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
GoiterDiffuseMultinodular
—SizeSmallLarge
—GrowthRapidSlow
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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