Thyroid nodules – when to be concerned…

The thyroid gland is situated in the front of the neck like a shield of a warrior protecting the windpipe or trachea which lies behind it. Indeed the word thyroid is derived from the Greek word for shield. The butterfly-shaped gland produces a hormone called thyroxine which is involved in the regulation of a variety of bodily functions. In essence, it controls your ‘metabolic rate’, so patients with low levels of thyroxine feel tired, lethargic and gain weight.

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Whilst those with high levels – a condition called thyrotoxicosis – suffer from ex300 sleeplessness, weight loss, palpitations and tremors.

The thyroid gland is prone to developing small lumps within it which are called nodules. These may appear gradually or suddenly. Occasionally they may be painful. Figure 1 shows a gland with several large nodules – a common condition known as multinodular goitre. About 60% of women will have a thyroid nodule present if they were to have

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an ultrasound scan of the neck. The vast majority of these nodules

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are benign but may require treatment if they cause swallowing or breathing problems. However, 5-10% of nodules may harbour a cancer and therefore require surgical removal. Trying to decide which 200-101 nodules are sinister is challenging.

Figure 1: A large 15 cm multinodular goitre removed from a patient. This had no cancer in it but caused swallowing difficulties

To decide if a nodule has a cancer within it, surgeons frequently use ultrasound scans and then take a small sample of cells from the nodule with a needle. Ultrasound can identify worrying features which signify cancerous change. There are now newer advanced applications such

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as elastography which help identify malignant nodules (see Figure 2). The cells sampled from a needle biopsy are analysed by cytologist to help make a diagnosis (see Figure 3). More recently, special molecular diagnostic techniques which identify point mutations in genes can help in the identification of malignancy. These include mutations in the BRAF and RAS genes.



Figure 2: Ultrasound scan of the thyroid gland utilizing elastography to identify sinister changes


Figure 3: Cells taken from a nodule are examined under a microscope. This is called cytology and gives a quick and accurate diagnosis

Once a nodule is deemed to be of concern, surgery is often advised. Surgical removal of the thyroid gland is known as thyroidectomy. If the nodule is clearly cancerous, the entire gland is removed in an operation called total thyroidectomy. This is a common operation, first performed by Professor Theodor Billroth in the 1860s in Europe. If the nodule has worrisome features based on the ultrasound scan or biopsy, some surgeons may choose to remove just half the gland first in an operation known as hemithyroidectomy or thyroid lobectomy. The nodule may then be sent for further analysis before the surgeon proceeds with further surgery.

The technique of thyroidectomy has evolved substantially. Technology has made this surgery safer and more effective. Amongst the more notable improvements is the use of nerve integrity monitoring which reduces the risk of nerve damage during which may affects the patient’s voice. The harmonic scalpel is another instrument which reduces blood loss from surgery and is associated with less pain following surgery.

The scar following thyroid surgery often heals well. Whilst it may appear unsightly initially, most people heal well and the scar is often imperceptible several months after surgery (see Figure 4).


Figure 4: The scar following thyroid surgery after 6 months

In selected patients, it may be possible to remove the thyroid gland using keyhole surgery (See Figure 5) or robotic surgery (see Figure 6) through the armpit. This clearly avoids the neck incision and is favoured by some women. It is best to seek the opinion of a surgeon if you wish to have this type of surgery.

Figure 5: Endoscopic thyroid surgery through the armpit. The author learnt this technique from Prof Luong (right) who is a leading authority on this approach

Figure 6: Robotic thyroidectomy using the da Vinci S system



Most patients survive thyroid cancer. The well differentiated cancer sub-types such as papillary and follicular thyroid cancer have very good outcomes. Figure 7 is the survival graphs from

a 10 year review of thyroid cancer at the author’s institutional practice. The average follow up period was 42 months. Survival was poorer for the less favourable sub-types such as Medullary and Anaplastic thyroid cancer

Figure 7: Survival outcomes in a review of 152 thyroid cancers treated at Tan Tock Seng Hospital, Singapore where the author is a Visiting Consultant

Preventing Major Amputations in Diabetic Patients without Major Operations



Having to undergo a major amputation like a below-knee-amputation (BKA) or above-knee-amputation (AKA) is one of the feared complications

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of Diabetes.

Patients with diabetes are at higher risk of amputations because of the damaging effects of diabetes on the patient’s nerves, arteries and immune (defense system against infection) system resulting in non-healing wounds can potentially lead to tissue death or gangrene

  1. Nerves: Patient losses sensations on his or her toes, increasing the chance of accidental injury to toes and


  2. Arteries: The blood vessels that bring oxygen and nutrients to the injured parts are often narrowed or blocked in Diabetes, making recovery almost impossible
  3. Immune system: With this affected, the non-healing wound can easily get infected leading to life-threatening infection (Sepsis).



2nd and 3rd toe gangrene

2nd and 3rd toe gangrene

Above Knee Amputation

Above Knee Amputation








This can be prevented by:

  1. Regular medical follow up with good control of diabetes
  2. Adequate day to day care of the foot with follow up by a Foot and Ankle Surgeon and adequate footwear advice from a Podiatrist.
  3. Screening to make sure the arteries to the foot are not blocked or narrowed. This is done by pressure measurements or ultrasound studies by trained personnel.


Once wounds occur, the body requires good blood supply to allow for healing at the area of injury. If the wound gets infected, antibiotics to fight the infection cannot reach the injured area if the blood vessels that carry them there are blocked.

In order to overcome this, something needs to be done to bring good blood supply to the area of need.

In the past, Vascular surgeons perform a by-pass operation to bring blood across the area of blockage. This is a major procedure requiring long inpatient stay and involving high risk of stroke or heart attack during the operation.


In the past decade, Vascular Surgeons increasingly are replacing this with the process of angioplasty or ‘ballooning’ (Endovascular Surgery). This procedure does not need General Anaesthesia, reducing the operation risks significantly. Patients usually only need to stay overnight for monitoring after the procedure.



Blocked Ankle Artery

Blocked Ankle Artery

Ankle Artery unblocked by Angioplasty

Ankle Artery unblocked by Angioplasty

It is hoped that with this procedure Vascular Surgeons can prevent major amputations in

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patients with less invasive methods

Contributing Specialist:

Dr Cheng Shin Chuen

Consultant Surgeon
FRCS Edin(Gen Surg)
Pacific Vein & Endovascular Centre
290 Orchard Road

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Chronic Ankle Pain – What could be the problem?


The ankle is a very complex joint. There are actually many small joints in the region of the “ankle”. One of which is the subtalar joint

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or “lower ankle joint”. Around the ankle are many tendons that runs from the leg to the

foot. These too can cause “ankle pain”.


A proper evaluation of ankle pain requires listening to the patient’s symptoms and then performing an examination of all the joints, tendons and ligaments. Sometimes, Xrays or MRI scan may be necessary to assist in confirming a diagnosis.


Treatment of ankle pain has advanced significantly. Many conditions

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which used to be less known and underdiagnosed can now be treated by minimally invasive surgery. The ankle can now be scoped (anterior and posterior ankle arthroscopy) from the front and also from the back. The tendons around the ankle can also be scoped (tenoscopic surgery). The subtalar joint can also be scoped (subtalar arthroscopy). Mini instruments have allowed us to treat many painful ankle conditions through “keyholes”. In my personal experience, the success of such surgery in improving the function of a damaged “ankle” ranges from 85 to 95%.

Ankle arthroscopy showing a “meniscoid lesion”. This is a fibrous “scar” that appears after an ankle injury that can get trapped in the joint, causing pain. Arthroscopic removal results in excellent pain relief.

Tendon scope (tenoscopic surgery) on the ankle. My published personal results

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This topic is courtesy of:

Dr. Chong Keen Wai

The Ortho Klinic

Gleneagles Medical Centre

Suite 08-01

6 Napier Road

Singapore ( 2588499 )

Clinic Tel: +65 64738826

Email: [email protected]