INTERNATIONAL SCHOOL OF INTERNATIONAL SCHOOL OF MEDICINEMEDICINE

PPT OF TOXIC NODULAR PPT OF TOXIC NODULAR GOITERGOITER

NAME JYOTI DAHIYA NAME JYOTI DAHIYA GROUP 21GROUP 21stst

SEMESTER 7SEMESTER 7thth

Surgical Anatomy of thyroid glandSurgical Anatomy of thyroid gland The thyroid gland has two lobes the right and the The thyroid gland has two lobes the right and the

left. These lobes are connected in the midline by a left. These lobes are connected in the midline by a sleeve of thyroid tissue known as the isthmus. The sleeve of thyroid tissue known as the isthmus. The whole gland is covered anteriorly by infrahyoid whole gland is covered anteriorly by infrahyoid group of muscles.group of muscles.

  Major blood supply to thyroid gland arises from the superior Major blood supply to thyroid gland arises from the superior thyroid artery a branch of the external carotid artery, and thyroid artery a branch of the external carotid artery, and inferior thyroid artery by way of the thyrocervical trunk. inferior thyroid artery by way of the thyrocervical trunk. Venous supply accompanies the arteries. A middle thyroid vein Venous supply accompanies the arteries. A middle thyroid vein directly drains into the internal jugular vein.directly drains into the internal jugular vein.

anatomyanatomy

Nerve relationship to thyroid glandNerve relationship to thyroid gland Recurrent laryngeal nerves and their relationship to the Recurrent laryngeal nerves and their relationship to the

thyroid gland: The recurrent laryngeal nerve innervate the thyroid gland: The recurrent laryngeal nerve innervate the intrinsic muscles of larynx. It also provides sensory intrinsic muscles of larynx. It also provides sensory innervation to the glottis. The recurrent laryngeal nerve innervation to the glottis. The recurrent laryngeal nerve arises from the vagus at the level of subclavian artery on arises from the vagus at the level of subclavian artery on the right side and at the level of the aortic arch on the left. the right side and at the level of the aortic arch on the left. The nerves then turn superio medially and runs towards The nerves then turn superio medially and runs towards the tracheo oesophageal groove. As the recurrent the tracheo oesophageal groove. As the recurrent laryngeal nerve ascends the tracheo oesophageal groove it laryngeal nerve ascends the tracheo oesophageal groove it is intimately related to the inferior thyroid artery. The is intimately related to the inferior thyroid artery. The nerves may pass superficial or deep between the branches nerves may pass superficial or deep between the branches of the inferior thyroid artery.of the inferior thyroid artery. The recurrent laryngeal nerve as it travels in the tracheo

oesophageal groove, it comes into intimate contact with the posterior portion of the thyroid gland.It is always better to identify the nerve at the level of cricothryoid joint, at which point it enters the larynx. Injury to this nerve should be prevented during surgery at all costs, as this will cause vocal cord paralysis. Damage to recurrent laryngeal nerves on both sides will cause stridor necessitating tracheostomy due to bilateral abductor palsy. Non recurrent laryngeal nerve: arises directly from the cervical portion of the vagus at about the level of the larynx and enters it at the level of the cricopharyngeal joint. Majority of these nerves occur on the right side and is commonly associated with an anomalous retro esophageal subclavian artery.

Nerve relationship Nerve relationship Superior laryngeal nerve: arise from the inferior vagal ganglion (nodose) Superior laryngeal nerve: arise from the inferior vagal ganglion (nodose)

and descend inferiorly deep to the carotid system. As the superior and descend inferiorly deep to the carotid system. As the superior laryngeal nerve descends towards the thyrohyoid membrane they pass laryngeal nerve descends towards the thyrohyoid membrane they pass anterior to the cervical sympathetic trunk and posterior to the carotid anterior to the cervical sympathetic trunk and posterior to the carotid system. Friedman proposed a classification to account for the anatomic system. Friedman proposed a classification to account for the anatomic variations of superior laryngeal nerve. They are:variations of superior laryngeal nerve. They are:Type I: The nerve runs superficial to the inferior constrictor muscle.Type I: The nerve runs superficial to the inferior constrictor muscle.Type II: The nerve penetrates the lower part of the inferior constrictor Type II: The nerve penetrates the lower part of the inferior constrictor muscle.muscle.Type III: The nerve penetrates the superior part of the inferior constrictor Type III: The nerve penetrates the superior part of the inferior constrictor muscle. muscle. The superior laryngeal nerve travels in close proximity to the superior The superior laryngeal nerve travels in close proximity to the superior thyroid artery. This nerve should be protected by the surgeon at all costs.thyroid artery. This nerve should be protected by the surgeon at all costs.Injury to this nerve will cause minor degrees of voice change since this Injury to this nerve will cause minor degrees of voice change since this nerve supply the cricothyroid muscle. It patient will not be able to raise nerve supply the cricothyroid muscle. It patient will not be able to raise the pitch of his voice. This becomes really troublesome for a singer. It also the pitch of his voice. This becomes really troublesome for a singer. It also supplies sensory innervation to larynx. supplies sensory innervation to larynx. Parathyroid glands: During surgery every effort should be made to Parathyroid glands: During surgery every effort should be made to identify and preserve the parathyroid glands. These glands are 4 in identify and preserve the parathyroid glands. These glands are 4 in number. The superior parathyroids embryologically arise from the 4th number. The superior parathyroids embryologically arise from the 4th pouch, while the inferior parathyroids arise from the 3rd pouch. The pouch, while the inferior parathyroids arise from the 3rd pouch. The superior parathyroid glands lies near the cricothryoid joint, at the superior parathyroid glands lies near the cricothryoid joint, at the intersection between the recurrent laryngeal nerve and the inferior intersection between the recurrent laryngeal nerve and the inferior thyroid artery. The inferior parathyroids are variable in position because thyroid artery. The inferior parathyroids are variable in position because it has to migrate long distances due to the position of the thymus gland. it has to migrate long distances due to the position of the thymus gland. Commonly they are located close to the inferior thyroid pole. The Commonly they are located close to the inferior thyroid pole. The parathyroid glands are supplied by branches from the inferior thyroid parathyroid glands are supplied by branches from the inferior thyroid artery, hence it should be protected.artery, hence it should be protected.

Toxic goiterToxic goiterToxic multinodular goiterToxic multinodular goiter (also known as  (also known as toxic nodular toxic nodular

goitergoiter, , toxic nodular strumatoxic nodular struma, or , or Plummer's diseasePlummer's disease) is a ) is a multinodular goitermultinodular goiter associated with a  associated with a hyperthyroidismhyperthyroidism..

It is a common cause of hyperthyroidism in which there is It is a common cause of hyperthyroidism in which there is excess production of excess production of thyroid hormonesthyroid hormones from functionally  from functionally

autonomous thyroid nodules, which do not require stimulation autonomous thyroid nodules, which do not require stimulation from from thyroid stimulating hormonethyroid stimulating hormone (TSH) (TSH)

Toxic multinodular goiter is the second most common cause of Toxic multinodular goiter is the second most common cause of hyperthyroidism (after hyperthyroidism (after Graves' diseaseGraves' disease) in the developed ) in the developed

world, whereas iodine deficiency is the most common cause world, whereas iodine deficiency is the most common cause of of hypothyroidismhypothyroidism in developing-world countries where the  in developing-world countries where the population is iodine-deficient. (Decreased iodine leads to population is iodine-deficient. (Decreased iodine leads to

decreased thyroid hormone.) However, iodine deficiency can decreased thyroid hormone.) However, iodine deficiency can cause goitre (thyroid enlargement); within a goitre, nodules cause goitre (thyroid enlargement); within a goitre, nodules

can develop. Risk factors for toxic multinodular goiter include can develop. Risk factors for toxic multinodular goiter include individuals over 60 years of age and being female.individuals over 60 years of age and being female.

Causes or etiologyCauses or etiology Functional autonomy of the thyroid gland appears to be related Functional autonomy of the thyroid gland appears to be related

to iodine deficiency. Various mechanisms have been implicated, to iodine deficiency. Various mechanisms have been implicated, but the molecular pathogenesis is poorly understood.but the molecular pathogenesis is poorly understood.

The sequence of events leading to toxic multinodular goiter is as The sequence of events leading to toxic multinodular goiter is as follows:follows:

Iodine deficiency leads to low levels of T4; this induces thyroid Iodine deficiency leads to low levels of T4; this induces thyroid cell hyperplasia to compensate for the low levels of T4.cell hyperplasia to compensate for the low levels of T4.

Increased thyroid cell replication predisposes single cells to Increased thyroid cell replication predisposes single cells to somatic mutations of the TSH receptor. Constitutive activation of somatic mutations of the TSH receptor. Constitutive activation of the TSH receptor may generate autocrine factors that promote the TSH receptor may generate autocrine factors that promote further growth, resulting in clonal proliferation. Cell clones then further growth, resulting in clonal proliferation. Cell clones then produce multiple nodules.produce multiple nodules.

Somatic mutations of the TSH receptors and G α protein confer Somatic mutations of the TSH receptors and G α protein confer constitutive activation to the cyclic adenosine monophosphate constitutive activation to the cyclic adenosine monophosphate (cAMP) cascade of the inositol phosphate pathways. These (cAMP) cascade of the inositol phosphate pathways. These mutations may be responsible for functional autonomy of the mutations may be responsible for functional autonomy of the thyroid in 20-80% of cases. [1]thyroid in 20-80% of cases. [1]

These mutations are found in autonomously functioning thyroid These mutations are found in autonomously functioning thyroid nodules, solitary and within a multinodular gland. nodules, solitary and within a multinodular gland. Nonfunctioning thyroid nodules within the same gland lack these Nonfunctioning thyroid nodules within the same gland lack these mutations.mutations.

Sign and symptomsSign and symptoms Thyrotoxic symptoms - Most patients with toxic nodular goiter (TNG) present Thyrotoxic symptoms - Most patients with toxic nodular goiter (TNG) present

with symptoms typical of hyperthyroidism, including heat intolerance, with symptoms typical of hyperthyroidism, including heat intolerance, palpitations, tremor, weight loss, hunger, and frequent bowel movements.palpitations, tremor, weight loss, hunger, and frequent bowel movements.

Elderly patients may have more atypical symptoms, including the following:Elderly patients may have more atypical symptoms, including the following:– Weight loss is the most common complaint in elderly patients with Weight loss is the most common complaint in elderly patients with

hyperthyroidism.hyperthyroidism.– Anorexia and constipation may occur, in contrast to frequent bowel Anorexia and constipation may occur, in contrast to frequent bowel

movements often reported by younger patients.movements often reported by younger patients.– Dyspnea or palpitations may be a common occurrence.Dyspnea or palpitations may be a common occurrence.– Tremor also occurs but can be confused with essential senile tremor.Tremor also occurs but can be confused with essential senile tremor.– Cardiovascular complications occur commonly in elderly patients, and a Cardiovascular complications occur commonly in elderly patients, and a

history of atrial fibrillation, congestive heart failure, or angina may be history of atrial fibrillation, congestive heart failure, or angina may be present.present.

Obstructive symptoms - A significantly enlarged goiter can cause symptoms Obstructive symptoms - A significantly enlarged goiter can cause symptoms related to mechanical obstruction.related to mechanical obstruction.

A large substernal goiter may cause dysphagia, dyspnea, or frank stridor. A large substernal goiter may cause dysphagia, dyspnea, or frank stridor. Rarely, this goiter results in a surgical emergency.Rarely, this goiter results in a surgical emergency.

Involvement of the recurrent or superior laryngeal nerve may result in Involvement of the recurrent or superior laryngeal nerve may result in complaints of hoarseness or voice change.complaints of hoarseness or voice change.

Asymptomatic - Many patients are asymptomatic or have minimal symptoms Asymptomatic - Many patients are asymptomatic or have minimal symptoms and are incidentally found to have hyperthyroidism during routine screening. and are incidentally found to have hyperthyroidism during routine screening. The most common laboratory finding is a suppressed TSH with normal free The most common laboratory finding is a suppressed TSH with normal free thyroxine (T4) levels.thyroxine (T4) levels.

Physical examinationPhysical examination Findings of hyperthyroidism may be more subtle than Findings of hyperthyroidism may be more subtle than

those of Graves disease. Features may include those of Graves disease. Features may include widened, palpebral fissures; tachycardia; hyperkinesis; widened, palpebral fissures; tachycardia; hyperkinesis; moist, smooth skin; tremor; proximal muscle weakness; moist, smooth skin; tremor; proximal muscle weakness; and brisk deep tendon reflexes.and brisk deep tendon reflexes.

The size of the thyroid gland is variable. Large The size of the thyroid gland is variable. Large substernal glands may not be appreciable upon substernal glands may not be appreciable upon physical examination.physical examination.

A dominant nodule or multiple irregular, variably sized A dominant nodule or multiple irregular, variably sized nodules are typically present. In a small gland, nodules are typically present. In a small gland, multinodularity may be apparent only on an multinodularity may be apparent only on an ultrasonogram. Chronic Graves disease may present ultrasonogram. Chronic Graves disease may present with some nodularity; therefore, establishing the with some nodularity; therefore, establishing the diagnosis is sometimes difficult.diagnosis is sometimes difficult.

Hoarseness or tracheal deviation may be present upon Hoarseness or tracheal deviation may be present upon examination.examination.

Mechanical obstruction may result in superior vena Mechanical obstruction may result in superior vena cava syndrome, with engorgement of facial and neck cava syndrome, with engorgement of facial and neck veins (Pemberton sign). [4]veins (Pemberton sign). [4]

Stigmata of Graves disease (eg, orbitopathy, pretibial Stigmata of Graves disease (eg, orbitopathy, pretibial myxedema, acropachy) are not observed.myxedema, acropachy) are not observed.

Pathophysiology to toxic nodular goiterPathophysiology to toxic nodular goiter PathophysiologyPathophysiology Toxic nodular goiterToxic nodular goiter (TNG) represents a spectrum of  (TNG) represents a spectrum of

disease ranging from a single hyperfunctioning nodule disease ranging from a single hyperfunctioning nodule (toxic adenoma) within a multinodular thyroid to a (toxic adenoma) within a multinodular thyroid to a gland with multiple areas of hyperfunction. The natural gland with multiple areas of hyperfunction. The natural history of a multinodular goiter involves variable history of a multinodular goiter involves variable growth of individual nodules; this may progress to growth of individual nodules; this may progress to hemorrhage and degeneration, followed by healing hemorrhage and degeneration, followed by healing and fibrosis. Calcification may be found in areas of and fibrosis. Calcification may be found in areas of previous hemorrhage. Some nodules may develop previous hemorrhage. Some nodules may develop autonomous function. Autonomous hyperactivity is autonomous function. Autonomous hyperactivity is conferred by somatic mutations of the thyrotropin, or conferred by somatic mutations of the thyrotropin, or thyroid-stimulating hormone (TSH), receptor in 20-80% thyroid-stimulating hormone (TSH), receptor in 20-80% of toxic adenomas and some nodules of multinodular of toxic adenomas and some nodules of multinodular goiters. [1] Autonomously functioning nodules may goiters. [1] Autonomously functioning nodules may become toxic in 10% of patients. Hyperthyroidism become toxic in 10% of patients. Hyperthyroidism predominantly occurs when single nodules are larger predominantly occurs when single nodules are larger than 2.5 cm in diameter. Signs and symptoms of TNG than 2.5 cm in diameter. Signs and symptoms of TNG are similar to those of other types of hyperthyroidism.are similar to those of other types of hyperthyroidism.

epidemiologyepidemiology FrequencyFrequency United StatesUnited States Toxic nodular goiter accounts for approximately 15-30% of Toxic nodular goiter accounts for approximately 15-30% of

cases of hyperthyroidism in the United States, second only cases of hyperthyroidism in the United States, second only to Graves disease.to Graves disease.

InternationalInternational In areas of endemic iodine deficiency, In areas of endemic iodine deficiency, toxic nodular goitertoxic nodular goiter

 (TNG) accounts for approximately 58% of cases of  (TNG) accounts for approximately 58% of cases of hyperthyroidism, 10% of which are from solitary toxic hyperthyroidism, 10% of which are from solitary toxic nodules. Graves disease accounts for 40% of cases of nodules. Graves disease accounts for 40% of cases of hyperthyroidism. In patients with underlying nontoxic hyperthyroidism. In patients with underlying nontoxic multinodular goiter, initial iodine supplementation (or multinodular goiter, initial iodine supplementation (or iodinated contrast agents) can lead to hyperthyroidism (Jod-iodinated contrast agents) can lead to hyperthyroidism (Jod-Basedow effect). Iodinated drugs, such as amiodarone, may Basedow effect). Iodinated drugs, such as amiodarone, may also induce hyperthyroidism in patients with underlying also induce hyperthyroidism in patients with underlying nontoxic multinodular goiter. Roughly 3% of patients nontoxic multinodular goiter. Roughly 3% of patients treated with amiodarone in the United States (more in treated with amiodarone in the United States (more in areas of iodine deficiency) develop amiodarone-induced areas of iodine deficiency) develop amiodarone-induced hyperthyroidism. [hyperthyroidism. [

Mortality/MorbidityMortality/Morbidity Morbidity and mortality from toxic nodular goiter (TNG) Morbidity and mortality from toxic nodular goiter (TNG)

may be divided into problems related to hyperthyroidism may be divided into problems related to hyperthyroidism and problems related to growth of the nodules and gland. and problems related to growth of the nodules and gland. Local compression problems due to nodule growth, Local compression problems due to nodule growth, although unusual, include dyspnea, hoarseness, and although unusual, include dyspnea, hoarseness, and dysphagia. Both TNG and Graves disease have increased dysphagia. Both TNG and Graves disease have increased mortality but for different reasons. [3]mortality but for different reasons. [3]

TNG is more common in elderly adults; therefore, TNG is more common in elderly adults; therefore, complications due to comorbidities, such as coronary complications due to comorbidities, such as coronary artery disease, are significant in the management of artery disease, are significant in the management of hyperthyroidism.hyperthyroidism.

SexSex Toxic nodular goiter occurs more commonly in women Toxic nodular goiter occurs more commonly in women

than in men. In women and men older than 40 years, the than in men. In women and men older than 40 years, the prevalence rate of palpable nodules is 5-7% and 1-2%, prevalence rate of palpable nodules is 5-7% and 1-2%, respectively.respectively.

AgeAge Most patients with toxic nodular goiter (TNG) are older Most patients with toxic nodular goiter (TNG) are older

than 50 years.than 50 years.

Laboratory studiesLaboratory studies Thyroid function tests [7] - Evidence of hyperthyroidism must be Thyroid function tests [7] - Evidence of hyperthyroidism must be

present in order to consider a diagnosis of toxic nodular goiter present in order to consider a diagnosis of toxic nodular goiter (TNG).(TNG).

See the list below:See the list below: Third-generation TSH assays are generally the best initial screening Third-generation TSH assays are generally the best initial screening

tool for hyperthyroidism. Patients with TNG will have suppressed tool for hyperthyroidism. Patients with TNG will have suppressed TSH levels.TSH levels.

Free T4 levels or surrogates of free T4 levels (ie, free T4 index) Free T4 levels or surrogates of free T4 levels (ie, free T4 index) may be elevated or within the reference range. An isolated may be elevated or within the reference range. An isolated increase in T4 is observed in iodine-induced hyperthyroidism or in increase in T4 is observed in iodine-induced hyperthyroidism or in the presence of agents that reduce peripheral conversion of T4 to the presence of agents that reduce peripheral conversion of T4 to triiodothyronine (T3) (eg, propranolol, corticosteroids, radiocontrast triiodothyronine (T3) (eg, propranolol, corticosteroids, radiocontrast agents, amiodarone).agents, amiodarone).

Some patients may have normal free T4 levels (or free T4 index) Some patients may have normal free T4 levels (or free T4 index) with an elevated T3 level (T3 toxicosis); this may occur in 5-46% of with an elevated T3 level (T3 toxicosis); this may occur in 5-46% of patients with toxic nodules. Note that the total T3 and T4 levels patients with toxic nodules. Note that the total T3 and T4 levels may often be within the reference range but may be higher than may often be within the reference range but may be higher than the normal range for a particular individual; this is especially true in the normal range for a particular individual; this is especially true in patients with nonthyroidal illness in which T3 levels are decreased.patients with nonthyroidal illness in which T3 levels are decreased.

Subclinical hyperthyroidism - Some patients may have suppressed Subclinical hyperthyroidism - Some patients may have suppressed TSH levels with normal free T4 and total T3 levels.TSH levels with normal free T4 and total T3 levels.

Imaging studiesImaging studies Nuclear scintigraphy [7]Nuclear scintigraphy [7] Nuclear scans should be performed on patients with biochemical Nuclear scans should be performed on patients with biochemical

hyperthyroidism. Nuclear medicine scans can be performed with hyperthyroidism. Nuclear medicine scans can be performed with radioactive iodine-123 ( 123 I) or with technetium-99m ( 99m Tc). These radioactive iodine-123 ( 123 I) or with technetium-99m ( 99m Tc). These isotopes are chosen for their shorter half-life and because they provide isotopes are chosen for their shorter half-life and because they provide lower radiation exposure to the patient when compared with sodium lower radiation exposure to the patient when compared with sodium iodide-131 (Na 131 I).iodide-131 (Na 131 I).

99m Tc is trapped in the thyroid but is not organified. Although 99m Tc is trapped in the thyroid but is not organified. Although convenient,99m Tc scanning may provide misleading results. Some convenient,99m Tc scanning may provide misleading results. Some nodules that appear hot or warm on 99m TC scan results may be cold nodules that appear hot or warm on 99m TC scan results may be cold on 123 I scan results. Nodules with discordant 99m Tc and 123 I scan on 123 I scan results. Nodules with discordant 99m Tc and 123 I scan results may be malignant; therefore, 123 I scanning is preferred.results may be malignant; therefore, 123 I scanning is preferred.

Nuclear scans allow determination of the cause of hyperthyroidism. Nuclear scans allow determination of the cause of hyperthyroidism. Patients with Graves disease usually have homogeneous diffuse uptake. Patients with Graves disease usually have homogeneous diffuse uptake. Glands with thyroiditis have low uptake.Glands with thyroiditis have low uptake.

In patients with toxic nodular goiter (TNG), the scan results usually reveal In patients with toxic nodular goiter (TNG), the scan results usually reveal patchy uptake (see the image below), with areas of increased and patchy uptake (see the image below), with areas of increased and decreased uptake. The uptake rate of radioiodine in 24 hours averages decreased uptake. The uptake rate of radioiodine in 24 hours averages approximately 20-30%. Radioactive Na 131 I ablation of the thyroid gland approximately 20-30%. Radioactive Na 131 I ablation of the thyroid gland may be considered if the thyroid uptake value is elevated. Several may be considered if the thyroid uptake value is elevated. Several therapeutic modalities have been suggested to increase uptake (eg, low therapeutic modalities have been suggested to increase uptake (eg, low iodine diet, lithium, recombinant TSH, propylthiouraciliodine diet, lithium, recombinant TSH, propylthiouracil

Ultrasound Ultrasound MRIMRI CT SCANCT SCAN

treatmenttreatment Antithyroid agents(Propylthiouracil, Methimazole (Tapazole))Antithyroid agents(Propylthiouracil, Methimazole (Tapazole)) Beta-adrenergic receptor antagonistsBeta-adrenergic receptor antagonists (Propranolol, a (Propranolol, a

nonselective beta blocker, may help to lower the heart rate, nonselective beta blocker, may help to lower the heart rate, control tremor, reduce excessive sweating, and alleviate control tremor, reduce excessive sweating, and alleviate anxiety. Propranolol is also known to reduce the conversion of anxiety. Propranolol is also known to reduce the conversion of T4 to T3.In patients with underlying asthma, beta-1 selective T4 to T3.In patients with underlying asthma, beta-1 selective antagonists, such as atenolol or metoprolol, would be safer antagonists, such as atenolol or metoprolol, would be safer options.options.

In patients with contraindications to beta blockers (eg, moderate In patients with contraindications to beta blockers (eg, moderate to severe asthma), calcium channel antagonists (eg, diltiazem) to severe asthma), calcium channel antagonists (eg, diltiazem) may be used to help control the heart ratemay be used to help control the heart rate

Radioactive iodines (Radioactive iodines (Sodium iodide-131 (Na131Sodium iodide-131 (Na131 I;I; Iodotope)Iodotope)

Used to treat hyperthyroidism by destroying follicular cells of the Used to treat hyperthyroidism by destroying follicular cells of the thyroid gland. The dose is determined by radioactivity thyroid gland. The dose is determined by radioactivity calibration system just prior to administration.calibration system just prior to administration.

Surgical careSurgical care Surgical therapy is usually reserved for young individuals, patients with Surgical therapy is usually reserved for young individuals, patients with

1 or more large nodules or with obstructive symptoms, patients with 1 or more large nodules or with obstructive symptoms, patients with dominant nonfunctioning or suspicious nodules, patients who are dominant nonfunctioning or suspicious nodules, patients who are pregnant, patients in whom radioiodine therapy has failed, or patients pregnant, patients in whom radioiodine therapy has failed, or patients who require a rapid resolution of the thyrotoxic state.who require a rapid resolution of the thyrotoxic state.

Total or near-total thyroidectomy results in rapid cure of Total or near-total thyroidectomy results in rapid cure of hyperthyroidism in 90% of patients and allows for rapid relief of hyperthyroidism in 90% of patients and allows for rapid relief of compressive symptoms. [21]  Goiter recurrence is lower patients who compressive symptoms. [21]  Goiter recurrence is lower patients who undergo total or near-total thyroidectomy compared to subtotal undergo total or near-total thyroidectomy compared to subtotal thyroidectomy.  [22]thyroidectomy.  [22]

Restoring euthyroidism prior to surgery is preferable.Restoring euthyroidism prior to surgery is preferable. Complications of surgery include the following:Complications of surgery include the following: In patients who are treated surgically, the frequency of hypothyroidism In patients who are treated surgically, the frequency of hypothyroidism

is similar to that found in patients treated with radioiodine (15-25%), is similar to that found in patients treated with radioiodine (15-25%), and is strongly dependent on the extent of the surgery.and is strongly dependent on the extent of the surgery.

Complications include permanent vocal cord paralysis (2.3%), Complications include permanent vocal cord paralysis (2.3%), permanent hypoparathyroidism (0.5%), temporary hypoparathyroidism permanent hypoparathyroidism (0.5%), temporary hypoparathyroidism (2.5%), and significant postoperative bleeding (1.4%).(2.5%), and significant postoperative bleeding (1.4%).

Other postoperative complications include tracheostomy, wound Other postoperative complications include tracheostomy, wound infection, wound hematoma, myocardial infarction, atrial fibrillation, and infection, wound hematoma, myocardial infarction, atrial fibrillation, and stroke.stroke.

In experienced hands the mortality rate is almost zero.In experienced hands the mortality rate is almost zero. When radioactive iodine, surgery or long-term antithyroidal drugs are When radioactive iodine, surgery or long-term antithyroidal drugs are

inappropriate or contraindicated, radiofrequency ablation can be inappropriate or contraindicated, radiofrequency ablation can be considered in select patients. considered in select patients.