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The Thyroid Gland
WHAT IS THE THYROID?
The thyroid is controlled by the pituitary gland.
The thyroid is a butterfly shaped gland located in the lower neck, just below your voice box (larynx).
It produces two thyroid hormones, Thyroxine, (T4) and triiodothyronine (T3). These hormones regulate how the body uses energy (controls your metabolism).
The thyroid, like many endocrine glands in your body, is controlled by the pituitary gland. The Pituitary gland is a pea-sized gland at the base of your brain that produces thyroid-stimulating hormone (TSH), which tells the thyroid how much hormone to make based on your bodies metabolic requirements.
Diseases of over or underactivity of the thyroid can be treated with medication, surgical approaches or the use of radioactive iodine as appropriate in accordance with individual patient wishes.
THYROID NODULES
Small growths within the thyroid are commonly referred to as nodules. These are often discovered accidentally during imaging procedures performed for unrelated reasons. Larger nodules are sometimes noted by patients by the sensation of a lump, pressure, difficulty swallowing or voice changes. Unless there is a family history of thyroid cancer, or known x ray or radiation exposure to the head and neck in the past, the risk of cancer in these growths is less than ten percent. To evaluate this risk, a procedure called FNA (fine needle aspiration) is performed in the office using ultrasound guidance. Local anesthetic is sometimes used, but not always required as the procedure uses very small needles.
A thyroidologist (endocrinologist with specific interest in thyroid disease) is the most skilled person to perform ultrasound-guided fine needle biopsy. Ideally the thyroidologist performing this procedure will have undergone additional training and certification in endocrine and neck ultrasound and list the letters ECNU after his or her name. (endocrine certification in neck ultrasound) Using ultrasound guidance, a needle is placed within the thyroid nodule under evaluation and a cell sample is aspirated for evaluation of possible cancer. At the same time imaging is performed, evaluation of neighboring lymph nodes in the neck as well as evaluation of possible parathyroid gland abnormalities is performed. In the event surgery is necessary, this additional information is crucial to guide surgical treatment and minimize the risk of recurrent cancer in the future. In some circumstances cellular examination of the cells obtained does not yield a clear result of benign vs malignant. In this circumstance, genetic evaluation of the material obtained at biopsy is performed. This technique can refine the relative risk of cancer in these indeterminate cases and help guide treatment decisions regarding possible surgery.
In the past, individuals who had indeterminate results from their nodule biopsies routinely were referred for surgery, and only 20 percent of these patients were found to have cancer. Since 2011, the availability of additional genetic testing has helped significantly reduce the number of unnecessary surgeries.
In the event that a nodule is found to contain cancer, referral to a skilled thyroid or head and neck surgeon who performs thyroid surgery regularly is highly important. Thyroidologists develop close working relationships with such surgeons, and guide their patients to individual surgeons likely to obtain the best possible outcomes.
PARATHYROID DISEASE
There are 4 parathyroid glands. They are located behind and adjacent to the thyroid 80% of the time. Parathyroid glands make a hormone called PTH (parathyroid hormone) which controls calcium metabolism. Occasionally these glands can become autonomous (make excessive amounts of hormone) and develop into tiny tumors or adenomas. These adenomas are rarely cancer, (less than 1% of the time). However, because they make excessive parathyroid hormone there is an uncontrolled hormonal signal that goes to your bones causing them to release calcium. As a result, calcium levels in your blood will rise. A minimal elevation of calcium may be asymptomatic, but more severe abnormalities of calcium levels can cause symptoms of irritability, depression, joint and muscle pains, numbness in the arms and legs, abdominal and muscle cramps and pain. If high blood calcium is long standing, or severe, it can cause cardiac problems and osteoporosis.
This disease can be surgically cured, once the tumor is localized. The adenoma can be found with high-frequency ultrasound in the hands of an experienced thyroidologist, preferably with ECNU certification, and typically localized in approximately 85% of cases. If there is uncertainty about the location or appearance of an “atypical” parathyroid adenoma, ultrasound guided aspiration of a suspect lesion can be performed, again by an experienced ECNU certified thyroidologist, to measure the presence and level of parathyroid hormone within the lesion and confirm a correct diagnosis and localization. Nuclear sestamibi scans are useful as well but may only be 50% accurate. Localizing studies are vitally important to the surgeon to make surgical treatment easier and less complicated for the patient.
If surgical treatment is not desired or contra-indicated, medical therapy of the condition is available in many cases.
Underactivity of the parathyroid glands can occur as a result of inadvertent damage during thyroid or neck surgical procedures, or as a result of other medical conditions causing loss of function. This condition can be treated successfully medically with the use of calcium supplements, synthetic vitamin D analog compounds and or the use of parathyroid hormone replacement.
THYROID ULTRASOUND
Real Time endocrine neck ultrasound
Diagnostic Ultrasound: Ultrasound utilizes harmless sound waves to produce images of the thyroid. Ultrasound exams are done in “real-time” by Dr. Michael during an office visit. The procedure is simple and painless. The patient lies flat with the neck slightly extended, transducer gel is placed on the neck and the ultrasound probe is moved over the gland and surrounding lymph nodes. By having an expert in thyroid ultrasound perform your thyroid images you will receive immediate results, a plan on how to treat your thyroid condition and biopsy at the same time if necessary and feasible. The technique is particularly useful in the following situations:
- Pre-operative Lymph node mapping
- Post-operative Thyroid cancer follow-up lymph node mapping
- Parathyroid adenomas (small tumors affecting blood calcium levels)
PERCUTANEOUS ETHANOL INJECTION:
Percutaneous Ethanol Injection: (PEI)
The injection of alcohol into thyroid cysts has been a successful alternative to prevent recurrence of thyroid cysts and an alternative to surgery for recurrent cysts in many cases.
Alcohol injections have also been used as an alternative to surgery for recurrent or residual cancer in lymph nodes in the Neck. The method is effective in killing lymph nodes with cancer and preventing continued growth in many cases and can often reduce the need for additional surgery.
Dr. Michael uses ultrasound guided ethanol injections (PEI), to treat thyroid nodules that are cystic, often eliminating the need for surgery. PEI can also be used to eradicate malignant lymph nodes in selected patients when surgery is undesired or not feasible.
