Thyroid and Parathyroid

thyroidectomy on the other side (Hartley-Dunhill procedure), leaving about 4 to 5 g of
. thyroid tissue
Total thyroidectomy can be performed with minimal risk of morbidity and is the
operation of choice in patients with coexisting eye disease. Catz and Perzik reported
no progression in 66 of 70 patients with total thyroidectomy. Similarly, Winsa and
colleagues reported that ophthalmopathy stabilized or improved in 96 percent of
patients 6 months or more postoperatively, which may be the result of removal of the
antigenic stimulus. In their series of patients undergoing total thyroidectomy for
Graves' disease, 21 of 25 patients not previously treated with 131I had normalization
. of TSH-receptor antibodies (TRAb) at 2.5 years
Advantages of thyroidectomy over radioiodine treatment are: immediate cure of
disease and decreased long-term incidence of hypothyroidism. Initial series probably
overstated the incidence of hypothyroidism because they failed to account for later
recovery of thyroid function. Other advantages include a decreased number of
outpatient visits and the potential removal of a coexisting thyroid carcinoma.
Disadvantages are: possible recurrent laryngeal nerve injury (approximately 1
percent), hypoparathyroidism (usually transient in approximately 13 percent and
. permanent in 1 percent), hematoma, and hypertrophic scar formation
Recurrent thyrotoxicosis usually should be managed by radioiodine treatment,
because reoperation carries a higher morbidity risk; when tissue has been left on one
side, the risk of complications is less. Long-term follow-up should be maintained for
all patients, with clinical review and yearly TSH measurement to detect the possible
. late onset of hypothyroidism or recurrent hyperthyroidism
Treatment of Exophthalmos
The severity of Graves' ophthalmopathy is independent of thyrotoxicosis; data
suggest, however, that recurrent hyperthyroidism and hypothyroidism aggravate the
eye problems. Some reports suggest that total thyroidectomy alleviates the eye
disease. It is unproved whether total thyroidectomy is preferable to near-total or
subtotal thyroidectomy. Total thyroidectomy should be undertaken only in patients
. with severe exophthalmos when they are well prepared
Severe or malignant exophthalmos is rare. Treatment is essentially symptomatic;
steroid eye drops or systemic steroids (60mg prednisolone daily) should be used
initially to alleviate chemosis. When symptoms are more severe upon awakening,
patients should tape their eyes closed at night, and the head of the bed should be
elevated. Patients whose eyes are worse during the day should wear glasses to protect
. the eyes from sun and wind and should use artificial tears to protect against drying
Lateral tarsorrhaphy to oppose eyelids helps to alleviate drying and subsequent
chemosis and corneal ulceration. In extreme situations, retro- orbital radiation or
. orbital decompression may be necessary to save vision
Toxic Nodular Goiter
Toxic nodular goiter, also known as Plummer's disease, is a consequence of one or
more thyroid nodules trapping and organifying more iodine and secreting more
thyroid hormone independently of TSH control. Toxic nodular goiter occurs most