Transcript Slide 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 Management of Toxic Goitre MMC • 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. Physiology 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 Toxic Goitre • Diffuse toxic goitre (Graves Disease) • Toxic multinodular goitre ( Plummers Disease) • Toxic solitary nodule • 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 Graves Disease • Parry • Robert Graves Graves Disease • • • • Diffuse toxic goitre Ophthalmopathy Dermopathy Acropachy 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 Exophthalmos Werner’s ‘NO SPECS’ Classification of Graves’ Ophthalmopathy Class 0 1 2 3 4 Definition No Physical Signs or Symptoms Only signs (no symptoms) – lid lag, lid retraction, proptosis upto 22 mm Soft Tissue Involvement (Symptoms and Signs) Proptosis (more than 22 mm) 5 Extraocular muscle involvement (Ophthalmoplegia) Corneal Injury 6 Sight 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 Pretibial myxedema Clinical presentation • • • • • Increased Heat production Neuropsychiatric changes Gastrointestinal Menstrual irregularities Cardiovascular Grave Disease Diagnosis • • • • TFT Thyroid Antibody titre Radioactive Iodine Uptake and Scan Ultrasound Scan Treatment • Antithyroid drugs • Surgery • Radioiodine ablation Antithyroid drugs Imidazoles • Carbimazole • Methimazole Thiouracil • Propylthiouracil Treatment Beta Blockers : Nonselective : Cardioselective Treatment • Surgery • Radioiodine ablation 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 6 -12 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- 5-20 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. 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 Nuclear Scan • 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 Plummer’s 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 Plummer’s 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 10 -20% 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 200-250mg every 4 hours orally, rectally or via nasogastric tube • Inorganic iodide Lugols Iodine – 5-8 drops 6 Hourly Saturated solution of Potassium Iodide - 5-8 drops 6 Hourly Sodium Ipodate – 0.5 -1 g 12 Hourly iv • Beta Blockers Propranolol – 20 - 80 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 “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 “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” `` Thank You