Hyperthyroidism

ug class

1. HYPERTHYROIDISM DR.R.DURAI MS ASSISTANT PROFESSOR DEPARTMENT OF GENERAL SURGERY MGMCRI

2. DEFENITION What is hyperthyroidism? Increased secretion of Thyroid hormones due to various stimuli. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 2 What is thyrotoxicosis?? Symptoms and signs produced by Increased secretion of Thyroid hormones due to various stimuli. 23-04-2016

3. TODAY’S MENU Clinical types Symptomatology Diagnosis of thyrotoxicosis Principles of treatment of thyrotoxicosis Choice of therapy Hyperthyroidism due to other causes Surgery for thyrotoxicosis HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 3 23-04-2016

4. CLINICAL TYPES

5. CLINICAL TYPES Diffuse toxic goitre (Graves’ disease ); Toxic nodular goitre; Toxic nodule; Hyperthyroidism due to rarer causes. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 5 23-04-2016

6. GUESS? HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 6 ROBERT JAMES GRAVES (1796-1853) 23-04-2016

7. DIFFUSE TOXIC GOITRE (GRAVE’S DISEASE) Graves’ disease , a diffuse vascular goitre Younger women Eye signs Primary Thyrotoxicosis Family H/o Autoimmune Endocrine diseases Whole gland – Hypertrophy & Hyperplasia – abnormal thyroid stimulating antibodies (TSH- Rab ) binding to TSH receptor HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 7 23-04-2016

8. TOXIC NODULAR GOITRE Plummer’s Disease Long duration Middle-aged or Elderly Infrequently is associated with eye signs. Secondary thyrotoxicosis. Nodules inactive Inter-nodular thyroid tissue overactive HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 8 23-04-2016

9. TOXIC NODULE(ADENOMA) Solitary overactive nodule Autonomous TSH secretion is suppressed by the high level of circulating thyroid hormones Surrounding normal thyroid tissue suppressed and inactive. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 9 23-04-2016

10. HISTOLOGY HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 10 23-04-2016

11. GRAVE’S HISTOLOGY HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 11 23-04-2016

12. SYMPTOMATOLOGY

13. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 13 23-04-2016

14. SYMPTOMATOLOGY Loss of weight despite a good appetite Heat intolerance Palpitations. Tachycardia Hot, moist palms Exophthalmos Eyelid lag/retraction Agitation Thyroid goitre and bruit. Tiredness Emotional lability Weight loss HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 14 23-04-2016

15. PRIMARY VS SECONDARY Symptom 1 st Goitre next Diffuse and vascular Large or small Firm or soft Thrill and a bruit Abrupt onset Frequent Remissions & exacerbations More severe No Cardiac manifestations All eye signs Goitre 1 st symptoms next Nodular Insidious Less severe Cardiac manifestations more Only Lid lag & Lid spasm HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 15 23-04-2016

16. CARDIAC RYTHM Fast heart rate during sleep Cardiac arrhythmias Stages Of Development Of Thyrotoxic Arrhythmias: multiple extrasystoles paroxysmal atrial tachycardia paroxysmal atrial fibrillation persistent atrial fibrillation, not responsive to digoxin. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 16 23-04-2016

17. MYOPATHY Weakness of the proximal limb muscles Thyrotoxic myopathy Recovery proceeds as hyperthyroidism is controlled. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 17 23-04-2016

18. EYE SIGNS HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 18 23-04-2016

19. Specific to Graves Disease 1 . Diffuse painless and firm enlargement of thyroid gland 2. Ophthalmopathy – Eye manifestations – 50% of cases Classification of Eye Changes in Graves' Disease 0) N o signs or symptoms. 1) O nly signs, no symptoms. (Signs limited to upper lid retraction, stare, lid lag.) 2) S oft tissue involvement (symptoms and signs). 3) P roptosis ( measured with Hertel exophthalmomete r) 4) E xtraocular muscle involvement. 5) C orneal involvement. 6 S ight loss (optic nerve involvement). HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 19 23-04-2016

20. Eye Signs in Toxic Goitre In early stages, may be unilateral but later may become bilateral. Order of appearance of signs Stellwag's sign : Absence of normal blinking—so staring look. Von Graefe`s sign : Upper eye lid lags behind the eye ball as the patient is asked to look downwards. Dalrymphe's sign : Upper sclera is visible due to retraction of upper eye lid. Joffroy's sign : Absence wrinkling in the forehead on looking upwards with the face inclined downwards. Moebius sign : Inability or failure to converge the eye balls Gifford's sign : Difficulty in eversion of the upper lid. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 20 23-04-2016

21. Specific to Graves Disease…….. 3. Thyroid dermopathy consists of thickening of the skin, particularly over the lower tibia, due to accumulation of glycosaminoglycans (pre tibial myxedema) Is usually bilateral 4. Thyroid Acropachy Thyroid acropachy is clubbing of fingers and toes in primary thyrotoxicosis. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 21 23-04-2016

22. DIAGNOSIS

23. DIAGNOSIS Examinations, symptoms Thyroid blood tests Thyroid function tests TSH , T4,T3 Thyrroid antibodies TSI, ANTI TPO, ANTI Tg Other  — nonspecific laboratory findings. low serum total, LDL, and (HDL) cholesterol concentrations normochromic, normocytic anemia Serum alkaline phosphatase HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 23 23-04-2016

24. Thyroid imaging Radionuclide imaging Size, shape & function of gland assessed Increased uptake=“hot", less risk of malignancy,<5% Decreased uptake=“cold" higher risk of malignancy,15-20% Ultrasound CT/ MRI good for assessment of retrosternal extension. pathology HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 24 DIAGNOSIS 23-04-2016

25. Algorithm for Hyperthyroidism Measure TSH and FT4  TSH,  FT4 Measure FT3 Primary (T4) Thyrotoxicosis High Pituitary Adenoma FNAC, N Scan Normal  TSH, FT4 N  TSH,  FT4 N TSH, FT4 N T3 Toxicosis Sub-clinical Hyperthyroidism Features of Grave’s Yes Rx. Grave’s No Single Adenoma, MNG Low RAIU  RAIU Sub Acute Thyroiditis, I 2 , ↑ Thyroxine F/u in 6-12 wks HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 25 23-04-2016

26. PRINCIPLES OF TREATMENT

27. MANAGEMENT HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 27 23-04-2016

28. Choice Of Therapy HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 28 23-04-2016

29. ANTITHYROID DRUGS Indications for antithyroid drugs: Patients with high likelihood of remission the elderly or others with comorbidities increasing surgical risk or with limited life expectancy Toxicity in pregnant women moderate to severe active Graves’ ophthalmopathy (GO) Before surgery , to make the patient euthyroid Soon after starting radioactive I 131 therapy for 6 to 12 weeks HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 29 23-04-2016

30. How long to give ATD ? improved symptoms in 2 weeks and euthyroid in about 6 weeks Check TSH and FT 4 every 4 to 6 weeks In Graves, remission after 12-18 months Monitor every 3 months for the 1st year, and then annually after ATD 40% recurrence in 1 yr. MNG and Toxic Adenoma will not get cured by ATD. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 30 23-04-2016

31. Adjuvants Beta blockers Inhibit adrenergic effects Indications Prompt control of symptoms; treatment of choice for thyroiditis; first-line therapy before surgery, radioactive iodine, and antithyroid drugs; Contraindications Use with caution in older patients and in patients with pre-existing heart disease, chronic obstructive pulmonary disease, or asthma Propranolol is the most commonly prescribed medication in doses of about 20 to 40 mg four times daily HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 31 23-04-2016

32. Iodides Block the conversion of T4to T3 and inhibit hormone release Indications preoperatively when other medications are ineffective or contraindicated; to reduce gland vascularity before surgery for Graves’ disease during pregnancy when antithyroid drugs are not tolerated; Complications Paradoxical increases in hormone release with prolonged use; common side effects of sialadenitis, conjunctivitis, or acneform rash; Adjuvants HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 32 23-04-2016

33. RADIOIODINE THERAPY Radioactive iodine Concentrates in the thyroid gland and destroys thyroid tissue High cure rates with single-dose treatment (80 percent); treatment of choice for Graves’ disease Multi nodular goitre , toxic nodules in patients older than 40 years, and In recurrent thyrotoxicosis It is effective, safe, and does not require hospitalization. Given orally as a single dose in a capsule or liquid form. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 33 23-04-2016

34. RADIOIODINE THERAPY……… Drawbacks Delayed control of symptoms; post treatment hypothyroidism contraindicated - pregnant or breastfeeding; transient neck soreness, flushing, and decreased taste; radiation thyroiditis in 1 percent of patients; may exacerbate Graves’ ophthalmopathy; may require pre treatment with antithyroid drugs in older or cardiac patients HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 34 23-04-2016

35. Surgical Treatment Surgical treatment is reserved patient preference Pregnant women who can’t tolerate ATD child or adolescent intolerant of ATDs large goiter, with or without compressive symptoms severe Graves’ ophthalmopathy the presence of suspicious nodules HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 35 23-04-2016

36. SURGICAL……….. GRAVES DISEASE Near-total or total thyroidectomy is the procedure of choice TMNG Near- total or total thyroidectomy should be performed TOXIC ADENOMA an ipsilateral thyroid lobectomy, or isthmusectomy In patients with coexisting eye disease, total thyroidectomy HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 36 23-04-2016

37. Other causes of Hyperthyroidism Thyrotoxicosis factitia Jod – Basedow thyrotoxicosis Subacute/acute forms of autoimmune thyroiditis or of de Quervain’s thyroiditis Secondary carcinoma Neonatal thyrotoxicosis HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 37 23-04-2016

38. SURGERICAL PROCEDURE

39. Preoperative Preparation Standard preparation make the patient euthyroid/ near euthyroid using antythyroid drugs Alternative method rapid control of thyroid status can be achieved with a combination of thionamides, SSKI, dexamethasone (1 to 2 mg twice daily), and beta blockers very rapid control=> operation within a week Lugol’s iodide solution or saturated potassium iodide( three drops twice daily) for 7 to 10 days HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 39 23-04-2016

40. SURGICAL TECHNIQUE Extent of thyroidectomy controversial, and determined by the desired outcome Risk of recurrence Vs hypothyroid, and surgeons experience Total or near thyroidectomy for patients with coexistent thyroid cancer, sever ophthalmopathy, life treating reactions to antythyroid drugs Subtotal thyroidectomy is recommended for the rest bilateral subtotal thyroidectomy in which 1–2 grams of thyroid tissue is left on both sides. Hartley Dunhill procedure HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 40 23-04-2016

41. TYPES OF THYROIDECTOMY HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 41 23-04-2016

42. Features Control of toxicity Return to euthyroid state Recurrence Thyroid failure Hypoparathyroidism Followup Total Thyroidectomy Immediate Immediate None 100% 5% Minimal Subtotal thyroidectomy Immediate Variable 5% 25% 1% lifelong Surgical options HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 42 23-04-2016

43. Postoperative management Following surgery, thyroid hormone replacement should be started TSH should be measured every 1–2 months until stable, and then annually RAIT should be used for retreatment of persistent or recurrent hyperthyroidism following inadequate surgery Following thyroidectomy, serum calcium hormone levels be measured, and oral calcium supplementation be administered based on these results HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 43 23-04-2016

44. NOVEL MINIMALLY INVASIVE THERAPIES Percutaneous Ethanol Injection (PEI) for Nodules Injections of ethanol can be administered directly to toxic thyroid nodules, cysts and large nontoxic thyroid nodules Ultrasound-Guided Laser Thermal Ablation (LTA) for Nodules Percutaneous laser thermal ablation is used to reduce both hyperfunctioning and compressive nodule HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 44 23-04-2016

45. Treatments Under Investigation Arterial Embolization Indicated in patients with severe hyperthyroidism who cannot tolerate or who prefer not to use conventional treatment methods The Novel Molecule a small-molecule antagonist that directly inhibits or prevents TSI antibodies from activating the TSH receptor. The small-molecule antagonist has not yet been studied in clinical trials Therapeutic Peptides antagonistic peptides that interfere with the action of TSH receptor antibodies as well as peptides that bind to TSH receptor antibodies, preventing them from reacting with the TSH receptor HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 45 23-04-2016

46. CHOICE OF THERAPY

47. Choice of therapy Diffuse toxic goitre over 45 years, radioiodine. under 45 years, surgery for the large goitre and anti-thyroid drugs or radioiodine for the small goitre Toxic nodular goitre Surgery Toxic nodule Surgery or radioiodine(>45) Recurrent thyrotoxicosis after surgery radioiodine is the treatment of choice, but anti-thyroid drugs may be used in young women intending to havechildren. Further surgery has little place. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 47 23-04-2016

48. COMPLICTIONS OF THYROID SURGERY

49. IMMEDIATE COMPLICATIONS HEMORRHAGE INFECTION RECURRENT LARYNGEAL NERVE PALSY THYROID CRISES OR STORM RESPIRATORY OBSTRUCTION PARATHYROID INSUFFICIENCY OR TETANY HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 49 23-04-2016

50. LATE COMPLICATIONS THYROID INSUFFIENCY RECURRENT THROTOXICOSIS PROGRESSIVE EXOPHTHALMOS HYPERTROPHIC SCAR OR KELOID. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 50 23-04-2016

51. HEMORRHAGE Incidence – 0.3-1% Two types - Deep to deep fascia Subcutaneous May be primary or reactionary A deep bleeding produces tension hematoma . Usually due to slipping of the ligature of the superior thyroid artery, though it can also be from a thyroid remnant or a thyroid vein. This compresses on the airway & potentially life threatening unlike the subcutaneous bleeding. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 51 23-04-2016

52. HEMORRHAGE GOOD INTRAOPERATIVE HEMOSTASIS Don’t traumatize the thyroid Avoid too much neck dressings Suction drain ?? Do not waste time on imaging A tension hematoma requires opening of the wound, evacuation of hematoma & ligature of the bleeding vessels A subcutaneous hematoma can be aspirated. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 52 23-04-2016

53. INFECTION Cellulitis – erythema, warmth & tenderness around the wound Abscess – superficial / deep Deep abscess associated with fever, leucocytosis , tachycardia HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 53 23-04-2016

54. INFECTION Pus for Gram’s stain & culture CT for deep neck abscess Can be prevented by proper hemostasis at the time of surgery & using suction drain. Per-operative antibiotics not recommended. Once established Antibiotics Drainage of abscess. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 54 23-04-2016

55. RECURRENT LARYNGEAL NERVE PARALYSIS Temporary paralysis is due to pressure of hematoma on the nerve. Recovers in 3 weeks to 3 month. Permanent paralysis is rare (<2%) and is due to undue stretching or its inclusion in a ligature. Unilateral – 1/3 rd are asymptomatic Change in voice Improves due to compensation by the healthy cord. Bilateral- dyspnea & biphasic stridor HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 55 23-04-2016

56. RECURRENT LARYNGEAL NERVE PARALYSIS Prevent injury to the nerve by Identify ITA ligated far from lobe Posterior layer of pretracheal fascia kept intact. Laryngoscopy, laryngeal EMG For unilateral paralysis no treatment is required. For bilateral paralysis Tracheostomy (with speaking valve. Lateralization of cord Arytenoidectomy Through endoscope Thyroplasty type 2 Cordectomy Nerve muscle implant HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 56 23-04-2016

57. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 57 23-04-2016

58. COMBINED PARALYSIS Unilateral Vocal cord lies in cadaveric position Hoarseness of voice & aspiration of liquids. Ineffective cough Bilateral Aphonia Aspiration Ineffective cough Bronchopneumonia ONLY superior laryngeal nerve palsy also occurs rarely & presents with hoarseness & loss of voice stamina. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 58 23-04-2016

59. COMBINED PARALYSIS Unilateral Speech therapy Medialise of cord Teflon paste injection Thyroplasty type 1 Muscle or cartilage implant Arthrodesis of arytenoid joint Bilateral Tracheostomy Epiglottopexy Vocal cord plication Total laryngectomy SLN: speech therapy HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 59 23-04-2016

60. THYROID CRISIS / STORM Acute exacerbation of hyperthyroidism as the patient has not been brought to the euthyroid state before operation. Tachycardia, fever(>105 C) , restlessness, delirium Mortality is 10% HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 60 23-04-2016

61. THYROID CRISIS / STORM Ensure euthyroid state before operation Sedation – morphine / pethidine Hyperpyrexia – ice bags. Tepid sponging, hypothermic blanket, rectal ice irrigation Oxygen administration IV glucose-saline for dehydration Potassium for tachycardia Cortisone – 100mg IV Carbimazole – 10- 20 mg 6th hourly Lugol’s iodine 10 drops 8th hourly by mouth or potassium iodide 1g IV Propranolol – 20-40mg 6th hourly Digoxin for atrial fibrillation Diuretics for cardiac failure HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 61 23-04-2016

62. RESPIRATORY OBSTRUCTION Laryngeal edema due to Tension hematoma Endotracheal intubation & surgical handling More chance in vascular goiters. Collapse / kinking of the trachea Bilateral recurrent nerve paralysis can aggravate obstruction if edema is present. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 62 23-04-2016

63. RESPIRATORY OBSTRUCTION Open the wound & release the tension hematoma Endotracheal tube if no improvement. INTUBATION TO BE DONE BY AN EXPERIENCED ANESTHETIST as repeated attempts cause more edema leading to cerebral anoxia. The tube is left in place for several days & steroids given to reduce the edema. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 63 23-04-2016

64. PARATHYROID INSUFFICIENCY Due to removal of parathyroids or the parathyroid end artery. Incidence – 1-3% Occurs 2 – 5% after operation. Can be delayed for 2-3 weeks or hypocalcemia may be asymptomatic. Classic triad – Carpopedal spasm Stridor Convulsions Latent tetany Trousseau’s sign Chvostek’s sign Persistant – grand mal epilepsy, cataracts, psychosis, calcification of basal ganglia, papilledema. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 64 23-04-2016

65. PARATHYROID INSUFFICIENCY Correct identification of the gland Ligate vessels distal to the parathyroids . Recognition of the parathyroid glands, which appear in a variety of shapes and have a caramel-like color, is critical. When they lose their blood supply, they turn black. The devascularized gland should be removed, cut into 1 to 2mm pieces, and reimplanted in the sternomastoid muscle or the forearm. Monitor serum Ca for 72 hrs post-operatively. 20 ml 10% solution of calcium gluconate IV 10 ml injected IM 2.5-5 G calcium carbonate / day PTH is unsatisfactory. Alfacalcidol HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 65 23-04-2016

66. THYROID INSUFFICIENCY INCIDENCE :20-25% of patients subjected to subtotal thyroidectomy for diffuse toxic goiter & toxic nodular goiters with internodular hyperplasia Time: <2 yrs. May be delayed >5yrs. Transient hypothyroidism may occur within 6 months which is asymptomatic. Due to change in nature of autoimmune response. More chance if less residual thyroid tissue Cold intolerance, fatigue constipation, weight gain, myxedema. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 66 23-04-2016

67. THYROID INSUFFICIENCY Thyroxine – start with 50 mcg/d, 100mcg/d after 3 weeks, and 150 mcg/d thereafter. Taken as a single daily dose. Monitoring – TSH in the lower end of reference range (0.15-3.5 mU / l) T 4 normal or slightly raised. (10 – 27 pmol / l) Manage ischemic heart disease with beta blockers & vasodilators Increase thyroxine during pregnancy. (50 mcg) Myxedema coma: IV thyroxine 20mcg 8th hourly followed by oral. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 67 23-04-2016

68. RECURRENT THYROTOXICOSIS Incidence 5 – 10% Due to inadequate removal or hyperplasia of remaining thyroid tissue. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 68 23-04-2016

69. RECURRENT THYROTOXICOSIS Less than 40 yrs – carbimazole 0-3wks 40-60mg/d 4-8wks 20-40mg/d 18-24 months 5-20mg/d More than 40 yrs – radioiodine 5-10mCi oral; 75% respond in 4-12 weeks Repeated after 12-24 weeks if no improvement. Beta blocker / carbimazole cover during lag period. Long term follow-up for hypothyroidism. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 69 23-04-2016

70. PROGRESSIVE / MALIGNANT EXOPHTHALMOS Occurs even when thyrotoxic features are regressing. Steroids & radiotherapy. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 70 23-04-2016

71. HYPERTROPHIC SCAR / KELOID Platysma to be divided at a higher level Occurs if scar overlies the sternum Some persons are more susceptible. May follow wound infection. Intradermal steroids, repeated monthly. HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 71 23-04-2016

72. HYPERTHYROIDISM AND OTHER CAUSES OF THYROTOXICOSIS: MANAGEMENT GUIDELINES OF THE ATA AND AACE Baskin HJ, Cobin RH, Duick DS, et al (American Association of Clinical Endocrinologists) 2011 Klein I, Becker D, Levey GS.Treatment of hyperthyroid disease. Ann Int Med.1994;121:281-288. Schwartz’s Principles of Surgery, 9 th ed. William’s Text Book Of Endocrinology, 11 th ed. Bailey & Loves’ Short Practice of Surgery, 25th ed. Greenspan’s Basic & Clinical Endocrinology, 8 th ed. Uptodate HYPERTHYROIDISM - DR.R.DURAI 23-04-16 MGMCRI 72 23-04-2016

73. Thank u !!!