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Thyroid & Parathyroid Department

Thyroid Nodules

The thyroid gland is a butterfly-shaped gland located in the low anterior neck. It produces thyroid hormone, which helps to regulate the body’s metabolism. The functional capacity of the thyroid is measured by blood tests. Excessive production of thyroid hormone (hyperthyroidism) can cause palpitations, tremors, weight loss, and heat intolerance. Conversely, an under-active thyroid gland (hypothyroidism) can result in fatigue, weight gain, and cold intolerance.

A thyroid nodule is a growth in the thyroid gland. Thyroid nodules are extremely common, and may be solitary or multiple (multinodular goiter). It is estimated that approximately 5-10% of the population has a palpable thyroid nodule, and between 30-85% have tiny thyroid nodules that are too small to palpate.

In most people with thyroid nodules, the gland produces a normal level of thyroid hormone (euthyroid state). Statistically, approximately 5-10% of nodules are cancerous. Some patients have findings that increase the risk of Thyroid and Parathyroid gland malignancy. A history of exposure to ionizing radiation to the neck is a risk factor, as is a family history of thyroid cancer. Hoarseness, lymph node enlargement, and fixation of the nodule can also increase the risk of malignancy. Fortunately, the vast majority of thyroid cancers are treatable and carry an excellent prognosis.

Thyroid Photo

Most thyroid nodules do not require surgery. The primary indications for thyroidectomy are suspicion of cancer, large size, substernal location (nodules that grow inferiorly into the chest), or symptoms (throat pressure, difficulty swallowing, respiratory distress, or cosmetic disfigurement from a visible goiter). Over-functioning nodules are sometimes best treated by surgery, as well.

The most important tests to evaluate a thyroid nodule are a TSH level (a blood test that evaluates the function of the gland) and a fine needle aspiration (FNA) biopsy to evaluate the nodule for malignancy. Although FNA is highly accurate, it is not 100% accurate in making a diagnosis. FNA is usually performed in our office, but for smaller nodules and others that are difficult to palpate, the biopsy is done by the radiologists under ultrasound guidance. There are some types of thyroid nodules (follicular tumors) where FNA cannot distinguish benign from malignant nodules- these nodules are usually best managed by thyroidectomy.

Endoscopic Thyroidectomy

Many patients with diseased thyroids have safe, effective treatment options. At the Northwest Thyroid and Parathyroid Center, Dr. Shatul Parikh offers certain patients the option of an endoscopic thyroidectomy. This procedure offers thyroid surgery in a way that can dramatically reduce the size of their neck incisions and speed recovery.

In endoscopic thyroidectomy Dr. Parikh works through an incision about one-third of the normal incision. Dr. Parikh is the only surgeon in the metro-Atlanta area that provides this option to his patients.

With the use of video cameras and slender instruments during surgery, Dr. Parikh is able to gain access to the thyroid gland by pushing muscles aside rather than cut through them. Not only does this allow for a significantly smaller incision, but decreased post-operative pain and risk of bleeding. Video monitoring equipment attached to the endoscope magnifies the anatomy about 20 times allowing for safe and effective removal of the diseased thyroid gland. The average time for surgery for endoscopic thyroidectomy is 45 minutes, and most patients who undergo this procedure go home within a few hours of the surgery and return to work within 3-5 days after surgery.

Conventional Thyroidectomy

A thyroidectomy is an operation that removes part or all of the thyroid gland. The most common indications for this operation are suspicion of malignancy, large nodules, substernal nodules (nodules that grow inferiorly into the chest), and nodules that cause symptoms (throat pressure, difficulty swallowing or breathing, or nodules so large they cause cosmetic disfigurement). Occasionally hyperthyroidism is treated surgically. The three most common types of thyroidectomy are total, subtotal (removes most of the gland), and hemi (removes one lobe of the thyroid). The extent of the operation depends upon the nature and extent of the pathology.

The patient is usually admitted on the morning of surgery, and the operation is done under general anesthesia. It generally takes about 1- 2 hours to perform, and is done through a horizontal incision (usually placed within a skin crease) in the low, anterior neck. Recovery is usually rapid- most patients are ambulatory the day of surgery, and most experience little or no pain after the first 24 hours. Most return to work with no restrictions within 1 week of surgery.

Parathyroid

What are the parathyroid glands?Thyroid Photo

The parathyroid glands are four pea-sized glands located on the thyroid gland in the neck. Occasionally, a person is born with one or more of the parathyroid glands embedded in the thyroid, in the thymus, or located elsewhere around this area. In most such cases, however, the glands function normally.

Though their names are similar, the thyroid and parathyroid glands are entirely different glands, each producing distinct hormones with specific functions. The parathyroid glands secrete PTH, a substance that helps maintain the correct balance of calcium and phosphorus in the body. PTH regulates the level of calcium in the blood, release of calcium from bone, absorption of calcium in the intestine, and excretion of calcium in the urine.

When the level of calcium in the blood falls too low, the parathyroid glands secrete just enough PTH to restore the blood calcium level.

What is hyperparathyroidism?

If the parathyroid glands secrete too much hormone, as happens in primary hyperparathyroidism, the balance is disrupted: blood calcium rises. This condition of excessive calcium in the blood, called hypercalcemia, is what usually signals the doctor that something may be wrong with the parathyroid glands. In 85 percent of people with primary hyperparathyroidism, a benign tumor called an adenoma has formed on one of the parathyroid glands, causing it to become overactive. Benign tumors are noncancerous. In most other cases, the excess hormone comes from two or more enlarged parathyroid glands, a condition called hyperplasia. Very rarely, hyperparathyroidism is caused by cancer of a parathyroid gland.

This excess PTH triggers the release of too much calcium into the bloodstream. The bones may lose calcium, and too much calcium may be absorbed from food. The levels of calcium may increase in the urine, causing kidney stones. PTH also lowers blood phosphorus levels by increasing excretion of phosphorus in the urine.

Parathyroid Surgery – Parathyroidectomy

Background of Parathyroid SurgeryThyroid Photo

We receive many patient inquiries regarding minimally invasive parathyroidectomy (MIP). Conventional open (4-gland) parathyroid exploration was considered the standard of care for treatment of primary hyperparathyroidism until the 1990s, when improvements in imaging techniques made limited (less than 4-gland) exploration feasible.

Now, many expert centers worldwide have adopted limited parathyroid exploration as their preferred surgical approach.

The underlying principle behind limited exploration is the fact that approximately 90% of individuals with primary hyperparathyroidism have only one diseased gland. The challenge is then to find the culprit gland successfully prior to operation. The essential imaging techniques used to localize solitary parathyroid adenomas are parathyroid sestamibi (a nuclear medicine test) and ultrasound.

Anesthesia – Parathyroid Surgery

Anesthetic care is individualized to the patient, with almost all patients given their choice of either general anesthesia (going completely to sleep) or light sedation. Both methods are safe and comfortable, and no patients have experienced any recollection or awareness of the procedure afterwards.

In all cases, the area of the incision is pre-treated with a local anesthetic (numbing medicine similar to what you might receive at a dentist’s office) that lasts approximately 6 hours. After surgery, our patients typically awaken with little or no pain, and the majority never require any pain medication after surgery. Our patients are routinely given anti-nausea medications during the operation to minimize nausea in the post-operative period.

Surgical Technique – Parathyroid Surgery

Dr. Parikh has had direct, hands-on experience with almost all of the minimally invasive parathyroid techniques. Research studies suggest that the various techniques all offer a similarly high success rate (>98%) and low complication rate (about 1%) when performed by experienced surgeons. At Northwest Thyroid and Parathyroid Center the preferred method of treatment is a directed parathyroidectomy of the offending gland that has been determined pre-operatively by nuclear medicine(Sestamibi) localization or high-resolution ultrasound.

Dr. Parikh does not routinely use intraoperative radio-guidance (gamma probe). His high success rates, which are equivalent to those published by other high-volume specialty centers, are based on experience, accurate localization studies, thorough knowledge of the anatomy and embryology, and sound surgical technique.

Length of Operation – Parathyroid Surgery

The average operating time is 30 minutes, with 90% of operations being completed in less than 45 minutes. Though Dr. Parikh values efficiency, he does not necessarily equate fast surgery with good surgery. Patient safety is our utmost priority. Ultimately, our operations take as long as necessary to complete in a safe and meticulous manner.

Surgeon-performed Ultrasound

Thyroid Photo

High-resolution ultrasound of the neck is increasingly acknowledged to be the most sensitive anatomic imaging modality for the thyroid and parathyroids.

New patients undergo ultrasound examination during their first clinic visit. Just before surgery is commenced, ultrasound is again used to position the incision directly over the diseased gland.

Intra-operative Parathyroid Hormone (IOPTH) Monitoring

We do use IOPTH monitoring as evidence of biochemical cure during surgery. We utilize the very latest rapid IOPTH assay platform, which returns results within 8 minutes. Four blood samples are drawn during the operation. Because parathyroid hormone is very short-lived in the bloodstream (half life about 3.5 minutes), hormone levels are observed to fall >50% or into the normal range within 10 minutes of removing the diseased parathyroid gland.

Duration of Hospitalization and Recovery Time

Most patients are observed for 4 hours before being discharged the same day, though the option to stay overnight is always available. Patients are able to return to normal light activities right away. We advise that strenuous activities, such as heavy lifting or sports, be avoided for 5 days after surgery. Most patients are physically able to return to work the day after surgery, though most choose to take a few days off to recover at their own pace. Dr. Parikh has performed this surgery on people from all over the country and has even traveled to Peru and India to teach the minimally invasive technique to other surgeons.

About the Surgeon

Shatul L. Parikh M.D. is Board Certified in Otolaryngology Head and Neck Surgery. His practice almost exclusively involves the surgical and medical management of thyroid and parathyroid disease. He has traveled to Peru, India and the United Arab Emirates to teach his techniques to other surgeons. He frequently is referred patients who have previously failed surgical therapy and can often accomplish a surgical cure in these refractory patients.

How to Make an Appointment

Dr. Parikh is frequently asked to review cases from outside the Atlanta area. He would be happy to review your case and make recommendations to you via email or telephone. With a large international airport nearby, travel to Dr. Parikh’s Parathyroid clinic in the Metro Atlanta area is quite convenient. His office is twenty-five minutes from the Airport by car. Often, he can review your lab-work and imaging studies by email or mail, and the only travel necessary is for the surgical procedure. Please contact the office at 770-427-0368 to set up a phone or email consultation or to see Dr. Parikh in person if you live in the metro-Atlanta area.

Ethanol Ablation of Thyroid Cysts

Dr. Parikh at Northwest Thyroid and Parathyroid Center is one of a few physicians in the country that will treat large cystic nodules with Ethanol Ablation. Ethanol, which is similar to drinking alcohol, has been shown in numerous studies to permanently reduce the size of cystic nodules. Europeans have been treating thyroid nodules with ethanol for decades, and this technology has recently been used in the United States. Dr. Parikh can inject a small amount of ethanol, under ultrasound guidance, into cystic nodules. Studies have shown dramatic reduction in size with as few as two injections. Please contact the Northwest Thyroid and Parathyroid center at 770-427-0368 to see if this non-surgical treatment for thyroid cysts is right for you.

In Office Ultrasound

Thyroid Photo

Northwest ENT and Allergy Center offers in office diagnostic ultrasound with ultrasound guided needle biopsy. We offer the powerful LOGIQ® e system with advanced image quality or functionality, making it possible to get clear, real-time images at the point of care – wherever that point may be.

Fully Capable the LOGIQ e features advanced technology – packed into an uncompromising, laptop-sized package. Its clear image quality helps our physicians make accurate assessments, and gives you a heightened level of diagnostic confidence.