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The best approach to removing a diseased thyroid, the endocrine gland just under the Adam's apple that controls the body's metabolic rate, amazingly may be from under the arm, according to a study published in the August issue of the journal Laryngoscope.
"It was simply the easiest way to take these glands out that provided a cosmetic incision," said Dr. David J. Terris, Porubsky Professor and chair of the Medical College of Georgia Department of Otolaryngology-Head and Neck Surgery and the article's lead author. "Because it requires coming from a little distance, it gives the surgeon additional perspective."
Using pigs as his animal model, Dr. Terris and his colleagues were the first to compare five different minimally invasive approaches, where surgeons use small incisions, tiny telescopes and video monitors. In other countries, these approaches already are being tested clinically for removing thyroids because of cancer and benign growths.
"Endoscopic thyroidectomy has been introduced as an alternative to open surgery because it is minimally invasive, provides superior visualization, and results in reduced scars," the authors write in Laryngoscope. "Several different endoscopic techniques have been proposed, and each was associated with good clinical and cosmetic results."
Their comparative study indicated that while the more distant approach through the armpit takes a little longer, the inconspicuous scars make it worth that effort.
"Some approaches previously explored included coming up under the chest skin, coming down from the upper neck and coming from the armpit (the axilla), but nobody had really compared these and there was no description in an animal model," Dr. Terris said. "We settled on the axilla because, as you can imagine, those incisions will be completely hidden. If it's your 23-year-old daughter, wouldn't you rather have this technique?"
The standard approach in the United States to removing half or all of the two-inch, two-lobed thyroid gland remains direct access through a several-inch incision near the base of the neck. But Dr. Terris predicts that procedure also will change in this country as it has for many surgeries.
The first minimally invasive techniques were used in the abdomen, where surgeons now routinely remove gallbladders, spleens, reproductive organs and others using this approach that requires smaller incisions and less healing time and minimizes scarring and complications.
Dr. Terris, who came to MCG from Stanford University Medical Center in September 2002, has enabled this approach in the comparatively tight confines of the neck by identifying the hernia balloon – already used in the groin region – as a way to create space that allows surgeons to see and work. "This has allowed us to safely introduce instruments so that we can remove lymph nodes, submandibular (salivary) glands and even do a neck dissection endoscopically in animal models. More recently, we have started doing thyroid surgery completely endoscopically in animal models as well," Dr. Terris said, hence the need to objectively assess which approach is best.
Now that he's completed the animal studies, he plans to test the axillary approach for thyroid removal in cadavers before using it in his clinical practice. Those cadaver studies are particularly important because the pig, while an excellent model for human anatomy between the armpit and neck, does have a few differences. In the human, parathyroid glands, which regulate calcium levels, as well as crucial nerves that go to the voice box, are close to the thyroid gland.
Problems with the thyroid gland tend to occur in women in their 30s, 40s and 50s. Growths or goiters can result in a hyperactive thyroid gland and jittery, sweaty patients who can't gain weight. Typically if there is a single growth, the surgeons take out that half of the gland, rule out cancer and that is the end of the problem. If it is cancer, the good news is the thyroid can be completely removed, cure rates are high and the gland's function can be replaced by a single, daily pill, Dr. Terris said. Known causes of thyroid cancer include radiation exposure.
He's already received clinical approval from MCG's Institutional Review Board to use the scar-reducing approach to remove lymph nodes and salivary glands in a small number of patients; once he's completed the small clinical study, he plans to offer that approach routinely.
Journal
The Laryngoscope