2. 

This disease result from an excess of
circulating thyroid hormone.
Its very important to distinguish disorders:
 1.Cause excess production of hormone - characterized by
increasing in radioactive iodine uptake.
 2.An other condition which release stored hormone such
as thyroiditis.

3. 
Not all manifestations are related to elevated
thyroid hormones.

4. 



Primary thyrotoxicosis – Grave’s Disease
Secondary Thyrotoxicosis – Plummer’s
Disease
Toxic nodule
Rare causes for hyperthyroidism

5. 



Diffuse vascular goitre.
Symptom appears with goitre
Younger women with eye
signs
TSH-R Abs – hypertrophy and
hyperplasia of the thyroid
tissue.

7. 



Long standing nodular goitre
Middle aged women
infrequently associated with eye signs
Internodular tissue is the active region
Rarely , autonomous nodules.

8. 


Overactive nodule part of generalised
nodularity or true toxic adenoma.
Not related to TSH-R Abs.
Normal thyroid tissue is suppressed and
inactive.

9. SCALLOPED
PATTERN

10. THYROXINE IS THE
KEY FOR
ADRENALINE TO ACT
ON THE CELL

12. Features
Goitre
Hyperthyroidism
CVS
Ophthalmic
Features
Primary
Thyrotoxicosis
Secondary
Thyrotoxicosis
Firm , diffuse and
vascular / Bruit
Nodular
Severe
Not severe
Rare
Most severe
More common
Lid lag and spasm

13. 
Secondary thyrotoxicosis
 Multiple extrasystoles
 Paroxysmal atrial fibrillations
 Paroxysmal atrial tachycardia
 Paroxysmal atrial fibrillations.

14. 







Primary thyroosicosis
Lid spasm – sympathetic overactivity
Exophthalmus
Joffrey’s and VonGraffe’s sign
Mobieus Sign
Auto immune etiology – glycosamino glycans
deposition
Weakness of extraoccular muscle
Pappilloedema and corneal ulcers

15. 
Malignant
exophthtalmus – eyes
may be destroyed.

16. 
Rx






Control of hyperthyroidism
Sleeping propped up position
Lateral tarsoraphy
Prednisone
Intraorbital steroid are to be avoided.
Thryoid ablation with radio iodine worsens the
malignant exophthalmus
 Orbital decompression.

18. 
Hyaluranic acid – dermis and subcutaneous
tissue.

Rx – topical steroids

19. 


Clinical features
Biochemical investigation
Thyroid antibodies
T3
T4
TSH
HYPERTHYROIDSM
INCREASED INCREASED SUPPRESSED
T3 TOXICOSIS
INCREASED NORMAL
SUPPRESSED

20. 
Thyroid scan
 Toxic nodular goitre

21. 
Anti thyroid durgs
 Carbimazole and propylthiouracil,
 Beta blockers – propranolol and nadolol
 Iodides – reduce vascularity, preoperative
scenario
 Cannot cure toxic nodule

23. 
Dosage – 10 mg of carbimazole tds can be
increased up to 120mg per day.

Levels of TSH R Ab fall and permanent cure in
50%

BLOCK AND REPLACEMENT REGIMEN
 Inhibit all T3 and T4 with high dose of carbimazole
and replace with thyroxine 0.1-0.15mg

24. 
Helps in reducing the mass of overactive
tissue.

Reduction of TSH R Abs or only limited
stimulation.

Toxic nodule – suppressed tissue acts normal
after the surgery.

25. 



Destroys thyroid cells.
Functioning tissue reduced beyond critical
level.
Accurate dosage is difficult and may require
further dose after 12 weeks.
No evidence proven – therapeutic dosage is
carcinogenic.

26. Anti- thyroid
drugs
Surgery
Radioiodine
• No surgery and
radio iodine
effects
• Goitre is removed
• Cure is rapid
• High cure rate
• No prolonged
drug therapy
• prolonged
• 50% failure rate
• difficult to
predict response.
• agranulocytosis
or aplastic
anemia
• Permanent
thyroid failure
• Hypoparathyroidi
sm
• Recurrence <5%
• indefinite follow
up
• slow response
• Accurate dosage
- difficult

27. 
Factors influencing
 Type of thyrotoxicosis
 Age of the patient
 Co existing medical illness
 Post treatment care
 Follow up
 Compliance and
 Patient wishes.

28. Age >45
Age<45
Radio Iodine
Large goitre –
surgery
Small goitre –
antithyroid
drugs or radio
iodine

29. 
Enlarges with antithyroid drugs.

Responds poorly with drugs and radio iodine

Surgical removal is the treatment.

30. 
Surgery vs Radio Iodine.

Pros and cons to be considered.

31. Pregnancy
Radio iodine –
absolute C/I
Surgery – abortion
Drugs –
hypothyroidism both
mother abd baby
Surgery in
second trimester
or careful
administration of
drugs
Children
Radio iodine –
C/I
Surgery recurrence
Drugs till
adoloscents
Surgery later.
Thyrocardiac
Severe cardiac
damage
Radio iodine
with anti
thyroid drugs

32. 
Thyrotoxicosis factitia

Jod-Basedow Thyrotoxicosis
 Large doses of iodine in endemic goitre

deQuervain’s thyroiditis

Carcinoma

33. 
Extent of resection

Biochemically euthyroid
 Antithyroid drugs
 Block and replacement regimen
 Lugol’s iodine
 Beta blockers

34. Surgical options
Features
Total Thyroidectomy
Subtotal
thyroidectomy
Control of toxicity
Immediate
Immediate
Return to euthyroid
state
Immediate
Variable
Recurrence
None
5%
Thyroid failure
100%
25%
Hypoparathyroidism
5%
1%
Followup
Minimal
lifelong

35. 
Thyroid storm

Acute exacerbation

Etiology
 Inadequately preapred
 Infection / stress

Clinical features
 Dehydration
 Hyperpyrexia
 Tacycardia
 Diaphoresis

36. 
Rx
 Intravenous fluids / rehydration
 Cooling the patient with ice packs
 Diuretics
 Manage cardiac failure with digoxin
 Hydrocortisone

Specific Rx
 Carbiamzole – 10-20mg q6hrly
 Lugol’s iodine 10drops q8hrly
 Sodium iodide 1g i.v
 Propranolol 1-2 mg i.v

37. 
Hypocalcemia

Thyroid function test

Replacement of thyroxine