need repeated TFTs as well as other blood tests to monitor the condition or treatment regime. You may also require an ultrasound scan to image the gland as part of the overall evaluation.

If you are diagnosed within the second group, you may also be required to undergo evaluation with blood tests and ultrasound imaging. In addition, your specialist may advise a fine needle aspiration biopsy (FNAB) of the thyroid growth or nodule(s). This is important to rule out the possibility of a cancerous growth within the thyroid. This is a simple and safe outpatient procedure performed in the doctor’s office. Typically, the biopsy is performed under ultrasound guidance to ensure accurate placement of the needle within the thyroid nodule. You will be asked to lie down on your back with your head tipped backwards, so that your neck is extended. During the procedure you may feel some neck pressure from the ultrasound probe and from the needle. You will be asked to remain as still as possible and to avoid coughing, talking, and swallowing during the biopsy (see annex). In my practice, patients who require a thyroid ultrasound and FNAC will be provided these evaluations within the same consultation.

Fine needle aspiration biopsy (FNAB)

This is a simple and safe outpatient procedure performed in the doctor’s office. Typically, the biopsy is performed under an expertise diagnostic ultrasound guidance to ensure accurate placement of a fine needle within the thyroid gland nodule. You will be asked to lie down on your back with your head tipped backwards, so that your neck is extended. During the procedure you may feel some neck pressure from the ultrasound probe and from the needle. You will be asked to remain as still as possible and to avoid coughing, talking, and swallowing during the biopsy. In my practice, patients who require a thyroid ultrasound and FNAC will be provided these evaluations within the same consultation so as to expedite a diagnosis. A full article written on Dr Thomas Ho’s study on the subject in Singapore can be read in the link here:

https://pubmed.ncbi.nlm.nih.gov/25028141/

What are the types of thyroid cancer in Singapore?

Papillary thyroid cancer is the most common type, making up about 70% to 80% of all thyroid cancers. Papillary thyroid cancer can occur at any age. It tends to grow slowly and often spreads to lymph nodes in the neck. However, unlike many other cancers, papillary cancer has a generally excellent prognosis, even if there is spread to the lymph nodes in the neck. 

Follicular thyroid cancer is the next most common and makes up about 10% to 15% of all thyroid cancers. Follicular cancer can spread to lymph nodes in the neck, but this is much less common than with papillary cancer. However, follicular thyroid cancer is more likely than papillary cancer to spread to distant organs, particularly the lungs and bones.

Both papillary and follicular thyroid cancers are also known as well-differentiated thyroid cancers (WDTC) and account for the majority of thyroid cancers diagnosed.

Medullary thyroid cancer is less common, only accounting for approximately 2% of all thyroid cancers. While most patients with medullary thyroid cancer are sporadic (occur in isolation), approximately 25% of these cancers occur in families and is associated with other endocrine tumours (Multiple Endocrine Neoplastic Syndrome). In family members of an affected person, a test for a genetic mutation in the RET proto-oncogene can lead to an early diagnosis of medullary thyroid cancer and, as a result, to curative surgery.

Anaplastic thyroid cancer is rare and found in less than 2% of patients with thyroid cancer. It is also the most aggressive cancer type, is often diagnosed at a later stage and hence, the least likely to respond to treatment. The overall prognosis is not favourable.

Why would I need thyroid surgery?

Thyroid surgery offers the advantage of removing the diseased gland for the following conditions:

  • Cancer is diagnosed or strongly suspected
  • Hyperparathyroidism of the parathyroid glands resulting in excess calcium levels
  • Possible cancer on FNAB (follicular neoplasm or atypical findings)
  • Thyroid gland and condition is not responding to medical treatment (typically Graves' disease)
  • Presence of symptoms arising from a goitre (large overgrowth of gland)
  • Nodule(s) that continue to enlarge on surveillance

The indication for thyroid surgery should be clearly explained by your surgeon.

What are the types of thyroid surgery and the cost?

Thyroid surgery can be classified as hemi-thyroidectomy (removal of half the gland) or a total thyroidectomy (complete gland removal). The extent of your surgery should be discussed between you and your surgeon. In the case of thyroid cancer, I generally would recommend a total thyroidectomy and this may also include a lymph node dissection.

The traditional approach for thyroid surgery is an open operation involving a linear incision in the neck. However, newer approaches for thyroid surgery include:

  • Endoscopic thyroidectomy (key-hole surgery)
  • Robot-assisted thyroidectomy (robotic-assisted surgery with use of the Da Vinci surgical system)

The above techniques involve the use of small incisions in the armpit(s) or chest instead of the traditional neck incision. This means the avoidance of a surgical scar in the neck which is a cosmetic incentive for some patients. The cost for these newer surgical approaches is higher because of additional costs for the use of endoscopic and robotic equipment.

Overall, the efficacy and surgical risks remain the same as the traditional approach.

What are the risks of a thyroid surgery?

Thyroid surgery is generally safe in experienced hands. The main complications are:

  • Post-operative bleeding that may lead to respiratory distress
  • Recurrent laryngeal nerve injury that can cause temporary or permanent hoarseness, or even respiratory distress in the event that the nerves on both sides are injured
  • Superior laryngeal nerve injury that can cause temporary or permanent change in the pitch of your voice
  • Parathyroid gland(s) trauma which leads to hypoparathyroidism and hypocalcaemia

Studies have shown that complication rates are lower when performed by a surgeon who has received special training and who performs thyroid surgery on a regular basis.

What can I expect after thyroid surgery?

Patients usually recover very quickly after thyroid surgery. The stay in hospital is usually 1-2 days and you can expect to return to a normal diet and daily activities soon after surgery. Strenuous physical activities that may require neck extension should be avoided. A drain may be placed during the operation and this will be removed before discharge from hospital. Generally, there will not be any sutures to remove.

In the longer term, you may be prescribed thyroid hormone replacement if you have undergone a total thyroidectomy. Patients who have thyroid cancer may be referred for radioactive iodine treatment. The majority of patients who have had a hemithyroidectomy do not require hormone replacement.

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