Graves' disease is an autoimmune disorder that results into overproduction of thyroid hormones.
Thyrotoxicosis signs and symptoms include hyperactivity, irritability, insomnia, dysphoria, sweating, heat intolerance, palpitations, weakness, fatigue, weight loss despite increased appetite, diarrhea, steatorrhea polyuria, decreased libido, tachycardia, tremor, goiter, alopecia, gynecomastia, eyelid lag or retraction and rarely periodic paralysis.
Clinical features in thyrotoxic patient that suggests Graves's disease are ophthalmopathy, thyroid dermopathy, thyroid acropachy, diffuse goiter, antibodies to thyroid peroxidase or thyroglobulin and thyroid radionuclide scan demonstrating a diffuse goiter.

Surgical Intervention

  • Surgery is not the first-line treatment; pharmacotherapy is usually preferred over surgery
  • Near-total or total thyroidectomy is the preferred surgery
  • Up to 98% success rate when performed by experienced surgeons
  • May be option for:
    • Suspected thyroid cancer (excision of thyroid nodules to rule out malignancy)
    • Patients with an obstructive goiter or very large goiter (≥80 g)
    • Patients with large thyroid nodules (>4 cm) or nonfunctioning or hypofunctioning thyroid nodules on 123I or 99mTc pertechnetate scanning
    • Patients with coexisting hyperparathyroidism
    • Patients who want unsightly goiter removed
    • Patients who refuse RAI and want definitive treatment
    • Patients with relatively low uptake of RAI
    • Pregnant patients who are intolerant of antithyroid agents
      • Thyroidectomy is best performed in the second trimester of pregnancy
    • Women planning pregnancy in <6 months
    • Patients with high TRAb levels 
    • Some physicians prefer surgery in pediatric/adolescent patients, especially if large goiter
    • Patients with moderate to severe Graves' orbitopathy
  • Potential complications: Hypoparathyroidism, laryngeal edema and paralysis, hemorrhage and nerve damage
  • Contraindicated in patients with significant comorbidity including presence of cardiopulmonary disease, end-stage cancer or other debilitating illness and lack of access to experienced surgeons
Prior to Surgery
  • Restoration of euthyroidism to decrease risk of thyrotoxic storm
    • Antithyroid drug treatment prior to surgery, with or without beta-adrenergic blockade and, with or without inorganic iodide given x 7-10 days prior to surgery to block thyroid hormone synthesis (cool down)
    • Inorganic iodide given x 7-10 days prior to surgery to block thyroid hormone synthesis, reduce gland vascularity, decrease blood flow and intraoperative blood loss during thyroidectomy
  • Calcium and vitamin D supplementation may be considered preoperatively in patients at increased risk for transient or permanent hypoparathyroidism
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Endocrinology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
01 Dec 2020
Tetanus toxoid 5 Lf, diphtheria toxoid 2 Lf, pertussis toxoid 2.5 mcg, filamentous haemagglutinin 5 mcg, fimbriae types 2 and 3 5 mcg, pertactin 3 mcg
Dr. Hsu Li Yang, Dr. Tan Thuan Tong, Dr. Andrea Kwa, 08 Jan 2021
Antimicrobial resistance has become increasingly dire as the rapid emergence of drug resistance, especially gram-negative pathogens, has outpaced the development of new antibiotics. At a recent virtual symposium, Dr Hsu Li Yang, Vice Dean (Global Health) and Programme Leader (Infectious Diseases), NUS Saw Swee Hock School of Public Health, presented epidemiological data on multidrug-resistant (MDR) gram-negative bacteria (GNB) in Asia, while Dr Tan Thuan Tong, Head and Senior Consultant, Department of Infectious Diseases, Singapore General Hospital (SGH), focused on the role of ceftazidime-avibactam in MDR GNB infections. Dr Andrea Kwa, Assistant Director of Research, Department of Pharmacy, SGH, joined the panel in an interactive fireside chat, to discuss challenges, practical considerations, and solutions in MDR gram-negative infections. This Pfizer-sponsored symposium was chaired by Dr Ng Shin Yi, Head and Senior Consultant of Surgical Intensive Care, SGH.
Pearl Toh, 26 Nov 2020
Inhaled corticosteroid (ICS) should be the mainstay of long-term asthma management — such is the key message of the latest Singapore ACE* Clinical Guidance (ACG) for asthma, released in October 2020.
3 days ago
Among patients with moderate-to-severe psoriasis, the use of biologics appears to lower the risk of being hospitalized for the novel coronavirus disease (COVID-19), a new study has found.