This section of surgeryinfo.org deals with surgeries of the head and neck. The neck in particular contains a number of vital structures including the carotid arteries, the trachea (the windpipe), and the thyroid gland. Surgery on the head and neck is performed by neurosurgeons, ear, nose and throat surgeons (otolaryngologist), vascular surgeons, thoracic surgeons, and general surgeons depending on the organ involved.
The thyroid gland sits in the middle of the neck atop the windpipe. The butterfly shaped gland has two lobes: a left lobe and a right lobe. The thyroid gland makes and secretes thyroid hormone. Thyroid hormone is involved in maintaining the body’s metabolism.The most common reason patients are referred for thyroid surgery is after evaluation for a thyroid nodule. Thyroid nodules are fairly common particularly in women. Because nodules are so common, further evaluation is warranted only after the nodule reaches a certain size, 1cm. A fine needle aspiration, which is performed in the office under local anesthesia, is the first step in diagnosis. A needle and syringe is inserted through the skin into the nodule to extract some cells for analysis. If the biopsy results come back as cancer or possible cancer, then thyroid surgery will be recommended.Surgery may also be recommended for a goiter, which is essentially an enlarged thyroid. A goiter is benign but, if large enough, can cause symptoms such as difficulty swallowing or pain and pressure in the neck.
Risk factors for thyroid cancer include
- Age – most patients who develop thyroid cancer are over 40 years old
- Women – women are three times as likely as men to develop thyroid cancer
- Race- Caucasians are more likely to get thyroid cancer than African-Americans
- Family history of thyroid cancer
- History of radiation exposure to the neck
- Iodine deficiency in the diet
How is it diagnosed?
The diagnosis of cancer or possible cancer is made with a thyroid biopsy. Thyroid biopsies can be done in the office. A small needle and syringe is inserted into the nodule and a few cells are aspirated. Those cells are examined under a microscope to make the diagnosis. If the results return as cancer or possible cancer, then surgery is scheduled.
How do I prepare for surgery?
If you are over 45 years old, you will need some additional preoperative testing to aid the anesthesiologist in taking care of you. Those tests include blood work, a chest X-ray, and an EKG.
How is the surgery performed?
A horizontal incision is made along the base of your neck usually along a skin crease. The thyroid gland is identified, carefully detached from the windpipe, and removed, with care taken not to destroy adjacent structures.
For a diagnosis of cancer, a total thyroidectomy, removal of the entire gland, is performed to remove any cancer cells that my have spread within the thyroid gland. Complete treatment of thyroid cancer includes administration of one dose of radioactive iodine to kill any remaining thyroid cells that may have spread beyond the thyroid.
For a diagnosis of possible cancer, only the lobe where the cancer is suspected is removed. This is a called a thyroid lobectomy. If after removal of the one lobe, the diagnosis of cancer is confirmed, then a second surgery is needed to remove the remaining thyroid.
For patients with hyperthyroidism, many surgeons recommend a subtotal thyroidectomy. This involves removing one lobe in its entirety and then a subtotal or near total resection of the opposite lobe. The small tuft of thyroid remaining may prevent the need for lifelong thyroid hormone supplementation.
Complications of Surgery
The most serious risks of thyroid surgery include bleeding underneath the skin resulting in a blood clot that puts pressures on other structures such as the windpipe. Pressure on the windpipe can cause difficulty breathing.
Two key structures exist in the neck close to the thyroid and can be damaged during surgery. The recurrent laryngeal nerve lies along the back of the thyroid. This nerve is responsible for movement of the vocal cords. Injury to the nerve can cause voice hoarseness which is most often temporary but can be permanent. The other structures are the parathyroid glands which control calcium levels in the body. They often get bruised during surgery, causing low calcium levels in your blood and requiring you to take calcium supplements temporarily. If they are permanently damaged, you will need to take calcium supplements for life.
The last two complications mentioned are rare in the hands of experienced surgeons. Patients at higher risk for these complications are those with large goiters extending below the collar bone or in those undergoing their second operation on the thyroid.
What to expect after surgery?
The surgery usually takes approximately 2 hours. There may be a surgical drain placed next to the incision in your neck. This will be removed the morning after surgery. Your throat may be sore because of the breathing tube placed during the operation. You will be able to drink liquids immediately after surgery and eat once you are fully awake. You will be discharged the day after surgery. Those who have had a thyroidectomy will be hypothyroid (exhibiting underactive thyroid function) after surgery and will need to take a daily thyroid hormone pill. If you had a diagnosis of cancer, you will need to see an endocrinologist to schedule the administration of the radioactive iodine. Those who have a thyroid lobectomy will not need any supplemental medication
Anatomy and Physiology
The trachea, or windpipe as it is known colloquially, is a circular tube that allows air you breathe to enter into your lungs. The trachea starts at your voice box in the upper part of the neck down into the chest. The trachea is a circular tube made up of 16-20 rings of cartilage. A tracheostomy is a surgically created opening into the trachea. A tracheostomy tube is inserted into that hole and allows a direct passage of air from the environment or from a breathing machine called a ventilator, into the lungs.
Who is at risk? A tracheostomy may be performed to fix a variety of problems including
- Decreased air flow into the lungs caused by an inherited abnormality of the larynx or trachea
- Compression of the trachea caused by swelling or bleeding brought on by severe neck or mouth injuries
- Damage to the trachea caused by breathing corrosive material, smoke, or steam
- A large object blocking the trachea, such as a tumor
- Excess secretions and mucous building up in the airway, of which a tracheostomy is used to facilitate clearance
- Paralysis of the muscles that affect swallowing
- Long-term unconsciousness or coma.
Patients who need prolonged breathing support from a ventilator (longer than 2 weeks) will often have this procedure performed. A tracheostomy in the neck is preferable to a breathing tube inserted through the mouth because it is often more comfortable for the patient. It can also be safer as the breathing tube through the mouth can cause damage to the trachea resulting in narrowing, if placed for longer than 2 weeks. Finally, it is easier to “wean” the patient off the ventilator with a tracheostomy tube than with a breathing tube. Patients can be disconnected from the ventilator and breathe on their own through a tracheostomy tube. These breathing trials – or trach collar trials, as they are often called – are often done as “mock” trials to see how well someone can breathe on their own without the help of a ventilator. Trach collar trials can be performed for a few hours at a time. In between trials, the tracheostomy tube is reconnected to the ventilator to provide the patient with a period of rest. How is the surgery performed? A small horizontal or vertical 1 inch incision is made into the neck below the Adam’s apple but above the breastbone. The neck muscles are parted and the trachea is identified. An incision is made between the tracheal rings. The tracheostomy tube is inserted through this hole between the rings down to the trachea. A supply of oxygen can be attached to the tube to increase the flow of oxygen to the lungs. The tracheostomy tube can also be attached to a ventilator if the patient is unable to breathe on his or her own.
Complications from Surgery? This is a commonly performed and safe procedure. Risks include damage to the voice box or esophagus during the procedure or a collapsed lung. These complications tend to occur early after surgery but are very rare. Complications that tend to occur months to years after tracheostomy surgery include erosion of the tracheostomy tube into a nearby artery or to the esophagus. These complications require an operation to be fixed. Tracheostomy tubes require regular maintenance cleaning or else they can get clogged with mucous or other secretions. What to expect after surgery?
It takes some time to adapt to breathing through a tracheostomy tube. With training and practice, most patients can learn to talk with a tracheostomy tube in place. However, when on the ventilator, a person is unable to talk.
Between 4 and 10 days after surgery, the initial tracheostomy tube will be changed to a smaller tube. Tracheostomies can be temporary or permanent. If temporary, the tracheostomy tube will be downsized to a smaller tube usually in at least two different changes. Once the tracheostomy tube is removed, a dressing is placed over the hole. The hole generally seals up on its own within a few days. In rare cases, the hole does not close and a second operation is required to close the it. If the tracheostomy is meant to be permanent, home care instructions will be given prior to discharge from the hospital. Regular cleaning of the tracheostomy is required to clean the secretions that might build up.
The common carotid artery carries blood from the heart to the brain. The main blood vessel exiting the heart is called the aorta. The common carotid artery is a branch off of the aorta and travels up the neck. Halfway up the neck, the common carotid branches into the internal and external carotid arteries. The internal carotid artery is the branch that eventually supplies the brain with oxygen-filled blood. There is a left and right carotid artery.
Atherosclerosis is a disease that describes the formation of plaque on blood vessels. Plaque is composed of cholesterol, calcium, and fibrous tissue. When it settles on the wall of the artery, the artery stiffens and narrows. Carotid stenosis is the term used to describe the narrowing of the carotid artery. As the stenosis progresses, blood flow to the brain becomes compromised. Carotid stenosis can lead to stroke and mini-strokes, also called transient ischemic attacks (TIA’s) in two ways, by narrowing the artery as described above or via an embolus. An embolus is a piece of plaque that was flicked off by the main plaque or a piece of clot that settled on the plaque and then migrated. The embolus gets carried away by the circulation of blood and eventually lodges into a smaller blood vessel in the brain, denying oxygen to a part of the brain and causing the stroke.
Many surgeons will recommend surgery to remove the plaque in the carotid artery when you have been found to have significantly advanced carotid stenosis putting you in danger of having a stroke or TIA.
Who is at risk?
Atherosclerosis has been linked directly to smoking and high cholesterol. In addition, diabetes and obesity are also associated with a high risk of developing atherosclerosis.How is it diagnosed?
Carotid stenosis can sometimes be detected by physical exam. When your physician holds the stethoscope against your neck, they may hear a “bruit” or sounds of turbulence in your artery. The diagnosis can be confirmed with an ultrasound of the blood vessels. If the results of the ultrasound are not conclusive a CT scan, MRA (magnetic resonance arteriography) or an arteriogram may be recommended by your physician.
How do I prepare for surgery?
Blood samples will be needed as well, as an EKG and chest X-ray. Depending on your health and medical history, your doctor may recommend a cardiac stress test to determine if your heart can withstand the stress of an operation. If you have lung disease, your doctor may also suggest tests of pulmonary function to help the anesthesiologist manage your lungs while you are under general anesthesia.
How is the surgery performed?
The surgery is usually performed under general anesthesia. Some surgeons do perform “awake” carotid endarterectomies if you have other medical problems that put you at high risk for surgery and general anesthesia. During an awake procedure, your surgeon will limit the amount of pain you feel by infusing local anesthesia under the skin. The benefit of having you awake during surgery is that your surgeon can check on you from time to time to make sure you are not experiencing an adverse reaction from having your artery clamped.
An incision will be made along your neck from the angle of the jaw down to the base of the neck. A clamp will be placed on the carotid artery temporarily preventing blood flow to your brain. Your brain will receive blood flow from the carotid artery on the opposite side where your surgeon is working. Then, the carotid artery will be opened. The plaque will be removed. The cut in the artery will then be sewn with a patch.
Carotid endarterectomy with patch
Potential Complications of Surgery
Most patients tolerate the surgery fairly well. Factors that increase your risk of developing a complication include high blood pressure that is not well managed, blockages in the carotid artery on the opposite side of where you are having surgery, and any history of a recent heart attack.
The earliest complication that could occur is bleeding under the skin that causes a blood clot. If you experience a significant amount of bleeding, the blood under the skin can push aside other structures in the neck, such as your windpipe. This would require an immediate trip back to the operating room to drain the blood. Another serious complication is that of a stroke. The risk is very low ranging between 1 and 3 percent.
Finally, re-blockage of the artery is another uncommon but possible complication, particularly if you have not modified any of the risk factors of atherosclerosis, such as smoking and a high fat diet. This complication if it occurs happens months to years after surgery.
What to expect after surgery?
You will be admitted on the day of surgery and watched closely overnight for any signs of bleeding or a stroke. Some surgeons will leave a temporary drain in your neck to catch any bleeding that might occur. This drain will be removed in the morning. Generally, patients are discharged the day after surgery.