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Thyroid Gland Anatomy

The thyroid gland consists of two lobes (right and left), an isthmus (the part connecting the two lobes), and a pyramidal lobe (an upper extension of the gland), which is present in about half of the population.

 

What are the common pathologies of the thyroid gland?

On physical examination, thyroid nodules can be palpated in about 5%–10% of the adult population.

In a neck ultrasound (US), thyroid abnormalities are found in a much higher percentage (around 50%). Fortunately, the majority of ultrasound-detected findings are benign and do not require further evaluation or treatment.

The evaluation of thyroid pathologies begins with blood tests to assess thyroid function—TSH, FT3, FT4, and an ultrasound of the gland and neck.

Most functional disorders of the gland, such as hyperthyroidism or hypothyroidism, are treated by an endocrinologist.
An ENT (Ear, Nose, and Throat) specialist or a head and neck surgeon gets involved in cases of suspicious or malignant lesions or when hyperthyroidism cannot be managed medically.

 

How do we interpret thyroid ultrasound results?

A universal scoring system has been developed to categorize thyroid ultrasound findings, known as TIRADS (Thyroid Imaging Reporting and Data System).

Each nodule in the thyroid is scored based on specific radiologic characteristics and the degree of suspicion, to determine whether a Fine Needle Aspiration (FNA) biopsy is needed.

Not every thyroid nodule requires a biopsy.

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​How do we interpret fine needle aspiration (FNA) biopsy results?

FNA biopsies of suspicious thyroid nodules are performed under ultrasound guidance using a fine needle to aspirate cells from the suspicious lesion. These cells are then placed on glass slides, stained, and evaluated by a cytopathologist.

Similar to the ultrasound scoring system, a special classification called the Bethesda System was developed to assess the level of suspicion in FNA samples.

In summary:

• Bethesda I: Non-diagnostic or unsatisfactory—too few or poor-quality cells; biopsy should be repeated.

• Bethesda II: Benign finding.

• Bethesda III-IV: Indeterminate; unclear if the nodule is benign or malignant.

• Bethesda V-VI: High likelihood of malignancy (over 75% in Bethesda V, and about 99% in Bethesda VI).

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When is it sufficient to remove only one lobe of the thyroid gland?

Indications for partial or total thyroidectomy are evolving. In 2015, a major update by the American Thyroid Association significantly reduced the number of total thyroidectomies.

Most benign enlargements or nodules require only partial thyroidectomy.

In addition, for malignant tumors less than 4 cm in diameter, well-contained within the gland, and without invasion into surrounding structures or lymph node metastasis, a partial removal may be sufficient.

A total thyroidectomy is usually performed when:

• Suspicious findings are present in both lobes

• The tumor is larger than 4 cm

• There are significant risk factors for recurrence

• There is evidence of cervical or distant metastases

If radioactive iodine therapy is needed after surgery, total thyroidectomy is required to enable effective treatment.

 

Is there a need for radioactive iodine therapy after surgery?

There is no single answer that applies to all patients. Each case of thyroid cancer is discussed individually, considering the patient’s background, risk factors, surgical findings, and the presence of metastatic disease.

Recently, there has been a tendency to reduce the use of radioactive iodine, due to a lack of clear evidence that it improves recurrence rates in less aggressive tumors.

Dr. Jubran Mansour works in close collaboration with endocrinologists and oncologists. Every thyroid cancer case is discussed in multidisciplinary meetings to determine the extent of surgery, the need for radioactive iodine therapy, or other biologic treatments.

 

What are the most common side effects of thyroid surgery?

Common side effects include:

• Mild local pain

• Sore throat or discomfort when swallowing for a few days

• A neck scar (usually very fine and hidden in natural skin folds)

• Numbness around the surgical site

 

Calcium Regulation:

Behind each thyroid lobe are two parathyroid glands (a total of four), which regulate calcium balance in the body. These glands are tiny (about 3–4 mm) and located on the posterior surface of the thyroid.

The surgeon's role is to identify and preserve these glands and their blood supply. Even one functioning gland is usually sufficient to maintain normal calcium levels, but the goal is to preserve all four.

A temporary drop in calcium levels is relatively common (15%–30%) after total thyroidectomy and usually resolves within 1–3 weeks.

In partial thyroidectomy (removal of one lobe), there is no risk to calcium balance, since the glands on the other side remain untouched.

 

Hoarseness:

Behind each thyroid lobe runs the recurrent laryngeal nerve, which is crucial as it innervates most of the laryngeal muscles, responsible for breathing and speaking.

• If one nerve is injured, the patient may experience hoarseness and a weak voice (an uncommon complication).

• If both nerves are injured (very rare), the patient may lose the ability to breathe independently and require temporary or permanent airway support.

Dr. Jubran uses active and electrical nerve monitoring (NIM) in every thyroid or parathyroid surgery to help avoid nerve injury.