Diagnostic Evaluation of Hyperthyroidism

  • Thyrotoxicosis:
    • Is the common feature of both:
      • Toxic nodular goiter (TNG) and Graves’ disease
    • It may be clinical or subclinical:
      • Subclinical hyperthyroidism:
        • Presents few, if any, mild symptoms ;
          • In the presence of a suppressed TSH with normal free thyroid hormones (T3 and T4)
    • Early in Graves’ disease:
      • Hyperthyroidism may be from:
        • Preferential T3 secretion:
          • So-called T3 toxicosis
  • History and Physical Examination:
    • The clinical presentation ranges from:
      • No symptoms and a suppressed sensitive serum TSH level to overt or obvious clinical hyperthyroidism:
        • The latter includes symptoms associated with:
          • Increased adrenergic tone and resting energy expenditure and other hormonal effects
          • Features related to increased adrenergic tone include:
            • Nervousness
            • Tremor
            • Increased frequency of defecation
            • Palpitations
            • Diaphoresis
            • Irritability
            • Insomnia
            • Headaches
            • Lid retraction and lid lag
            • Muscle weakness
            • Tachycardia
            • Hyperreflexia, and widened pulse pressure
          • Those related to increased energy expenditure include:
            • Heat intolerance
            • Unintentional weight loss without anorexia
            • Warm, moist skin
        • In elderly subjects, the presentation may be subtle, with:
          • Atrial fibrillation
          • Weight loss
          • Weakness
          • Depression
      • Goiter may be detected in patients with either TNG or Graves’ disease:
        • Nodular irregularity is characteristic of TNG:
          • Whereas Graves’ disease is more typically:
            • Diffuse, soft, and rubbery and may have an overlying thyroid region bruit
    • Patients with Graves’ disease often have a:
      • Goiter:
        • Diffuse, soft, and rubbery:
          • May have an overlying thyroid region bruit
      • May present with hyperthyroidism alone, or
      • May have one or more extra-thyroidal manifestations
    • Clinically apparent eye disease may occur in up to a third of patients with Graves’ disease:
      • But orbital CT may detect changes in a majority of patients
      • Signs of eye disease include:
        • Proptosis or exophthalmos
        • Lid lag and retraction
        • Impaired extraocular muscle function
      • Eye symptoms and signs generally begin about six months before or after the diagnosis of Graves’ disease:
        • It is generally uncommon for eye involvement to develop after the thyroid disease has been successfully treated:
          • There is great variability, however, and in some patients with eye involvement, hyperthyroidism may never develop
        • The severity of eye involvement is not related to the severity of hyperthyroidism
        • Early signs of eye involvement may be:
          • Red or inflamed eyes
        • Ultimately, proptosis may develop from the inflammation of retro-orbital tissues
        • Diminished or double vision is a rare problem:
          • That usually occurs later
        • It is not well known why, but problems with the eyes occur much more often in people with Graves’ disease who smoke cigarettes than in those who do not smoke
    • Other features of Graves’ disease include:
      • Onycholysisacropachy, and pretibial myxedema
      • Pretibial myxedema:
        • Is a rarereddish lumpy thickening of the skin of the shins
        • This skin condition is usually painless and is not serious
        • Like the eye disorders of Graves’ disease, the skin manifestation does not necessarily begin precisely when hyperthyroidism starts
        • Its severity is not related to the level of thyroid hormones
        • It is not known why this problem is usually limited to the lower leg or why so few people have it
    • Occasionally symptoms related to the mass effect of a large goiter may occur:
      • Very large goiter may extend retrosternally or substernally, resulting in symptoms and signs of tracheoesophageal pressure:
        • These may include:
          • Dysphagia
          • Cough
          • Choking sensation
          • Stridor:
            • Particularly if severe tracheal narrowing exists
          • The development of facial plethoracyanosis, and distention of neck veins:
            • With raising both arms simultaneouslymay result from deep goiter compression of the structures located within the bony confines of the thoracic inlet (Pemberton sign)
CharacteristicGraves’ DiseaseToxic Nodular Goiter
Patient age, y< 45> 50
Hyperthyroid onsetRapidSlow
Histologic featuresFollicles similar, intense iodine metabolismVariable follicular size, shape, and intensity of iodine metabolism

#Arrangoiz #CancerSurgeon #ThyroidSurgeon #ParathyroidSurgeon #HeadandNeckSurgeon #ThyroidExpert #SurgicalOncologist #EndocrineSurgery #MountSinaiMedicalCenter #Miami #ThyroidNodule #ToxicNodularGoiter #TNG #MultinodularGoiter #GravesDisease #Hyperthyroidism #Goiter

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