Hyperthyroidism

HYPERTHYROIDISM
DR.R.DURAI MS
ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL SURGERY
MGMCRI

DEFENITION
 What is hyperthyroidism?
 Increased secretion of Thyroid hormones due to various
stimuli.
HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI
2
 What is thyrotoxicosis??
 Symptoms and signs produced by Increased secretion of
Thyroid hormones due to various stimuli.
23-04-2016

TODAY’S MENU
 Clinical types
 Symptomatology
 Diagnosis of thyrotoxicosis
 Principles of treatment of thyrotoxicosis
 Choice of therapy
 Hyperthyroidism due to other causes
 Surgery for thyrotoxicosis
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CLINICAL TYPES
 Diffuse toxic goitre (Graves’ disease);
 Toxic nodular goitre;
 Toxic nodule;
 Hyperthyroidism due to rarer causes.
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GUESS?
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ROBERT JAMES GRAVES
(1796-1853)
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DIFFUSE TOXIC GOITRE
(GRAVE’S DISEASE)
 Graves’ disease, a diffuse vascular goitre
 Younger women
 Eye signs
 Primary Thyrotoxicosis
 Family H/o Autoimmune Endocrine diseases
 Whole gland – Hypertrophy & Hyperplasia –
abnormal thyroid stimulating antibodies (TSH-
Rab) binding to TSH receptor
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TOXIC NODULAR GOITRE
 Plummer’s Disease
 Long duration
 Middle-aged or Elderly
 Infrequently is associated with eye
signs.
 Secondary thyrotoxicosis.
 Nodules inactive
 Inter-nodular thyroid tissue
overactive
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TOXIC NODULE(ADENOMA)
 Solitary overactive nodule
 Autonomous
 TSH secretion is suppressed
by the high level of
circulating thyroid
hormones
 Surrounding normal thyroid
tissue suppressed and
inactive.
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HISTOLOGY
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GRAVE’S HISTOLOGY
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SYMPTOMATOLOGY
 Loss of weight despite a good
appetite
 Heat intolerance
 Palpitations.
 Tachycardia
 Hot, moist palms
 Exophthalmos
 Eyelid lag/retraction
 Agitation
 Thyroid goitre and bruit.
 Tiredness
 Emotional lability
 Weight loss
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PRIMARY VS SECONDARY
 Symptom 1st Goitre next
 Diffuse and vascular
 Large or small
 Firm or soft
 Thrill and a bruit
 Abrupt onset
 Frequent Remissions &
exacerbations
 More severe
 No Cardiac manifestations
 All eye signs
 Goitre 1st symptoms next
 Nodular
 Insidious
 Less severe
 Cardiac manifestations more
 Only Lid lag & Lid spasm
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CARDIAC RYTHM
 Fast heart rate during sleep
 Cardiac arrhythmias
 Stages Of Development Of Thyrotoxic Arrhythmias:
1. multiple extrasystoles
2. paroxysmal atrial tachycardia
3. paroxysmal atrial ﬁbrillation
4. persistent atrial ﬁbrillation, not responsive to digoxin.
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MYOPATHY
 Weakness of the proximal limb muscles
 Thyrotoxic myopathy
 Recovery proceeds as hyperthyroidism is controlled.
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EYE SIGNS
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Specific to Graves Disease
 1. Diffuse painless and firm enlargement of thyroid gland
 2. Ophthalmopathy – Eye manifestations – 50% of cases
 Classification of Eye Changes in Graves' Disease
 0) No signs or symptoms.
 1) Only signs, no symptoms. (Signs limited to
upper lid retraction, stare, lid lag.)
 2) Soft tissue involvement (symptoms and signs).
 3) Proptosis (measured with Hertel exophthalmometer)
 4) Extraocular muscle involvement.
 5) Corneal involvement.
 6 Sight loss (optic nerve involvement).
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Eye Signs in Toxic Goitre
In early stages, may be unilateral but later may
become bilateral.
 Order of appearance of signs
 Stellwag's sign : Absence of normal
blinking—so staring look.
 Von Graefe`s sign : Upper eye lid lags behind
the eye ball as the patient is asked to look
downwards.
 Dalrymphe's sign : Upper sclera is visible due
to retraction of upper eye lid.
 Joffroy's sign : Absence wrinkling in the
forehead on looking upwards with the face
inclined downwards.
 Moebius sign : Inability or failure to
converge the eye balls
 Gifford's sign: Difficulty in eversion of the
upper lid.
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Specific to Graves Disease……..
 3. Thyroid dermopathy
 consists of thickening of the skin,
particularly over the lower tibia, due to
accumulation of glycosaminoglycans
 (pre tibial myxedema)
 Is usually bilateral
 4. Thyroid Acropachy
 Thyroid acropachy is clubbing of fingers and
toes in primary thyrotoxicosis.
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DIAGNOSIS
 Examinations, symptoms
 Thyroid blood tests
 Thyroid function tests TSH , T4,T3
 Thyrroid antibodies TSI, ANTI TPO, ANTI Tg
 Other — nonspecific laboratory findings.
 low serum total, LDL, and (HDL) cholesterol concentrations
 normochromic, normocytic anemia
 Serum alkaline phosphatase
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 Thyroid imaging
 Radionuclide imaging
 Size, shape & function of gland assessed
 Increased uptake=“hot", less risk of
malignancy,<5%
 Decreased uptake=“cold" higher risk of
malignancy,15-20%
 Ultrasound
 CT/ MRI good for assessment of retrosternal
extension.
 pathology
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DIAGNOSIS
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Algorithm for Hyperthyroidism
Measure TSH and FT4
 TSH,  FT4
Measure FT3
Primary (T4)
Thyrotoxicosis
High
Pituitary Adenoma FNAC, N
Scan
Normal
 TSH, FT4 N  TSH,  FT4 N TSH, FT4 N
T3 Toxicosis
Sub-clinical Hyperthyroidism
Features of Grave’s
Yes
Rx.
Grave’s
No
Single Adenoma,
MNG
Low RAIU RAIU
Sub Acute Thyroiditis, I2, ↑ Thyroxine
F/u in 6-12 wks
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MANAGEMENT
Approaches
• Anti thyroid
drugs,beta blockers
• Radioactive Iodine
I131
• Surgery
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Choice Of Therapy
• Type of thyrotoxicosis
• Age of the patient
• Co existing medical illness
• Severity of thyrotoxicosis
• Goitre size
• Presence of ophtalmopathy
• Patient preference
Factors
influencing
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ANTITHYROID DRUGS
 Indications for antithyroid drugs:
 Patients with high likelihood of remission
 the elderly or others with comorbidities increasing
surgical risk or with limited life expectancy
 Toxicity in pregnant women
 moderate to severe active Graves’ ophthalmopathy
(GO)
 Before surgery, to make the patient euthyroid
 Soon after starting radioactive I131therapy for 6 to 12
weeks
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How long to give ATD ?
 improved symptoms in 2 weeks and euthyroid in about 6 weeks
 Check TSH and FT4 every 4 to 6 weeks
 In Graves, remission after 12-18 months
 Monitor every 3 months for the 1st year, and then annually after ATD
 40% recurrence in 1 yr.
 MNG and Toxic Adenoma will not get cured by ATD.
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Adjuvants
 Beta blockers
 Inhibit adrenergic effects
 Indications
 Prompt control of symptoms;
 treatment of choice for thyroiditis;
 first-line therapy before surgery, radioactive iodine, and
antithyroid drugs;
 Contraindications
 Use with caution in older patients and in patients with pre-
existing heart disease, chronic obstructive pulmonary disease,
or asthma
 Propranolol is the most commonly prescribed medication in
doses of about 20 to 40 mg four times daily
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 Iodides
 Block the conversion of T4to T3 and inhibit hormone release
 Indications
 preoperatively when other medications are ineffective or
contraindicated;
 to reduce gland vascularity before surgery for Graves’ disease
 during pregnancy when antithyroid drugs are not tolerated;
 Complications
 Paradoxical increases in hormone release with prolonged use;
 common side effects of sialadenitis, conjunctivitis, or acneform rash;
Adjuvants
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RADIOIODINE THERAPY
 Radioactive iodine
 Concentrates in the thyroid gland and destroys thyroid
tissue
 High cure rates with single-dose treatment (80 percent);
 treatment of choice for
 Graves’ disease
 Multi nodular goitre, toxic nodules in patients older
than 40 years, and
 In recurrent thyrotoxicosis
 It is effective, safe, and does not require hospitalization.
 Given orally as a single dose in a capsule or liquid form.
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RADIOIODINE THERAPY………
 Drawbacks
 Delayed control of symptoms;
 post treatment hypothyroidism
 contraindicated - pregnant or breastfeeding;
 transient neck soreness, flushing, and decreased taste;
radiation thyroiditis in 1 percent of patients;
 may exacerbate Graves’ ophthalmopathy;
 may require pre treatment with antithyroid drugs in
older or cardiac patients
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Surgical Treatment
 Surgical treatment is reserved
 patient preference
 Pregnant women who can’t tolerate ATD
 child or adolescent intolerant of ATDs
 large goiter, with or without compressive
symptoms
 severe Graves’ ophthalmopathy
 the presence of suspicious nodules
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SURGICAL………..
 GRAVES DISEASE
 Near-total or total thyroidectomy is the procedure of
choice
 TMNG
 Near- total or total thyroidectomy should be performed
 TOXIC ADENOMA
 an ipsilateral thyroid lobectomy, or
 isthmusectomy
 In patients with coexisting eye disease,
 total thyroidectomy
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Other causes of Hyperthyroidism
 Thyrotoxicosis factitia
 Jod–Basedow thyrotoxicosis
 Subacute/acute forms of autoimmune thyroiditis or of de
Quervain’s thyroiditis
 Secondary carcinoma
 Neonatal thyrotoxicosis
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Preoperative Preparation
 Standard preparation
 make the patient euthyroid/ near euthyroid using antythyroid drugs
 Alternative method
 rapid control of thyroid status can be achieved with a combination of
thionamides, SSKI, dexamethasone (1 to 2 mg twice daily), and beta
blockers
 very rapid control=> operation within a week
 Lugol’s iodide solution or saturated potassium iodide( three
drops twice daily) for 7 to 10 days
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SURGICAL TECHNIQUE
 Extent of thyroidectomy
 controversial, and determined by the desired outcome
 Risk of recurrence Vs hypothyroid, and surgeons experience
 Total or near thyroidectomy
 for patients with coexistent thyroid cancer, sever ophthalmopathy, life
treating reactions to antythyroid drugs
 Subtotal thyroidectomy is recommended for the rest
 bilateral subtotal thyroidectomy in which 1–2 grams of thyroid tissue is
left on both sides.
 Hartley Dunhill procedure
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TYPES OF
THYROIDECTOMY
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Features
Control of toxicity
Return to euthyroid
state
Recurrence
Thyroid failure
Hypoparathyroidism
Followup
Total Thyroidectomy
Immediate
Immediate
None
100%
5%
Minimal
Subtotal
thyroidectomy
Immediate
Variable
5%
25%
1%
lifelong
Surgical options
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Postoperative management
 Following surgery, thyroid hormone replacement should be
started
 TSH should be measured every 1–2 months until stable, and
then annually
 RAIT should be used for retreatment of persistent or
recurrent hyperthyroidism following inadequate surgery
 Following thyroidectomy, serum calcium hormone levels be
measured, and oral calcium supplementation be
administered based on these results
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NOVEL MINIMALLY INVASIVE
THERAPIES
 Percutaneous Ethanol Injection (PEI) for Nodules
 Injections of ethanol can be administered directly to toxic thyroid
nodules, cysts and large nontoxic thyroid nodules
 Ultrasound-Guided Laser Thermal Ablation (LTA) for
Nodules
 Percutaneous laser thermal ablation is used to reduce both
hyperfunctioning and compressive nodule
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Treatments Under Investigation
 Arterial Embolization
 Indicated in patients with severe hyperthyroidism who cannot tolerate or
who prefer not to use conventional treatment methods
 The Novel Molecule
 a small-molecule antagonist that directly inhibits or prevents TSI antibodies from
activating the TSH receptor.
 The small-molecule antagonist has not yet been studied in clinical trials
 Therapeutic Peptides
 antagonistic peptides that interfere with the action of TSH receptor antibodies as
well as peptides that bind to TSH receptor antibodies, preventing them from
reacting with the TSH receptor
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Choice of therapy
Diffuse toxic goitre
 over 45 years, radioiodine.
 under 45 years,
 surgery for the large goitre and
 anti-thyroid drugs or radioiodine
for the small goitre
 Toxic nodular goitre
 Surgery
 Toxic nodule
 Surgery or radioiodine(>45)
 Recurrent thyrotoxicosis after surgery
 radioiodine is the treatment of choice,
but anti-thyroid drugs may be used in
young women intending to havechildren.
Further surgery has little place.
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COMPLICTIONS OF
THYROID SURGERY

IMMEDIATE COMPLICATIONS
 HEMORRHAGE
 INFECTION
 RECURRENT LARYNGEAL NERVE PALSY
 THYROID CRISES OR STORM
 RESPIRATORY OBSTRUCTION
 PARATHYROID INSUFFICIENCY OR TETANY
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LATE COMPLICATIONS
 THYROID INSUFFIENCY
 RECURRENT THROTOXICOSIS
 PROGRESSIVE EXOPHTHALMOS
 HYPERTROPHIC SCAR OR KELOID.
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HEMORRHAGE
 Incidence – 0.3-1%
 Two types -
 Deep to deep fascia
 Subcutaneous
 May be primary or reactionary
 A deep bleeding produces tension hematoma. Usually due to slipping of
the ligature of the superior thyroid artery, though it can also be from a
thyroid remnant or a thyroid vein. This compresses on the airway &
potentially life threatening unlike the subcutaneous bleeding.
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HEMORRHAGE
 GOOD INTRAOPERATIVE HEMOSTASIS
 Don’t traumatize the thyroid
 Avoid too much neck dressings
 Suction drain ??
 Do not waste time on imaging
 A tension hematoma requires opening of the
wound, evacuation of hematoma & ligature of the
bleeding vessels
 A subcutaneous hematoma can be aspirated.
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INFECTION
 Cellulitis – erythema, warmth & tenderness
around the wound
 Abscess – superficial / deep
 Deep abscess associated with fever,
leucocytosis, tachycardia
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INFECTION
 Pus for Gram’s stain & culture
 CT for deep neck abscess
 Can be prevented by proper hemostasis at the time
of surgery & using suction drain.
 Per-operative antibiotics not recommended.
 Once established
 Antibiotics
 Drainage of abscess.
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RECURRENT LARYNGEAL
NERVE PARALYSIS
 Temporary paralysis is due to pressure of hematoma on
the nerve. Recovers in 3 weeks to 3 month.
 Permanent paralysis is rare (<2%) and is due to undue
stretching or its inclusion in a ligature.
 Unilateral –
 1/3 rd are asymptomatic
 Change in voice
 Improves due to compensation by the healthy cord.
 Bilateral- dyspnea & biphasic stridor
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RECURRENT LARYNGEAL
NERVE PARALYSIS
 Prevent injury to the nerve by
 Identify
 ITA ligated far from lobe
 Posterior layer of pretracheal fascia kept intact.
 Laryngoscopy, laryngeal EMG
 For unilateral paralysis no treatment is required.
 For bilateral paralysis
 Tracheostomy (with speaking valve.
 Lateralization of cord
 Arytenoidectomy
 Through endoscope
 Thyroplasty type 2
 Cordectomy
 Nerve muscle implant
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COMBINED PARALYSIS
 Unilateral
 Vocal cord lies in cadaveric position
 Hoarseness of voice & aspiration of liquids.
 Ineffective cough
 Bilateral
 Aphonia
 Aspiration
 Ineffective cough
 Bronchopneumonia
 ONLY superior laryngeal nerve palsy also occurs rarely & presents with
hoarseness & loss of voice stamina.
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COMBINED PARALYSIS
 Unilateral
 Speech therapy
 Medialise of cord
 Teflon paste injection
 Thyroplasty type 1
 Muscle or cartilage implant
 Arthrodesis of arytenoid joint
 Bilateral
 Tracheostomy
 Epiglottopexy
 Vocal cord plication
 Total laryngectomy
 SLN: speech therapy
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THYROID CRISIS / STORM
 Acute exacerbation of hyperthyroidism as the patient has
not been brought to the euthyroid state before
operation.
 Tachycardia, fever(>1050C) , restlessness, delirium
 Mortality is 10%
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THYROID CRISIS / STORM
 Ensure euthyroid state before
operation
 Sedation – morphine / pethidine
 Hyperpyrexia – ice bags. Tepid
sponging, hypothermic blanket,
rectal ice irrigation
 Oxygen administration
 IV glucose-saline for dehydration
 Potassium for tachycardia
 Cortisone – 100mg IV
 Carbimazole – 10- 20 mg 6th hourly
 Lugol’s iodine 10 drops 8th hourly by
mouth or potassium iodide 1g IV
 Propranolol – 20-40mg 6th hourly
 Digoxin for atrial fibrillation
 Diuretics for cardiac failure
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RESPIRATORY
OBSTRUCTION
 Laryngeal edema due to
 Tension hematoma
 Endotracheal intubation & surgical handling
 More chance in vascular goiters.
 Collapse / kinking of the trachea
 Bilateral recurrent nerve paralysis can aggravate
obstruction if edema is present.
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RESPIRATORY
OBSTRUCTION
 Open the wound & release the tension hematoma
 Endotracheal tube if no improvement. INTUBATION TO
BE DONE BY AN EXPERIENCED ANESTHETIST as repeated
attempts cause more edema leading to cerebral anoxia.
 The tube is left in place for several days & steroids given
to reduce the edema.
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PARATHYROID
INSUFFICIENCY
 Due to removal of parathyroids or the parathyroid end artery.
 Incidence – 1-3%
 Occurs 2 – 5% after operation. Can be delayed for 2-3 weeks or hypocalcemia may be
asymptomatic.
 Classic triad –
 Carpopedal spasm
 Stridor
 Convulsions
 Latent tetany
 Trousseau’s sign
 Chvostek’s sign
 Persistant – grand mal epilepsy, cataracts, psychosis, calcification of basal ganglia,
papilledema.
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PARATHYROID
INSUFFICIENCY
 Correct identification of the gland
 Ligate vessels distal to the parathyroids.
 Recognition of the parathyroid glands, which appear in a variety of shapes
and have a caramel-like color, is critical. When they lose their blood supply,
they turn black. The devascularized gland should be removed, cut into 1 to
2mm pieces, and reimplanted in the sternomastoid muscle or the forearm.
 Monitor serum Ca for 72 hrs post-operatively.
 20 ml 10% solution of calcium gluconate IV
 10 ml injected IM
 2.5-5 G calcium carbonate / day
 PTH is unsatisfactory.
 AlfacalcidolHYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI
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THYROID INSUFFICIENCY
 INCIDENCE :20-25% of patients subjected to subtotal thyroidectomy for diffuse
toxic goiter & toxic nodular goiters with internodular hyperplasia
 Time: <2 yrs. May be delayed >5yrs.
 Transient hypothyroidism may occur within 6 months which is asymptomatic.
 Due to change in nature of autoimmune response.
 More chance if less residual thyroid tissue
 Cold intolerance, fatigue constipation, weight gain, myxedema.
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THYROID INSUFFICIENCY
 Thyroxine – start with 50 mcg/d, 100mcg/d after 3 weeks,
and 150 mcg/d thereafter. Taken as a single daily dose.
 Monitoring –
 TSH in the lower end of reference range (0.15-3.5 mU / l)
 T 4 normal or slightly raised. (10 – 27 pmol / l)
 Manage ischemic heart disease with beta blockers &
vasodilators
 Increase thyroxine during pregnancy. (50 mcg)
 Myxedema coma: IV thyroxine 20mcg 8th hourly
followed by oral.
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RECURRENT
THYROTOXICOSIS
 Incidence 5 – 10%
 Due to inadequate removal or hyperplasia of
remaining thyroid tissue.
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RECURRENT
THYROTOXICOSIS
 Less than 40 yrs – carbimazole
 0-3wks 40-60mg/d
 4-8wks 20-40mg/d
 18-24 months 5-20mg/d
 More than 40 yrs – radioiodine
 5-10mCi oral; 75% respond in 4-12 weeks
 Repeated after 12-24 weeks if no improvement.
 Beta blocker / carbimazole cover during lag period.
 Long term follow-up for hypothyroidism.
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PROGRESSIVE / MALIGNANT
EXOPHTHALMOS
 Occurs even when thyrotoxic features are regressing.
 Steroids & radiotherapy.
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HYPERTROPHIC SCAR /
KELOID
 Platysma to be divided at a higher level
 Occurs if scar overlies the sternum
 Some persons are more susceptible.
 May follow wound infection.
 Intradermal steroids, repeated monthly.
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References
 HYPERTHYROIDISM AND OTHER CAUSES OF THYROTOXICOSIS: MANAGEMENT
GUIDELINES OF THE ATA AND AACE Baskin HJ, Cobin RH, Duick DS, et al
(American Association of Clinical Endocrinologists) 2011
 Klein I, Becker D, Levey GS.Treatment of hyperthyroid disease. Ann Int
Med.1994;121:281-288.
 Schwartz’s Principles of Surgery, 9th ed.
 William’s Text Book Of Endocrinology, 11th ed.
 Bailey & Loves’ Short Practice of Surgery, 25th ed.
 Greenspan’s Basic & Clinical Endocrinology, 8th ed.
 Uptodate
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Hyperthyroidism

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