Graves’ and Thyroid Disease: The Journey CHASE LAY MD ENT – OCULOPLASTICS – SKULL BASE Cupertino, CA Graves’ and Thyroid Disease: The Journey

Surgical Considerations Grave’s Disease Surgical Considerations

Thyroid hormone is critical for regulating mood, weight, and mental and physical energy levels. If the body makes too much thyroid hormone, the condition is called hyperthyroidism. (An underactive thyroid leads to hypothyroidism.) Graves disease is the most common cause of hyperthyroidism. Caused by an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormones. Body actually produces antibodies that activate thyroid hormone production The Thyroid & Grave’s

Grave’s Eye Disease - Inflammation

Signs & Symptoms Anxiety Breast enlargement in men (possible) Double vision Eyeballs that stick out (exophthalmos) Eye irritation and tearing Frequent bowel movements Heat intolerance Increased appetite Menstrual irregularities in women Muscle weakness Nervousness Rapid or irregular heartbeat (palpitations or arrhythmia) Restlessness and difficulty sleeping Tremor Weight loss (rarely, weight gain)

Testing for Graves Simple blood test TSH, T3, T4 TSH receptor antibody; Thyroid stimulating immunoglobulin or “TSI” Ultrasound of the neck if thyroid is enlarged or mass felt

Surgical Grave’s Disease Hyperthyroidism or progressing eye disease in patients who can’t be treated with radioactive iodine therapy Rapidly worsening Thyroid Eye Disease Enlarged thyroid or Goiter causing difficulty breathing or swallowing Women interested in becoming pregnant Nodule in a patient with Grave’s or a family history of thyroid cancer Suspicious thyroid nodules Change of malignancy in thyroid nodules is double in context of Graves

Thyroid nodules are common Can be found in 5% of the general population Mostly benign Can be observed if there are no risk factors www.mythyroid.com

Detecting Thyroid Nodules Physical Exam Ultrasound

What is a suspicious thyroid nodule? A large nodule, >1cm Any nodule over 0.5cm in size in a Grave’s patient A thyroid nodule in a patient with A family history of thyroid cancer A history of radiation exposure Age younger than 20 Age older than 50

Surgery & Risks General anesthesia Small incision in the lower neck Hoarse voice Vocal cord weakness Visible incision Bleeding Low Calcium (Total thyroidectomy)

After Surgery Small incision – Quick healing Typically stay in the hospital overnight Back to work in a 2 to 6 days. Complications with nerve weakness, post-operative bleeding, or calcium regulation may delay return to work.

Surgical Treatment of Eye Disease

Marty Feldman

Grave’s Eye Disease - Inflammation

Combination of compression of the optic nerve and inflammation of the nerve

Orbital Decompression & Fat Removal Performed both endoscopically and externally Surgical treatment to save or restore vision Should be thought of as a medical necessity Additional corrective surgeries are often required Typically outpatient procedures

Endoscopic Decompression Extended or Advanced Sinus Surgery

External Decompression

Risks of Decompression Surgeries CSF leak during endoscopic surgery Diplopia or Double Vision (often pre- existing) Bleeding Infection Eyelid retraction or drooping

Droopy eyelid repaired

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