Endoscopic Thyroid Surgery: An Innovative Procedure

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Guest: Dr. Joshua D. Hornig - Otolaryngology - Head and Neck Surgery (ENT)

Host: Dr. Linda Austin - Psychiatrist.

Announcer: Welcome to an MUSC Health Podcast.

Dr. Linda Austin: I am Dr. Linda Austin. I am talking to Dr. Joshua Hornig, who is Assistant Professor of Otolaryngology that is ear, nose, and throat here at the Medical University of South Carolina. Dr. Hornig, I know that you and Dr. Eric Lentsch have teamed up together to do some very innovative procedures in thyroid surgery. What exactly are you doing?

Dr. Joshua D. Hornig: I am focusing on that new thing that we are doing that we are going to offer people and this is basically a new technique that we call endoscopic thyroid surgery and basically, it has all the advantages of pervious thyroid surgery, except we are able to do it through a very small incision and when I say small, I mean less than 1-inch incision, we are talking about a 0.5-inch incision. The traditional thyroid incision was about 4-inches in length, so we are talking about incision that is 8 times smaller. With the new instrumentation that we have, we are now able to go underneath the skin, do the entire thyroid operation that we could do with cameras and specialized instrumentation and then actually remove the thyroid or the thyroid cancer that people have through the small incision. A big advantage that people have; number one, they have a small incision and the second is because the surgery is much more focused, there is a lot less dissection and the advantage to the patient is there is less bleeding and there is less pain. So, people go home earlier and get back to work much sooner.

Dr. Linda Austin: Now, let’s talk about some of the thyroid conditions that would require someone to come to you for this sort of surgery. What are the most important conditions you are treating here?

Dr. Joshua D. Hornig: Sure, the one that I was concerned about is thyroid cancer and so anytime you have a small thyroid cancer, this would be a perfect kind of operation for that person. The person that I think benefits most from these is the younger patient that is, you know, in their 30s, 40s, and 50s that has had an ultrasound done of the neck, which shows a small nodule in the thyroid that then leads to a needle biopsy and sometimes the needle biopsies can’t make the determination if it’s cancerous or not. So, often you will go the operating room, remove part of that thyroid gland basically just to get a diagnosis and often it is just a benign thyroid nodule, which probably never needed to be removed in the first place. So, the advantage of doing it this way is you make this very small incision; it’s almost like a biopsy really and people would just recover faster, not have a big unsightly scar and a long postoperative recovery as associated with the traditional surgery.

Dr. Linda Austin: So, roughly of patients, who go to the OR in that set of circumstances, there is a nodule you don’t really know, what fraction of the time is it cancerous and what fraction is benign?

Dr. Joshua D. Hornig: It’s about 90% of the time that it will be benign and 10% of the time it will be malignant or be a thyroid cancer.

Dr. Linda Austin: Now, can that be determined by the pathologist at the time of surgery or does this require then a second procedure?

Dr. Joshua D. Hornig: What I prefer to do is do that one procedure, make sure we got the correct diagnosis, and then if it is cancerous, then we would come back for a second operation that we would both be going to discuss in detail the risks and the benefits of the operations exactly what we are doing. I typically don’t like to get an intraoperative diagnosis and then change the whole scenario as I feel the patient is sometimes not ready to make that jump to this big operation from a very small focused operation. So, I always like to wake them up and talk about the diagnosis and their subsequent treatment in detail.

Dr. Linda Austin: Especially since I am sure most people going into and think they will be in that 90% for whom it is a benign lesion.

Dr. Joshua D. Hornig: Exactly, and once you have thyroid cancer, we have a very large and specialized team that are all thyroid specialists that are not just surgeons, but are endocrinologists and speech therapists that I would like to have involve sort of a large multidisciplinary team that can really take care of these patients in this kind of setting, so you don’t get that benefit if you don’t have that diagnosis beforehand.

Dr. Linda Austin: How would someone become aware of having a thyroid nodule to begin with?

Dr. Joshua D. Hornig: Often people notice that they have a small lump at the front part of their neck that usually moves with swallowing. It is usually nontender and they just notice that it’s there and kind of might even be growing with time. Sometimes, people have some problem swallowing or some changes in their voice 04:25 if there is a lump in the back of the throat and all those are sometimes associated with a nodule. Often, they are picked up from other scans or getting an ultrasound done of the neck and a nodule was not even felt before, it just was picked up by a scan and that’s actually very favorable, this is usually very small.

Dr. Linda Austin: How that is associated with an abnormality of thyroid hormone?

Dr. Joshua D. Hornig: Excellent question, most thyroid nodules that need to be surgically removed aren’t functioning, so they are not producing thyroid hormone. So, usually someone has normal thyroid levels. There are nodules that are hyperfunctioning, that are producing lots of thyroid hormone and those in the vast majority of cases can be treated with medicines and do not need to go to surgery.

Dr. Linda Austin: After the surgery, how long do the patients have to stay in the hospital?

Dr. Joshua D. Hornig: Typically, when you have the endoscopic thyroid surgery, you would go home the same day. In the traditional way of doing the thyroid surgery, you would stay in hospital for several days. The other important difference is you do not need to have a drain placed. So, you go home. There are no extra stab incisions inside the neck. So, people just recover faster and look much better afterwards.

Dr. Linda Austin: You make it sound so easy.

Dr. Joshua D. Hornig: Well, every time we do these cases, I always grumble that we have made a moderately easy surgery into a very difficult one, but the benefit is always when the patient comes back to your office and they have recovered fast and almost looks like having done surgery. So, I always know that we have made the right choice when they come to see me.

Dr. Linda Austin: Tell us something about the training that you had to receive all of the years of training in order to be able to do this surgery.

Dr. Joshua D. Hornig: Sure, so, I have had 15 years of training to get to this point. This particular surgery, this endoscopic thyroid surgery when I was reviewing what people were doing and how to treat these patients most effectively and in the most minimally invasive way, there is one surgeon in Italy who is by far in a way the expert in the world and so, I actually went and studied under him for several weeks to see how he does this surgery and to bring these techniques back in United States. So, I did that in October 2006 and surgery is much like riding a bike. You can read about it as much as you want, but until you see it and actually do it yourself, there is really no substitute for that.

Dr. Linda Austin: Now when you say 15 years of training, spell that out for us.

Dr. Joshua D. Hornig: Sure, so that would be -- that’s four years of undergraduate work and then after that I received a four-year degree through a medical school. I spent a year doing research after that, and then five years of residency, and then two year of fellowship. I think that’s adds up to 15. I don’t know, I am not a math teacher.

Dr. Linda Austin: A long time as my uncle used to see more degrees in the thermometer I am sure at this point.

Dr. Joshua D. Hornig: Right, it was fun though.

Dr. Linda Austin: But very exciting to be able to offer that surgery, really it sounds like its groundbreaking surgery and fantastic that we can offer here in Charleston.

Dr. Joshua D. Hornig: Yes, we have had people flying from all over the country to have it done and we expect that to continue. It’s a really fabulous way of treating this disease and we hope that we will be able to train more people as part of our fellowship program, so it may be more and more people can benefit from this surgery.

Dr. Linda Austin: Dr. Hornig, thank you so much.

Dr. Joshua D. Hornig: It’s a pleasure being here.

Announcer: If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection at (843) 792-1414.

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