Thyroidectomy (Thyroid Surgery) Risks

Thyroid removal (either total or only one side) is a common surgery performed by general surgeons as well as ENTs for thyroid cancer or masses suspicious for cancer.

Though I no longer perform this surgery, I often get asked for my opinion regarding this surgery. Rationale for why surgery should be done or not, I leave to others as it would literally take a textbook, especially given the controversy regarding when to observe and when to surgically remove. Back when I WAS performing thyroidectomy, I should state my bias was towards removal... and belief that a needle biopsy is not 100% accurate. Indeed, in certain situations, a needle biopsy (FNA) is at best no better than flip of a coin whether cancer is present (it is wrong 50% of the time!).

In any case, there are several risks involved when this surgery is performed. Other than the typical risks common to all surgeries like infection and the ho-hum bleeding, there are several unique risks specific to thyroid surgery. Let's go over each one:

Windpipe
Given the thyroid is located over the windpipe, the surgeon may accidentally (or deliberately if thyroid cancer is invading the windpipe's wall) enter into the airway. Why may this be a problem? Well, it may cause air to leak into the neck causing it to suddenly swell up and potentially lead to a pneumothorax (collapsed lung) if severe enough. The scary thing is that it could potentially occur days after the surgery though if it is going to happen, it usually occurs within hours after surgery.

Bleeding
Bleeding is ALWAYS a risk of surgery causing a hematoma to form. What makes this particular complication especially concerning is that it often occurs DAYS after surgery. Even more worrisome is that it could lead to death as the hematoma formation can cause significant swelling with resulting airway compression (remember that the thyroid is located over the windpipe). This particular complication unfortunately occurs not uncommonly... and often leads the patient to obtain emergency care in the local ER by a local surgeon to drain/remove the hematoma and stop the bleeding even if the surgery was done by surgeon located an hour or more away. A tracheostomy (a hole in the neck to the windpipe) may need to be performed at this time as well.

Recurrent Laryngeal Nerve Damage
The nerve that allows you to talk is called the recurrent laryngeal nerve. This nerve is RIGHT NEXT to your thyroid gland. As such, it can be damaged or cut resulting in a very breathy sounding voice. Oftentimes, it is temporary. Rarely, BOTH nerves can get cut if undergoing total thyroidectomy causing stridor or airway problems mandating a tracheostomy.

In the event that a patient suffers a vocal cord paralysis from recurrent laryngeal nerve damage, it can be corrected surgically resulting in an almost normal sounding voice. If BOTH vocal cords are paralyzed... well... breathing and talking will be a problem and options are quite limited if this unfortunate complication occurs.

Superior Laryngeal Nerve Damage
With this type of nerve damage, you can talk just fine... but you lose your upper range and falsetto.

Parathyroid Gland Loss

The parathyroid glands are located behind the thyroid gland in the 4 corners as depicted by the golden nuggets seen in the diagram to the right. These glands are very important regulating the calcium levels in the blood. In the devastating event that all 4 parathyroid glands get damaged or removed (as might occur during total or completion thyroidectomy), the patient loses the ability to maintain calcium levels in the blood resulting in cardiac and neurologic problems that could lead to death if not immediately addressed. Even if the parathyroid glands are preserved, if the blood supply to the 4 glands get cut off or damaged by the thyroid surgery, blood calcium levels may deteriorate.

Summary
Thyroid surgery has risks and should be performed by a well-qualified surgeon. However, keep in mind that the best person to take care of you should you experience any surgical complication is the surgeon who actually did the surgery (one of many factors to take into consideration when considering having the surgery done far from home).

References:
Mediastinal emphysema and pneumothorax following thyroidectomy. The Journal of Clinical Endocrinology Vol. 9, No. 10 987-998 doi:10.1210/jcem-9-10-987

Complications of Thyroid Surgery. EMedicine

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ENT Problem at the Biblical Wall of Jericho

Many people may be aware of the Sunday School story regarding the Wall of Jericho in the Bible. In this story, seven priests blew 7 trumpets of rams' horns resulting in the collapse of the wall of Jericho (Joshua 6:4-5) allowing the Israelites to conquer the city.

"4: And seven priests shall bear before the ark seven trumpets of rams' horns: and the seventh day ye shall compass the city seven times, and the priests shall blow with the trumpets. 5: And it shall come to pass, that when they make a long blast with the ram's horn, and when ye hear the sound of the trumpet, all the people shall shout with a great shout; and the wall of the city shall fall down flat, and the people shall ascend up every man straight before him."

Now... from an ENT standpoint, I can imagine the mayhem this weaponized horn sound must have caused not only to the wall of Jericho, but also to the surrounding soldiers and people.

Back than, city walls were constructed of brick and mud. It is entirely possible that a loud enough sound can certainly cause the collapse of this wall, but it would have to be very loud... at least 180dB (decibels) loud.
 
Just how loud is this sound? Well, a motorcycle is 100dB; a jet engine is 140dB. From a human ear standpoint, ear pain starts at 125dB. Permanent hearing loss due to ear tissue death occurs at 180dB... but before ear tissue death occurs, the eardrums will rupture at 160db.
 
Even if the Israelites wore ear plugs and ear muffs (like airplane workers do), it only decreases the sound intensity by 15-45dB. So, the rams' horn sound blast at 180dB would still result in the Israelite soldiers being exposed to 140dB of sound with its attendant ear pain and temporary threshold shift (temporary hearing loss).
 
So... though not expressly reported in the Bible, I'm sure not only did God supply the device causing the fall of Jericho's walls... but also appropriate ear & hearing protection for Joshua and his army.
 
In fact... even if the walls did not fall, its inhabitants certainly would be deaf from ruptured eardrums and hearing nerve death. And if Jericho's army is unable to talk and hear each other, its fighting effectiveness would be pretty much severely compromised.
 
Of note... the United States military utilizes weaponized acoustic devices that produce only 155dB.
 
Lung rupture and presumably embolism due to air blast occur at 200 decibels which can lead to death.
 
If you want to read more about acoustic weapons, click here which will probably provide more info than you ever wanted on this subject.

Of note, I can't take full credit for the idea of this blog post which is based on an episode on NPR Radiolab. The NPR Radiolab episode purely focused on the acoustic physics whereas I've taken the extra step of how it can cause health problems.

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How Does Coblation Work?

Coblation is a unique technology that cuts and stops bleeding simultaneously using radiofrequency plasma technology. This technology is used in many ENT procedures including turbinate reduction, tonsillectomy, adenoidectomy, respiratory papilloma excision, cryptolysis, etc.

The benefit of this technology over cauterization which does the same thing is that coblation occurs near room temperature opposed to cauterization which may produce temperatures exceeding 400 degrees celsius. Such high temperatures with cauterization can cause thermal damage to surrounding normal tissue leading to prolonged healing and swelling.

Watch a video of coblation being used for tonsillectomy and turbinate reduction.

Here's a video I shot using coblation on a piece of chicken to illustrate closely what is happening.

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Pacemaker To Cure Obstructive Sleep Apnea (OSA)?

The Huffington Post on Dec 27, 2010 published a story about a potential new treatment whose goal is  obstructive sleep apnea cure (OSA) cure using a pacemaker made by Inspire Medical... for the tongue. The New York Times also published a similar story more recently about the same device on 1/8/2014.

The device works by stimulating the nerve going to the tongue (hypoglossal nerve) to contract with every breath a person takes while sleeping.

Why would this help? In some patients with severe obstructive sleep apnea, the tongue falls backward against the throat's back wall (tongue prolapse) causing airway obstruction. By stimulating the tongue's nerve, the tongue is stimulated to move forward when a patient takes a breath preventing obstruction.

Of course, this treatment works ONLY if the obstruction is due to tongue prolapse.

There are other treatments that also accomplish the same thing including:

• Base of tongue coblation/reduction
• Geniohyoid advancement
• Repose procedure
• Oral appliance

At least in our office, we only offer the base of tongue reduction to address tongue prolapse that may lead to obstructive sleep apnea.

This pacemaker for the tongue is currently experimental and not available for the general public yet.

Sources:
Sleep Apnea: Experiments Test If Implant Can Block Sleep Problem. Huffington Post 12/27/10

For Sleep Apnea Patients, a Possible Alternative to Masks. NYT 1/8/14

Reference:
Upper-Airway Stimulation for Obstructive Sleep Apnea. New England Journal of Medicine. January 9, 2014DOI: 10.1056/NEJMoa1308659

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Santa Claus, A Sick Patient Needing Medical Care

ENT Journal published in December 2003, a humorous paper on Santa Claus as a patient with numerous medical problems. Given it is Christmas Eve, it is probably worth revisiting the article which lists among his many medical problems:

• Allergies to woodwork (sawdust and varnish) and materials used in preparing teddy bears, dolls, and other gilts.
• Asthma exacerbated by reindeer exposure as well as the hay and straw in the stable which makes his nose run
• His symptoms get worse when he leaves the North Pole where there is no pollen to regions of the Earth where vegetation and pollen are plentiful, especially in the Southern Hemisphere where it is summer.
• Going down chimney's irritates the eyes and his nose resulting in sneezing fits. Probably carcinogenic as well.
• Santa is considerably overweight, and his cheeks appear quite ruddy suggesting high blood pressure.
• Probably has type 2 diabetes exacerbated by milk and cookies left for him in millions of homes.
• He smokes a pipe putting him at increased risk of oral, throat, and lung cancer

Merry Christmas!

Suggest you leave for Santa a glass of water and a low-calorie, low-salt granola bar instead of milk and cookies tonight!

Read the full article here.

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Can Placebo Be Used to Help People Instead of Drugs?

On my way to work On December 23, 2010, I heard a great story on NPR regarding how placebos can potentially be used to help people... EVEN if they know it's a placebo!

Based on research done at Harvard, they found that a placebo helped patients with irritable bowel syndrome 59% of the time compared to a similar group that received nothing. Of greater significance... the treatment group with placebo KNEW they were getting a placebo.

Given that many medications have similar (and even lower) improvement rates, that's quite amazing.

Why does placebo work?

My own personal belief is that this is truly a case of mind over matter.

The human body is literally a pharmaceutical manufacturing company able to naturally produce all sorts of chemical compounds. Pretty much every drug that you can take in pill form, the human body already produces within to some degree. Drugs in essence augments what the body is already able to naturally produce.

The placebo effect is (in my opinion) when the human mind is able to boost the production of the appropriate drugs the body is already able to naturally produce.

The REAL key to improving the human health condition and avoid all the drugs and their potential for side effects is to somehow figure out how to enable the placebo effect on command.

Read the NPR story here.

Reference:
Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLoS One. 2010

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Can Humming Ease Sinus Problems?

Well... according to a recent New York Times article published Dec 20, 2010, the answer is yes...

Apparently, humming can keep air moving through the sinuses and nasal cavity which suggests improved ventilation. Good sinus ventilation means healthy sinuses.

Their conclusion is based on two studies listed under the references below. Unfortunately, the conclusion can't extend to stating humming prevents sinus infections. The only way to evaluate that hypothesis is to do a study comparing two groups of patients with chronic sinus infections and instruct one to hum and the other not to and see if there's any difference in the intervention group over time. Even better would be to do a prospective double-blinded study, but not sure how one can perform a double-blinded study in this case.

Read the NYT article here.

References:
Humming greatly increases nasal nitric oxide. Am J Respir Crit Care Med. 2002 Jul 15;166(2):144-5.

Assessment of nasal and sinus nitric oxide output using single-breath humming exhalations. Eur Respir J. 2003 Aug;22(2):323-9.

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