1. MS, FRCS (Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAES
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
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

3. MMC

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. Classification of Graves’ Ophthalmopathy
Werner’s ‘NO SPECS’
Classification of Graves’ Ophthalmopathy
Class
Definition
No Physical Signs or Symptoms 1
Only signs (no symptoms) – lid lag, lid
retraction, proptosis upto 22 mm 2
Soft Tissue Involvement (Symptoms
and Signs) 3
Proptosis (more than 22 mm) 4
Extraocular muscle involvement
(Ophthalmoplegia) 5
Corneal Injury 6
Sight 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 2nd dose.
5% of cases may need a 3rd 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 Plummer’s 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 Plummer’s 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. Gelette Burgess “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”

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