The thyroid gland is an important gland in the endocrine system. Located in the neck, the thyroid gland consists of two lobes, which sit to the right and the left of the trachea, or windpipe. The two lobes are connected by a thyroid tissue that runs across the front of the trachea.
The function of the thyroid is extremely important. It produces a hormone called thyroxine, which, once released into the bloodstream, controls the body's metabolism, determines the rate at which the heart moves, and the movement of the gastrointestinal tract. Thyroxine affects bone loss, as well as how the body makes and uses sugar. The pituitary gland plays an important role, releasing its own hormone called thyroid stimulating hormone, or THS, which stimulates the thyroid to make and release more thyroxine into the body.
Diseases of the Thyroid Gland
Thyroid Nodule: The term 'thyroid nodule' refers to any abnormal growth of thyroid cells into a lump within the thyroid gland. They may occur as single nodules or multiple nodules in the setting of an enlarged thyroid (nontoxic nodular goiter). Thyroid nodules are very common, occurring in up to 30 percent of the population. Though most thyroid nodules are benign, solitary thyroid nodules more than 2cm in size have an increased risk of being malignant.
Most thyroid nodules do not cause symptoms. If symptoms are present however, they may include:
- Pressure in the neck
- Difficulty swallowing
- Difficulty breathing
- Chronic cough
Thyroid Cancer: Thyroid cancer is one of the few cancers where the actual incidence is increasing. It is estimated that 47,000 new cases of thyroid cancer are diagnosed each year. Women over the age of 45 years have experienced the most dramatic increase thyroid cancer. Papillary thyroid cancer is the most common type of thyroid cancer (80 percent). Other types of thyroid cancer include follicular, medullary, anaplastic, and lymphoma.
The most important signs of thyroid cancer are a lump or nodule in the thyroid gland or a chronically hardened lymph gland in the neck area. Although most thyroid cancers do not cause symptoms, if present, they may include:
- Pain in the neck, jaw or ear
- Difficulty swallowing
- Difficulty breathing
- Firm neck lymph nodes
- Chronic cough
- Pressure in the neck
A diagnosis of thyroid cancer is made based upon the results of a fine needle aspiration biopsy of a thyroid nodule or neck lymph node in the neck. Ancillary studies may play a role in the diagnosis and surgical planning including:
- Thyroid ultrasound
- Cross-sectional imaging of the neck: Computerized tomography (CT) scan, Magnetic resonance imaging (MRI)
- Chest X-ray
- Flexible nasolaryngoscopy
- Blood test for medullary thyroid cancer in selected patients- calcitionin
Hyperthyroidism: The term 'hyperthyroidism' refers to any condition in which there is too much thyroid hormone in the body or an overactive thyroid gland. It is a common disorder affecting over two million Americans, most of whom are women. There are several types of hyperthyroidism, each associated with a different particular cause and different options for therapy, which include:
- Graves' disease (also called diffuse toxic goiter) caused by antibodies in the blood which stimulate the thyroid to grow and produce excess hormone
- Toxic multinodular goiter, an enlarged, lumpy thyroid gland in which individual thyroid nodule(s) are responsible for excess thyroid hormone production
- Thyroid adenoma, or a single nodule within the thyroid gland
- Thyroiditis (inflammation of the thyroid), a self-limiting disease possibly caused by an infection and often associated early on with an increased release of thyroid hormone
Thyroid hormone regulates the body's metabolism; accordingly, excess thyroid hormone can cause the following symptoms:
- Nervousness, irritability, anxiety
- Increased perspiration and heat intolerance
- Increased resting heart rate and palpitations
- Hypertension (high blood pressure)
- Hand tremors
- Weight loss or alterations in appetite
- Frequent bowel movements- although diarrhea is uncommon
- Thin, delicate skin, irregular fingernails and fine, brittle hair growth
- Menstrual disturbance (decreased flow and decreased cycles)
- Impaired fertility
- Mental disturbances
- Sleep disturbances (including insomnia)
- Changes in vision, eye irritation, or exophthalmos: significant protrusion of the eyes due to swelling of the tissue behind them causing elevation of the upper eye lids (with Graves' disease)
The diagnosis of hyperthyroidism is made on the basis of findings during a physical exam and confirmed by laboratory tests and complementary functional imaging of the thyroid gland (iodine-uptake scans).
- Thyroid stimulating hormone (TSH)- the single best screening test for hyperthyroidism; most types result in a below average level
- Levels of thyroid hormone (thyroxine, or T4; triiodothyronine, or T3)
- Thyroid-stimulating antibodies that cause Graves' disease
- Radioactive iodine scan to see whether the entire thyroid gland is overactive
- Clues that hyperthyroidism is caused by Graves' disease
- Presence of Graves' eye disease
- Enlarged thyroid or goiter
- History of other family members with thyroid problems (hyperthyroidism or hypothyroidism)
- Family members with other autoimmune disorders (premature gray hair, juvenile diabetes, rheumatoid arthritis, pernicious anemia due to lack of vitamin B12, or vitiligo)
Mount Sinai offers a comprehensive, multidiscplinary approach to caring for patients with thyroid disorders. Our team of thyroid specialist can work patients up from beginning to end in a "one stop" clinical environment where all the patient's thyroid needs can be met. We perform simple and complex operations, such as minimally invasive thyroid surgery, total thyroid excision for cancer, lymph node dissections, and thyroid surgery for benign conditions such as symptomatic goiter. We specialize in minimally invasive techniques including:
- Video-assisted thyroidectomy
- Mini-incision thyroid surgery
- Thyroid surgery under local anesthesia
- Endoscopic transaxillary thyroid surgery
- Robotic-assisted thyroid surgery
- Intraoperative nerve monitoring
Diseases of the Parathyroid Glands
The parathyorid glands are small glands located behind the thyroid gland that regulate calcium and phosphorous levels in the body. These glands produce a hormone call parathyroid hormone (PTH), which acts on bone, the kidneys, and the gastrointestinal tract to regulate calcium heomstasis in the body. Disorders involving the parathyroid system may include benign sporadic or inherited conditions of hyperactivity. Rarely (about one percent) of cases of hyperparathyroidism may be caused by parathyroid cancer.
Hyperparathyroidism is a condition characterized by overproduction of PTH, which invariably leads to an elevation in blood calcium levels by releasing calcium from bone and increasing retention of calcium from the kidneys and intestines. The diagnosis is often made when routine blood testing demonstrates an elevated blood calcium level. In other cases, the patient may present with symptoms which leads the astute clinician to evaluate the patient for a parathyroid disorder. Twenty-four hour urine collections for calcium and bone density studies may also play a role in the diagnosis.
Common symptoms of hyperparathyroidism include:
- Loss of appetite
- Frequent urination
- Muscle weakness
- Joint pain
- Nausea and vomiting
- Trouble with concentration and/or memory loss
Medical conditions that may be caused by overactive parathyroid glands include:
- Kidney stones
- Osteopenia and osteoporosis
- Unintentional weight loss
- Pancreatitis or ulcers
- Blood in the urine
- Glucose intolerance and diabetes
Targeted or minimally invasive parathyroid surgery is the preferred approach at Mount Sinai. To plan for a minimally invasive approach, preoperative localizing studies are obtained in all patients so that the surgical team can have as much anatomical information about abnormal parathyroid gland location as possible prior to surgery. You will undergo an office-based parathyroid ultrasound during your consultation. Other localizing studies offered by our program include:
- Thin cut parathyroid CT scanning
- Sestamibi scanning with SPECT
- Selective venous sampling for PTH
Once the localizing studies have been completed, your surgeon will have a "road map" in place on how best to conduct your operation in a minimally invasive manner. Our philosophy is to perform the least amount of surgery possible to cure you of your condition.
Intraoperative PTH monitoring, an intraoperative point of care test that allows your surgeon to assess the completeness of surgery prior to the patient leaving the operating room, is utilized in every parathyroid operation at Mount Sinai. Your surgeon will use a combination of preoperative localizing studies, intraoperative findings and intraoperative PTH levels to determine the extent of surgery. However, 90 percent or more cases of hyperparathyroidism are caused by a solitary parathyroid adenoma. We have considerable expertise in performing parathyroid operations under local anesthesia using the latest minimally invasive techniques. Minimally invasive parathyroid operations performed in our program include the following:
- Mini incision, targeted parathyroidectomy under local anesthesia (very small incision placed in a natural skin crease)
- Video endoscopic parathyroidectomy (very small incision lower in the neck)
- Remote access endoscopic parathyroidectomy (incision in axilla or anterior chest wall, i.e. no scar on the neck)
- Bilateral neck exploration under local anesthesia
- Complex revisional and reoperative parathyroid surgery (for patients who have failed parathyroid surgery in the past)
- Parathyroid surgery with intraoperative nerve monitoring
- Mediastinal or ectopic parathyroid surgery (for parathyroid glands located in the chest)
- Familial parathyroid surgery (hereditary forms of hyperparathyroidism, often in children)
Disorders of the Adrenal Glands
There are two adrenal glands, each sitting on top of the kidneys. They produce a host of hormones, including cortisol, aldosterone, and the sex steroids estrogen and testosterone. Cortisol helps the body to respond to stress while aldosterone controls the balance of electrolytes including sodium nd potassium in the body. The adrenal glands also produce catecholamines called epinephrine and norepinephrine. Together these hormones contribute to the "flight or fight" response to rigorous activity and stress. These glands are redundant organs such that the removal of one gland does not interfere with normal production and function of hormones from the remaining gland.
Disorders of the adrenal glands are often the result of over production of the various hormones described above. Medications can sometimes control the excess hormone release, but most often surgery is the only cure.
These tumors produce too much catecholamines resulting in dangerously high blood pressure which can often lead to stroke, heart attacks, and even death if left untreated. Removal of these tumors can be life saving and prevent devastating complications. Althought they can be difficult to diagnose, patients often present with flushing, palpitations, and high blood pressure. These tumors can have malignant potential and patients require lifelong monitoring once diagnoses and treated.
These tumors produce too much aldosterone, often resulting in high blood pressure. Patients are usually on several medications with increasing doses to control their blood pressure. Patients are frequently found to have low potassium because aldosterone directly affects our salt and water balance. As a result, patients can complain of muscle cramps and weakness. These tumors are benign and once removed, can result in significant improvement in blood pressure. These tumors can be small and often adrenal venous sampling is required to help determine the side of the aldosteronoma.
Cushing's dyndrome is an over production of cortisol, the body's primary intrinsic steroid. This can result in a host of problems. Prolonged exposure to cortisol can result in weight gain, acne, thinning hair, and easy bruising. Patients can even suffer from diabetes, increased susceptibility to infection, and brittle bones. Over production of cortisol can be associated with both benign and malignant conditions of the adrenal gland.
Patients are often found to have incidental growths on their adrenal glands from imaging studies done for other reasons. These incidentalomas are most often found on CT and MRI. The majority of these growths have no clinical significance and are truly incidental. However, it is important that both overproduction of hormones and the possibility of malignancy are excluded. Surgery is only performed if they are found to be producing excess hormone or if they reach a certain size, often 4cm or greater.
Cancer of the adrenal gland is uncommon. These cancers can produce a variety of hormones and often result in the rapid onset of symptoms. Surgery is often the only option for treatment and possible cure. These tumors can be large at the time of diagnosis and require open surgery for removal.
Surgery for Adrenal Cancer
Most adrenal tumors can be removed using minimally invasive techniques. We offer a wide variety of approaches that are tailored to the individual needs of the patient in order maximize patient outcomes. These techniques include:
- Laparoscopic transabdominal approach where small incisions are made in the abdomen to access the adrenal glands.
- Laparoscopic retroperitoneal approach where small incisions are made on the back to gain access to the adrenals
- Single incision laparoscopic surgery (SILS) where a single incision is made at the belly button to perform the surgery
The hormones produced by the adrenal gland are essential to normal function, but because the adrenal glands are redundant organs, patients can function with one gland. However, some conditions may require removal of both glands. We offer adrenal sparing surgery to patients who would normally require removal of both glands. For patients who do not meet criteria for adrenal sparing surgery, we offer adrenal autotransplantation in the hopes of avoiding lifelong medication.
The Aufses Division of General Surgery
5 East 98th Street, 14th Floor
New York, NY 10029