Hyperthyroidism: Differential Diagnosis and Surgical Management

Hyperthyroidism has many etiologies including single or multiple toxic nodules, Graves’ disease, or medication-induced. Its clinical severity is wide-ranging from mild symptoms in subclinical hyperthyroidism (anxiety, weight loss, palpitations, etc.) to overt thyroid storm (life-threatening end-organ dysfunction). Workup is dependent on the suspected etiology, and should include laboratory studies and possible radiographic evaluation (US, thyroid scan). Short-term medication use or definitive therapy with radioactive iodine ablation or thyroidectomy are potential treatment options. Medications are contraindicated when allergies, intolerance, or organ damage (hepatotoxicity, agranulocytosis) are evident. Radioactive iodine is contraindicated in pregnancy, smoking, and when thyroid eye disease is present. In preparation of surgical management, a euthyroid state should be achieved and calcium supplementation should be initiated. Surgical management is based on etiology, and includes a lobectomy for a toxic adenoma or a total thyroidectomy for toxic multinodular goiter, Graves’ disease, and medication-induced hyperthyroidism. Permanent complication rates of nerve injury, hypoparathyroidism, and hematoma are no greater than for other indications for surgery. Temporary hypocalcemia rates are higher in thyroidectomy patients with overt hyperthyroidism. Thyroid radiofrequency ablation or other ablative techniques may also be a treatment option for single toxic adenomas.