Producing Quality Outcomes in Thyroid Surgery

April 8, 2010

Up to 50 percent of Americans will be diagnosed with a thyroid nodule at some time in their lives, found either by palpation or incidentally on a radiographic imaging study. About 4 to 7 percent of these nodules will be malignant, and the remainder will be benign. For all thyroid diagnoses, the Department of Otorhinolaryngology-Head and Neck Surgery at The University of Texas Medical School at Houston and Memorial Hermann-Texas Medical Center offers comprehensive care and surgical expertise in a single location.

“Thyroid surgery carries inherent risks, including the possibility of injury to the recurrent laryngeal nerve, which can lead to a hoarse voice, and injury to the parathyroid gland, which can lead to problems with calcium metabolism,” says Etan Weinstock, MD, a board-certified otorhinolaryngologist and assistant professor in the Department of Otorhinolaryngology-Head and Neck Surgery at the UT Medical School. “It’s a complex anatomical area, with only a small amount of real estate in which to work. The key to preserving the voice and parathyroid glands is good surgical technique.”

The workup of a nodule or enlarged thyroid begins with ultrasound. “Our clinic is equipped with an advanced, highly sensitive ultrasound machine with the capability to do ultrasound-guided needle biopsy on the spot,” says Ron Karni, MD, a board-certified otorhinolaryngologist and assistant professor at the UT Medical School. “Once we get the results of the biopsy, we can discuss all treatment options up front and develop a comprehensive care plan without the need for further investigation or appointments. Our one-stop approach offers patients excellent service with convenience.”

While most thyroid cancers are confined to the gland, an important component of the preoperative workup of a suspicious thyroid nodule is the ultrasound evaluation of other areas of the neck where cancer can spread into lymph nodes. Some thyroid cancers can also cause damage to surrounding tissues, including the trachea, larynx, and esophagus. In these patients, voice changes, shortness of breath, or trouble swallowing can be the first sign of a thyroid nodule. For this reason, patients with a suspicious thyroid nodule should be evaluated by a dedicated head and neck surgeon who performs thyroidectomies on a regular basis.

Patients with asymptomatic benign disease are followed with serial ultrasound studies and physical examinations. For many patients with malignancies, survival rates are high. “Data are available following patients post surgery for many years after resection,” Dr. Weinstock said. “The most important thing in the event of a malignancy is to remove all of the disease.”

“Areas where tissue may be left behind include the recurrent laryngeal nerve; Berry’s ligament, which connects the thyroid to the trachea; and the Tubercle of Zuckerkandl, an extension of the thyroid gland on the posterior side of each lobe. Tissue left in the thyroid bed can lead to recurrence of cancer in this area, adjacent to the recurrent laryngeal nerve, which makes repeat surgery even more complicated, with a higher risk of injury to the parathyroids and nerve,” Dr. Weinstock said. “Much of our practice involves re-operation for recurrent and persistent disease. Sometimes thyroid cancers may involve the trachea, which requires removal of a portion of it and reconstruction. A surgeon who performs thyroid surgery for cancer should be able to deal with tracheal invasion and neck dissection on the first go-round. A comprehensive clean-out improves the chance of success.”

The ORL department uses a multidisciplinary approach, working closely with endocrinologists and radiation oncologists in cases that involve cancer. “We discuss complex cases in a monthly conference and also rely on our endocrinologists to help guide postoperative treatment with radiation,” said Dr. Karni. “Typically, after a thyroid cancer is surgically removed, patients will be followed with serial blood tests and an iodine whole body scan. A thyroid uptake scan can determine whether there’s any cancer remaining, and treatment with radioactive iodine will destroy the remaining cells.”

The OR at Memorial Hermann-TMC is specially equipped for recurrent laryngeal nerve monitoring. “We monitor the integrity of the nerve through the entire operation, which gives us another level of assurance and helps ensure quality outcomes,” Dr. Karni said.

Both surgeons also do minimally invasive parathyroidectomy on an outpatient basis, using ultrasound and intraoperative parathyroid hormone (PTH) monitoring to confirm the success of the procedure.

In the past six months, the two physicians have developed a large thyroid practice, ensuring a high level of expertise. “The most important part of thyroid surgery, even when it’s routine, is to anticipate unexpected findings and do a good job of responding to them,” Dr. Weinstock said. “Those who use their voices in their jobs—CEOs, teachers, and singers, for instance—tend to find their way to ENTs because they know we play close attention to the recurrent laryngeal nerve and voice box.”

For more information on thyroid and parathyroid surgery, please visit

To refer a patient to either Dr. Karni or Dr. Weinstock, please call 713-486-5000 or visit

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