Thyroid Treatments and Graves' Disease Overview

Subtotal Thyroidectomy

• First line treatment for large goitres in some countries
• Usually near total thyroidectomy
• Results in hypothyroidism, patients will require lifelong levothyroxine
• Potential complications include:
  • Hypothyroidism (~25%)
  • Transient hypocalcaemia (10%)
  • Permanent hypoparathyroidism (1%)
  • Recurrent laryngeal nerve palsy (1%)

Radioactive Iodine Ablation (RAI)

• Alternative treatment for large goitres
• Administered orally and trapped in the thyroid
• Effective in 75% of patients within 4-12 weeks
• Potential complications:
  • Hypothyroidism - most likely outcome
  • Exacerbation of Graves' ophthalmopathy

Antithyroid Drug Therapy

• High doses of Carbimazole or Propylthiouracil are used
• Used as a bridge for patients receiving RAI
• Can result in recurrence of thyrotoxicosis, especially in young patients

Graves' Disease

• Autoimmune thyroid disease
• Characterised by:
  • Thyrotoxicosis
  • Goitre
  • Ophthalmopathy
  • Dermopathy
• Thyroid-stimulating immunoglobulins (TSI) or TSH receptor antibodies (TRAb) are found in 80-95% of patients
• Strong genetic component with 50% concordance in monozygotic twins and only 5% in dizygotic twins

Thyroid Acropachy

• Rare complication of Graves' disease
• Characterized by swelling and thickening of the hands and feet
• Results from fibroblast activation in the areas which leads to increased connective tissue production

Subclinical Thyrotoxicosis

• Serum TSH is undetectable
• Serum T3 and T4 are elevated
• Patients have increased risk of atrial fibrillation and osteoporosis
• Requires treatment, usually with RAI
• 5% chance of developing overt thyrotoxicosis (elevated T4 and/or T3) annually

Transient Thyroiditis

• Inflammation of the thyroid gland, usually after viral infection
• Two forms:
  • Subacute (de Quervain’s) thyroiditis
  • Postpartum thyroiditis

Subacute (de Quervain’s) thyroiditis

• Characterised by:
  • Pain in the thyroid region that is worsened by swallowing, coughing, and neck movement
  • Palpable and tender thyroid gland
  • Systemic upset is common
• Usually affects women aged 20-40
• Responds to anti-inflammatory medication (NSAIDs)
• Release of stored thyroid hormones is followed by damaged thyroid cells and impaired hormone synthesis
• Ultimately, TSH suppression occurs in 25% of cases, with T4 and T3 levels in the reference range or elevated

Multinodular Goiter (MNG)

• Usually diagnosed in patients presenting with thyrotoxicosis, a large goitre with or without tracheal compression, or sudden painful swelling caused by haemorrhage into a nodule or cyst
• Goitre is nodular or lobulated and palpable
• Can cause mediastinal compression leading to stridor, dysphagia and superior vena cava obstruction
• Hoarseness can occur due to recurrent laryngeal nerve palsy
• Diagnosis is confirmed with ultrasonography and/or thyroid scintigraphy
• Treatment usually with RAI or antithyroid drugs (higher relapse rate with drugs)
• Thyroid surgery may be indicated in thyrotoxic patients with a large goitre

Simple Diffuse Goitre

• Presents between 15-25 years, often during pregnancy
• Characterised by:
  • Soft and symmetrical goitre
  • Thyroid enlargement to 2-3 times normal size
  • No tenderness or lymphadenopathy
  • Normal T3, T4, and TSH levels
  • No thyroid autoantibodies
• No treatment is necessary and the goitre usually regresses
• May become multinodular with areas of autonomous function due to recurrent episodes of hyperplasia and involution

This quiz explores various treatment options for large goitres, including subtotal thyroidectomy, radioactive iodine ablation, and antithyroid drug therapy. It also covers the implications of these treatments, such as complications and the management of Graves' disease. Test your knowledge on these essential endocrine topics.