Thyroid surgery safe for older patients, study finds

AUGUSTA, Ga., 22 oct 2009 – Thyroid surgery is safe for older patients, say physicians who found only slight differences in rates of complications and hospital readmissions in a multi-year study.

"We were pleasantly surprised," says Dr. Melanie W. Seybt, endocrine-head and neck surgeon at the Medical College of Georgia and first author in the October issue of Archives of Otolaryngology – Head and Neck Surgery. "We suspected older patients might be admitted to the hospital more often, have more complications and more cancer."

But their study of 428 thyroidectomy patients at MCGHealth Medical Center and the Charlie Norwood Veterans Affairs Medical Center between November 2003 and December 2007, including 44 patients over age 65 and 86 between ages 21-35, showed few differences in the two groups.

Surgeons found:

• They could do outpatient surgery in both groups at essentially the same rate, 45.5 percent in the elderly and 51.2 percent in younger patients
• Similar complication rates, with 12.5 percent of older patients having transient problems with low calcium versus 11.1 percent of younger patients.
• The thyroid growth was suspected to be malignant in 4.5 percent of elderly patients and 2.3 percent of younger patients. Final pathology revealed cancer in 27.3 percent of elderly patients and 18.6 percent of older patients.
• Elderly patients had a slightly higher hospital readmission rate – 4.5 percent versus 1.2 percent – but readmissions were related to the transient problems with calcium levels not age-related complications.
• Neither group had post-operative bleeding or permanent vocal cord paralysis.

She hopes the findings will decrease concerns among patients and practitioners about the safety of thyroidectomies in the growing elderly population, noting that thorough preoperative screening, important at any age, likely helped minimize adverse reactions in their older patients.

Although thyroid disease tends to be most common in young women, the number of older patients diagnosed with the problem is escalating, Dr. Seybt says, noting that the oldest patient in this study group was 84. With a geriatric population that has increased by 90 percent in the last 30 years, according to the U.S. Census Bureau, the numbers are likely to continue upward.

"A lot of our older patients have other problems, such as heart failure, hypertension and restrictive lung disease, so we are very aggressive about getting medical clearance and optimizing control of their other problems," Dr. Seybt says.

She notes that head and neck surgeries generally have less complications and quicker recoveries than procedures in other parts of the body, such as the abdomen or chest. Low calcium levels are a common complication of thyroid surgery because the adjacent parathyroid glands are typically a little stunned by removal of the thyroid gland, she says. To help avoid problems, patients are routinely placed on a three-week tapering dose of calcium but sometimes still have transient problems, most commonly numbness or tingling around the lips and cramping of the hands and feet. Because of the close proximity to the vocal cords, patients also can have transient or permanent hoarseness.

While its exact cause is unknown, thyroid disease tends to run in families and radiation exposure is believed to be a risk factor for thyroid cancer. The increased availability of quality, non-invasive screening such as ultrasound likely means more cases are being identified at every age, Dr. Seybt says.

Laptop-sized ultrasounds are showing up in many physician offices and thyroid nodules also show up when patients have more sophisticated studies of the head and neck, such as an MRI scan, for other reasons. Patients or their doctors often just feel nodules in the neck although they can be oddly asymptomatic until they grow large enough to impact swallowing and/or breathing. While some of these larger growths are very obvious, those that grow downward into the chest or toward the back can be harder to detect. In older patients, many of the growths likely have been there a while, Dr. Seybt says.

Depending on the size of the growth in patients, surgeons at MCG and the VA will use one of three different approaches. These include a standard, several-inch incision at the base of the neck for the largest growth as well as include minimally invasive thyroidectomy, in which surgeons work through an incision about half the size of the norm, and an endoscopic approach, in which video monitoring and a thin, ultrasonic scalpel reduce incision size another half.

Dr. David Terris, chair of the Department of Otolaryngology-Head and Neck Surgery in the MCG School of Medicine and a pioneer of the minimally invasive approaches, showed in the March 2006 issue of Laryngoscope that the newer, minimally invasive approaches, which reduce the incision size and recovery time, could be used safely in most patients. Dr. Terris is corresponding author on the current study.

Dr. Terris and Sunny Khichi, a senior medical student at MCG, are study co-authors.