The document discusses the history and evolution of thyroid surgery. It notes that in 1866, thyroid surgery was considered extremely dangerous but by 1920 it had become a routine procedure. It then describes the thyroid gland and its hormones. It discusses hyperthyroidism and thyrotoxicosis, listing their clinical features. The document outlines the indications for thyroid surgery and the different types of thyroid surgeries. It provides details on the history, examination, investigations, medical management, and preparation of hyperthyroid patients for thyroid surgery.

2. BY
KANZA KHALID
BUSHRA KHAN

3. 1866……
 – “If a surgeon should be so
 foolhardy as to undertake it
 [thyroidectomy] … every step of
 the way will be environed with
 difficulty, every stroke of his knife
 will be followed by a torrent of
 blood, and lucky will it be for him
 if his victim lives long enough to
 enable him to finish his horrid
 butchery.”
 Samuel David Gross
 Samuel

4. 1920….
 “feat which today can be
 accomplished by any
 competent operator
 without danger of mishap”
 (William Halsted)

5. The thyroid gland secretes two
principal hormones –
THYROXINE (T3) AND
TRIIODOTHYROXINE (3).
These major metabolic hormone
are required for homeostasis of
all cell and influences cell
differentiation ,growth , and
metabolism

6. HYPERTHYROIDISM
 Hyperthyroidism is the overproduction of thyroid
hormones by an overactive thyroid.
THYROTOXICOSIS
Thyrotoxicosis is defined as the clinical syndrome of
hypermetabolism resulting from increased free
thyroxine (T4) and/or free triiodothyronine (T3) serum
levels

7. CLINICAL FEATURES OF
HYPERTHYROIDISM
Sudden weight loss
Rapid heartbeat (tachycardia) — commonly more than 100 beats a
minute — irregular heartbeat (arrhythmia) or pounding of your heart
(palpitations)
Increased appetite
Nervousness, anxiety and irritability
Tremor — usually a fine trembling in your hands and fingers
Sweating
Changes in menstrual patterns
Increased sensitivity to heat
Changes in bowel patterns, especially more frequent bowel movements
An enlarged thyroid gland (goiter)
Fatigue, muscle weakness
Difficulty sleeping
Skin thinning . Fine, brittle hair

8. WHAT IS GOITER??
 A goitre is a swelling of
the neck or larynx
resulting from
enlargement of the
thyroid gland
(thyromegaly), associated
with a thyroid gland that
is not functioning
properly.

11. INDICATIONS FOR
THYROIDECTOMY
 Thyroid cancer
 Toxic thyroid nodule (produces too much thyroid
hormone)
 Multinodular goiter (enlarged thyroid gland with
many nodules), especially if there is compression of
nearby structures
 Graves' disease, especially if there is exophthalmos
(bulging eyes)
 Thyroid nodule, if fine needle aspirate (FNA) results
are unclear[

12. TYPES OF THYROID SURGERIES
 Thyroid lobectomy to remove a nodule (solitary hot or
cold nodules) and goitres that occur in one lobe.
 Partial thyroid lobectomy to remove a solitary nodule in
one specific part of the thyroid.
 Thyroid lobectomy with isthmectomy for benign
Hürthle cell tumours and for non-aggressive thyroid
cancers.
 Subtotal thyroidectomy (leaving enough of the gland to
produce some hormones) is now little used and has been
replaced by total thyroidectomy or thyroid lobectomy
alone.
 Total thyroidectomy for thyroid cancers, Hürthle cell
tumours and also increasingly for multinodular goitres and
patients with Graves' disease.

14. HISTORY History of onset, duration, rate of growth
 History suggestive of primary or secondary
thyroid toxicity
 History of pain
 History of palpitation, precordial pain,
exhaustion
 History of pressure effects- like dyspnoea,
dysphagia, hoarseness of voice.
 Past history/family history.
 Personal history-diet, menstrual, mental attitude,
sleep

15. PHYSICAL EXAMINATION
 General appearance
 Vital signs
 Respiratory system
 CVS system
 Abdomen
 Extremities and spine
 Neurologic system

16. GENERAL PHYSICAL EXAMINATION
 Built, nourishment
 Fullness of thyroid region, pallor, icterus, cyanosis,
clubbing, oedema
 Temperature, Sleeping pulse rate, blood pressure
 Skin- hot and moist palm
 Tremors
 Mental status-anxiety, nervousness.
 Airway assessment

17. Local examination
Inspection :
 Whether diffuse/ nodular swelling
 Pizzillo's method : in obese and short necked patient
hands are placed behind head and patient is asked to
push head backwards against her clasped hand. Ask
the patient to swallow, thyroid slowly moves upwards
on deglutition.
 Pemberton's sign : Patient is asked to raise both the
arm over his head until they touch the ears. This is
maintained for a while, congestion of face and distress
becomes evident because of obstruction of great veins
at thoracic inlet.

18.  Palpation:
 Percussion : Over manubrium sterni to exclude
presence of a retrosternal goiter.
 Auscultation : A systolic bruit may be heard over
goiter due to increased vascularity in primary toxic
goiter.

19. Systemic examination
CVS :
 Enlarged heart
 Atrial fibrillation
 Signs of CCF.
 Systolic murmurs
CNS :
 Myopathy and tremors
 Reflexes- hyperreflexia

20. INVESTIGATIONS
 Complete Blood Count, BT, CT to rule out
anemia, thrombocytopenia and
agranulocytosis.
 Urine Albumin, Sugar, Microscopy
 RBS, B. Urea, Serum creatinine
 ECG- Sinus tachycardia, ST elevation, QT
shortening, atrial fibrillation/flutter, ventricular
ectopics

21. INVESTIGATIONS
THYROID FUNCTION TESTS:

22.  TSH Assay : single best test of Thyroid Hormone
action at cellular level.
 Normal level : 0.4-5.0 mU/L.
 Subclinical hyperthyroidism : TSH level is 0.1-
0.4mU/L with normal FT3 & FT4.
 Overt hyperthyroidism : TSH level is <0.03mU/L with
increased T3 & T4.
 Thyroid Storm : TSH level is <0.01mU/L.
 Free T4 (FT4) : approx 0.02% of total T4.
 Elevated in 90% of patients with hyperthyroidism.
 Decreased in 85% of patients with hypothyroidism

23.  Radioactive iodine uptake : I123, I131 & Tc99
 Varies directly with functional state of thyroid.
 24 hr thyroid uptake is measured.
 Normal value range – 10-25%
 Used to confirm Hyperthyroidism

24.  Ultrasonography: to differentiate between cystic,
mixed or solid lesion in gland.
 Thyroid scan using I123 or Tc99 evaluate nodules as
 Warm/ Normal
 Hot/ Hyperfunctioning.
 Cold/ Hypofunctioning.

25. CHEST X-RAY PA view- position of trachea,
deviation, retrosternal goiter,
calcification.
 Lateral view and barium
swallow- pressure effects on
trachea and oesophagus

26.  CT scan and MRI scan-for airway evaluation and
extension of thyroid.

27. Difficult tracheal intubation in
thyroid surgery
 6% of tracheal intubations for
thyroid surgery will be
difficult.
 When conventional methods of
laryngoscopy and endotracheal
intubation do not provide
airway management. The best
choice is
 Fiberoptic intubation.
 If fiberoptic bronchoscope
is not available, mask
ventilation, laryngeal mask,
combitube, nasotracheal
intubation, rigid
bronchoscope intubation.

28. MEDICAL TREATMENT
 OBJECTIVES
Making the patient asymptomatic
Making a thyrotoxic patient euthyroid before surgery

29. WHAT IS EUTHYROIDISM??
 Euthyroid is clinically assessed by-
◦ Sleeping pulse rate < 90/min
Progressive weight gain
◦ Disappearance of toxic symptoms like tremors,
nervousness, anxiety etc .
◦ No requirement of sedation for sleep.
◦ Normal pulse pressure, sinus rhythm, disappearance
of cardiac murmurs

30. Making the patient Euthyroid
• Anti thyroid drugs : Carbimazole vs. PTU
• Start Carbimazole 10-30 mg/day based on severity of
symptoms and time left for surgery
• Call back after 6 weeks and reassess

31. MAKING THE PATIENT
ASYPMTOMATIC
 Beta blockers
• Reduces myocardial oxygen consumption,
reduces heart rate, improves myocardial
efficiency
• Used to prepare patients for surgery
• Used with caution in patients with
congestive heart failure, bronchial asthma
• Useful in thyrotoxic crisis

32. ANTITHYROID DRUGS
 CARBIMAZOLE: commonest drug used.
 Dose: 5-10mg, 8hrly.
 Maintenance Dose: 5mg 6-24 months.
 Blocks the synthesis of thyroid hormones.
 Suppresses the autoimmune process in Grave’s disease.
 METHIMAZOLE: Alike carbimazole. Dose is 5-20mg
daily.

33. ANTI THYROID DRUGS
 PROPYLTHIOURACIL:
 Blocks thyroid hormone synthesis.
 Blocks peripheral conversion of T4 to T3.
 Decreases thyroid autoantibody levels.
 Safe to be given in children and pregnancy.
 Dose: 200mg 8hrly.
 Side Effects: agranulocytosis and aplastic anemia

34. BETA BLOCKERS
 β-Blockers reduces the cardiac symptoms .
 Blocks peripheral conversion of T4 to T3.
 Propranolol 80 -160 mg once daily
 Atenolol 25-100 mg once or twice daily
 Metoprolol 50 - 200 mg divided 2 or 3 times
per day

35. IODIDES
 Saturated solution of potassium iodide: 1-3 drops 3
times per day
 Lugol’s solution (5%Iodine +10%KI) : 5 drops 3 times
per day dissolve in a full glass of water
 Iodide therapy added 1 wk before surgery and continued
through the day of surgery
 Involution of the gland
 Decreases its vascularity, (decreased rate of
 intraoperative blood loss)
 • Contraindicated in toxic multinodular goiter and AFTN

36. BLOCK AND REPLACEMENT
TREATMENT
 It is giving high dose of carbimazole to inhibit T3 and
T4 production completely with a maintainence dose of
0.1 mg of L Thyroxine .It reduces iatrogenic thyroid
insufficiency.
 For Emergency Surgery
 Esmolol 100-300 mcg/kg/min IV until heart rate
<100/min

37. Why should a toxic patient be
Euthyroid before surgery ?
To Prevent
 Thyrotoxic crisis
 Cardiac arrhythmias and tachycardia
 Worsening of co existent medical conditions:
Cardiovascular
Diabetes mellitus
Blood pressure
 Hemodynamic compromise
 Anesthetic drug interactions

38. Thyroid Storm
 Is a life threatening emergency
 Characterized by sudden
appearance of clinical signs of
hyperthyroidism due to the abrupt
release of T4 and T3 into
circulation.
 Mortality is as high as 25% to 30%.
 Commonly associated with Grave's
disease.

39. Triggers
 Trauma
 Infection
 Surgery

40. THYROID STORM
CLINCAL PRESENTATION
 2 most important defining features :
 High fever (usually over 40 degrees C)
 Significantly abnormal mental status
 Agitation, confusion, psychosis, coma
 May also exhibit :
 Marked tachycardia
 Vomiting, diarrhea
 Jaundice (in 20 %)
 Associated signs of Graves' disease

41. TREATMENT OF THYROID STORM High flow O2
 Rapid cooling if markedly hyperthermic
 Ice packs, cooling blanket, mist / fans, nasogastric
tube lavage, acetominophen (Salicylates
contraindicated because cause peripheral deiodination
to T3)
 IV fluid bolus if dehydrated
 May need inotropes instead if in CHF
 Propranolol 1 mg doses or labetolol 10 to 20 mg doses
IV & repeat doses as needed

42.  IV diltiazem +/- digoxin for rate control for atrial fib
 IV diuretics if in CHF
 IV hydrocortisone (or equivalent) 100 mg
 Propylthiouracil (PTU) 600 to 1200 mg PO or by NG
 Sodium iodide 1 gram IV one hour after the PTU
 Find and treat the precipitating cause

43. PRE OP ORDERS……….
 Informed consent
 Keep NPO.
 Absolute bed rest.
 Sedation : Diazepam 2mg-5mg
 Resting pulse chart
 Patient must be made euthyroid or near euthyroid at
operation.
 Sleeping pulse rate < 90/min
 Progressive weight gain

44. THANK
YOU!!