Hyperthyroidism

Case Presentation
PATIENT DETAIL
• Name: NWM
• Age: 36 years old
• Gender: female
• Race: Malay
• Date of admission: 2/6/2016
• Chief complain: electively admitted for total thyroidectomy
• Underlying medical illness: endometriosis stage 4
History of presenting illness

Presented with symptoms Deranged thyroid - Patient remained

Follow up at HPJ
January 2015

Current admission
of hyperthyroidism during function test: symptomatic during
third pregnancy (19th hyperthyroidism follow up despite on anti-
weeker) – 1 month Started on T carbimazole thyroid drug
- Irritability 10 mg OD and T - Also in view of
- Heat intolerance metoprolol 50 mg OD progressive nodular
(allergy towards goiter and uncontrolled
- Increase appetite propranolol) thyroid function test,
- Loss of weight Done ultrasound, FNAC -she was planned for total
- Associated with and radioactive iodine thyroidectomy for this
progressive neck swelling uptake study. admission
confirm diagnosis of
Toxic multinodular goiter
Past medical and surgical history:
• 20 years ago have appendicitis – done open appendicectomy, no
complication from surgery
• With accidental finding of endometriosis and adhesiolysis was done
then was started on oral contraceptive then change to depot provera
injection January 2016 until currently.
• Otherwise, no other underlying medical illness or surgical operation
done
Past obstetric and gynaecological history
• Para 3 – via spontaneous vaginal delivery, diagnosed as
hyperthyroidism during third pregnancy ( 1 ½ year ago). No other
antenatal problem. Postnatal history was uneventful. Since then she
was started on carbimazole for hyperthyroidism and was under follow
up hospital putrajaya.

• Attained menarche at the age of 13 years old, have irregular interval

menses, when had menses usually have per vaginal blood spotting for
5-6 days. Claimed had dysmenorrhea before she was on depot
provera injections.
Family history
• Both father and mother have diabetes mellitus and hypertension.
• No family history of hyperthyroidism/hypothyroidism
• No family history of malignancy
Drug and allergy history
• Allergy to propanolol
• Was on T. carbimazole 10mg BD, and T metoprolol 50mg OD
Social history
• Housewife,
• Husband 41 years old, worked as PPK at Hospital Putrajaya
• Live at kuarters kerajaan precint 9
• Financially stable
• Do not smoking, not drink alcohol
PHYSICAL EXAMINATION
General examination
• Alert and conscious, not in toxic looking, no hoarseness of voice, not cachexic
looking, not in respiratory distress
• On hand, no fine tremor, sweaty hands, warm peripheries, capillary refill time
<2 sec, pulse palpable, 94 bpm, regular rhythm, good volume, normal character,
• No pallor, no jaundice,
• Oral hydration is good
• No dry scaly skin

• No pretibial myxedema
• No proximal muscle weakness
Neck examination
• Inspection:
- There is a mass about 2 x 2cm at right anterior part of the neck, rounded in shape, no skin changes of overlying skin, no
dilated vein, no discharge
- Mass does not move with protruding of tongue
- Moves with deglutition
• Palpation:
- Normal temperature
- Single, rounded mass, at right anterior part of neck, size 2x2cm, smooth surface, firm consistency, not mobile, normal
overlying skin
- Trachea centrally located, not deviated
- No cervical lymph node palpable
• Percussion:
- No retrosternal extension– resonance heard over manubrium of sternum
• Asucultation:
-no vascular bruit heard
Eye examination
• No exopthalmus
• No lid retraction
• No lid lag
• No opthalmoplegia
• No chemosis
• OTHER SYSTEMIC EXAMINATION ARE UNREMARKABLE
INVESTIGATION
 THYROID FUNCTION TEST
ULTRASOUND NECK
(7/1/2015)
(5/8/2016)
TSH: 0.051 (low) Free T4: 13.1 (normal) free T3: 7.4(high)
There is a heterogenous mixed solid and cystic nodule in
(17/8/2015) right thyroid lobe measuring 2.4 x 1.2 x 2.4 cm
TSH: 0.041 (low) Free T4: 12.2 (normal) free T3: 7.5(high) Impression: nodular goiter suggest for fine needle
(26/4/2016) aspiration cytology (FNAC)
TSH: 0.187 (low), Free T4: 10.8 (normal) Free T3: 6.8 (high)

DIAGNOSTIC
INVESTIGATION

FINE NEEDLE ASPIRATION CYTOLOGY RADIOACTIVE IODINE UPTAKE STUDY

(5/8/2016) (5/8/2016)
nodular goiter with cystic degeneration scan features are suggestive of toxic multinodular goiter with
hot nodule seen at right lobe
 Full blood count Renal profile
Hb 13.3, HCT 40.9, PLT 384, twc urea 4.3, sodium 135, potassium
8.6 5.8, chloride 108, creatinine 48.

PREOPERATIVE
INVESTIGATION
Liver function test
: total protein 68, albumin 38, Chest x ray
total bilirubin 34.1, indirect Normal, no trachea deviation
bilirubin 19.2, ALP 114, ALT 85,
AST 72
Definitive diagnosis:
• Toxic Multinodular goiter and planned for total thyroidectomy
MANAGEMENT
- Baseline serum calcium??
 • For consent taking
• To book operation theatre
• Keep nil by mouth at 12 am
• When nil by mouth, to start IV drip 4 pint normal saline/ 24 hours
2/6/2016
• Inform anaesthesia team for pre-operative and vocal cord assesment

• Right thyroid nodue measuring 2x2cm

• Thyroid gland weight 28 gram
• Right and left recurrent laryngeal nerves identified and preserved
• Right superior and inferior parathyroid glands seen and preserved
3/6/2014 • Left superior and inferior parathyroid glands seen and preserved
OP: TOTAL • Thyroid gland sent to lab for HPE
THYROIDECTOMY

• Hourly vital sign (BP/PR/T/RR/SPO2) till stable then 4 hourly

• Daily drain chart, keep vacuum
• Allow orally once patient fully conscious
• Off IV drip once patient able to tolerate orally well
• Serum calcium 6 hours (9.00pm) and serum calcium cm
• Wound inspection on post operative day 3
3/6/2016
• -IV tramadol 50 mg TDS X 1/7
POST OPERATIVE • -Start C celecoxib 200 mg BD
ORDER
• -start T paracetamol 1g QID
• -start L-thyroxine 100mcq OD cM
 • Complained of mild nausea, perioral numbness, itchiness around the neck, and productive cough, otherwise no other complain,
• Vital sign stable, chovstek –ve, no neck hematoma, wound clean, no discharge, noted mild urticarial rash over micropore area.
• Drain output: 70 cc hemoserous
POD1 •
•
Calcium 6 hours post op : 2
Calcium POD 1: 1.9
(4/6/2016)

• Start t. ranitidine 50 mg TDS

• Start T. calcium lactate 2 tab BD
• Calcium gluconate bolus- stat
• For CMC ointment for chlopheniramine 4 mg TDS
POD1 •
•
Thymol gargle
Bromhexine
(4/6/2016) • Syrup diphenhydramine

• Comfortable, no active complains, no more numbness, no hoarseness of voice, still complain

of itchiness around the micropore area but reducing from yesterday. Calcium trending: 2.0 ->
1.9 -> 2.04
POD2 • Add T. alphacalcidol 0.5mcg OD
(5/6/2016) • T. calcium lactate 3 tab BD (increase dose)
 • Comfortable, no active complains, no more numbness, no hoarseness of voice, still complain of itchiness around the
micropore area but reducing from yesterday.
• Drain output: 70  40cc hemoserous
POD3 • Calcium trending: 2.0 -> 1.9 -> 2.04
• Corrected calcium : 1.93
(6/6/2016)

• T. alphacalcidol 1mcg OD (increase dose)

• T. calcium lactate 4 tab BD (increase dose)
POD3 (PLAN)

• Currently comfortable, no active complains, no hoarseness of voice, no more numbness

• Calcium: 2.0 -> 1.9 -> 2.04 -> 1.93 -> 2.09
• Allow discharge--- TCA in 2 weeks sopd clinic on Friday
• Calcium level on arrival
• Discharge Medication:
POD4 • Calcium lactate 4 tab QID
(7/6/2016) • Alphacalcidol 1 mcg BD
• L- thyroxine 100 mcg OD
Learning Issues
 Learning Issue 1: Approach to neck swelling

“A patient presents with a central neck swelling in the SOPD. How

is the patient assessed and managed?”
History
• Age
• Gender
• HOPI
• Swelling- duration, progression
• Pain
• Compression & obstruction symptoms
• Symptoms of thyrotoxicosis
• Menstrual hx (in women)
• Hx of malignancy
• Past Medical Hx
• Drug history
• Diet hx
• Family hx
• Native place
• Social hx
 PE
General inspection:
• General condition
• Appearance- still and composed/ fidgety/ restless/ agitated/sweaty/ slow/ cold
• Nutritional status- Thin/ underweight/ obese/ overweight/ cachexic/ presence of
anemia
• Respiratory distress
• Hands
• Pulse- resting tachycardia (thyrotox)/ bradycardia (myxoedema)/ irregularly irregular
(AF)
• Palms- moist, sweaty and warm/ dry and inelastic skin
• Fine tremors
• Eyes
• Pallor
• Lid retraction
• Lid lag
• Exophthalmos
• Ophthalmoplegia
• Chemosis
• (Loss of lateral 1/3) Eyebrows
• Area around eyes (for puffiness)
• Legs
• Proximal muscle weakness
• Delayed reflexes
• Thyroid dermopathy
• Ankle oedema
Neck Examination
• Inspection-
• Number, site, size, shape, surface, skin over swelling pulsation
• Movement with deglutition
• Movement with tongue protrusion
• Distension of neck veins/ dilatation of subcutaneous veins of upper anterior thorax
• Pemberton sign
• Position of thyroid cartilage
Palpation
• From front
• Confirm inspection findings
• Position of trachea
• From back
• Tenderness, shape, size, surface, consistency, mobility, skin attachment
• Ask pt to swallow
• Cervical/ supraclavicular lymphadenopathy
Percussion
• Along clavicles and over manubrium sternum and upper chest
Auscultation
• Over swelling for vascular bruit
Other systems
• CVS
• Features of cardiac failure
• Respiratory
• Secondary mets
• Bibasal crepts
• MSK
• Spine, long bones- mets
• Proximal muscle wasting and weakness
• CNS
• Fine tremors in hands and tongue
 INVESTIGATIONS
• Thyroid function test
• TSH
• T3/ T4

Thyroid functional state TSH Free T3 Free T4

Euthyroid Normal Normal Normal

Thyrotoxic Low/ undetectable High High

Developing thyroid failure High Low - normal Low – normal

Myxoedema High Low Low

Suppressive T4 therapy Undetectable High Normal - high

T3 toxicity Low/ undetectable Normal High

• Thyroid autoantibodies
• Long acting thyroid antibodies (LATS) in Graves
• Thyroid peroxidase antibody (TPO) in Hashimoto
• Neck ultrasound
• Confirm presence of thyroid enlargement
• Solitary/ multiple nodules
• Type of mass (cystic/ solid)
• Retrosternal extension and cervical lymphadenopathy
• Target FNA and biopsy
• FNAC (free-hand/ ultrasound guided)
• To determine morphology
• Cannot differentiate between folicular adenoma & carcinoma
• US guided core biopsy/ open incisional biopsy
• Radioactive iodine uptake study- differentiate between hot and cold
nodules
• Hot nodule: hyperthyroidism
• Warm nodule: Same activity as surroundings
• Cold nodule: Hypothyroidism, malignancy, post-FNAC
• Serum calcium
• Parathyroid function
• Serum calcitonin (screening for medullary CA)

• CT/ MRI neck

• Pts with known malignancies/large thyroid masses/ retrosternal extension/
tracheal deviation/ compression sx
• CXR/ Thoracic inlet XR- mets/ retrosternal extension

• Other routine ix (FBC, RP, LFT, ECG, coagulation profile) done on a case-
to-case basis
 TREATMENT
Antithyroid drugs
• Carbimazole
• Inhibit iodination
• Symptoms improve in 2-6 weeks
• SE: Agranulocytosis, rash (Steven Johnson syndrome), aplastic anemia, vasculitis,
polyarthritis
• Initial: 10 mg 3-4x/day (6-8 hrly), with latent interval of 7-14 days
• Once pt is euthyroid, maintenance dose (5 mg 2-3x/day given for 6-24 months)
• Alternately: Block & Replace Regimen for pts w/ poor control (give high-dose
carbimazole to inhibit all T3 & T4 production, then maintenance dose of 0.1-0.15 mg
daily)
• Propylthiouracil
• Lower risk of transplacental transfer than carbimazole
• Inhibits peripheral conversion of T4 – T3 (prevent thyroid storm)

• Beta-blocker (Propanolol- 40 mg TD, nadolol- 160 mg OD

• Block CVS effects of T4
• Reduces sympathetic simulation and reduces T4- T3 conversion – reduces effect f
thyroid hormone
Radioactive iodine ablation
• 131I, 8-12 millicurie
• Destroys thyroid cells and reduces mass of functioning thyroid tissue
• Indications:
• Primary thyrotoxicosis (> 45 y/o)
• Toxic nodule (> 45 y/o)
• Relapse after medical/ surgical therapy
• Pt contraindicated for medical/ surgical therapy
• CI:
• Child-bearing age/ pregnant/ breast-feeding mothers
• Requires 4 weeks to be effective, substantial improvement in 8-12 weeks
• Cover with carbimazole in 1st 4 weeks
• No close contact, especially with children for 2 weeks post treatment (preferably
quarantined)
 Learning Issue 2: Pre-operative Assessment
“On elective admission of a patient with multinodular goitre, how
should this patient be prepared pre-operatively?”
• Determine thyroid state via clinical assessment
• Improvement in prev. sx, weight gain, etc
• TFT
• Make the patient euthyroid in case of toxicity, to prevent post-op thyroid
storm
• Carbimazole 30-40 mg/day until euthyroid
• Reduce dose to 5 mg 8hrly
• Alternatively, beta-blockers to eliminate clinical manifestations of toxic state, and
control sympathetic activity
• Propanolol 40 mg TD/ Nadolol 160 mg OD- rapid effect in days instead of weeks
• However, the beta-blocker must be given for at least 7-10 days post-op to prevent
thyroid storm
• Lugol’s iodine, 5 drops/day for 7 days, start 10-14 days prior to surgery
• To reduce gland vascularity
• To make gland firmer by fibrosis
• Con: Can cause too much fibrosis, adhesion with surrounding structures.
• If patient on wafarin (d/t AF), stop wafarin 2/7 before surgery and switch to
LMWH
• ENT : Indirect laryngoscopy to assess vocal cords
• Baseline calcium levels
Learning Issue 3: Taking
Informed Consent
Components of consent-taking for surgical
procedure
1. Indication for procedure
2. Brief description of procedure
3. Risks of procedure
- General risks
- Specific risks
4. Alternative treatments
5. Risk of not performing this procedure
1. Indication for surgery
• Introduce yourself and identify patient
• Reclarify with the patient regarding their diagnosis
• Ask if they have any concerns they want to address before discussing
the surgery with them
• Ensure it is the right surgery they are having!
• Check their symptoms are still the same and in the same location as in
the notes
2. Brief description of procedure
• In simple layman’s terms
• Also layman terms when telling patient about risks!

“Thyroidectomy is where part or all of the thyroid gland/s are removed

through a cut along the ‘necklace’ line of the neck.”
3. Risks – General
• Infection
- Wound site
- Post operative hospital acquired infection (e.g.: urine, lung)
• Bleeding – during or after the operation
• Atelectasis
• Thrombosis - DVT/PE (post-op)
Anaesthesia complications:
- Nausea and vomiting
- Confusion and disorientation
3. Risks- General (Simplified & elaborated)
In simple layman terms:
• Infection can occur, requiring antibiotics and further treatment.
• Bleeding could occur and may require a return to the operating room. Bleeding is more
common if you have been taking blood thinning drugs such as Warfarin, Asprin,
Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).
• Small areas of the lung can collapse, increasing the risk of chest infection. This may need
antibiotics and physiotherapy.
• Increased risk in obese people of wound infection, chest infection, heart and lung
complications, and thrombosis.
• Heart attack or stroke could occur due to the strain on the heart.
• Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may
break off and go to the lungs.
3. RISKS - Specific
• Hematoma
• Hypothyroidism
• Hypocalcaemia – perioral numbness, carpopedal spasms
• Recurrent laryngeal nerve palsy
• Keloid scar
 3. RISKS – Specific (Simplified &
elaborated)
• Possible bleeding in the tissues of the neck which may result in swelling about
the wound or a fluid discharge, or on rare occasions, pressure in the wind pipe
which may cause breathing problems. This may require emergency surgery.

• After removal of part of the gland the function of the thyroid may decrease
and you may need a thyroid function test and possible treatment for under
activity of the thyroid. With total removal of the gland, life long thyroxine is
required.

• Rarely a small gland behind the thyroid, called the parathyroid, may be
damaged and this may result in tingling of the fingers and spasms of the hands
and toes. This is usually a temporary problem but occasionally long term
calcium supplements are necessary.
• Rarely, an important nerve in the area of the back of the thyroid may
be damaged which could result in a permanent hoarse voice, or
difficulty with the higher pitch of the voice.
- Warn patient that their voice will be different a few days post op
anyway because of intubation and local swelling from the operation
- It is very common to have a temporary hoarse voice for a few days as
this operation is near the larynx.
- If both of these nerves were damaged, severe breathing difficulty
may occur with the need for respiratory support. This may be
permanent.
• Keloid scar: In some people healing of the wound can become
thickened, red and painful
4. Alternatives to procedure
• Needle biopsy
• Observation
5. Risks of not performing the procedure
• The growth may become enlarged. This may put pressure on the
esophagus (swallowing tube) and trachea (breathing tube).
Learning Issue 4: Post-op
Assessment
REMEMBER S.O.A.P!!!
• Subjective- Symptoms patient has
• Objective – On examination
• Assessment – Your impression/ diagnosis for today
• Plan- Ultimate aim : to discharge patient
Subjective

General Specific (to thyroid In our case)

• Pain
• Fever (but can also assess using
charts in Objective component
later)
• Vomiting/ tolerating orally
• Mobilization
• Shortness of breath –
compression symptoms possibly
indicating hematoma
• Change in voice (another
approach: before asking patient
directly, you yourself assess
voice character by asking how
are you etc)
 Objective

General Specific (to thyroid In our case)

• Alert, pink, concious • Assess wound at neck
etc - A postoperative dressing should be removed earlier than
the recommended 48 hours if there are clear signs of
• Vital signs hourly until complications, eg signs of excessive inflammation which
stable then 4 hourly may suggest infection, specific wound pain or pressure
reported by the patient that is difficult to control with
analgesia, evidence of wound separation (partial or full
thickness dehiscence), excessive exudate, strikethrough or
leakage, or evidence of periwound skin stripping or blisters
• Elicit Chvostek & Trosseau sign
Objective
• Investigations:
- Full blood count: look for leukocytosis suggesting infection
- Serum calcium
Assessment
Depending on patient, comment on day xx post-op if they are:
1. Stable
2. Improving
3. Develop complications (state what complications )
Plan (aim to discharge)
• Discharge when;
-Patient can mobilize, no complications, can PU/BO, can tolerate orally
(convert IV meds to oral), no pain, wound healed
• Follow-up plan: schedule appointment at SOPD clinic (2 weeks)
• Discharge with calcium supplements and thyroxine
The end!