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BackTable / ENT / Podcast / Transcript #139
Podcast Transcript: Radiofrequency Ablation: Modern Management of Thyroid Nodules
with Dr. David Goldenberg
In this episode of BackTable ENT, Dr. Gopi Shah and Dr. David Goldenberg, head and neck surgeon and department chair at PennState Health in Pennsylvania, discuss radiofrequency ablation (RFA) of thyroid nodules. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Introduction to the Evaluation & Management of Thyroid Nodules & the Role of Radiofrequency Ablation (RFA)
(2) RFA for Thyroid Nodules: Procedure & Techniques
(3) Evaluating Candidates for Thyroid RFA: Risks & Criteria
(4) Complications in Thyroid RFA
(5) Thyroid RFA Aftercare: Pain Management, Follow-Up, & Reablation Insights
(6) Treating Bilateral Thyroid Nodules & Addressing Potential Recurrence
(7) Building Skills in RFA: Training, Equipment, & Guidelines Explained
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[Dr. Gopi Shah]
Hello, everyone, and welcome to the BackTable ENT Podcast where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice. My name is Gopi Shah and I'm a pediatric ENT. I have a very special guest, a returning guest on our show today for a really, really awesome episode.
I have Dr. David Goldenberg. He's professor and chair of the Department of Otolaryngology at Pennsylvania State University in Hershey, Pennsylvania. He's a head and neck surgical oncologist. You may have heard him on BackTable ENT Episode 35, Thyroid Nodules, and episode 85, Surgical Management of Parathyroid Disease. Dr. Goldenberg is here today to talk to us about radiofrequency ablation of thyroid nodules. Welcome to the show, David. How are you?
[Dr. David Goldenberg]
I'm fine, Gopi. Thank you very much for having me back again.
[Dr. Gopi Shah]
Thanks for coming on. For our listeners who may not know you, can you tell us a little bit about yourself and your practice?
[Dr. David Goldenberg]
Sure. I'm a head and neck surgeon at Penn State Health and Penn State College of Medicine in Hershey, Pennsylvania. A lot of my practice and research and education efforts center around thyroid and parathyroid disease, and thought it natural that we talk about the newest intervention kit on the block, which is radiofrequency ablation of thyroid nodules.
(1) Introduction to the Evaluation & Management of Thyroid Nodules & the Role of Radiofrequency Ablation (RFA)
[Dr. Gopi Shah]
That's great. Before we get into the newest intervention, can we set the stage, just a brief overview for evaluation and management of thyroid nodules, just setting the stage?
[Dr. David Goldenberg]
Before performing any intervention on thyroid nodules, there needs to be some comprehensive workup to ensure that patients are safe and appropriate for whatever procedure we're doing. Typically, we talk about medical history and physical exam just like any other illness or any other syndrome or any other issue. We want to make sure of pre-existing medical conditions, medications, allergies, et cetera.
Oftentimes, we get imaging studies when it comes to thyroid. Typically, that is an ultrasound, which is the imaging modality of choice. Oftentimes, we'll get thyroid function tests at the very least a TSH level. Many times, patients are sent to us with these values already in their chart. Patients may have had a final aspiration biopsy or a core biopsy. Sometimes we need to send them for that. Other laboratory tests, in some cases, auto-antibody testing for inflammatory conditions, patient's evaluation perhaps for anesthesia, and obviously, the discussion of the risks and benefits.
[Dr. Gopi Shah]
When we think of a patient that presents to you with thyroid nodules, you have the ultrasound and depending on how big it is, symptoms, you decide to get an FNA. That's still part of your management?
[Dr. David Goldenberg]
Yes. FNA is paramount for evaluating whether the patient has benign or malignant disease, and that's typically why we get it. It's both highly specific and sensitive, and it's the cornerstone of interventional treatment of thyroid nodules, whether it be surgery or radiofrequency ablation.
[Dr. Gopi Shah]
When I think of before radiofrequency ablation, I think of, we get the FNA, if it's benign, and the patient's asymptomatic, then we may watch them in that pathway. If we're not sure, or if they're symptomatic, or if there's a concern for malignancy, we think of a surgical pathway. How does radiofrequency ablation work for a thyroid nodule and where does it fit into the algorithm now?
[Dr. David Goldenberg]
You put it exactly the way it was up until now. If it was benign, it was either watched or removed depending on whether it was bothersome or worrisome. If it was malignant, it was part of a surgical algorithm that the very least would be removal of a lobe and at the very most, total thyroidectomy and a variety of lymph node dissections. RFA is typically used for benign thyroid nodules, that's first of all, either cystic or non-cystic, sometimes for goitrous lesions, for autonomously functioning thyroid lesions, and nodules that are growing and symptomatic.
Symptomatic means they're causing compressive symptoms to swallowing, to comfort, to breathing, or they are a cosmetic concern for the patient. There is a potential application for micropapillary thyroid cancers which is being evaluated as we speak and is used in other parts of the world. That's where RFA fits in. Oftentimes, patients will come specifically asking because they do not want to have surgical intervention but the nodule is bothering them in some way.
[Dr. Gopi Shah]
When this is sort of on the table as an option, is there a certain size that's too small for this or how do you decide who's going to be a good candidate?
[Dr. David Goldenberg]
We typically say larger than two centimeters. If they exhibit increase in size, I have to be convinced that their compressive symptoms are being caused by this. As you well know, patients sometimes will have compressive or what they call compressive symptoms or cough or issues that may be attributable to other things including something as benign as laryngeal reflux, but in their mind, their thyroid nodule is causing it. When you look at the nodule, it's half a centimeter, it's obviously not causing it.
In those cases, it's very important to have a discussion with the patient and explain to them what other issues can be causing their symptoms. Obviously, for them, radiofrequency ablation would not be appropriate.
[Dr. Gopi Shah]
Who's doing the radiofrequency ablation? Is this something otolaryngologists are doing? Is this the interventional radiologists who's actually performing the procedure?
[Dr. David Goldenberg]
Yes to all of those. Endocrinologists are doing it, otolaryngologists, head and neck surgeons are doing it, endocrine surgeons are doing it, endocrinologists are doing it. It doesn't really matter as long as the doctor who's doing this is trained and the most important thing is they have to be facile with interventional ultrasound. They have to be very comfortable with ultrasound anatomy because this is done under continuous ultrasonic guidance with the tip of the needle being visualized the entire time to keep it safe.
[Dr. Gopi Shah]
Are patients able to have radiofrequency ablation for more than one nodule at the same time?
[Dr. David Goldenberg]
They can. Usually, if a person has more than one nodule, we'll see which one is the one that is causing an issue and target that first and foremost. The idea I think would not be-- Each one of these takes about 40, 45 minutes. Most patients tolerate really well. Typically, I guess most of my patients have had one ablated at a time. Yes, that's typically the way it's done.
(2) RFA for Thyroid Nodules: Procedure & Techniques
[Dr. Gopi Shah]
Are the patients under general anesthesia, sedation? Is this in the OR, the clinic?
[Dr. David Goldenberg]
We do this in the clinic. The patient receives local anesthesia, regional anesthesia, cervical block, and some sedation, but it's done completely awake in clinic. I ask that they have a driver and they go home right afterwards. Yes, it's very convenient for the patients.
[Dr. Gopi Shah]
David, can you go into what you're using for your local, regional cervical blocks, and then the steps to perform those blocks?
[Dr. David Goldenberg]
First and foremost, the patient is given 0.5 or 1 milligram of Ativan prior to the procedure. The procedure itself is not painful, but I do say that it is intense because I am leaning right over their face and their neck while they're awake with a big needle in their neck and an ultrasound probe in the other hand. What we do is we give a local anesthetic in the midline over the isthmus of the thyroid with lidocaine. Then we make a small stab incision with an 11 blade.
Then under ultrasonic guidance, using a spinal needle, we insert the needle in between the strap muscles above and the capsule of the thyroid gland below, and then we use the lidocaine to hydro-dissect and basically anesthetize the capsule of the thyroid gland. Once that's done, the radiofrequency ablation probe is inserted through the stab incision through the isthmus of the thyroid. From there, it's placed inside the nodule that we're going to ablate.
The heat that's produced by the electric tip causes tissue necrosis and fibrosis, introducing a high-frequency alternating current, raises the temperature to 60 to 100 degrees Celsius. We use something called the moving shot technique. We work from medial and deep to lateral and superficial, and we constantly move the radiofrequency ablation probe. I say that because radiofrequency ablation is not a new technology. For the decades, it's been used for liver tumors and for pain management. Originally, when it was first used, they would place the radiofrequency probe in the middle of whatever lesion they were going to ablate and turn on the heat and just leave it there and let it heat from the inside out. That's not what we do with thyroid.
Here, what we do is we keep on moving the needle to make sure that we get all of or as much of the nodule ablated as possible, but also so that we are able to continue to see what it looks like and the ablation does not obscure the rest of the nodule. This way we get a really good ablation, and then it will scar down and the body will remove a lot of this necrotic tissue.
[Dr. Gopi Shah]
Going back a step, when you do the local, anhydrous dissection with the local, you're doing that under visualization?
[Dr. David Goldenberg]
The local anesthetic, where we put it just under the skin, we don't need that, but once I've made the stab incision where the local is placed, which is usually in the middle of the neck over the isthmus of the thyroid, tiny little incision, then a spinal needle is used under ultrasound visualization in between the strap muscles above and the thyroid capsule below it. Then the lidocaine is injected in between those two layers, and this is how we anesthetize the capsule of the thyroid gland.
[Dr. Gopi Shah]
Then you said when you put the RFA needle in, your ultrasound probe is visualizing the nodule the whole time so that you can see the needle?
[Dr. David Goldenberg]
At all times.
[Dr. Gopi Shah]
At all times, and you're going and moving the needle as you ablate from medial and deep to lateral and superficial. As you do that, are you holding it for like one or two seconds-
[Dr. David Goldenberg]
Yes, yes.
[Dr. Gopi Shah]
-and then taking incremental-- Is there a pedal and then you're holding it down the whole time, or do you have to start, stop, start, stop?
[Dr. David Goldenberg]
You have to start, stop. It's under direct visualization. You can actually see as the changes in the thyroid at the tip of the needle, sometimes it bubbles and pops and you'll see this white trail. In addition, you're able to look at the impedance on the machine. If the baseline impedance for where you are in the nodule suddenly jumps, what that means is that area has already been ablated and we move on.
[Dr. Gopi Shah]
I see. Do you have to adjust your ultrasound hand at the same time a little bit? Because the nodules--
[Dr. David Goldenberg]
At all times.
[Dr. Gopi Shah]
It's dynamic. You have to --
[Dr. David Goldenberg]
It is very dynamic.
[Dr. Gopi Shah]
How do you know when you've ablated enough? Are you going to see, "Okay, 50% of it looks like it's shrunk now and we're good?" How do you make that call?
[Dr. David Goldenberg]
There's obvious sonographic features that guide the operator in real time. Microbubbling, as I explained, and the increase in the general impedance as the tissue stiffens, which is an indication of coagulative necrosis. What we're trying to do is approach the tissue in subunits from the deepest to the most superficial so that we don't obscure ourselves. What you see is these white tracks where you have ablated. It's very, very obvious. Once you've finished ablating, then I will go from a transverse view to a lateral view to make sure that I have hit all the levels.
Now, there are important areas that you want to avoid. For instance, at all times, you'll see the carotid artery, and at all times, you'll see the danger triangle, which is the area where the recurrent laryngeal nerve is tethered to the trachea, close to the posterior medial aspect of the thyroid gland. In those areas, I typically do not ablate because of the risk to the patient.
(3) Evaluating Candidates for Thyroid RFA: Risks & Criteria
[Dr. Gopi Shah]
I'm glad you talked about risk, and I wanted to next talk about patient selection. Are there certain nodule characteristics where you're like, "Hmm, this may not be a good candidate because the nodule's in the danger triangle, or I have to worry about the recurrent laryngeal nerve?" Tell me some of that when you have to think about the nodule and if this is a good candidate for radiofrequency ablation.
[Dr. David Goldenberg]
That's--
[Dr. Gopi Shah]
Do you just not put your needle in so deep for that one?
[Dr. David Goldenberg]
No, no, no. There is something to be said about-- It's really important patient selection just like any other procedure. It's really important that, first and foremost, that the patient wants to have this done. Usually they seek me out to have this done. I have to evaluate them first to make sure that they're appropriate candidates from what they have and what their expectations are. I explain to them, for instance, that this does not shrink overnight. As a matter of fact, it may swell up a little bit the next day from the work that I've done, and that the body has to evacuate the necrotic tissue for this to shrink.
Patient expectations, I guess there are certain ultrasonic characteristics which may make this more difficult. That would be patients who have large coarse calcifications, patients who I suspect that the lesion is malignant. Sometimes you'll have patients who they're looking for an answer and sometimes it's not really the answer they want to hear. Uncooperative patients, for instance, it's very important to make sure that you have a patient who is not cognitively impaired, someone who will cooperate. Cooperation means lying still and notifying me if they need to swallow because there's a large needle in their neck.
Actually, we give them a little squeaky ball if they need to swallow. Sometimes you'll have patients who it's very difficult for them to comply with. Obviously, patients who have allergies or reactions to anesthesia, those would not be favorable patients.
[Dr. Gopi Shah]
What about patients with high BMI or a bigger neck? Any concerns with like, "Do you need the neck extended," or if they have C-spine issues, anything like that may make you say, "I don't know if this is going to be a good procedure for you?"
[Dr. David Goldenberg]
Absolutely. That's a great point. I have done patients with issues with their C-spine and I've done morbidly obese patients as well. The discussion is had up front. Just like before I do thyroid surgery, I always check a patient's ability to hyperextend and also to tilt their neck because sometimes when a nodule is close to the clavicle, all you need them to do is turn their head in the opposite direction to bring it out. I do have patients hyperextended like thyroid surgery, and when they're awake, it's a lot less tolerable than when we have them doing so for a thyroidectomy when they're asleep.
Morbid obesity, I've not found these to be issues with patients. Typically, I can always use a probe that has a greater depth. It has not been an issue.
[Dr. Gopi Shah]
In terms of the nodules that are by the clavicle or near the sternum, is there any contraindication or does it just make it more difficult? Are you still able to get those that are, right at the sternal notch? What do you need to make that nodule work with RFA?
[Dr. David Goldenberg]
They're evaluated. Remember, all these patients, before they are found to be appropriate for RFA, they all have ultrasounds, which I view personally, and they all have at least one benign biopsy. That's really important. If I'm comfortable that we can do this, then it's fine. I've had patients who came to me who have a retrosternal goiter, most of it in the mediastinum, and I tell them, "This is not appropriate for you."
Sometimes people understand and they just undergo a surgical procedure with me and they get the result that they need. There are sometimes patients who they'll go find someone else because they don't like the answer they hear.
[Dr. Gopi Shah]
You mentioned large calcifications, you mentioned malignancy, is there ever a role for radiofrequency ablation? You said potentially for the microcarcinomas?
[Dr. David Goldenberg]
Yes. It's a great question, Gopi. The contraindications for RFA would be large malignant nodules, unsuitable nodule characteristics like we discussed, whether it's too close to a blood vessel or a nerve and it's unsuitable. Pregnancy, I don't think that we should be doing this on pregnant patients. It's certainly usually not an urgent issue. As you know, obviously, thyroid nodules will fluctuate during pregnancy, and after pregnancy, and lactation, et cetera.
Actually, active infection, which is not something I've seen, severe bleeding disorders, and uncooperative patients or patients who have cognitive impairment of some kind. Those would be your contraindications, but there is a role, a growing role for microcarcinomas. This is done routinely in Brazil and Korea and there's a clinical trial going on here in the United States.
I would feel comfortable doing a microcarcinoma if it was in the right place and in the right patient. For that, they would totally destroy the nodule. The rationale being that there are patients who are undergoing active surveillance. Most of my thyroid cancer patients, I continue to watch anyway. These are patients who would just be watched very closely with serial ultrasound.
[Dr. Gopi Shah]
Some of your recurrences. You've already done surgery, for example, papillary thyroid cancer, and now we have a recurrent nodule. Any role for recurrent RFA and recurrent lesions?
[Dr. David Goldenberg]
Again, abroad, there are people who are doing that. There are people who are doing parathyroid lesions. I personally have not done those and I guess I would personally-- I would look at recurrent cancer very skeptically given the fact that if it's a recurrence, is that the only area? I'm not really sure. It's not something that I would feel comfortable doing at this point in time.
(4) Complications in Thyroid RFA
[Dr. Gopi Shah]
In terms of complications from RFA, we talked about the danger triangle and having heat close to the recurrent laryngeal nerve. When you counsel patients on a potential voice injury, or recurrent laryngeal nerve injury, how do you counsel them? What other potential complications do you counsel the patient on?
[Dr. David Goldenberg]
Complications for RFA are similar to those for thyroid surgery, but they occur at a lower rate. We're actually doing a study right now, which hopefully will be ready this year, looking at complication rates and comparisons. Obviously, you have vocal cord paralysis, bleeding, infection, and damage to surrounding structures in the neck. There are reports of Horner syndrome.
Like I said, the complication rates are lower in the literature and there are some complications, for instance, that I don't know of any descriptions of a thyroid hematoma. A thyroid hematoma after thyroidectomy or a hematoma in the central compartment after thyroidectomy is life-threatening because you have a large bleed in an area near the airway. I don't know that this really occurs with RFA. The thyroid is still in situ and I've not seen or read about any severe hemorrhaging or hematomas. I have not read about thyroid storms, but I would just say that they have similar complications, but to a lower degree.
(5) Thyroid RFA Aftercare: Pain Management, Follow-Up, & Reablation Insights
[Dr. Gopi Shah]
They come in, it's about 45 minutes. What are your post-op instructions? You had mentioned that sometimes they can swell back up a little, their neck can have a little swelling afterwards. Do they have to do warm compresses? Is there any reason for antibiotics?
[Dr. David Goldenberg]
No, we typically don't treat. It's a clean, sterile procedure. I do not give antibiotics. Their pain, I typically will put a little bit of ice on the neck. Their pain is controlled typically with non-steroidal anti-inflammatory drugs. I've not had any patients who have had any need for anything further than that.
[Dr. Gopi Shah]
When do you see them back? Do you see them back in a couple of weeks? Is it like before their next ultrasound in a couple of months?
[Dr. David Goldenberg]
We typically check up on them that week to see how they're doing. When I first started, I was getting ultrasounds at 3, 6, and 12 months. Now I get them at 6 and 12 months. Since I've been doing this, and until recently, I'm the only person in the Commonwealth of Pennsylvania doing it, I have people traveling from very far away. I don't want it to be a hardship for them to have to travel back for me to say, "Hey, how are you doing? I'll feel your neck."
We typically do it at 6 and 12 months. If they come from far, I'm agreeable to them getting an ultrasound in their home location as long as I can get my hands on the actual images, and then we assess it. Typically, we like to see a reduction of 50% to 80% at a year. It's very important that the patients, again, understand this does not occur overnight.
[Dr. Gopi Shah]
A good result is 50% to 80% at a year. Let's say the size has gone down 50%, but it was really big in the beginning, and maybe they still have some dysphagia or compressive symptoms. How often do you have to go back and reablate or are there risks associated with that?
[Dr. David Goldenberg]
No, you can ablate more than once. I've done it on, I believe, two occasions. One is someone who had a huge partially cystic, partially solid nodule, and a lot of it reaccumulated in both of these. It just had a lot of islands that were secreting. I had one patient who after one time opted for surgery and I did that. It does not preclude you from doing it again if necessary. It's usually not necessary. When it is necessary, it's in patients who have really huge nodules. When I started patient selection, I tried to be very, very careful when I was doing patients with really large nodules. Those are the patients who need to have it done a second time typically.
(6) Treating Bilateral Thyroid Nodules & Addressing Potential Recurrence
[Dr. Gopi Shah]
For patients that have bilateral big nodules or an extensibility, do you do both sides at the same time?
[Dr. David Goldenberg]
I don't do them at the same time. To be honest, I'm trying to remember if there's anyone who I've done more than one. Typically, that's not the issue. There is one that is the offending nodule. I'm sure you can do it twice. I'm trying to think offhand. I don't remember if I've had patients who have asked or needed it done, but it's possible. I probably wouldn't do it at the same time just because like I said, it's intense and for patient comfort.
[Dr. Gopi Shah]
In terms of recurrence, let's say you got a good result. It shrunk down. The nodule shrunk down 80% or asymptomatic. It's small. Do these nodules tend to regrow or get big again?
[Dr. David Goldenberg]
I guess you and I will both have to stand by for an answer to that. So far, I've not had any. I've only been doing this for about maybe three years now, so I've not had any who have regrown again, except for this nice patient who had the cystic. I had to go back for that one.
(7) Building Skills in RFA: Training, Equipment, & Guidelines Explained
[Dr. Gopi Shah]
Just going back in terms of how you got training in this, you said that the person who's the operator, the person that's performing the procedure has to be very facile with the ultrasound. Tell me a little bit about that. Then where do you have to do a course? How do you get skilled at this?
[Dr. David Goldenberg]
I've been doing ultrasounds for many years. I was an ultrasound instructor for the College of Surgeons. I've been comfortable with ultrasound for a long time. When radiofrequency came up, I was going to travel abroad to get trained. Then our friendly neighborhood pandemic arose and travel was precluded. I bought the machine, I practiced on phantoms. Then when we had our first two cases, I brought up a former mentor of mine, then at Johns Hopkins, and he came up and he watched me do a couple of cases, and that was it.
Are there courses? Now there are. We just put on a very successful course at Penn State in June of last year. Hopkins also has a course, John Russell. I don't know how many courses there are in the United States. There are in Korea and in Brazil every now and again. Courses help and watching videos, but it's like any other procedure that you and I do. How are you taught? You learn the technique, you make sure that you can serve your patients and be safe and feel comfortable doing it. You make sure the patient understands. When I did my first, second, third, fourth, I told my patients, "You're my first, second, third, fourth," and they understood that.
[Dr. Gopi Shah]
Was it difficult to get the equipment? Did you have to get buy-in from your hospital? Tell me a little bit about that. Can you share the equipment? Is this something that's shareable?
[Dr. David Goldenberg]
You always have to have buy-in, always, always, always. The piece of equipment is not that expensive. Some institutions will already have a version of it because a lot of people, like I said, this is not new technology. While I didn't ask specifically, I'm pretty sure that my institution does this for the liver and for pain management, and they probably have that equipment. Like I said, ultrasound, we've been doing for a very, very-- Interventional ultrasound, my department does them in many, not only in thyroids, and parotids, and Botox, and all kinds of other injections.
Once we had the buy-in, it was not that big a deal. What it is a generator? It provides the exact amount of electricity to target the diseased tissue, if you will. There was not that difficult an issue. I do know of colleagues of mine who have been fighting the bureaucracy that goes with purchasing cutting edge technology, but this is the healthcare system we all live in.
[Dr. Gopi Shah]
RFA, are there guidelines or consensus statements, or is it part of the ATA now? Where are we at with the guidelines?
[Dr. David Goldenberg]
That's a great question. Are there guidelines? There are lots of guidelines. Various medical societies and organizations have developed guidelines for radiofrequency ablation of thyroid nodules. You have to keep in mind that these guidelines change and evolve and that then they are just that. The Korean Society has guidelines. The American Thyroid Association came out with guidelines and they stress the need for proper patient selection and nodules that cause symptoms.
The European Thyroid Association has guidelines. The American Association of Clinical Endocrinologists and the American College of Endocrinology all have guidelines. They are all very, very similar. The Italian Society and Japanese Society also have guidelines. A place where they may vary is how many benign biopsies do you get before you do a radiofrequency ablation? Some of them insist on two and some of them say one is enough, but for the most part, the guidelines are incredibly similar.
[Dr. Gopi Shah]
As we start to round out the discussion, wrap it up, what final pearls do you have for this technology?
[Dr. David Goldenberg]
One thing that you have to discuss with your patients is that radiofrequency ablation may not be covered by insurance at this point in time. Sometimes it is, sometimes it's not. I've worked very, very hard with my fantastic, and I mean fantastic revenue cycle people before I did that. It's really important that you do so if you're going to start this practice. Like I said, there are courses here in the United States. If you want to go to Brazil or Korea, they have them there as well. Now that there are more courses, it's probably smart. When we did our course, not only did we have phantoms, we had cadavers, we had lectures, we had question and answer, and it was very well received, so if you want to start doing that. We also had a lecture on how to start the practice with all those pearls about buy-in and cost and who you have to rope into the conversation and what codes to use. In this day and age, as it's becoming more and more mainstream, that's important. Patient selection, as always, is incredibly important.
The most important thing to remember is this is just another tool in a thyroid practice. Every patient who comes in to me with a benign thyroid nodule is offered the options of observation with no intervention, radiofrequency ablation, if appropriate, or surgery, if appropriate. We don't force people into anything. We just make them aware of the options. Patients tend to come to places where they get good clinical care and that they have an array of options and someone's willing to discuss it with them, but I guess that's the way it has been with us.
[Dr. Gopi Shah]
One last question for you. Are your medical students and residents, your trainees, getting exposure to this procedure with you? Because I would imagine it's something still very new. Not everybody's doing it and so to have that exposure early on is probably very helpful.
[Dr. David Goldenberg]
I'm going to give you just a little long-winded answer, if you don't mind. When I first came to Penn State Health back in 18 years ago, I asked a resident if the patient had any imaging, and that resident's answer was, "No, just ultrasound." From that, I learned that it's really important that residents are trained in otolaryngology on ultrasound. We've been giving internal courses on head and neck ultrasound for the last 18 years, every two or three years. Yes, residents are observing and participating in radiofrequency ablation. It's our obligation to teach them everything that we do and know so that when they go out, they're able to offer this. I do not have medical students doing this.
[Dr. Gopi Shah]
No, no, they're watching.
[Dr. David Goldenberg]
Anyone? Yes.
[Dr. Gopi Shah]
There's a lot to learn just from watching. [chuckles]
[Dr. David Goldenberg]
Oftentimes, the room is very crowded when we do this, and that's great.
[Dr. Gopi Shah]
I think it's great. That's awesome. Thank you so much, David. We always love having you on. You always contribute so much education to our platform, so we appreciate it. For our listeners that want to learn more, how can they get in touch with you? Also, tell us about the RFA training course next June, 2024?
[Dr. David Goldenberg]
Last, it will probably be at the beginning of June. Come up to Hershey. It's beautiful here, really, really beautiful. It's a two-day course, intense. First time we had 25 people. We limited it to 25 people so that everyone could get hands-on, personalized training by the-- We flew up Dr. Rangel from Brazil, from Rio de Janeiro. We flew Ralph Tufano up from Sarasota, and it was very well-received. I assume we'll be doing it in the first couple of days of June in 2024.
[Dr. Gopi Shah]
Awesome. Any social media handles for you or for the OTO program at Penn State?
[Dr. David Goldenberg]
Absolutely. My X, Twitter, X handle is @thyroid_surgeon, and the department is @PSH_OTO.
[Dr. Gopi Shah]
Awesome. Then just for our audience, remember Dr. Goldenberg has a textbook, Head to Neck Endocrine Surgery, a comprehensive textbook, surgical, and video atlas. Please check that out. It's wonderful to see you and talk with you. I think it's a wrap.
[Dr. David Goldenberg]
All right. Thank you, Gopi. It's always a pleasure.
Podcast Contributors
Dr. David Goldenberg
Dr. David Goldenberg is a professor and the chair of the department of otolaryngology - head and neck surgery at Penn State in Hershey, Pennsylvania.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, October 31). Ep. 139 – Radiofrequency Ablation: Modern Management of Thyroid Nodules [Audio podcast]. Retrieved from https://www.backtable.com
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