Thyrotoxicosis

Dr P K Sahoo
Professor, Surgery
Thyrotoxicosis

• A complex disorder that occurs due to increased levels of thyroid hormone

( hyperthyroidism) and manifests clinically with various signs & symptoms
involving many body systems mostly eye & CVS
Clinical types:
• Primary thyrotoxicosis
• Secondary thyrotoxicosis : secondary to nodular goitre
• Solitary toxic nodule
Thyrotoxicosis

Thyrotoxicosis : The clinical condition and the physiological / biochemical

findings that results when tissues are exposed to high levels of circulating TH

Hyperthyroidism :The manifestations result from overproduction of hormone by

the thyroid gland itself (excess thyroid gland function )

Major causes :
• Graves
• Toxic MNG
• Toxic adenoma
Thyrotoxicosis : Aetiology
Other Causes :
• Thyrotoxicosis factitia : due to overdose of thyroxine
• Jod Besedows thyrotoxicosis : ( Jod – iodine, Besedow – toxic goitre)
• Initial stage of thyroididtis
• Malignant goitres
• Neonatal thyrotoxicosis
• TSH secreting tumor of pituitary
• Struma ovarii : Ectopic thyroid tissue in ovarian teratoma
• Drugs : Amiodarone
Graves Disease (Primary thyrotoxicosis) : Aetiopthogenesis
Diffuse toxic goitre
Exact aetiogy not known
Possible causes :
• Autoimmune disorder – TSH receptor antibodies
• Familial /genetic – HLA B8, DR3, DQA1
• Thyroid stimulating immunoglobulins (TSI) and long acting thyroid stimulator ( LATS)
• Exophthalmos producing substance (EPS)
• Female sex – Emotions, stress, hormones
Triggering factors :
• Postpartum state
• Iodine excess
• Lithium therapy
• Infections – bacterial/ viral
Thyrotoxicosis : Pathophysiolology
Continuous stimulation  Acinar hypertrophy,
hyperplasia  Tall columnar cells
normal colloid disappears  Rich vascularity 
Small follicles with hyperplastic columnar epithelium

Various triggering factor sensitization of T helper

cells stimulation of B lymphocytesAntibody
production Excess thyroid hormone synthesis
Thyrotoxicosis : C/F
• More common in females( 8:1) , age group 15-25 yrs
• CF & Goitre appears simultaneously

Changes in the gland

• Diffuse goitre with smooth surface
• Firm in consistency
• Warm , highly vascular
• Bruit may be heard

CNS symptoms
• Tremors
• Hyperkinesia
• Warm moist palm , increased sweating
• Heat intolerance
• Waight loss despite a good appetite
Thyrotoxicosis : C/F
CVS :
• Tachycardia ( mild : 90-100, moderate : 100-110, sevsere : > 110 )
• Palpitation
• Arrhythmia
• Extrasystole
• Fibrilation
• Cardiac failure
Thyrotoxicosis : C/F

EYE signs : • Graves ophthalmopathy( 5P )

• Exophthalmos : prominent eyeball • Prominent eyes
with retraction of lids • Periorbital oedema
• Lid spasm , lid lag • Papilloedema
• Conjuctival oedema • Proptosis
• Chemosis • Palpebral fissure widening
• Progeression to blindness
• Diplopia
• Keratitis
• Papilloedema
Thyrotoxicosis : C/F
• EYE signs :

• Moebius sign : Loss of convergence of eye ball

• Stellag’s sign : In frequent blinking & widening of palpebral
fissure
• Joffroy’s sign : Absence of wrinkling of forehead on looking
upwards
• Von graefe’s sign : Upper eyelid cann’t copeup with moving
finger
• Gifford’s sign : Difficulty in everting upper eye lid
• Kocher’s sign : Upper eyelid springs up more quickly than
eyebrows
Thyrotoxicosis : Eye signs

• Malignant exophthalmous ( Autoimmune condition)

• Infrequent blinking of eyes exposure of cornea 
Keratitis, corneal ulcer, conjunctivitis blindness
• Optic nerve damage  blindness

Treatment of Graves ophthalmopathy :

Massive dose of steroids
Lateral tarsorrhaphy
Orbital decompression
Guanethidine eyedrop
Methyl cellulose eyedrop
Head end elevation
Black glasses
Thyrotoxicosis : C/F

Myopathy & Dermopathy

• Weakness proximal limb muscles
• Periodic palsy
• Pretibial myxoedema
• Pruritus
• Palmar erythema
• Thinning of hair
Thyrotoxicosis : C/F

• In Females

• Amenorrhoea
• Menorrhagia
• Infertility
• Miscarriages
Thyrotoxicosis : Primary Vs Secondary
• Age : 20-40 yrs • 30-50yrs
• C/F : Goitre & toxic features appears • MNG appears 1st , toxic features are
simultaneously secondary
• Skin over thyroid : warm • Not warm
• Consistency : soft to firm • Firm to hard
• Surface : smooth • Nodular
• Auscultation : Bruit • Bruit uncommon
• Eye signs : more • Rare
• CNS predominant • CVS predominant
• Pretibial myxoedema • Not seen
• Proximal myopathy • Not seen
• Malignant exophthalmos • Not seen
Thyrotoxicosis : Management
Investigations
• Routine : CBC, FBS, PPBS
• TFT : T3 ,T4 ,TSH
• TSH auto antibodies
• Radioiodine scan only in toxic adenoma
• Sleeping pulse rate
• Cardiac evaluation
• Eye evaluation
Thyrotoxicosis : Management
Aim :

• To restore euthyroid state

• To reduce the functioning of thyroid
• To minimize complications
Thyrotoxicosis : Management
To restore euthyroid state

• Antithyroid dugs
• Methimazole / carbimazole : 10mg 6hrly reduced to 10mg BD
• PTU : 50-150 mg 3 times
• Propranolol : 20-40mg 3 to 4 times
• Lugols iodine : 10-12 drops 3 times , 10days before surgery
• Corticosteroids: 20-40 mg prednisolone
Thyrotoxicosis : Surgical management
To reduce functioning of gland
• Subtotal thyroidectomy
• Total thyroidectomy
• Radioiodine : 150 microcurie
To minimize complications
• Good preop preparation
• Good anesthesia
• Good surgical technique
Secondary Thyrotoxicosis : Plummers disease

• Nodular goitre present for a long time

• Nodules are inactive , internodular tissue is active
• In some cases few nodules are active
• Tx :
• Antithyroid drugs
• Propranolol
• Radioiodine
• Management of Cardiac conditions
• Subtotal / Total thyroidectomy
Solitary toxic nodule
• Autonomous nodule, may be apart of generalised nodularity
• Not under control of TSH
• TSH secretion is supressed by high level of thyroid hormone produced
by the nodule
• Radioiodine scan ( I131 / Tc 99m )
• Hot nodule takes up isotope
• Tx : Antithyroid
• Hemithyroidectomy
• Radioiodine