A reader recently wrote with questions regarding upcoming thyroid surgery. We haven’t addressed this area for a while, and it bears revisiting. Thyroid disease is common among women, and thyroid surgery is of particular concern for singers. One note of disclosure: although I treat singers with thyroid disease, I personally do not perform thyroid surgery. For this reason, I invited Dr. Youngnan Jenny Cho to co-author this column. Dr. Cho is a New York otolaryngologist who is medical director for New York City Opera and also works with us at the Met. She sees many singers and is an excellent thyroid surgeon.
The thyroid gland sits in the middle of your neck, right in front of your larynx. This is one of the reasons why thyroid surgery has particular implications for the singer. The thyroid gland consists of two oblong lobes located on either side of the larynx, which are connected by the thyroid isthmus. The location of the isthmus is in the midline, just below the larynx. The nerves that move the vocal folds (recurrent laryngeal nerves) run between the thyroid lobe and the upper trachea on each side. Obviously, taking care of these nerves during surgery is very important.
The thyroid is one of the most important endocrine glands in the body. In short, it is responsible for metabolism. Patients who are hyperthyroid burn food at a higher rate. They are often skinny, flushed, and have a rapid heart rate. Conversely, hypothyroid patients are frequently cold, sluggish, and overweight. Your thyroid gland has a say in almost every bodily function, including hair and skin texture, menstrual periods, and even bowel function.
From the medical point of view, thyroid disease is probably more common than is suspected. Since middle-aged women not infrequently have low thyroid function, mild cases are not infrequently seen among singers. Subclinical hypothyroidism can be caused by an autoimmune condition (Hashimoto’s thyroiditis), which manifests very subtly. These patients are overweight and have difficulty losing weight, have problems with their periods, feel tired, and may be hoarse. Sounds like most perimenopausal women, right? This is why the condition is frequently overlooked. When mild hypothyroidism is diagnosed, it is easily treated with oral medication, with resolution of symptoms. We always consider the possibility of mild hypothyroidism in such patients, especially when they have other autoimmune disorders.
But this column is about thyroid surgery. There are two main reasons why the thyroid gland may need to be partially or completely removed. If the gland contains nodules which may be suspicious for cancer, surgical removal is the usual treatment. Such nodules may be solitary or multiple and can be small or large enough to be palpated as a discrete mass. If there is concern on examination, an ultrasound evaluation will often reveal the full size of the mass, its location in relation to other structures in the neck, and the possible presence of other, impalpable masses.
The next step is a fine needle aspiration (FNA) biopsy which is a simple procedure done in the office. The physician inserts a thin needle into the area and aspirates cells from the nodule or mass. By obtaining a microscopic diagnosis, the nature of the growth, whether benign or malignant, and what type of malignancy can usually be made. Although FNA is the standard diagnostic test, it may not always give an accurate diagnosis, since some growths have different populations of cells, and the sample in the aspiration may not be fully representative of the growth.
The second indication for thyroid-ectomy is for benign enlargement of the thyroid (goiter) where it has grown so large that it is pushing against the trachea or it is causing a cosmetic deformity. Occasionally the thyroid gland is quite massive and extends below the clavicles into the middle part of the chest (mediastinum).
Three aspects of thyroid surgery have specific implications for the singer. First, the need to carefully preserve the nerves which move the vocal folds is paramount. Although there are some cases of aggressive and invasive cancer where one or the other recurrent laryngeal nerve is encased by tumor, in the vast majority of cases the nerves can and should be identified and preserved. This is primarily a matter of skill and experience on the part of the surgeon. Although some surgeons monitor the integrity of these nerves during dissection by the use of special endotracheal tubes, other surgeons find that these tubes just give a false sense of security.
The best insurance against laryngeal nerve damage is careful and skillful surgery performed by an experienced thyroid surgeon. While even in the best of hands the nerve is occasionally injured (after all, the overriding purpose of cancer surgery is to remove the cancer), everything possible should be done to minimize this possibility. Be aware, however, that even when the nerve is structurally preserved, displacement or stretching during surgery can cause a temporary weakness of one of the vocal folds which, over time, typically fully recovers.
A second area of concern is preservation of the muscles in the front of the neck. If the thyroid is massively enlarged, these muscles can be in the way and make gland removal more difficult. This is the case in those large tumors that extend down into the chest: dividing the muscles can release the tumor, allowing it to rise and be delivered up into the neck for removal. But for smaller tumors, cutting these muscles is not necessary. In singers, our suggestion is to try to preserve these as much as possible. Not only do these muscles play some role in moving the larynx, but cutting them may also increase scar tissue formation in the anterior neck and make the normal sliding of the larynx and trachea more difficult.
The final area of concern is probably medically (and vocally) the least important, although the most obvious: the scar left by the procedure. Since the gland is removed through a horizontal incision across the front of the neck, a scar in this location will result. In deciding on the length of this incision, the surgeon must weigh the final cosmetic appearance of the scar against the need to fully expose and be able to remove the gland, taking care not to damage other structures—including, of course, the recurrent laryngeal nerves. In most cases of skillful thyroid surgery, good cosmetic closure will leave the patient with a hairline scar which is not obvious even on close encounter, let alone on the stage. Having said that, however, we need to remember that some darker-skinned individuals are prone to keloid formation. Keloids are thick scars which can be unsightly. Although they can be treated in a variety of ways, such as cortisone injection, the end result may still be visible.
You may have heard or read about transaxillary robotic surgery of the thyroid. This approach uses computer-controlled instruments to remove smaller thyroid tumors. The instruments are long and are inserted through an incision in the armpit, almost like a laparoscopic procedure. The technique was invented in Korea, where any scar on the neck of a woman is considered to be unattractive. The obvious purpose of this approach was to avoid an incision on the neck. Although there was an initial flurry of interest in this technique, there are limitations to this approach as well as potential complications which make it less applicable, and possibly less therapeutically effective, than conventional thyroid surgery. For this reason, interest in this technique is already waning, at least in the U.S.
A few final words of advice to singers who may be considering thyroid surgery. If you feel uncertain, consider a second opinion. Ask around among other singers to find a surgeon who has significant experience, a good reputation, and is sympathetic to your concerns as a singer. For any surgery, don’t be seduced by buzzwords such as “robotic surgery” or “laser surgery.” Although in some unfortunate situations the cancer may be aggressive and the outcome determined by the nature of the tumor, in the majority of cases good clinical outcome is the result of skillful diagnosis and surgery.
