1. HYPERTHYROIDISM A Practical Approach to Dx. and Rx.
Dr. R.V.S.N.Sarma., M.D., M.Sc., (Canada)
Consultant Physician and Chest Specialist

2. Clinical Exam. of Thyroid
Have patient seated on a stool / chair
Inspect neck before & after swallowing
Examine with neck in relaxed position
Palpate from behind the patient
Remember the rule of finger tips
Use the tips of fingers for palpation
Palpate firmly down to trachea
Pemberton’s sign for RSG

3. Where to look for Thyroid ?

4. Clinical Anatomy of Thyroid

5. Clinical Exam of Thyroid

6. Clinical Exam of Thyroid

7. Clinical Exam of Thyroid

8. Thyromegaly

9. Hyperthyroidism A hyper metabolic biochemical state
It is a multi system disease with
Elevated levels of FT4 or FT3 or both
What is thyrotoxicosis ?
What is hyperthyroidism ?
What are the various causes ?
How to differentiate the causes ?
What is the appropriate treatment ?

10. Causes of Hyperthyroidism
Graves Disease – Diffuse Toxic Goiter
Plummer’s Disease – Toxic MNG
Toxic phase of Sub Acute Thyroiditis - SAT
Toxic Single Adenoma – STA
Pituitary Tumours – excess TSH
Molar pregnancy & Choriocarcinoma (↑↑ βHCG)
Metastatic thyroid cancers (functioning)
Struma Ovarii (Dermoid and Ovarian tumours)
Thyrotoxicosis Factitia ; INF, Amiodarone, SSRIs

11. Graves Disease The most common cause of thyrotoxicosis (50-60%).
Organ specific auto-immune disease
The most important autoantibody is
Thyroid Stimulating Immunoglobulin (TSI) or TSA
TSI acts as proxy to TSH and stimulates T4 and T3
Anti thyro peroxidase (anti-TPO) antibodies
Anti thyro globulin (anti-TG) Anti Microsomal and other
Autoimmune diseases - Pernicious Anemia, T1DM
RA, Myasthenia Gravis, Vitiligo, Adrenal insufficiency.

12. I 123 or TC 99m Normal v/s Graves
Graves Disease
I 123 or TC 99m Normal v/s Graves

13. Graves Disease

14. Toxic Multinodular Goiter (TMG)
TMG is the next most common hyperthyroidism - 20%
More common in elderly individuals – long standing goiter
Lumpy bumpy thyroid gland
Milder manifestations (apathetic hyperthyroidism)
Mild elevation of FT4 and FT3
Progresses slowly over time
Clinically multiple firm nodules (called Plummer’s disease)
Scintigraphy shows - hot and normal areas

15. Toxic Multinodular Goiter (TMG)

16. Toxic Multinodular Goiter (TMG)

17. Sub Acute Thyroiditis (SAT)
SAT is the next most common hyperthyroidism – 15%
T4 and T3 are extremely elevated in this condition
Immune destruction of thyroid due to viral infection
Destructive release of preformed thyroid hormone
Thyroid gland is painful and tender on palpation
Nuclear Scintigraphy scan - no RIU in the gland
Treatment is NSAIDs and Corticosteroids

18. Toxic Single Adenoma (TSA)
TSA is a single hyper functioning follicular thyroid adenoma.
Benign monoclonal tumor that usually is larger than 2.5 cm
It is the cause in 5% of patients who are thyrotoxic
Nuclear Scintigraphy scan shows only a single hot nodule
TSH is suppressed by excess of thyroxines
So the rest of the thyroid gland is suppressed

19. Toxic Single Adenoma (TSA)
Nucleotide Scintigraphy

20. Age and Sex Age Graves disease 20 to 40 Toxic MNG > 50 yrs
Toxic Single Adenoma 35 to 50
Sub Acute Thyroiditis Any age
Sex M : F ratio
Graves Disease 1: 5 to 1:10
Toxic MNG 1: 2 to 1: 4

21. Nucleotide Scintigraphy

22. Clinical Features Those that occur with any type of thyrotoxicosis
Those that are specific to Graves disease
Non specific changes of hyper metabolism

23. Common Symptoms Nervousness Anxiety Increased perspiration
Heat intolerance
Tremor
Hyperactivity
Palpitations
Weight loss despite increased appetite
Reduction in menstrual flow or oligo-menorrhea

24. Common Signs Hyperactivity, Hyper kinesis
Sinus tachycardia or atrial arrhythmia, AF, CHF
Systolic hypertension, wide pulse pressure
Warm, moist, soft and smooth skin- warm handshake
Excessive perspiration, palmar erythema, Onycholysis
Lid lag and stare (sympathetic over activity)
Fine tremor of out stretched hands – format's sign
Large muscle weakness, Diarrhea, Gynecomastia

25. Specific to Graves Disease
Diffuse painless and firm enlargement of thyroid gland
Thyroid bruit is audible with the bell of stethoscope
Ophthalmopathy – Eye manifestations – 50% of cases
Sand in eyes, periorbital edema, conjunctival edema (chemosis), poor lid closure, extraocular muscle dysfunction, diplopia, pain on eye movements and proptosis.
Dermoacropathy – Skin/limb manifestations – 20% of cases
Deposition of glycosamino glycans in the dermis of the lower leg – non pitting edema, associated with erythema and thickening of the skin, without pain or pruritus - called (pre tibial myxedema)

26. Clinical Presentations

27. Diffuse Graves Thyroid
MNG and Graves
Huge Toxic MNG
Diffuse Graves Thyroid

28. Higher grades of Goiter
Toxic MNG
(Diffuse) Graves

29. Grade IV Toxic MNG
Huge Toxic MNG
Huge Toxic MNG

30. Thyroid Ophthalmopathy
Proptosis
Lid lag

31. Ophthalmopathy in Graves
Periorbital edema and chemosis

32. Ophthalmopathy in Graves
Occular muscle palsy
Laka Laka Laka

33. Severe Exophthalmia

34. Pink and skin coloured papules, plaques on the shin
Thyroid Dermopathy
Pink and skin coloured papules, plaques on the shin

35. Graves with Acropathy
Graves Goiter
Acropathy

36. Thyroid Acropathy
Clubbing and
Osteoarthropathy

37. Onycholysis

38. Non specific changes Hyperglycemia, Glycosuria
Osteoporosis and hypercalcemia
↓ LDL and Total Cholesterols
Atrial fibrillation, LVH, ↑ LV EF
Hyper dynamic circulatory state
High output heart failure
H/o excess Iodine, amiodarone, contrast dyes

39. THYROID STIMULATING HORMONE - TSH
Nine Square Approach
PRIMARY
HYPERTHYROID
FREE THYROXINE or FT4
LOW NORMAL HIGH
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH

40. THYROID STIMULATING HORMONE - TSH
Nine Square Approach
SUB CLINICAL
HYPERTHYROID
FREE THYROXINE or FT4
LOW NORMAL HIGH
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH

41. Diagnosis Typical clinical presentation
Markedly suppressed TSH (<0.05 µIU/mL)
Elevated FT4 and FT3 (Markedly in Graves)
Thyroid antibodies – by Elisa – anti-TPO, TSI
ECG to demonstrate cardiac manifestations
Nuclear Scintigraphy to differentiate the causes

42. Primary (T4) Thyrotoxicosis Sub Acute Thyroiditis, I2, ↑ Thyroxine
Algorithm for Hyperthyroidism
Measure TSH and FT4
 TSH,  FT4
 TSH, FT4 N
 TSH,  FT4
N TSH, FT4 N
Primary (T4) Thyrotoxicosis
Pituitary Adenoma
FNAC, N Scan
Measure FT3
High
T3 Toxicosis
Features of Grave’s
Normal
Sub-clinical Hyper
Yes No
 RAIU
Low RAIU
F/u in 6-12 wks
Rx. Grave’s
Single Adenoma, MNG
Sub Acute Thyroiditis, I2, ↑ Thyroxine

43. Treatment Options Symptom relief medications Anti Thyroid Drugs – ATD
Methimazole, Carbimazole
Propylthiouracil (PTU)
Radio Active Iodine treatment – RAI Rx.
Thyroidectomy – Subtotal or Total
NSAIDs and Corticosteroids – for SAT

44. Symptom Relief Rehydration is the first step
β – blockers to decrease the sympathetic excess
Propranalol, Atenelol, Metoprolol
Rate limiting CCBs if β – blockers contraindicated
Treatment of CHF, Arrhythmias
Calcium supplementation
SSKI or Lugol solution for ↓ vascularity of the gland

45. Anti Thyroid Drugs (ATD)
Imp. considerations
Methimazole
Propylthiouracil
Efficacy
Very potent
Potent
Duration of action
Long acting BID/OD
Short acting QID/TID
In pregnancy
Contraindicated
Safely can be given
Mechanism of action
Iodination, Coupling
Conversion of T4 to T3
No action
Inhibits conversion
Adverse reactions
Rashes, Neutropenia
Rashes, ↑Neutropenia
Dosage
20 to 40 mg/ OD PO
100 to 150mg qid PO

46. How long to give ATD ? Reduction of thyroid hormones takes 2-8 weeks
Check TSH and FT4 every 4 to 6 weeks
In Graves, many go into remission after months
In such pts ATD may be discontinued and followed up
40% experience recurrence in 1 yr. Re treat for 3 yrs.
Treatment is not life long. Graves seldom needs surgery
MNG and Toxic Adenoma will not get cured by ATD.
For them ATD is not the best. Treat with RAI.

47. Radio Active Iodine (RAI Rx.)
In women who are not pregnant
In cases of Toxic MNG and TSA
Graves disease not remitting with ATD
RAI Rx is the best treatment of hyperthyroidism in adults
The effect is less rapid than ATD or Thyroidectomy
It is effective, safe, and does not require hospitalization.
Given orally as a single dose in a capsule or liquid form.
Very few adverse effects as no other tissue absorbs RAI

48. Radio Active Iodine (RAI Rx.)
I123 is used for Nuclear Scintigraphy (Dx.)
I131 is given for RAI Rx. (6 to 8 milliCuries)
Goal is to make the patient hypothyroid
No effects such as Thyroid Ca or other malignancies
Never given for children and pregnant/ lactating women
Not recommended with patients of severe Ophthalmopathy
Not advisable in chronic smokers

49. Surgical Treatment Subtotal Thyroidectomy, Total Thyroidectomy
Hemi Thyroidectomy with contra-lateral subtotal
ATD and RAI Rx are very efficacious and easy – so
Surgical treatment is reserved for MNG with
Severe hyperthyroidism in children
Pregnant women who can’t tolerate ATD
Large goiters with severe Ophthalmopathy
Large MNGs with pressure symptoms
Who require quick normalization of thyroid function

50. Preoperative Preparation
ATD to reduce hyper function before surgery
βeta blockers to titrate pulse rate to 80/min
SSKI 1 to 2 drops bid for 14 days
This will reduce thyroid blood flow
And there by reduce per operative bleeding
Recurrent laryngeal nerve damage
Hypo parathyroidism are complications

51. Dietary Advice Excess amounts of iodide in some
Avoid Iodized salt, Sea foods
Excess amounts of iodide in some
Expectorants, x-ray contrast dyes,
Seaweed tablets, and health food supplements
These should be avoided because
The iodide interferes with or complicates the management of both ATD and RAI Rx.

52. Summary of Hyperthyroidism
Age %
Enlarged
Pain
RAIU
Treatment
Graves (TSI Ab
eye, dermo, bruit)
60%
Diffuse
None ↑↑
ATD – 18 m
Toxic MNG
> 50
20%
Lumpy
Pressure ↑
RAI, Surgery
Single Adenoma 5%
Single
RAI, ATD
S Acute Thyroiditis
Any age
15%
Yes ↓↓
NSAID, Ster.
TSH is markedly low, FT4 is elevated

53. Thyrotoxicosis Factitia
Excessive intake of Thyroxine causing thyrotoxicosis
Patients usually deny – it is willful ingestion
This primarily psychiatric disorder
May lead to wrong diagnosis and wrong treatment
They are clinically thyrotoxic without eye signs of Graves
High doses of Thyroxine lead to TSH suppression
This causes shrinkage of the thyroid
Stop Thyroxine and give symptom relief drugs

54. Algorithm for Thyroid Nodule
Low TSH
Normal TSH
TC 99 Nuclear Scan
FNAC or US guided biopsy
Hot Nodule
Cold Nodule 4%
10%
69%
17%
RAI Ablation, Surgery or ATD
Non diagnostic – repeat FNAC
Malignant
Suspicious or follicular Ca
Benign
Cyst
T4 suppression
Surgery or Cytology
Surgery

55. Case # 1
A patient complains of “sandy” sensation in his eyes,weight loss, and a tremor. His extraocular muscles are inflammed. His thyroid is diffusely enlarged and non tender.
The most likely diagnosis is
a. Iodine deficiency
b. Sub-acute thyroiditis
c. Multinodular goiter
d. Graves’ disease
e. Silent thyroiditis

56. Case # 2
A 55 year old woman is anxious, irritable, frequent semi solid stools and she reports weight loss of 5 kgs in the past six months. She was having a lumpy bumpy painless swelling in her neck for past 20 years.
The most likely diagnosis is
a. Iodine deficiency goiter
b. Sub-acute thyroiditis
c. Multinodular goiter
d. Graves’ disease
e. Solitary toxic adenoma

57. Case # 3 A 60 year patient from a mountain region complains of
constipation. He has a heart rate of 60, dry thick skin,
and a tongue that has scalloped edges from teeth
indentation. He has a goiter.
The most likely diagnosis is
a. Iodine deficiency
b. Subacute thyroiditis
c. Graves’ disease
d. Silent thyroiditis

58. Case # 4
A 25 year old woman is three months pregnant. She has a large goiter. Her exam is otherwise normal. Her thyroid tests are normal.
You recommend
a. Cassava five times weekly
b. Fish three times weekly
c. Formula milk for the baby when it is born
d. A very low salt diet

59. Case # 5 A 72 year old man complains of tremor and inability to
concentrate. On exam, he has a heart rate of 100 beats
per minute. He has a large goiter with many nodules. He
has a fine tremor. His serum T4 is very high and TSH is
very low.
Treatments that are likely to improve his symptoms are
a. Iodine therapy
b. Ethanol injection of his thyroid (PEI)
c. 6 weeks of Methimazole
d. Radio Active Iodine therapy

60. Case # 6 In Nuclear Scintigraphy Scan I123 uptake is very high in
the thyroid of patients with
a. Silent thyroiditis
b. Single functional adenoma
c. Sub-acute thyroiditis
d. Acute ingestion of animal thyroid extract
e. Graves’ disease

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