Surgery for Hyperthyroidism

In this episode of PodMD, specialist general surgeon Dr Michael Ng will be discussing the topic of surgery for hyperthyroidism, including when patients should consider having surgery for hyperthyroidism, the risks and benefits of surgery, the likelihood of recurrence, when to refer and more. This is the second part in a two-part series. The first podcast discussed hyperthyroidism.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Michael Ng

    Dr Michael Ng is a specialist general surgeon with special interests in Endocrine (Thyroid and Parathyroid) surgery and Thoracic surgery.

    Michael completed his medical degree at the University of Melbourne and became a Fellow of the Royal Australasian College of Surgeons in 2012 by completing his postgraduate surgical training via the Austin Hospital, Western Hospital and Royal Melbourne Hospitals. Aside from consulting at the Specialist Centre Ballarat, Michael also consults in Maryborough, Metropolitan Melbourne and is currently in the process of commencing consulting in Melbourne’s North and East.

    Today, we’ll be discussing the topic of Surgery for Hyperthyroidism, which is the second part in a two-part series. The first podcast discussed Hyperthyroidism.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Michael, thanks for talking with us on Pod MD today.

    Michael: Thank you for having me.

    Question 1
    The topic of today’s discussion is Surgery for Hyperthyroidism. Michael, Can you describe for our listeners when patients should have surgery for Hyperthyroidism?

    Michael: So hyperthyroidism is a common disease process, and when you look at the literature it suggests anywhere from a 1 to 5% incidence of disease in the community, so it’s certainly much more prevalent than what many people think of. I would certainly agree with any comment that says that many of cases of hyperthyroidism do not need surgery, but that’s equally true for many disease processes.

    What I will, however, say is, surgery for hyperthyroidism, if conducted with the appropriate reasons is currative and this would, and this could possibly mean that, we don’t have to worry about any long-term effects of hyperthyroidism, particularly on the heart or the bones and it may also prevent certain securely of the causes of that the disease process that is associated with hypothyroidism, such as in particular Graves’ disease.

    Question 2
    What are the common treatment modalities for Hyperthyroidism?

    Michael: So, so the common treatment modalities for hyperthyroidism include observation in mild or subclinical hyperthyroidism. Hyperthyroidism can be controlled with medication. Radioactive fighting has been used in treatment of hyperthyroidism, the downside being that you can go too far and render patients hypothyroid.
    Lastly, surgery, obviously as we are discussing today, can be used for hyperthyroidism and is highly effective in the appropriate clinical scenario.

    Question 3
    Michael, why should patients undergo surgery for hyperthyroidism?

    Michael: Patients should should consider surgery for hyperthyroidism, and it’s not really appropriate for every patient obviously, and it does depend a little bit on the reasons that patients have hyperthyroidism and we can talk particularly about a few scenarios. The first is our patients with Graves’ disease. Now Graves’ disease is an autoimmune condition which not only causes hyperthyroidism but also causes other issues such as problems with vision and we refer to this as graves ophthalmopathy.

    Now the cause of ophthalmopathy in Graves disease actually, really has nothing to do with hyperthyroidism. It’s actually everything to do with fibrous deposition and problems with the grey the receptors on the thyroid. Now controlling the chemical imbalances in Graves’ disease with medication, although that world control hyperthyroidism really does not do anything for controlling worsening eye signs in Graves’ disease. So really the only treatment for worsening I signs in Graves’ disease is surgery or at the moment anyway.

    Patients with goitres have large thyroid glands, which may or may not produce hormones, but certainly patients can be hyperthyroid with goitres. Now treatment again of the hyperthyroidism does not do anything for the structural problems with goitres and thus surgery should be curative for the structural problems, so really two birds, one stone.

    Lastly, a small proportion of patients will have autonomously functioning tumours which produce thyroid hormone and surgery for in this cohort of patients is curative and should not render patients hypothyroid, so basically a curative operation with a little or few requirements for ongoing management.

    Lastly, there are a subset of patients who are refractory to medical management of hypothyroidism and certainly surgery for this is curative and whether the cause of the treatment resistance is behavioural or chemical, surgery for hyperthyroidism is currative in both these situations.

    Question 4
    What are the risks and benefits of surgery?

    Michael: So like any surgical procedure, there are risks with surgery and general risks include the requirement for anaesthetic. You have a scar generally in your neck holder, there are other approaches for thyroid surgery. Risks of bleeding and infection, although the risks are quite low.

    Specific risks of thyroid surgery include risk to the recurrent laryngeal nerves which may cause a hoarse voice. The risk of this permanent risk of this is less than 1%, although you can have temporary damage to the nerves in 20 to 30%.

    There is also a small risk of damage to the Super laryngeal nerve which controls pitch and projection of voice that’s much more commonly injured unfortunately, and risks range again from 10 to 40%. There’s also a risk of injury to the parathyroid glands, which controls the calcium in the body. Permanent damage is again less than 1%.

    And lastly, which is not really a risk, but in the circumstance of a total thyroidectomy, patients will really be required to be on thyroxine replacement for the rest of their life that now that’s generally 1 tablet a day, sometimes more, sometimes less, but generally very very well tolerated. The benefit of surgery is that as I mentioned thyroxine replacement is really very very well tolerated and replacement of a of insufficient thyroid hormone is certainly much easier to manage than an overactive thyroid.

    The risks of the medication are also lesser than treatment medication treatment for hyperthyroidism. Surgery in the appropriate setting should also mean that hyperthyroidism should not really recur.

    Question 5
    What is the likelihood of recurrence of the condition?

    Michael: So nowadays there are really thyroid surgeries, really separated into hemithyroidectomy and total thyroidectomy and again depending on the indication for surgery, but really in the modern day with the appropriately chosen operation, surgery should really be curative for most cases of hyperthyroidism.

    Now I will say that in the historical setting and what I’m talking about is really 30 to 40 years ago, there was a vote to perform subtotal thyroidectomy’s. Now unfortunately there is a significant recurrence rate for that and that is why we are now seeing a small subset of patients who are returning for redue thyroidectomy’s, but really with modern techniques, surgery should be curative and there should really be no or minimal risk of recurrence of hype authorities and post-surgery.

    Question 6
    When should a GP refer?

    Michael: I think GP should be mindful of surgery as a potential management pathway for hyperthyroidism and in particular in particular patients with Goitres, Graves’ disease and in particular Graves’ disease with eye signs. Patients who have nodules in their thyroid in the context of hyperthyroidism and lastly patients who are refractory to medical management of hypothyroidism. Surgery should certainly be considered in all of these settings as surgery is likely to be curative.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on surgery for hyperthyroidism?

    Michael: So firstly, hyperthyroidism is common and surgery should be considered as a management pathway for hyperthyroidism.

    Secondly, there are a number of causes of hyperthyroidism and certain scenarios which would certainly prompt discussion and thought regarding surgery for hyperthyroidism and in particular conditions such as Graves’ disease, Goitres, tumours of or nodules found in the thyroid inn in the context of hyperthyroidism.

    And lastly, patients, particularly who are pregnant or thinking about getting pregnant and who are hyperthyroid should be considered for surgery.
    Lastly, although there are risks with surgery, the risks are generally low and surgery is generally safe for hyperthyroidism and most importantly, it is curative in most cases.

    Thanks for your time and the insights you’ve provided.

    Michael: Thanks for having me

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.