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:
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
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.
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
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
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)
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
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 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 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.
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
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 Plummers 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 Plummers 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 % 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 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
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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