GPrinz  EAghini-Lombardi One patient had an incidental 2.5-cm medullary carcinoma diagnosed on final pathologic examination. Associated carcinoma was present in 4 (7%) of the 54 patients. 1. The second patient was an 85-year-old paraplegic man with significant cardiopulmonary disease, refractory supraventricular arrhythmias, and a massive multinodular goiter, causing shortness of breath, dysphagia, and swelling of his face and neck. National Library of Medicine All Rights Reserved.  O Get free access to newly published articles. Early in our experience, subtotal thyroidectomy with 3-g remnants was routinely performed for Graves' disease.  KPiwonka  CRSperoff  et al Amiodarone: a common source of iodine-induced thyrotoxicosis.Â, Hans Patients treated by subtotal thyroidectomy however need closer review because of the risk of recurrent hyperthyroidism as well as hypothyroidism. Thyrotoxicosis due to ectopic lateral thyroid tissue presenting 5 years after total thyroidectomy. The extent of thyroidectomy in patients with Graves' disease included 17 total, 7 near-total, and 8 subtotal thyroidectomies. The 2 patients with relapsing thyroiditis were treated with a β-receptor antagonist alone. 2012 Sep. 109(3):466-7. . Patients with thyrotoxicosis constituted 16% (54/347) of all patients referred for thyroidectomy at our institution during the 9-year study. The indications for operation were compressive symptoms or substernal extension or both (35 patients), patient preference (12 patients), thyrotoxicosis (4 patients), or a dominant nodule (3 patients). It is considered that the term " hypoparathyroidism " is misleading when used for hypocalcæmia developing within one or two days of thyroidectomy in thyrotoxic patients.  P Total thyroidectomy: the preferred option for multinodular goiter.Â, Nademanee Thyroidectomy is performed after achieving a euthyroid state.  YObara  ACrummer  JADaykin Thionamides are used to restore euthyroidism before thyroidectomy to avoid more severe thyrotoxicosis from leakage of thyroid hormone into the circulation at the time of surgery and to reduce operative and postoperative complications associated with anaesthesia and surgery in thyrotoxic …  BLagasse Our results demonstrate that near-total and total thyroidectomy in patients with thyrotoxicosis can be performed with a low morbidity. A study published in NEJM in 1978 reported a series of 100 patients with thyrotoxicosis who underwent successful subtotal thyroidectomy following treatment with propanolol as monotherapy, without major perioperative or postoperative morbidity and importantly, with no cases of thyroid storm . Pathologic evaluation of the dominant nodule in 3 patients with Graves' disease revealed a 2-cm papillary carcinoma in 1 and a follicular adenoma in 2. The average follow-up for the entire group was 22 months. A study of patients with recurrent thyrotoxicosis after subtotal thyroidectomy has shown that the operation has a profound effect on the natural history of Graves's disease. Your thyroid gland has become overactive and is producing too many hormones. The only mortality in our series occurred in a patient with amiodarone-induced thyrotoxicosis, emphasizing that these patients may be at higher risk for surgery related to their underlying comorbid diseases.  TFujimoto Generalised anxiety disorder following thyroidectomy Eleftheria Panteliou & Khash Nikookam.  CB Discussion: surgery still has a role in Graves' hyperthyroidism.Â, Mulligan To the best of our knowledge this is the first reported case of this condition. Other authors20-22 have documented that total thyroidectomy can be performed safely in patients with Graves' disease or multinodular goiter. Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis [ 1 ].  QDjuricin A retrospective review of all patients undergoing thyroidectomy between 1990 and 1998 was completed, and those who underwent thyroidectomy for thyrotoxicosis were identified. It is followed by pronounced changes in the immunological features of the disease, with a fall in the prevalence of serum thyroid autoantibodies, including the long-acting thyroid stimulator.  TOzaki  et al Surgical treatment of Graves' disease: subtotal or total thyroidectomy?Â, Torring Near-total or total thyroidectomy, when it can be performed safely, should be considered for definitive management of Graves' disease, toxic multinodular goiter, chronically remitting thyrotoxicosis secondary to thyroiditis, and amiodarone-induced thyrotoxicosis. Hungry bone syndrome occurs exclusively in thyrotoxic subjects and constitutes the major cause of postoperative hypocalcemia after total thyroidectomy. Graves' disease, an autoimmune disorder of uncertain origin, accounted for 59% (32 patients), and toxic multinodular goiter, a disease characterized by multiple autonomously functioning thyroid nodules, accounted for 18 (33%) of the patients with surgically-treated thyrotoxicosis in our series. Postoperative hypocalcemia occurred in 35 patients (65%), 10 (29%) of whom were symptomatic.  MRao Twenty-eight of 32 patients with Graves' disease received an antithyroid drug, 17 of whom also received a β-receptor antagonist. Reply. The first is the use of preoperative pharmacological preparation that has effectively eliminated thyroid storm. Vocal cord paresis and a hematoma requiring operative evacuation occurred in 1 patient each. Accessibility Patients with toxic multinodular goiter were noted to have larger thyroid glands and more frequent substernal extension and compressive symptoms. Two or more parathyroid glands were preserved in situ in all patients. Bethesda, MD 20894, Copyright Others have not been able to demonstrate a clear-cut relationship between the size of the remnant and achievement of a euthyroid state.12 Even if such a determination could be made, standardizing the remnant size is inherently difficult. Thyroid surgery for Graves' disease and Graves' ophthalmopathy. Unable to load your collection due to an error, Unable to load your delegates due to an error. Though the behaviour of a group ofpatients after surgery From the Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.  TIto Approximately 2 years later, recurrent thyrotoxicosis was evident off levothyroxine.  S Two patients with relapsing thyroiditis experienced alternating episodes of symptomatic hyper- and hypothyroidism for 5 and 10 years' duration. Their FT4 levels were 30.37 pmol/L (2.36 ng/dL) and 55.34 pmol/L (4.3 ng/dL), and both had a low radioiodine uptake. The most common reason for recommending surgical therapy was marked thyroid enlargement, with associated substernal extension or compressive symptoms or both.  M Retrospective analysis of prognostic factors affecting the thyroid function status after subtotal thyroidectomy for Graves' disease.Â, Patwardhan  VAiba We attribute this to several factors.  et al Early recurrence of hyperthyroidism in patients with Graves' disease treated by subtotal thyroidectomy.Â, Miccoli Since more than 30% of patients with thyrotoxicosis treated by bilateral subtotal thyroidectomy become hypothyroid within 20 years of surgery, close follow-up is required to prevent delay in recognition and treatment of hypothyroidism. Thyroidectomy for Selected Patients With Thyrotoxicosis. Customize your JAMA Network experience by selecting one or more topics from the list below. The recurrence rate is less than that after the administration of antithyroid drugs, and postoperative complications are rare.  SBraverman The cause of thyrotoxicosis was Graves' disease in 32 patients (59%), toxic multinodular goiter in 18 (33%), relapsing thyroiditis in 2 (4%), and amiodarone-induced thyrotoxicosis in 2 (4%) patients. Two patients, both with Graves' disease treated by subtotal thyroidectomy, developed recurrent thyrotoxicosis.  PRago The mean ± SD FT4 level in patients with Graves' disease was 54.18 ± 19.43 pmol/L vs 33.08 ± 17.63 pmol/L (4.21 ± 1.51 ng/dL vs 2.57 ± 1.37 ng/dL) in patients with thyrotoxicosis from other causes (P<.05). The reported incidence of recurrent hyperthyroidism in patients undergoing subtotal thyroidectomy varies between 1.2% and 16.2% (Table 1).2,11,13-19 This can be explained in part by the differences in remnant size and may also be related to differences in length of follow-up.  GTorring Results  Our series emphasizes that massive thyroid enlargement with compressive symptoms, a dominant nodule with abnormal fine-needle aspiration biopsy findings, failed radioiodine therapy, or patient preference, especially when there are concerns about radioiodine-induced aggravation of ophthalmopathy, are established indications for surgical treatment of thyrotoxicosis. These reasons underscore the clinician's responsibility to discuss all therapeutic alternatives for thyrotoxicosis with the patient. It has also been shown to damage thyroid cell membranes, resulting in increased release of large stores of thyroid hormone.5 Amiodarone-induced thyrotoxicosis has also been reported to occur in patients with preexisting thyroid disease, most commonly multinodular goiter.5,24 It is often resistant to amiodarone withdrawal and conventional pharmacological therapy. Intraoperative photograph of a large substernal thyroid gland in a patient with amiodarone-induced thyrotoxicosis and multinodular goiter (the patient's head is to the right).  BNorby  RMariotti All patients with Graves' disease received 10 days of iodine treatment before surgery to reduce the vascularity of the thyroid gland. Vertebral osteoporosis and hypomagnesemia within 72 hours after total thyroidectomy is associated with the risk of hungry bone syndrome. Hypocalcaemia after subtotal thyroidectomy for thyrotoxicosis Hypocalcaemia after subtotal thyroidectomy for thyrotoxicosis Ramus, N. I. To examine the indications for operation and the frequency, efficacy, and outcome of surgical therapy for thyrotoxicosis. Terms of Use| In 2 asymptomatic patients with mild thyrotoxicosis, no additional therapy was required after amiodarone cessation and serial thyroid function tests showed resolution. One patient developed a hematoma that required operative evacuation following subtotal thyroidectomy for Graves' disease. A study of patients with recurrent thyrotoxicosis after subtotal thyroidectomy has shown that the operation has a profound effect on the natural history of Graves's disease.  et al Increased aggressiveness of thyroid cancer in patients with Graves' disease.Â, Tallstedt Careers. Symptomatic hypocalcemia occurred in 10 patients (19%), with a mean free thyroxine level of 60.49 ± 16.09 pmol/L vs 40.41 ± 19.56 pmol/L (4.70 ± 1.25 ng/dL vs 3.14 ± 1.52 ng/dL) in 25 patients (46%) with asymptomatic hypocalcemia (. 2010 Nov-Dec;132(11-12):355-60.  O Occurrence of ophthalmopathy after treatment for Graves' hyperthyroidism: the Thyroid Study Group.Â, Rastad  SRossi  LEUtiger In national surveys from the United States and Japan, the incidence of thyroid storm was 0.57 to 0.76 and 0.20 per 100,000 persons per year, respectively, and 4.8 to 5.6 per 100,000 hospitalized patients per year [ 2-4 ]. Long-term follow up after surgery for thyrotoxicosis.  LGlinoer Before treatment, resorption is much greater than formation, causing reduced BMD, which is referred to as thyrotoxic osteodystrophy.4 After thyroidectomy, thyrotoxic state was suddenly removed, bone formation exceeds bone resorption in reverse and rapid skeletal uptake of calcium from blood causes severe and persistent hypocalcaemia, which is called hungry bone syndrome.5 After total thyroidectomy … Of the 347 patients undergoing thyroidectomy, 54 (16%) were referred for treatment of thyrotoxicosis. The mean pretreatment FT4 level in patients with symptomatic hypocalcemia was 60.49 ± 16.09 pmol/L vs 40.41 ± 19.56 pmol/L (4.70 ± 1.25 ng/dL vs 3.14 ± 1.52 ng/dL) in patients with asymptomatic hypocalcemia (P<.05). Because of his comorbid diseases and in accordance with his living will, the family allowed him to die, with comfort measures only. This is an uncommon scenario. Tallstedt and colleagues8 have previously reported the potential for worsening of Graves' eye disease in patients treated with 131I. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2001;127(1):61-65. doi:10.1001/archotol.127.1.61. A total thyroidectomy was performed in 12 patients, near-total thyroidectomy in 5, and a unilateral resection of a large substernal goiter in a single elderly patient with subclinical thyrotoxicosis, minimal disease in the contralateral thyroid lobe, and a markedly attenuated recurrent laryngeal nerve on the side of the substernal goiter. doi: 10.1002/14651858.CD010576.pub2. Near-total or total thyroidectomy is safe and more effective than subtotal thyroidectomy in preventing recurrence and should be considered in most patients referred for surgical treatment of thyrotoxicosis.  MSheppard 8600 Rockville Pike The operation and treatment information on this page is published under license by Healthdirect Australia from EIDO Healthcare Australia and is protected by copyright laws. To examine the indications for operation and the frequency, efficacy, and outcome of surgical therapy for thyrotoxicosis. An associated dominant nodule with abnormal findings on fine-needle aspiration biopsy was the principal indication for surgery in 3 (9%) of our patients with Graves' disease, 1 diagnosed as having a papillary carcinoma and 2 as having a follicular adenoma. Vascularized thyroid tissue was noted on ultrasound, and a radioactive iodine scan indicated increased uptake in the right thyroid region.  KMimura Patient preference was the primary reason for operation in 12 (38%) of the 32 patients with Graves' disease. There was no incidence of nerve transection. Bilateral subtotal thyroidectomy has been advocated for patients with Graves' disease to establish a euthyroid state and to reduce the risk of recurrent laryngeal nerve injury and hypoparathyroidism. I’m just glad I switched to Armour Thyroid and will never switch to a synthetic medication. The most common cause of thyrotoxicosis is Graves' disease, accounting for 60% to 90% of all cases of thyrotoxicosis.1 Toxic multinodular goiter and a solitary toxic nodule are less common causes of thyrotoxicosis. The medical records of all patients who underwent thyroidectomy between 1990 and 1998 were reviewed. The patient, a 27-year-old woman, elected to have a total thyroidectomy and began levothyroxine after the procedure.  DW The reference ranges for the laboratory indices analyzed were: FT4, 9.40 to 25.87 pmol/L (0.73 to 2.01 ng/dL); thyrotropin, 0.46 to 3.59 mIU/L; calcium, 2.1 to 2.5 mmol/L (8.4 to 10.0 mg/dL); and alkaline phosphatase, 25 to 136 U/L. In the same patients only one had a transient right sided recurrent laryngeal nerve palsy. © 2021 American Medical Association. Postoperative complications included vocal cord paresis in 1 patient that resolved 1 month after a near-total thyroidectomy for Graves' disease. Meticulous technique in maintaining parathyroid gland blood supply and autotransplantation of parathyroid glands that cannot be preserved in situ have been important in reducing the incidence of permanent hypoparathyroidism. At operation, the patient was noted to have a massive substernal goiter (Figure 2). We discuss the implications of this rare scenario-recurrence of thyrotoxicosis after near-total thyroidectomy. Graves' disease in a mediastinal mass presenting after total thyroidectomy for nontoxic multinodular goiter: a case report. Recent Pat Endocr Metab Immune Drug Discov. 2021 American Medical Association. The final pathologic finding was chronic lymphocytic thyroiditis in both patients, 1 of whom also had an incidental 0.4-cm papillary carcinoma. after partial thyroidectomy ranges from 3-5 to 35% in this country (Riddell, 1962; Hedley et al., 1970a) and 4-5 to48%intheUnitedStates(Cattell, 1949;BeahrsandSakulsky, 1968), but the higher figures may merely represent more critical evaluation of postoperative thyroid status. All Rights Reserved. The modern "fashion" of total thyroidectomy for thyrotoxicosis reduces the incidence of recurrent thyrotoxicosis to zero but has a significant rate of hypoparathyroidism in non specialist hands.  S The influence of remnant size, antithyroid antibodies, thyroid morphology, and lymphocytic infiltration on thyroid function after subtotal resection for hyperthyroidism.Â, Davenport Total thyroidectomy for hyperthyroidism is usually curative. [Radioiodine versus surgery in the treatment of Graves' hyperthyroidism].  RD Modified subtotal thyroidectomy for Graves' disease: a two-institution study.Â, Jortso  AGarofalo  SLindstrom  ELLiechly One patient, previously described,5 was a 72-year-old man with significant cardiopulmonary disease and refractory ventricular arrhythmias, who had a 30.7-g thyroid resected. Since more than 30% of patients with thyrotoxicosis treated by bilateral subtotal thyroidectomy become hypothyroid within 20 years of surgery, close follow-up is required to prevent delay in recognition and treatment of hypothyroidism.2,13 Following near-total or total thyroidectomy, all patients are immediately started on a replacement dose of thyroid hormone. However, only 1 patient remained euthyroid, 2 developed recurrent hyperthyroidism, and 5 developed hypothyroidism after a mean 28-month follow-up. The average weight of the resected gland in patients with toxic multinodular goiter was 184 g (range, 34-1025 g).  SJAskari Copyright © 2020 Baylor University Medical Center. It also simplifies the long-term assessment of patients' thyroid function postoperatively. Rapid control of thyrotoxicosis for urgent thyroidectomy . Seventeen patients (26%) initially commenced glucocorticoids (GC), 23 (35%) thionamides (THIO), and 24 (36%) GC and THIO simultaneously or within 2 weeks of each other (COMB). By continuing to use our site, or clicking "Continue," you are agreeing to our, Rates of Recurrent Hyperthyroidism in Patients Undergoing Subtotal Thyroidectomy*.  et al Graves' hyperthyroidism: treatment with antithyroid drugs, surgery, or radioiodine: a prospective, randomized study.Â, Liu Get the latest from JAMA Otolaryngology–Head & Neck Surgery.  PVitti Iodine administration in patients with Graves' disease has been helpful in reducing intraoperative bleeding, which can affect the identification and preservation of the recurrent laryngeal nerves and the parathyroid glands. Conclusions  Cunha FM, Rodrigues E, Oliveira J, Saavedra A, Vinhas LS, Carvalho D. J Med Case Rep. 2016 Mar 31;10:70. doi: 10.1186/s13256-016-0878-7. Braverman Approximately 2 years later, recurrent thyrotoxicosis was evident off levothyroxine. Ages ranged from 23 to 85 years (mean age, 42 years). Massive thyroid enlargement with compressive symptoms, a dominant nodule, and patient preference are indications for surgical treatment of thyrotoxicosis.

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