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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.

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Presentation on theme: "Prof. S. VITTAL MS, FRCS (Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAES Emeritus Professor Surgical Endocrinology The Tamil Nadu Dr.MGR Medical University."— Presentation transcript:

1 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

2 Management of Toxic Goitre



5 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

6 Thyroid Secretes two principal hormones Thyroxine (T4) Triiodothyronine (T3)

7 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.

8 Physiology

9 Hyperthyroidism Is reserved for disorders that result from overproduction of hormones by thyroid gland

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

11 Toxic Goitre Diffuse toxic goitre (Graves Disease) Toxic multinodular goitre ( Plummers Disease) Toxic solitary nodule

12 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

13 Graves Disease Parry Robert Graves

14 Graves Disease Diffuse toxic goitre Ophthalmopathy Dermopathy Acropachy

15 Graves Disease Caused by an activating autoantibody that targets the TSH receptor Autoimmune Genetic Stress Environmental

16 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

17 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



20 Exophthalmos

21 Werners NO SPECS Classification of Graves Ophthalmopathy ClassDefinition 0No Physical Signs or Symptoms 1Only signs (no symptoms) – lid lag, lid retraction, proptosis upto 22 mm 2Soft Tissue Involvement (Symptoms and Signs) 3Proptosis (more than 22 mm) 4Extraocular muscle involvement (Ophthalmoplegia) 5Corneal Injury 6Sight loss (optic nerve involvement)

22 Ophthalmopathy Methylcellulose eye drops Tinted glass or side sheets attached to spectacles Oral glucocorticoids Orbital irradiation Orbital Decompression Surgery

23 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

24 Pretibial myxedema

25 Clinical presentation Increased Heat production Neuropsychiatric changes Gastrointestinal Menstrual irregularities Cardiovascular

26 Grave Disease

27 Diagnosis TFT Thyroid Antibody titre Radioactive Iodine Uptake and Scan Ultrasound Scan


29 Treatment Antithyroid drugs Surgery Radioiodine ablation

30 Antithyroid drugs Imidazoles Carbimazole Methimazole Thiouracil Propylthiouracil

31 Treatment Beta Blockers : Nonselective : Cardioselective

32 Treatment Surgery Radioiodine ablation

33 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

34 Preoperative preparation Euthyroid at the time of surgery Antithyroid drugs Beta Blockers Iodine

35 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 months of treatment

36 Radioiodine Ablation Patient not in the reproductive age group Serious Comorbidity Recurrence following surgery

37 Radioiodine Ablation Produces the ablative effects of surgery but not the complications of surgery Dose mci of I 131 Majority [around 80%] respond well with a single dose. Another 10%-15% respond with 2 nd dose. 5% of cases may need a 3 rd dose.

38 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

39 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.

40 Treatment Surgery Radioiodine Ablation


42 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

43 Nuclear Scan

44 Surgery Radioiodine Ablation

45 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?

46 Do patients with a large thyroid gain greater benefit from thyroidectomy? Are compression symptoms an indication for surgery?

47 What is the risk of malignancy in patients with Plummers disease? Is there an optimal treatment dose or regimen for Radioiodine ablation?

48 Is percutaneous ethanol ablation a useful treatment modality ? What is the best cost-effective strategy for the treatment of Plummers disease?

49 Special Situations Thyrotoxicosis and pregnancy Thyroid storm

50 Thyrotoxicosis and Pregnancy Propylthoiuracil preferred over Imidazoles Lowest possible dose of PTU must be used Radioiodine absolutely contraindicated Surgery – Second trimester

51 Thyroid Storm The clinical manifestations of thyroid storm are consistent with marked hypermetabolism resulting in multiorgan dysfunction Mortality between % even for treated patients Exaggeration or accentuation of the signs and symptoms of thyrotoxicosis

52 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

53 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

54 Treatment Blockage of the release and effects of circulating thyroid hormones Supportive care Identification and treatment of precipitating event

55 Treatment Propylthiouracil(PTU) given as a loading dose of 600 mg followed by mg every 4 hours orally, rectally or via nasogastric tube Inorganic iodide Lugols Iodine – 5-8 drops 6 Hourly Saturated solution of Potassium Iodide drops 6 Hourly Sodium Ipodate – g 12 Hourly iv Beta Blockers Propranolol – mg orally 6 Hourly or 1 -5 mg iv 6 Hourly Esmolol - Ultrashort acting especially useful in the management of thyroid storm

56 Treatment Supportive Care Hyperthermia - Antipyretics - Alcohol sponge, ice packs Correction of dehydration Steroids – Dexamethasone or Hydrocortisone iv Treatment of precipitating event Antibiotics

57 Hyperthyroidism Thyrotoxicosis Types of Toxic goitre Ultrasound and Nuclear Scans will aid in determining the etiology Medical treatment

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

59 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

60 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

61 `` Thank You

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