BackTable / VI / Podcast / Episode #182
Thyroid Nodule Ablation
with Dr. Tim Huber
Dr. Aparna Baheti talks with Dr. Timothy Huber about performing thyroid nodule ablation procedures, including patient selection, technique pearls and pitfalls, and how to incorporate the procedure into your practice.
BackTable, LLC (Producer). (2022, January 28). Ep. 182 – Thyroid Nodule Ablation [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Tim Huber
Dr. Timothy Huber is an interventional radiologist at Oregon Health & Science University in Portland, Oregon.
Dr. Aparna Baheti
Dr. Aparna Baheti is a practicing Interventional Radiologist in Tacoma, Washington.
In this episode, interventional radiologist Dr. Tim Huber and our host Dr. Ally Baheti discuss the process of thyroid nodule radiofrequency ablation, including patient selection, workup, procedural technique, and follow up.
Dr. Huber describes the most common indication for ablation, which is the presence of benign thyroid nodules that cause compressive symptoms. These can affect quality of life when they restrict a patient’s ability to swallow, breathe, and speak. He recommends ablation for symptomatic nodules that are over 2 cm in diameter. Dr. Huber also mentions functional nodules as more challenging cases, but still treatable with ablation. Though ablation for thyroid malignancies is rare, it is a field of active and growing research.
In his workup, Dr. Huber uses ultrasound to assess nodular composition, vasculature, size, and nearby enlarged lymph nodes. Next, he obtains two benign fine needle aspiration samples and checks TSH levels before proceeding with ablation. During the procedure, he anesthetizes the skin of the neck with lidocaine, and periodically checks in with patients about pain level. Dr. Huber describes his “trans-isthmic approach” that keeps the needle as stable as possible. He exercises caution when ablating near the “danger triangle” containing the recurrent laryngeal nerve which innervates the vocal cords. While ablating posterior to anterior, Dr. Huber tracks echogenic changes on ultrasound.
After the procedure, patients are monitored for one hour and then followed up in one month, and then three months over the next year. Dr. Huber warns interventionalists that post-ablation zones may look disfigured on ultrasound, but this will revert back to normal within 3-6 months.
European Thyroid Association Guidelines:
Korean Society of Thyroid Radiology Guidelines:
[Dr. Aparna Baheti]:
And then how about a location of the thyroid nodule? You've already kind of spoken about the ones that go below the sternum, but how about the just deep, deep nodules? Are you allowed to ablate those?
[Dr. Tim Huber]:
So really you shouldn't be ablating, anything that you can't see. So as long as you can see the nodule, or at least the portion nodule that you're ablating, that's fine. But if there's a portion of nodule that is just too deep for your ultrasound unit to kind of register clearly or to see the tip of your electrode well, then I would stay away from that, but that's really the only sort of limit.
[Dr. Aparna Baheti]:
Okay. Could you touch a little bit on the danger triangle? I remember Dr. Park always talking about that way when he talked about thyroid ablations.
[Dr. Tim Huber]:
Yeah. So there's a term, they throw around in the thyroid literature that you'll see if you start reading the papers, and they it called the danger triangle. And basically it's where the recurrent laryngeal nerve lives. And basically it's a triangle that's bordered by the thyroid gland and the trachea. And so we know that's anatomically where the recurrent laryngeal nerve is going to be, and that's basically the big concern during most thyroid surgeries that you ding the recurrent laryngeal nerve and paralyzed vocal cord. So when we do the technique that we, recommend it's this trans-isthmic approach that we talk about, and that's kind of going from a medial to a lateral approach with your electrode. It makes it really, really hard, I find, to direct the tip of my electrode back into that danger triangle. So when Dr. Beck was developing this in Korea, he sort of thought of that and kind of developed it in this way to prevent damage the recurrent laryngeal nerve.
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