continued continued

Wednesday, October 05, 2005

Very Prolonged Painful Viral thyroiditis: Why No Physicians Treated Her Neck Pains

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Very Prolonged Painful Viral thyroiditis: Why No Physicians Treated Her Neck Pains

41 Y/O female developed a sore throat, and neck discomfort. This was followed by enlarging mass in the thyroid area on the left. The mass was tender to touch, and pain began in addition to tenderness. She saw an ENT physician who gave her antiboitics, and an allergy steroid dose pack for 5 days. The pain was gone, but returned when the pack was finished. The ENT did not continue the steroids. She continued to have pain, which was only slightly relieved with Motrin. She returned crying, when the pain and mass migrated to the other side of the neck. The ENT told her it could be cancer, and did a FNA. She screamed with each of 3 needle sticks. She was told it was not cancer. She indured the pain for 4 months with only slight relief from non-steroidals, and 2 other physicians she visited for opinions did not offer a solution to her pain. Her pain finally went away on it’s on, and she was euthyroid by 6 months.

She had a classic case of Viral Subacute Thyroiditis SAT. She became hyperthyroid first, TSH 0.01, and then hypothyroid TSH 6, and was normal TSH 2.1 by 6 months. Her goiter disappeared as well.

The only thing one can do for this type of patient is to relieve the pain! This was not done. The pain of SAT is quickly treated with Prednisone, and the dose may be needed for weeks to a few months. The band aid of a 5 day dose pack was inadequate to help her overcome the painful symptoms of SAT.

Also a biopsy is the last resort in this disease because it is very painful!

None of the physicians offered her prednisone or even an endocrine consultation to help treat her.


Thursday, September 29, 2005

Laser Thermocoagulation of Benign Solid Thyroid Nodules

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Laser Thermocoagulation of Benign Solid Thyroid Nodules: A New Therapy

We now put alcohol into recurrent cysts, as an alternative to surgery. Now there are studies published in Clinical Thyroidology 2003;15:11 on the effective use of another form of destruction of thyroid tissue. The use of a laser to “cook” the inside of solid FNA proven benign nodules that cause local symptoms in the neck, or appearance issues. Randomly assigned 30 females to Laser or no therapy for six months. The method involves Ultrasound Guided 18 G needle into the nodule.Then a o.4 mm wire is inserted into the center of the nodule.The needle is withdrawn.Then 2.5-3.0 W output power is given to the nodule. Vapor is seen in the area of the wire on ultrasound, and the area becomes hypoechoic. Two more 2.5-3.0 W outputs complete the therapy, for a total median energy of 2007 J.

The results:
The median volume decreased from 8.2 to 4.8 ml, while the volume increased from 7.5 to 9.0 ml in the untreated patients. A 44% reduction. The controls increased 9 %. There was a 53% difference between the two groups at 6 months. 7/15 in the laser group had neck pain, or tenderness for up to seven days. However, all would have the therapy again if needed. No serious complications occurred, such as vocal cord paralysis. 13/15 laser group patients had pressure symptoms before, and 10/13 had marked relief after the therapy. Cosmetic symptoms also decreased. There was no change in symptoms in the control group, even though the size increased an average of 9%.

Hegedus et al Eur J Endocrol 2005; 152:341-5

Dr Robert Utiger, editor of Clinical thyroidology, states that this seems to be a reasonable way to reduce nodules.
Even though the nodules did not disappear, they decreased enough to reduce symptoms and appearance problems. Usually symptomatic nodules were referred to surgery, but now this is a reasonable alternative.

Clinical thyroidologists will be offering this in the near future. Check to see if any are offering this now.


Recurrent Thyroid Cysts: Surgery or PEI ?

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Recurrent Thyroid Cysts Surgery or PEI

The standard therapy for a benign recurrent thyroid cyst is to remove it at surgery.
However, there are now alternative therapies for recurrent symptomatic thyroid cysts.
The use of alcohol injection, called Percutaneous Ethanol Injection PEI, have been very effective alternative to thyroidectomy. A 5 year study from Italy of 58 patients with cysts found about 90% had volume reduction. Baseline Volume was 13.7 cc, Ethanol injected 7.3 cc.Volume after 5 years was 2.3 cc. There were only 2 recurrences.
PEI is offered at centers around the country. Check for one near you. Go in for an evaluatuion to see if you are a candidate for this alternative to surgery.


Thursday, September 22, 2005

30 Year Follow Up of Toxic Psychosis Secondary to Hyperthyroid Graves’ disease

63 Y/O Female returns for her yearly examination, S/P subtotal thyroidectomy 30 years ago, for Graves’ hyperthyroidism, on T4 replacement therapy. Her story is amazing.

At age 33 she had a 50 pound weight loss, and severe anxiety to the point of admission for psychosis. While being treated on the Psych ward, a total T4 was drawn and was 20. n 4.2-12.
She was paranoid, and stated 3 men broke into her house. One of them was a well known
actor. People were talking about her outside her window all night. She was mad all the time, and lost her temper, and could not work. Her employer stated she was a very normal employee for 10 years with no sick days. She had other Sx of hyperthyroidism, such as tremo.. Smooth soft skin, muscle weakness, sweats, and palpitations. There was no FH of thyroid disease, but her dad killed himself after returning from army combat.

I saw her 10 days after admission, and she had a dull stare, drooling from the mouth, and a coarse tremor. She had smooth soft skin, pulse of 136, and a diffuse smooth goiter 2-3 times normal size.

She was on large doses of Thorazine. She was under the care of a conservator due to her acute
mental illness. She was considered an endocrine emergency, and under Inderal blockade, she had an uneventful total thyroidectomy. She was kept on Thorazine for 6 week post surgery, became euthyroid and was never treated again for mental illness.Not even a tranquilizer, for 30 years! She had a recurrence of hyperthyroidism 3 years later, that was treated with radioiodine, but there was no flare up of mental illness. She return to her job, and has spent the last 30 years mentally “normal”.
She had examinations by experts in mental illness after her recovery, and they found no abnormal thought processes. I have seen her twice a year since 1976, and she is a very normal lady.


Thursday, September 08, 2005

Tango and Thyroid

Well, I am off to Argentina in October to learn the tango, and have one of my thyroid cancer studies presented as an oral presentation at the International Thyroid Congress.
The LAC/Keck/USC Thyroid Cancer Group has a paper on the cancer marker thyroglobulin, TG. The study will look at the value of improved TG sensitivity in the long term followup of well differentiated papillary thyroid cancer.Some of our members are Carole Spencer, John Lopresti,and Peter Singer. On the way back, I stop in Dallas to attend the AACE’s New advances in the use of Ultrasound for thyroid. This will include interventional ultrasound techniques.


Wednesday, September 07, 2005

Thyroid Cancer Occuring with Graves’ Disease. Is it More Aggressive?

At LAC/USC Thyroid Conference, a patient was presented and discussed, who had papillary thyroid Cancer and newly diagnosed Graves’ Disease with hyperthyroidism. A paper from Italy was presented, and it claimed that the cancers were more aggressive in Graves’ patients. I discussed my experience with this rare combination. My 5 cases were not more aggressive than the typical papillary cancer. No one of the experts present had more than one or two cases to talk about.Prior studies have not always agreed with the more aggressive concept.

What can you do to make sure your Graves’ patient does not harbor a rare cancer as well?
Any palpable nodule needs ultrasound, I/123 imaging for cold nodules, and possible FNA biopsy. Ultrasound will find any non-palpable significant nodules, and it can help guide the needle into the mass.Significant nodules would be hypoechoic, irregular borders, vascular, and micro-calcifications. If the biopsy is suspicious or positive for cancer, than surgery will be the ideal therapy for both diseases. A rare medical “two for one”. After a 4-6 week course of anti-thyroid drug therapy total thyroidectomy needs to be done.


Tuesday, September 06, 2005

Thyroid Nodular Goiter in a Horse:Is it Cancer, or Just Too Much or Too Little Iodine?

I have treated two horses in my life with thyroid disease. In 1972, a physician friend ask me to look at her horse. It had recently been purchased, and was noted on arrival to have an enlarged thyroid gland. I felt a 3-4 times enlarged nodular goiter.The blood testing of T4 was very low. I first thought the horse was hypothyroid, but after consultation with vet endocrine experts, I was told the horse’s total T4 thyroid blood test will seem low by human standards, but the free T4 will be normal. The most likely cause was either a benign tumor, or enlargement secondary to either excess iodine in supplements, or iodine deficiency. There was no use of iodine supplements, so I diagnosed iodine deficiency.
Iodine salt lick was added to the horses diet, and the goiter markedly reduced in size.
The second horse had a large nodule, and after ultrasound studies , it was not consistent with a follicular tumor which is common in horses, but was more likely to be part of a diffuse goiter with a nodule. This time the owner did use kelp supplements,
which contained large amounts of iodine. Fortunately, with removal of the kelp, the nodular goiter reduced in size. Cancer of the thyroid is rare in horses.

Even horses can develop a goiter from excess or deficient iodine in their diet.
Humans in the USA, have a higher chance to develop excess iodine goiter from supplements, as iodine deficiency is rare in the USA.

My daughter’s horse, Casey, does not have a goiter, thank God, or I would have had to treat my third horse in 31 years!

I will stick to human thyroid disease, as horses can not tell me what bothers them.


Saturday, September 03, 2005

Free Questions Answered By “Ask the Thyroid Doctor”, for Katrina, and Flood Victims

Any thyroid patients in the New Orleans, Mississippi, or Alabama areas, who are displaced and wondering about the status of their thyroid condition, or about thyroid medications they are taking, you can get answers from The Thyroid Home Page. Just bypass the usual pay site that includes Paypal credit card section, and go to my email address: [email protected] Be sure to state you are a Katrina victim, as there is usual fee of $35 for all others, at the official “Ask The Thyroid Doctor” site on

Here is a two thyroid patient points to remember:

1. The thyroid hormone used to treat hypothyroidism is not an emergency hormone. You have several weeks to get a new supply, without serious effects.

2. However, the drugs used to treat hyperthyroidism such as Graves’ Disease have a short life in your body.Tapazole has an 8 hour half life, and PTU is even shorter. This means your condition will worsen after 1-2 weeks. If you are taking one of these drugs, please notify the nearest medical facilities you come to, that you need this drug refilled, if you lost them in the storm surge, or flood.

The Ask The Thyroid Doctor service has helped many thyroid patients get help all over the world. We want to help you. Please email me if you need thyroid help.

God Bless you all,


Anaplastic Thyroid Cancer Claims Chief Justice Rehnquist

September 3, 2005, After a 10 month battle with the most
aggressive form of thyroid cancer, he has passed away at home. The patients with his cancer usually live 3-6 months, but he battled the cancer for 10 months. He swore in the president for a second term. He continued on the court , when lesser men would have resigned. In October, we in the thyroid medical field predicted he had this lethal form of thyroid cancer. He did not have his thyroid removed, but only had a a hole put into his air-pipe to breath. This was the major clue he did not have much time left. He was able to continue to vote on cases before the court, and with difficulty swore in President Bush. He lived to see his clerk, Roberts nominated to the court.
He outlived every one of my own cases of anaplastic thyroid cancer, by 4 months! He was a brave man with a mission, and even a thyroid death sentence did not stop him, from achieving his last goals. No matter what your political goals for the new court, we need to salute his brave, and classy exit.

Bravo to the Chief


Monday, August 08, 2005

Iodine from Large Amounts of Kelp Causes Goiter Progression in a Young Lady

36 year old female is seen in consultation for goiter, referred by her family physician. Prior work up included an FNA that was read as colloid goiter. Ultrasounds have shown progressive enlargement. There is a family hx of goiter in a sibling.
She as a history of ingesting a large amount of iodine containing supplements. She eats seaweed, kelp, and powdered seaweed at each meal. Bilateral nodular goiter is noted on neck examination. TFT’s were borderline with TSH of 2.8 N 0.4-2.5,FT4 0.89 N 0.8-2.0 FT3 2.6 N 1.9-5.1 TG 154, TPO <10.1 TG AB <1,0. 24 hour urine free iodine was 3002 mcgs N 100-400.

The excessive use of iodine containing products such as seaweed will cause progressive thyroid enlargement as in this case.It can cause hypothyroidism in patients with autoimmune thyroid disorders, such as Hashimoto’s thyroiditis. Non-toxic goiters can become toxic goiters. Even a normal thyroid that has 1/2 left after lobectomy may fail under the pressure of high dose iodine supplements.


Saturday, July 30, 2005

Wilson’s Syndrome: A Bogus Thyroid Diagnosis Trips up another Physician

A physician Naturopath, was following E.Denis Wilson’s
methods to treat functional hypothyroidism in over 200 patients in a western state.
In 1994, he began treating a patient by online contact, with just a history form , and no physical examination from another western state. He sent instructions to take tempatures, and send them to him. After looking at the hx and temp. charts he diagnosed Wilson’s syndrome. He did not do any lab testing. He odered T3, cytomel which was sent via mail from his local pharmacy. By 1995, he was treating 100 long distance patients, via online,telephone, and mail.
T3, cytomel is normally used at doses of 25-75 mcgs. He gave up to 300 mcgs. 25% were on > 200 mcgs. Overmedication with T3, can be very dangerous and cause death. Even his claim that he saw tests from the patient’s primary care group was not factual, as the records release came after he started treating the patient. In 1992, Wilson was suspended and fined and has not returned to practice in Florida. He was ordered to receive metal health assistance as part of the order. His website is still up, and caught this naturapath, in it’s bogus web.
1998, the naturapath was fined $3,000, and given a 30 month suspension. He was ordered not to treat out of state patients, without a physical examination, and only with the help of tandem physician in the state of the residence of the patient. He had to submit to audits of his patient records for an additional 2 years after suspension.

The American Thyroid Association stated:
1.Wilsons is inconsistent with known facts about the thyroid gland.
2. Diagnosis is imprecise, using non-specific symptoms and body temperature.
3. T3 is no better than placebo in treating non-specific symptoms, of patients with normal thyroid hormone concentrations.
4.T3 results in wide swings in blood levels, and can produce symptoms, and cardiovascular complications in some patients, that can be potentially dangerous.

Wilson’s Syndrome as described by Denis Wilson is a bogus diagnosis, but there is a real Wilson’s disease , but it is a rare disease of copper metabolism.


Disciplinary actions: E.Denis Wilson MD #0048922
Longwood FL. 2/12/92 Board of Medicine 8(2):10,1992
FL.Depart. of Professional Regulations Tallahassee FL.

TSH, and usually T4, will be abnormal BEFORE you have symptoms of hypothyroidism. Throw away the thermometer, unless you need it for your child’s fever, mom!

Even with the new TSH upper normal of 2.5-3.0, you need to have the TSH > 5-10 before symptoms occur.


Thursday, July 28, 2005

Women Smokers have higher incidence of Graves’ Disease

115,000 women’s lifestyles were studied to see the effect on the incidence of Graves’ Disease. 543 women developed Graves’ Disease. Heavy smokers > 25/day, were 3 times more likely to develop Graves’ Disease. The rate decreased if they quit 10-15 years ago. However, even past smokers were still more likely to develop Graves’. Archives of internal Medicine, July 25 2005 vol.165, pp.1606-1611.

Now, besides worsening thyroid eye disease, we now know we have more Graves’ Disease in smoking women!


Monday, July 25, 2005

Overcoming Thyroid Problems: A Great New Book from Harvard Medical School Guide Series. A Book Review.

Dr.Jeffery R.Garber,assistant clinical professor, Harvard Medical School, and a fellow member of the Academy of Clinical Thyroidologists ACT,, American Thyroid Association ATA, and American Association of Clinical Endocrinologists AACE,, has written a thyroid patient book for the Harvard Medical School Guide series.
The introduction compares thyroid disease to the auto part you never heard of until your car breaks down. This is a good start. He has contact to the laymen, by this simple, but apt analogy.He states the thyroid is undervalued, and it is normal for patients, to not know it’s basic functions. He tells the reader thyroid works behind the scenes, and can effect every organ if it is malfunctioning. The only thing most people know is that thyroid failure causes obesity, and that is wrong.

The chapters are well written, and have great side bars.
An example is the one on Kelp, Myth or Fact:
The myth is that kelp is good for you if you have thyroid problems, while the fact is just the opposite, it can harm you. He includes excessive kelp or iodine under risk factors for hypothyroidism, nodular goiter, Hashimoto’s thyroiditis, and hyperthyroidism.
The use of the myth or fact approach is seen next in the thyroid medication section.No, it does not cause osteoporosis if the the dose of thyroid hormone is normal. No, hypothyroidism does not cause obesity. And, no, it is not a good therapy to cause significant long term weight loss. No, animal thyroid products, or T4/T3 combinations are not better than T4 alone.
The section on ultrasound for nodules is very up to date.
He describes changes seen on ultrasound that point to cancer, and the need for FNA. However, I think he needed to tell the patients, that ultrasound results depend on the person doing the examination. Clinical thyroidologists, doing their own ultrasound can yield better information to help manage patients with a the thyroid nodule.
The section on pregnancy is excellent, and a must read for pregnant thyroid patients.The need for iodine in prenatal vitamins, and the need to take thyroid hormone at a different time than the prenatals with iron. The present day feelings that ATD’s for treating hyperthyroidisms, can be given to breast feeding mothers is discussed.
Finally, he brings up the most important issues.
Who do you see about your thyroid problem? He talks about the thyroid surgeon with a high number of thyroid surgeries/ year, and the endocrinologist with extra training, and experience with thyroid problems. He calls them clinical thyroidologists. He talks about finding out if the physician sees a high percentage thyroid patients, and are less active in diabetic care. Because, the new clinical thyroidolgists society ACT, was just formed , he failed to put the thyroidologists website as a source of referrals to endocrinologists that practice 50-100% thyroidology. The site,, I hope will be listed in his revised edition in the future.

In conclusion, I will recommend this book to my patients,
and hope to see it become a classic in thyroid patient
literature.It is an excellent book, to give to all my new thyroid patients at the initial consultation. The book is available at the bookstore section on, or at It is worth the $14.95 retail price in the USA, $19.95 Canadian, or 8.99
English Pounds in the UK.


The Thyroid Home Page is First!

The Thyroid Home Page, the official website for Santa Monica Thyroid Center, was recently re-evaluated by a company that ranks websites by visitor traffic. They only rank the first 900,000 websites. Any lower ranking, is listed as “not ranked”. was ranked first for pure thyroid websites at 156,000.
Only was ranked higher at 47,000, but it had wider draw as it included all of endocrinology. American Thyroid Association,, was ranked 195,000, or second. Thyroid Foundation of America was not ranked, nor was Stats were not available for , because it was part of a large corporation website, AACE website was ranked 164,000, but it was a general endocrine website. Canadian Thyroid Website, was ranked 322,000.

Even though may be googled at 2nd through the 5th position, it still is the most visited pure thyroid website.

Thanks for all your support,


Wednesday, July 13, 2005

Visit to Ireland: Birthplace of The Physician who was one of the first to describe Hyperthyroid Graves’ Disease

We just returned from Ireland, home of Sir Robert Graves. He was born in Dublin in 1796. He graduated from Trinity College in medicine when he was 22. He was a dynamic fellow. In a severe storm when the ship he was traveling on, was about to sink, due to damaged pump values, he took an axe to the lifeboat, because he knew they would all perish in it.He then took over command of the ship, and using his own boot leather, repaired the pumps.He published “Newly observed afflection of the thyroid gland in females” in the London Medical Journal in 1853. He detailed the clinical features of what is now recognized as Graves’ disease, even though it was described earlier by Caleb Perry in 1825. It is remarkable that it is the one contribution that is most remembered today. Few call it Perry’s Disease today!

In 9 days traveling throughout Ireland, I did not see a single goiter.

My daughter rode horses in western Galway, and at Castle Leslie in the northern Irish Republic, she rode cross-country on the castle’s 1000 acre eventing course.

My Irish wife searched out her clans, the Delaneys, and McMonagles.
We found her family McMonagle homestead in Meenagoland,Donegal and the graveyard with 26 McMonagles in nearby Finn Town. There were 600 Delaney’s in the Kilkenny phonebook!

It is good to be back.


Friday, July 01, 2005

Ireland on Horseback: Sir Robert Graves, Here We Come

Well, it is the time of the year to get away from the
usual daily exposure to the many problems associated
with caring for thyroid patuents, and lay back and relax.
However, my 14 Y/O daughter A.J. is an eventer. That means she rides horses over fixed objects, such as stone fences, logs, and water holes. We are going to the land of Sir Robert Graves, one of the first physicians to describe the disease of hyperthyroidism. A.J. will be riding Irish Horses all across western Ireland, and will
then travel to Castle Leslie to jump 150 fixed sites in 5 days. Thyroid clinic is less stressful, than watching her, in a titanium helmut, and flack jacket, jump irsh stonewalls. However, because my wife is second generation 100% Irish, we will search for her roots in Donnigal,in Northwest Ireland, for the McMonigle homestead. We will also look in Killkenny for signs of the Delaney clan. I will research the exact location of the famous man who
has his name on one of my most common disorders, Graves’ Disease, I see in my center. It should be fun, if all goes well with my little horse mad daughter. Delaney, my wife, and a private chef,, will get a few cooking tips from Darina Allen. She is the most famous chef in Ireland, and has a cooking school just outside of Cork. We will stay in the Red Room at Castle Leslie on the last night in Ireland.
This is for me. I am half Italian from Umbria Italy.The Red Room is decked out in rare items from Umbria.
Paul McCartney was married there to his second wife.
I will return on July 13, 2005. I will post a blog, if I find anything about Sir Robert Graves.


Treating Hypothyroid Patients By Symptoms Alone. Trouble Brewing in the UK

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English Physician Diagnoses and Treats Hypothyroid Patients by Symptoms Alone. He Does Not Believe in TSH.

A private clinic in a large city in England treating 4000 patients
referred by GP’s for hypothyroidism, by symptoms alone. The physician
felt blood tests failed to diagnose hypothyroidism. He had testimonials
of dramatic cures, including shedding wheelchairs, curing depression, and severe lethargy. He defended his methods saying you could not rely on T4, TSH testing.
The British Thyroid Association and the General Medical council, considered removing his certificate to practice medicine, but due to no fatal outcomes recorded, they allowed him to continue to practice, but with restrictions. He was not to accept
referrals from GP’s that were not endocrine in nature. He was to inform the GP of the exact thyroid diagnosis, and thyroid therapy given. He also had to keep detailed records of all patients treated with thyroid hormone, who did not have modern thyroid testing proof, ie T4,TSH of hypothyroidism.

Beware of physicians who claim you are hypothyroid, when you present with symptoms, but
when your prior endocrinologist’s testing results were normal. Check to see if his new tests are normal also. Treating by symptoms for hypothyroidism is wrong.
The thyroid tests are always abnormal before symptoms occur.

This physician, although they allowed him to continue practice, with careful supervision, is at risk to do harm in the furtue. This will not be the last we hear about this clinic.

Be Safe,
It is a jungle out there!


Monday, June 20, 2005

A Rare Thyroid Disease in A Teenager

I recently saw a 17 year old high school student, and it reminded me of a patient I saw a few years ago with a similar problem. He had thyroid nodule 3 years before I first saw him. His Pediatrician sent him to see a pediatric endocrinologist. All thyroid tests were normal,except the TSH was slightly low. The Thyroid scan showed a “hot” Nodule, with suppressed thyroid uptake on the other side.The 6/24 HR uptakes were normal.He was followed 3 times a year. The nodule increased in size, the TSH decreased, and the T3 increased, but still in the normal range. Because the T3 was still normal, inspite of significant decrease in TSH, there was no therapy given. Finally, one year later the T3 was abnormally elevated.
The TSH was very low. He had increased resting heart rate in the 90’s. Again, there was no therapy for hyperthyroidism offered. He was seen again 5 months later, and the again the tests clearly confirm T3 Toxicosis. They considered surgery vs. radioiodine, but deferred to an adult endocrinologist. The reason they gave was they were not used to treating a teenager with Toxic Nodule, just Graves’ Disease.
There was no anti-thyroid drug, or beta blocker given. The tests again showed T3 toxicosis at the second opinion 4 months later. The recommendation was for surgery, but no therapy was offered. 3 months later he was still untreated, and referred to me.
He was 17. School grades were poor. He had poor concentration, and memory problems.He had sweats, felt jittery, and had palpitations, and lost 12 pounds from his normal weight.Also had symptoms of hypoglycemia, without diabetes. Mentally, He had nightmares, a short temper,and felt very tense.
PE: WT loss 12 LBS, BP 110/60 P 130 regular
With mild exercise up stairs the pulse increased to 180. Proximal muscle weakness, and a large visible mass on the right side of his neck. The U.S. showed a 5 cm mixed mass. It was 2.5 cm larger that 3 years ago. in benign thyroid nodules.The scan confirmed a hot nodule. The I/123 uptake was elevated at 60 % N 8-32%. My testing confirmed hyperthyroidism secondary to a toxic nodule. This is rare in teenagers. The T3 was elevated, TSH was non-detectable, and the T4 was upper normal.
He finally had surgery after 6 weeks, when he was euthyroid. He is doing well in college now.

The time between childhood and adulthood, can be a wasteland for teenage thyroid patients. His health, and schooling suffered because he had a rare disease, Toxic Nodule in childhood, which is common in older adults.There was never any therapy given to combat his hyperthyroidism, and only a plan for definitive surgery, or radioiodine was offered. He needed to be rendered euthyroid before surgery anyway, and even probably before radioiodine. Surgery is the therapy of choice for a teenager. A more rapid referral to adult endocrinologist, who is used to treating toxic nodules in the adult population, may have saved 2 years of reduced health and poor school grades.


Tuesday, June 14, 2005

They Changed Your T4 Brand at the Pharmacy. What happens to your health?

A Pharmetrics study of 196 patients who were switched to a different T4 brand, but at the same dose. Prior to the switch, the titration blood studies confirmed they all had normal TSH.


1. 35% had a change of TSH of less than 0.5. This may not be important, unless the patient had cancer, were even that small change could stimulate cancer cell growth. Also T4 suppression therapy for goiters may be impacted.

2. 20% had a change of TSH of 0.5-1.0. Again not bad except for suppression or cancer therapy.

3. 17% had TSH change of 1.0-1.5. Again major impact of cancer and suppression. But could also impact hypothyroid therapy.

4. 5% had TSH changes of 1.5-2.0 Major impact on cancer, goiter suppression, and some on hypothyroidism.

5. However, the big news was that 25% had TSH changes of >2.0. This has a major impact on all types of thyroid hormone therapy.

Do not let them switch you, and if they do, demand another blood test within 6 weeks from your physician.It is mandated to re-test if switched by 6 weeks.
Switching T4 products may result in harm to the patient without retesting.

Patients must be pro-active to secure safe, effective thyroid hormone therapy.


Monday, June 06, 2005

Recommendations for FNA of Non-Palpable Thyroid Nodules and Neck Lymph Nodes

At the first meeting of the Academy of Clinical Thyroidologists, the group produced a position paper on non-palpable thyroid nodules, and neck lymph nodes.

Here are the indications for Ultrasound guided FNA of thyroid
micronodules( 0.5-1cm):

1.History of radiation to head and neck during childhood.
2.Family history of medullary, or papillary thyroid cancer.
3.Micronodule in remaining lobe after hemithyroidectomy for thyroid cancer.
4.Hypoechoic micronodule with one of the following ultrasound findings.

A.Blurred margins
B.Intranodular vascularity
C.Taller that wide
E.Significant neck lymphadenopathy

Our indications for FNA of neck lymph nodes found in thyroid cancer patients

Any node >5 mm in height without a hilar line, and having one or more of the following characteristics:

A.Anterior-posterior/transverse ratio >0.5, in the transverse view.
C.Cystic Necrosis
D.Peripheral vascularity
E.Causes deviation of the internal jugular vien

We recommend all thyroid nodules >2 cm be biopsied, unless it is known to be “hot” on I/123 Iodine scanning.

Nodules 1.1-1.9 cm were felt to need biopsy, but the judgement of the endocrinoiologist was paramount in this decision. Some features such as comet tail, and hyperechogenicity were felt to be reasons to delay FNA, as long as there would be follow up obervation.

The full text of the position paper can be found found on
This includes references.
The work of H.Jack Baskin M.D., expert in thyroid ultrasound, was the driving force behind these recommendations.

Thank you,

Richard Guttler
The Thyroid Blog
The Thyroid Home Page

Thursday, April 28, 2005

Cancer Surgery Pre-Operative Lymph Node Evaluation is Important

With the new high frequency ultrasound machines, it is now possible to evaluate the lymph nodes in patients with proven papillary, follicular, or medullary cancer on FNA, prior to the surgery. This will allow the surgeon to add a lymph node removal to the total thyroidectomy and central compartment surgery.Here is a case.

61 Y/O female with FNA proven papillary thyroid cancer on USG FNA, returns for a pre-op neck US lymph node evaluation. There are 3 nodes located lateral to the primary thyroid cancer thyroid nodule. They are suspicious as they do not have hilar lines. These are found in benign nodes, and disappear in cancer nodes.There is chaiotic blood flow in the nodes, on power doppler. They are tall compared to width with a ratio >0.5. Biopsy was positive for papillary cancer, and the Thyroglobulin washings were positive for high levels of TG in the node. The surgeon was notified about positive nodes in zone 4 on the right lateral to the thyroid mass. He was advised to consider node removal along the whole right jugular chain at the time of the standard total thyroidectomy, and central compartment node removal.

What this means to patients with biopsy proven cancer, is that they need a diagnostic Neck lymph node ultrasound with new high frequency untrasound machines, and if a suspicious node is found, then an USguided FNA, and Cancer Tg washing should be done.
This will result in a change in the surgery if positive.


Wednesday, April 27, 2005

The Absent Thyroid Lobe or Thyroid Hemiagenisis

The last blog about a patient born with only half of a thyroid, was followed by questions of why, from emailers ?
Well, there are some 100 cases of failure to produce a thyroid lobe.Usually it is in a female, and 75% on the left lobe.There is a high degree of disease in the opposite lobe. The most common disease is Hyperthyroid Graves’. Absent thyroid lobe was found in less than 0.01% of 24,000 screened children. There is an even rarer type, that includes the isthmus. My patient had absent isthmus and left lobe. She also had a nodular cystic goiter in the remaining lobe. The past work up included thyroid scans before and after Bovine TSH Stimulation. Now the ultrasound allows early definitive diagnosis. Failure to know about this can cause patients to become hypothyroid after unilateral lobectomy. If the lobe is absent, the patient needs thyroid hormone therapy. Usually, if the lobe is normal, and present, the patient may not need thyroid hormone after lobectomy.


Tuesday, April 26, 2005

What Happened to the Left Lobe of my Thyroid?

40 Y/O female presented with a right side 2.5 cm nodule felt by her internist.She was euthyroid, with normal TSH, negative TPO antibodies. A large mass was visible from across the room. The left lobe was not palpible. The ultrasound confirmed the presence of a complex cystic mass. However, when we looked at the left lobe it was absent!
She asked me what happened to her left lobe, if she did not have surgery? This is a rare congenital defect. total absence of the lobe, plus isthmus. This will not impact the overall thyroid problem, but if she needs surgery, to remove the right nodule and lobe, she will be rendered hypothyroid, and will need to take thyroid hormone.Her work up for the nodule was negative, and she was treated with thyroid hormone.


Monday, April 25, 2005

Pregnancy Problems without Support from her Thyroidologist

32 Y/O female calls about her thyroid condition after 2 misscarriages. She is my patient, and was treated with radioiodine for Graves’ Disease 3 years ago.She was last seen 2 years ago, and stated she was seeing her internist for her thyroid hormone RX’s, and did not feel she needed to see me. During the last two years, she had two miscarriages. She a prior a prenancy which resulted in a healthy baby. The last one prompted her return for my opinion. She had elevated TSH when she last conceived ( TSH 7.0 ). She took prenatal vitamins which contained iron, at the same time as her thyroid hormone.She stated none of the other doctors, including her OB told her iron caused decreased absorbtion of the thyroid hormone,. and hypothyroidism. She also was never told that she needed prenatal vitamins with iodine during the pregnancy. However she was lucky, that the vitamins, called
Citracal had 150 mcg of iodine. She was never told of the potential danger of the Graves’ thyroid stimulation antibody, TSI, which can not hurt her, because she had her thyroid gland destroyed by Radioactive iodine, but could stimulate her baby’s thyroid, causing Neonatal Graves Disease. This is a rare, but serious disease she could pass to her baby. A blood test, which was never done in the two pregnancies, could have diagnosed this and allowed early therapy. I told her she was high risk, due to her Graves’ thyroid diease and therapy, and needed to be sure her TSH was normal 0.5-2.0, before conception. IQ and neuologic problems occur if you are hypothyroid at conception. Also 6 weeks after conception, there is a 20-50% increase in thyroid hormone needed during the pregnancy. Finally, The thyroid blood hormones need to be kept in the upper normal range, during the pregnancy, and 6 week post delivery, there is a lowering of the dose back to pre-pregnancy levels. She felt she did not need me during the prior pregnancies, but clearly realized she was wrong. I am monitoring her thyroid status this time.


Friday, April 22, 2005

40 Years after a Total Thyroidectomy, a thyroid nodule is found.

A 60 Y/O female, decides to have her thyroid re-evaluated,after her 2 children were found to have thyroid disease. She had her thyroid removed 40 years ago, and remembers they told her they left 1/16 of the thyroid.She also remembers that gland removed, was not harboring cancer. She took thyroid hormone for 40 years until her visit to see me, for replacement therapy, after the surgery.She does not recall any other therapy, such as radioiodine after the surgery. She had a 1-2 cm nodule in the right lobe.It was firm.There was a well healed thyroidectomy scar. He thyroid tests were normal, including TSH on LT4 therapy, and TPO antibody.
The ultrasound showed absent left lobe, but a right lobe with a nodule with coarse calcifications. The nodule had an irregular shape. Because of previous surgery, and the low risk situation, I elected to scan her with I/123. The right lobe was present with a cold nodule in the area of palpated mass. There was faint uptake in the left lobe. I elected to do an ultrasound guided biopsy of this calcified mass, because there was no way to get the medical records, pathology report, or slides from a 40 year old surgery in the southern state of Georgia. I expected the biopsy to be a remnant benign goiter nodule, or Hashimoto’s thyroiditis that had recently involved the thyroid tissue left after the original surgery. I was shocked to see papillary thyroid cancer staring up at me from my microscope!
This is a good lesson for us thyroidologists. If you can’t get the old records, including the original pathology report and slides, you must treat the case as a new case, and do a complete work up. The coarse calcification 40 years after her surgery was a red herring. She will have a pre-op neck lymph node evaluation, to see if the cancer has spread to her nodes, and will have a node biopsy if I find any suspicious nodes. This will add a node removal to the surgery. If the neck nodes are negative, I will ask the thyroid surgeon to remove the remaining thyroid,nodule, and clean out the central compartment.


Thursday, April 21, 2005

The Growth Hormone,DHEA, Bioidentical Estrogen, and Thyroid Hormone “Cocktail”

61 Y/O female was referred by her worried primary care physician.She had seen a doctor in Beverly Hills, who wanted to treat her with a cocktail of Human Growth hormone, DHEA, bioidentical estrogen, and thyroid hormone T4. He asked her to see me before starting the thyroid hormone. She has all the classic symptoms of hair loss, low body temp., fatigue, constipation, dry skin, and depression. The physical exam was normal. The thyroid was not enlarged, no nodules were felt. To complete the exam, a thyroid ultrasound was done to be 100% sure the thyroid was normal structurally. It was normal in size and sound wave texture. The thyroid tests were also normal, including TSH of 1.8 normal 0.4-4.0. The doctor in B.H. told her the symptoms were due to thyroid deficiency, even though the thyroid blood testing has always been normal, including 2 years ago when another alternative physician in Santa Monica gave her thyroid hormone for 6 monhs without an improvement in her similar symptoms. She told me the BH physician adds thyroid to all his patient’s hormone “cocktails”, even if all thyroid tests are normal. To help her to decide not to go back to that doctor, I even did an ultrasound to prove that she had a lovely normal thyroid that worked perfectly well.Taking thyroid hormone would not help, but could hurt her in the long run.Bone loss, and heart problems were a real possibility in her age group.

Remember, symptoms are non-specific, and must be confirmed by thyroid hormone blood studies.


Wednesday, April 20, 2005

Alcohol Injections for Toxic Nodule?

43 Y/O female with a long history of refusing surgery, or radioactive iodine for a toxic nodule, presents with information obtained from the internet, about alcohol injection to destroy her toxic nodule.She dose not want radioactive iodine or surgery.The mass is 5×4 cm in size.It is mostly solid. The TSH confirms hyperthyroidism, <0.01. I told her that her large non-cystic toxic nodule would probably be reduced in size with alcohol by 60%, but only 20% chance of a cure of her hyperthyroid state with a return a normal TSH. This is a poor form of therapy for solid toxic nodules. There is 100% success with surgery, or radioiodine in curing the hyperthyroid state,and reducing, or removing the toxic nodule.

It is vary hard for patients to read the medical journals, and plan a therapy course.
Most experts have given up using alcohol to treat solid nodules, and reserve it for cysts.Cyst therpy with alcohol,however, is very effective.


Tuesday, April 19, 2005

Medullary Thyroid Cancer with Low levels of Calcitonin years after the Surgery.Where is the cancer located?

Many patients have cancer marker for medullary thyroid cancer, years after the surgery. PET Scanning, MRI, CT, and Iodine scanning are usually negative. Where is the cancer?
A 52 Y/O female, 10 years after total thyroidectomy for medullary thyroid cancer sees me for a second opinion.She has a calcitonin of 35. Her pre-surgery calcitonin was 11,234. She knows she still has some cancer, but she is disturbed, that physicians can’t find it. Also, she has a mother with the same disease. However, she is afraid to have her kids screened for the disease, because she is worried, they wont be able to get medical insurance, if they are found to have the same cancer. Her neck examination was negative except for a thyroidectomy scar. However, I was able to find, with the new high frequency Italian Ultrasound, several abnormal tall nodes in Zone 4 lateral to the thyroid bed,that had the findings of suspect cancer nodes. Using modern ultrasound methods, a biopsy of the largest node was performed, and washings from the aspirate from the node was positive for calcitonin. The patient is having a lateral neck lymph node surgery soon. As for the 6 children, who have not been sceened for cancer, they have set up appointments for DNA studies to see if they have the gene for this cancer. If they have the gene, and are treated by total thyroidectomy before the cancer occurs, they will be cured, and will never have the cancer at all.
They will be able to have medical insurance coverage, as the diagnosis was pre-cancer.The ones with the cancer will be picked up early with the best prognosis for long term survival.

Remember,if you have cancer marker for thyroid cancer, thyroglobulin TG, or Medullary cancer marker, calcitonin, and all the studies are negative, you need a complete neck cancer lymph node evaluation by a thyroidologist with high frequency ultrasound equipment, to look for the location of your residual metastatic cancer, which is surely there in the neck.

Check, for one of our thyroidologists near you.


The Academy of Clinical Thyroidologists’ Website Launched


The temporary website for the new society of clinical thyroidologists is up with a list of thyroidologists from around the country that practice clincal thyroidology almost exclusively. The site is These physicians are meeting in Washington DC on May 22 2005 to begin the process of starting our society. The list is not complete, but will increase when we locate other clinical thyroidologist.These
physicians will be able to take care of any thyroid problem you may have. Visit them
for a thyroid evaluation soon.


Monday, April 18, 2005

What is the difference between a Diagnostic Ultrasound and one done to guide the needle for a thyroid biopsy?

45 Y/O male sees me today for a second opinion. He has a large thyroid nodule, noted on
Chest Xray, and CT scans. An ultrasound guided biopsy was done.They only looked at the nodule, to aim the needles. There was no diagnostic U.S. done. When I saw him, I did the diagnostic U.S. with the new high freguency U.S. from Italy. There were multiple abnormal nodes directly next to the nodule. Some had a cystic component. These were 7-9 mm tall.They are suspicious for metastatic papillary thyroid cancer, and need to be biopsed, and a washing taken for thyroid cancer markers. His HMO failed to do a diagnostic U.S. and set him up for surgery. It is necessary to know about the nodes, BEFORE surgery, as it can change the extent of the surgery.
Beware of rushed and incomplete evaluations at HMO’s, before they send you to surgery.
Anyone referred for thyroid surgery, should have a neck lymph node U.S. prior to the surgery, even when the biopsy is definitely positive for cancer. Positive nodes by node biopsy, will change the extent of the surgery to include central, and lateral neck node removal.


Saturday, April 16, 2005

Thyroid Surgery What are the risks?

Recurrent nerve injury accounts for 2-3% of medical legal claims in general surgery.
Identification of the nerve is a key to reduction in nerve injuries.

Nerves not identified during the surgery 5.2% nerve injury
Nerves identified during the surgery 1.2% nerve injury

Parathyroid Calcium damage 1-4% present incidence
This is due to these procedures at surgery
Routine idenification of the glands at surgery,
preserving blood supply, autotransplantation
of parathyroid glands damaged and without blood supply.

Experience of 50-150 thyroidectomies a year by the surgeon, results in the lowest complication rate.
Check out the surgeon before you sign up for the surgery


Who Should Do Your Thyroid Surgery?

60,000 thyroidectomies were performed in the US in 2002.
This is the most common surgery done, even more than hernia repair! Remember the volume of cases per year is a key factor in short hospital stays, and a reduced complication rate for coronary bypass surgery, transplants, value repalcements, and pancreatic cancer surgery. Well, it also applies to thyroid cancer surgery. During 1991-1996, in Maryland, the high volume thyroid surgeons, had the best results! The one surgeon that did 346 thyroidectomies over 6 years, or 60 per year had the best results! Thyroid Vol.15 #3 p.185-187, 2005
The range of complication rates reported.
Permanent Nerve Damage 0%-14%
Permanent Parathyroid Damage 1.2-11%

Where do you want to be after surgery?
I would want to be in the 0% or 1.2 % group, who took the time to research the surgeon before letting them put me under their knives.

Many HMO’s let any general surgeon, or ENT, or head and neck surgeon do thyroid surgery. Think twice before allowing this to happen to you.


Wednesday, April 06, 2005

Black Thyroid / A Rare Complication of Acne Therapy

No,this not some plot by the dark forces to invade the thyroid gland.
A 32 Y/O female presented with a cold nodule. The ultrasound guided biopsy was done, and when the slides returned to review, I was shocked to see all of the thyroid cells had black pigment granules in them. This was 4+ in every cell.The biopsy was negative for cancer, and was a colloid nodule. Years ago I did some research with a new drug called minocycline, Minocin R, and remembered it could cause black pigment in the thyroid gland in animal studies. I called the patient and asked her about acne therapy. She took Minocin for years for acne. The human cases with black thyroid are rare. Several cases were similar to this case, with black pigment in the colloid nodule. One had no pigment in the surrounding thyroid tissue, and the other had black pigment in the nodule, but also in the rest of the gland.There is no data about this pigment causing any functional problem of the gland.The exact cause of the pigment is unknown.


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