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Prof. S. VITTAL
MS, FRCS (Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAES
Emeritus Professor
Surgical Endocrinology
The Tamil Nadu Dr.MGR Medical University
Past Chairman
Royal College of Surgeons of Edinburgh – Indian Chapter
Surgical Tutor
Royal College of Surgeons of Edinburgh
Past President
International College of Surgeon – Indian Section
Past President
The Association of Surgeons of India
Founder President
Indian 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
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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
0
1
2
3
4
Definition
No Physical Signs or Symptoms
Only signs (no symptoms) – lid lag, lid
retraction, proptosis upto 22 mm
Soft Tissue Involvement (Symptoms
and Signs)
Proptosis (more than 22 mm)
5
Extraocular muscle involvement
(Ophthalmoplegia)
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
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Increased Heat production
Neuropsychiatric changes
Gastrointestinal
Menstrual irregularities
Cardiovascular
Grave Disease
Diagnosis
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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
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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
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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
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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
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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
“In the last ten years, if you have not changed your
technique or acquired a new technique,
Check Your Pulse,
Chances are you may be Dead “
Gelette Burgess
“The purpose of life is the expansion of happiness”
“ Very little is needed to make life happy”
“ If you want happiness for a lifetime – help the
next generation”
``
Thank You