Published September 26 2016
Although it would be great if everyone with a thyroid or autoimmune thyroid condition was able to avoid conventional medical treatment in the form of prescription drugs, surgery, and other procedures, the truth is that these treatment methods are sometimes necessary. Everything comes down to risks vs. benefits, and while many medical doctors will do a good job of explaining the benefits of conventional medical treatment, they don’t always reveal the complete risks. And so the goal of this article is to discuss some of the risks of receiving thyroid surgery and radioactive iodine.
But before I talk about the risks associated with these procedures, I do want to let you know that there is a time and place for these treatment options. Although one can argue that there is no good reason to receive radioactive iodine, one can’t make a good argument that thyroid surgery is never necessary. And so while too many people receive radioactive iodine treatment and thyroid surgery, there are times when a partial or complete thyroidectomy is necessary. And sometimes it can be challenging to know when such a procedure is necessary. For example, if someone has a large thyroid nodule that is suspicious of being malignant, even though a malignancy hasn’t been confirmed, it can be difficult to know for certain if thyroid surgery is the best option, or if it is wise to just continue monitoring the nodule.
Also, when discussing the risks of thyroid surgery and radioactive iodine I’m not going to discuss “hypothyroidism” as being one of the risks. Sure, this is a likely outcome for anyone who receives thyroid surgery or radioactive iodine, although there are exceptions. But while becoming permanently hypothyroid is without question a big deal, I’m going to focus on some of the other risks associated with these procedures. Truth to be told, while many endocrinologists try to convince their patients that becoming hypothyroid is actually a benefit since it’s easy to manage, many people who become hypothyroid after receiving these treatment methods never feel the same again. For some people it’s just a matter of getting the dosage of thyroid hormone medication right, but others experience symptoms for years after receiving surgery or RAI.
Risks of Thyroid Surgery
So let’s start out by looking at some of the risks of having a partial or complete thyroidectomy:
Infection. Of course having an infection is a risk with any type of surgery. Surgical site infections after getting a thyroidectomy are rare, but when they do happen they can be serious at times. One study showed that out of 49,326 patients who underwent a thyroidectomy from 2005 to 2011, only 179 (0.36%) had a surgical site infection (1).
Uncontrolled bleeding. With any surgery there is risk of uncontrolled hemorrhage, but there is an increased risk with thyroid surgery due to the fact that the major blood vessels are in the vicinity of the thyroid gland, and of course there can be injury to the blood vessels of the thyroid gland itself. Hemorrhage is a common post-op complication and can cause compression over the neck structures, leading to acute airway obstruction (2), which is considered to be an emergency situation.
Problems with anesthesia. There are always risks of anesthesia with any type of surgery, although with a thyroidectomy the attending anesthesiologist has a greater challenge when administering anesthesia compared to other types of surgeries. In order to minimize the risks, the endocrinologist, surgeon, cardiologist, and anesthesiologist need to carefully work together during the pre-op examination. General anesthesia with endotracheal intubation is considered to be the safest approach for thyroidectomies (2).
Injury to the recurrent laryngeal nerve. Damage to the recurrent laryngeal nerve can be caused by traction, transaction, entrapment or ischemia and can be permanent or transient (2), and some of the signs of injury during surgery include breathing difficulty, hoarseness of voice and difficulty in vocalization (2). One study involving 623 patients who received thyroid surgery showed that injury to the recurrent laryngeal nerve occurred in 4.98% of patients (3). Of the 31 patients who had a recurrent laryngeal nerve injury, 28 had a temporary injury while 3 patients suffered a permanent injury (3).
Injury to the superior laryngeal nerve. The superior laryngeal nerve gets damaged in 3-5% of the thyroidectomy procedures, and the commonest injury occurs to external branch of superior laryngeal nerve, resulting in the paralysis of cricothyroid muscle which causes alteration in the quality of voice as the vocal folds fail to tense during sound production (2). Damage to this nerve can also result in dysphagia (difficulty swallowing) due to problems with the swallowing reflex.
Damage to the parathyroid glands. One of the operative complications of thyroidectomy is injury to parathyroid glands or its accidental removal which can manifest in the form of acute hypocalcemia in approximately 20% of the patients. Features of hypocalcemia include peri-oral tingling, mental confusion, muscular twitching, seizures and tetany (2). Keep in mind that temporary parathyroid insufficiency is much more common than permanent hypoparathyroidism.
Tracheomalacia. A large-sized goiter compressing over the tracheal structures for a long duration can cause pressure atrophy and erosion of the cartilaginous tracheal rings (2). Post procedure, the tracheal wall loses the surrounding support and can collapse in antero-posterior direction leading to respiratory obstruction.
Thyroid storm. Having a thyroid storm during surgery is rare, as when this happens it usually is caused by either an acute illness, or due to poor preoperative preparation for the thyroid surgery.
While the risk of having any one of these complications during thyroid surgery is low, the overall risk of experiencing complications is high. For example, one study involving 301 patients with multinodular goiter who received a total thyroidectomy showed that complications were present in 62 patients (4). So 21% of the patients presented with complications, including 29 with hypoparathyroidism, 26 recurrent laryngeal nerve injuries, 4 lesions of the superior laryngeal nerve, 3 cervical hematomas, and one infection (4).
How To Minimize The Risks Associated With Thyroid Surgery
Perhaps the best way to minimize the risks of complications associated with getting a thyroidectomy is to choose your team carefully. Of course choosing a competent surgeon who has a good amount of experience is important, but having a competent endocrinologist and cardiologist can also be important.
Some people reading this might wonder about the risks associated with robotic transaxillary thyroidectomies. The main reason this approach was developed was to avoid an incision in the neck, and thus to avoid scars. In other words, it’s done mainly for cosmetic purposes. But does the procedure come with the same risks as a conventional thyroidectomy? Well, a meta-analysis showed that the robotic approach was found to have a similar risk of total postoperative complications when compared to the conventional and endoscopic approaches, although it is associated with longer operative time (5).
Risks of Receiving Radioactive Iodine Treatment
Before talking about the risks of receiving radioactive iodine, I want to briefly list some of the precautions recommended by the American Thyroid Association after someone has received I-131 RAI treatment (6):
- Sleep in a separate bed from another adult
- Delay return to work
- Maximize distance from children and pregnant women
- Limit time in public places
- Do not travel by airplane or public transportation
- Do not travel on a prolonged automobile trip with others
- Maintain prudent distances from others
- Do not prepare food for others
- Do not share utensils with others
- Flush the toilet two to three times after use
Once again, this list is directly from the American Thyroid Association’s website, and so even without reading about some of the risks I’m about to discuss, hopefully you get the idea that radioactive iodine isn’t as harmless as many endocrinologists claim it to be. And sure, most of these precautions are only for a few days, but if radioactive iodine was completely safe then why have any of these precautions at all?
With that being said, let’s take a look at some of the risks associated with radioactive iodine:
Radiation exposure. Just a reminder that iodine-131 is a radioactive isotope, and these radioisotopes travel through the bloodstream. And while I-131 is used to destroy the cells of the thyroid gland, RAI can also effect other cells. For example, the breasts also absorb iodine, and as a result, radioactive iodine can potentially affect the cells of the breast. I spoke more about the impact of radiation on thyroid health in an article I wrote entitled “Radiation and Thyroid Health”.
Infertility in men. According to the American Thyroid Association, there is no evidence that RAI leads to infertility in women, which is good news (7). However, the ovaries are exposed to radiation after treatment (which of course isn’t a good thing), and because of this they recommend postponing pregnancy for at least 6 to 12 months after receiving RAI. On the other hand, men who receive RAI treatment may have decreased sperm counts and temporary infertility for periods of two years (7).
Salivary dysfunction and sialadenitis. Sialadenitis is inflammation of the salivary gland, and it’s a common long-term complication of radioactive iodine treatment (8) (9) (10). One study showed that about 20% of the salivary glands were dysfunctional five years after a single RAI ablation, especially in patients who received higher doses of RAI (10). One of the common side effects of salivary dysfunction is xerostomia, which is a dry mouth.
Nasolacrimal duct obstruction. This is also a potential complication of radioactive iodine. This involves the obstruction of the nasolacrimal duct, which leads to the excess overflow of tears. This is known as epiphora. One study showed that 2.2% of patients who received radioactive iodine developed this condition (11). Another study showed that out of 390 patients who received radioactive iodine, 10 patients reported epiphora (12). And while most people who receive radioactive iodine don’t develop obstruction of the nasolacrimal duct, those that do might need to get lacrimal duct surgery.
Secondary malignancies. High doses of radioactive iodine can kill cancer cells. However, there is also evidence that higher doses can cause cancer, which shouldn’t be surprising since it involves radiation. However, there is some controversy over whether receiving radioactive iodine can increase the risk of developing breast cancer. An article from breastcancer.org discussed a research study which showed that women who received radioactive iodine were 53% more likely to develop breast cancer compared to those who did not receive radioactive iodine (13). However, I didn’t see the reference from the study they mentioned, and another study involving 1,005 women with hyperthyroidism treated with I-131 didn’t find an increased risk of breast cancer, and mentioned that this probably was due to the moderately low doses of I-131 (14). And this is an important point to bring up, as some endocrinologists will recommend higher doses of radioactive iodine than others.
Choosing Between Thyroid Surgery and Radioactive Iodine
My goal is to help people restore their health so that they don’t have to receive radioactive iodine or thyroid surgery. However, there are times when someone will ask me if I had to choose one of these procedures which one would it be? Although I restored my health when I was diagnosed with Graves’ Disease, if for any reason I wasn’t able to get into remission naturally I probably have looked into other treatment options before choosing either thyroid surgery or radioactive iodine. This would include taking low doses of antithyroid herbs or medication to help manage the symptoms, low dose naltrexone, and thyroid arterial embolization.
But if I absolutely had to choose between thyroid surgery and radioactive iodine for Graves’ Disease, I’m pretty sure I would choose thyroid surgery. Even though there are risks involved with thyroid surgery, I don’t think I would feel comfortable receiving radioactive iodine. Of course it’s easy for me to say this when I’m not in a situation where I have to make such a decision, but I’m pretty sure that with the knowledge I currently have I would choose thyroid surgery over radioactive iodine, if I had to choose between the two.
With that being said, after reading this article I’m hoping that more people will realize the risks associated with these treatment procedures, and will try to address the cause of their condition so that they can avoid both thyroid surgery and radioactive iodine. Sure, I realize that conventional medical treatment is sometimes necessary, and I also understand that some endocrinologists can be very convincing when discussing the “benefits” of radioactive iodine, along with the risks of not getting your thyroid gland obliterated or surgically removed. For someone who doesn’t have a lot of knowledge in this area it is easy to fall for common scare tactics. And to be fair, many times the endocrinologist truly thinks that radioactive iodine or thyroid surgery is the best option, as they don’t know what else to do, and most are too closed minded to think about looking into the cause of the condition.
What If You Already Received Radioactive Iodine or Thyroid Surgery?
For those who have already received radioactive iodine or thyroid surgery, of course there is nothing you can do but move forward. And while you might need to take thyroid hormone medication on a permanent basis (especially if you had a complete thyroidectomy), you still can do things to improve your health. For example, if someone had Graves’ Disease and received radioactive iodine or thyroid surgery, you still can do things to improve the health of your immune system, which can help prevent the development of other autoimmune conditions in the future.
So hopefully you have a better understanding of the risks associated with both thyroid surgery and radioactive iodine. Some of the risks associated with thyroid surgery included infection, uncontrolled bleeding, problems with anesthesia, injury to the recurrent laryngeal nerve and superior laryngeal nerve, damage to the parathyroid glands, tracheomalacia, and rarely a thyroid storm. Some of the risks associated with radioactive iodine include radiation exposure, infertility in men, salivary dysfunction, nasolacrimal duct obstruction, and secondary malignancies. This doesn’t mean that there isn’t a time and place for conventional medical treatment, but in many cases these procedures are unnecessary, yet are commonly recommended by endocrinologists.
