Prof. S. VITTALMS, FRCS (Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAES

Emeritus ProfessorSurgical Endocrinology

The Tamil Nadu Dr.MGR Medical University

Past Chairman Royal College of Surgeons of Edinburgh – Indian Chapter

Surgical TutorRoyal College of Surgeons of Edinburgh

Past PresidentInternational College of Surgeon – Indian Section

Past PresidentThe Association of Surgeons of India

Founder PresidentIndian Association of Endocrine Surgeons

Chief Surgeon – Sree Sai Krishna Hospital, Chennai

Management of Toxic Goitre

MMC

• Emil Theodor Kocher was awarded the Nobel Prize in 1909 for his work on the physiology, pathology and surgery of the thyroid gland

• Father of Thyroid Surgery• Established the Kocher Institute in Berne

Thyroid

Secretes two principal hormones

• Thyroxine (T4)

• Triiodothyronine (T3)

Thyroid Hormones• Almost all circulating T3 & T4 are

bound to TBG , TBPA or albumin.

• It is only the free (unbound) hormones are metabolically active. T3 formed mainly by peripheral deiodination of T4 to T3, is the biologically active hormone.

Physiology

Hyperthyroidism

Is reserved for disorders that result

from overproduction of hormones by

thyroid gland

Thyrotoxicosis

Is the clinical syndrome that occurs when the body is exposed to increased circulating levels of thyroid hormones

Toxic Goitre

• Diffuse toxic goitre (Graves Disease)

• Toxic multinodular goitre ( Plummers Disease)

• Toxic solitary nodule

• Transient phase of thyroiditis• Iodide induced - Drugs ( Amiodarone)

- Contrast media

- Iodine prophylaxis • Extra-thyroidal source of Thyroid Hormone

- Factitious

- Struma Ovari• TSH induced

- TSH secreting Pituitary Adenoma

- Choriocarcinoma & Hydatidform

mole

Graves Disease

• Parry

• Robert Graves

Graves Disease

• Diffuse toxic goitre

• Ophthalmopathy

• Dermopathy

• Acropachy

Graves Disease

• Caused by an activating autoantibody that targets the TSH receptor

• Autoimmune• Genetic• Stress• Environmental

Opthalmopathy

• Infiltrative ophthalmopathy causing exopthalmos and ophthalmoplegia

• Immunologically mediated• TRAb binds to retro-orbital tissue• Secretion of Hydrophilic glycosoaminoglycans• Proptosis causes symptoms of Exposure

Keratitis• Strong linkage with smoking

Exophthalmos

• May precede, coincide or succeed Clinical Graves Disease

• May not appear at all

• May be the only manifestation of Graves Disease

• May be unilateral or bilateral

Exophthalmos

Werner’s ‘NO SPECS’ Classification of Graves’ Ophthalmopathy

Class Definition0 No Physical Signs or Symptoms

1 Only signs (no symptoms) – lid lag, lid retraction, proptosis upto 22 mm

2 Soft Tissue Involvement (Symptoms and Signs)

3 Proptosis (more than 22 mm)

4 Extraocular muscle involvement (Ophthalmoplegia)

5 Corneal Injury

6 Sight loss (optic nerve involvement)

Ophthalmopathy

• Methylcellulose eye drops• Tinted glass or side sheets attached to

spectacles• Oral glucocorticoids• Orbital irradiation• Orbital Decompression Surgery

• Dermopathy – Pretibial myxedema - Pink or purplish plaques of non pitting edema - Anterior aspect of leg

• Acropachy - Digital Clubbing - Soft tissue swelling of hands and feet - Periosteal bone formation

Pretibial myxedema

Clinical presentation

• Increased Heat production

• Neuropsychiatric changes

• Gastrointestinal

• Menstrual irregularities

• Cardiovascular

Grave Disease

Diagnosis

• TFT

• Thyroid Antibody titre

• Radioactive Iodine Uptake and Scan

• Ultrasound Scan

Treatment

• Antithyroid drugs

• Surgery

• Radioiodine ablation

Antithyroid drugs

Imidazoles

• Carbimazole

• Methimazole

Thiouracil

• Propylthiouracil

Treatment

Beta Blockers : Nonselective

: Cardioselective

Treatment

• Surgery

• Radioiodine ablation

Surgery• Large goitres• Retrosternal goitres• Pregnant or lactation• Reproductive age group• Children below 16 years• Coexistent suspicious nodules• Severe intolerance to antithyroid medication• Graves Opthalmopathy

Total or Near Total Thyroidectomy

Preoperative preparation

Euthyroid at the time of surgery

• Antithyroid drugs

• Beta Blockers

• Iodine

Advantages of Surgery

• Immediate cure of disease

• Controlled hypothyroidism

• Adequate management of coexisting malignancy

• Can be offered to pregnant patients or those patients desiring pregnancy within 6 -12 months of treatment

Radioiodine Ablation

• Patient not in the reproductive age group

• Serious Comorbidity

• Recurrence following surgery

Radioiodine Ablation

• Produces the ablative effects of surgery but not the complications of surgery

• Dose- 5-20 mci of I 131• Majority [around 80%] respond well with a single

dose.• Another 10%-15% respond with 2nd dose.• 5% of cases may need a 3rd dose.

Toxic MNG

• Plummers Disease

• Older individuals

• Long history of MNG

• More prevalent in iodine deficient areas• Pathogenesis – Somatic mutation IN TSH

receptor activation leading to constitutive receptor activation and upregulation of cyclic AMP

Toxic MNG

• Cardiovascular symptoms more prominent• Diagnosis• T3 alone can be elevated in some cases (T3

Thyrotoxicosis)

• Radioactive Iodine Scan – Increased Uptake and heterogenous pattern with focal areas of increased uptake corresponding to hyperfunctioning nodules.

Treatment

• Surgery

• Radioiodine Ablation

Toxic Nodule

• Autonomous Nodule• Younger age group• One of the most frequent causes of Isolated T3

Thyrotoxicosis• Radioactive Iodine uptake shows increased

uptake over nodule with evidence of suppressed uptake throughout the remainder of the gland

Nuclear Scan

• Surgery

• Radioiodine Ablation

• Should patients with Solitary Toxic Nodule and those with Toxic Multinodular Goitre be treated differently?

• Does the presence of subclinical hyperthyroidism affect the treatment outcome?

• Do patients with a large thyroid gain greater benefit from thyroidectomy?

• Are compression symptoms an indication for surgery?

• What is the risk of malignancy in patients with Plummer’s disease?

• Is there an optimal treatment dose or regimen for Radioiodine ablation?

• Is percutaneous ethanol ablation a useful treatment modality ?

• What is the best cost-effective strategy for the treatment of Plummer’s disease?

Special Situations

• Thyrotoxicosis and pregnancy

• Thyroid storm

Thyrotoxicosis and Pregnancy

• Propylthoiuracil preferred over Imidazoles

• Lowest possible dose of PTU must be used

• Radioiodine absolutely contraindicated

• Surgery – Second trimester

Thyroid Storm

• The clinical manifestations of thyroid storm are consistent with marked hypermetabolism resulting in multiorgan dysfunction

• Mortality between 10 -20% even for treated patients

• Exaggeration or accentuation of the signs and symptoms of thyrotoxicosis

Thyroid Storm

• Fever greater than 38 C• Marked diaphoresis• Tachycardia, Atrial fibrillation and Cardiac failure• Severe diarrhoea• Agitation, confusion and delirium, progressing to

frank psychosis, stupor and coma

Diagnosis

• Early diagnosis and treatment are the most important determinants in the successful management of thyroid storm

• Essentially a clinical diagnosis• There are no differences in the results of TFT in

patients with thyroid storm when compared with patients who have symptomatic hyperthyroidism

Treatment

• Blockage of the release and effects of circulating thyroid hormones

• Supportive care

• Identification and treatment of precipitating event

Treatment

• Propylthiouracil(PTU) given as a loading dose of 600 mg followed by 200-250mg every 4 hours orally, rectally or via nasogastric tube

• Inorganic iodide Lugols Iodine – 5-8 drops 6 Hourly Saturated solution of Potassium Iodide - 5-8 drops 6

Hourly Sodium Ipodate – 0.5 -1 g 12 Hourly iv• Beta Blockers Propranolol – 20 - 80 mg orally 6 Hourly or 1 -5 mg iv 6

Hourly Esmolol - Ultrashort acting especially useful in the

management of thyroid storm

Treatment

Supportive Care • Hyperthermia - Antipyretics

- Alcohol sponge, ice packs• Correction of dehydration• Steroids – Dexamethasone or Hydrocortisone iv

Treatment of precipitating event• Antibiotics

• Hyperthyroidism

• Thyrotoxicosis

• Types of Toxic goitre

• Ultrasound and Nuclear Scans will aid in determining the etiology

• Medical treatment

• Definite treatment with Surgery or Radioactive Iodine is recommended for Graves disease, Toxic MNG AND Toxic Adenoma

• Special Circumstances

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