Whither thyrotoxicosis?

Abstract

For 30 years the thyrotoxic patient has been subjected to a plurality of treatments by surgery, radio-iodine and long term anti-thyroid drugs. These therapies have been accepted as complementary to the needs of the individual patient, without regard for long term results or the economic situation as it affects both patient and hospital services. In the context of surgical treatment which is now available, it is suggested that the advantages of operation over other therapies presage a reversion to surgery as the treatment of choice.

Beta-blockers and the thyrotoxic patient for thyroid and non-thyroid surgery: A clinical review

“…The choice of beta-blocker is clinician-dependent and should be titrated to ideally achieve a heart rate of <90 beats per minute and the absence of symptomatic thyrotoxicosis prior to proceeding to surgery. If this Clinical evidence for specific betablockers Propranolol is the most commonly used beta-blocker to treat thyrotoxicosis and has been the mainstay betablocker therapy to prepare thyrotoxic patients for surgery 21,22,[32][33][34][35][36][37][38][39][40]42,44,45 . An advantage of propranolol compared to other beta-blockers is that it blocks peripheral conversion of T 4 to T 3 at high doses.…”

“…The circumstances in which thyroid storm occurred were either the dosage of propranolol being too low (160 mg/day or less) or the response to beta-blocker therapy not iodine in the preoperative treatment and stabilization of the thyrotoxic patient. These results are summarized in Table 2 [31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] . They show that this regime can safely provide rapid control of the peripheral manifestations of hyperthyroidism, producing a clinically euthyroid patient in a relatively short period of time.…”

The relationships between surgical histometry, outcome and pre-treatment in Graves' disease

“…The results of surgery for Graves' disease are nevertheless relative satis¬ factory. A majority of patients achieve long-term euthyroidism (Michie 1975) and when present, hypothyroidism is often mild or only exposed by therapeutic trials with thyroid hormone (Hedley et al 1970). How does such a favourable situation arise when the epithelial mass left in the neck at operation is so uncertain and so variable?…”

“…Among those most commonly cited are the extent of infiltration of the thyroid by lymphocytes (Whitesell & Black 1949;Levitt 1951;Greene 1953) and the size of the remnant left by the surgeon Michie 1975). Both associations, however, are based on traditional methods dependent on the subjective impressions of histologist and surgeon, and recent attempts to quantify these impressions place their value in serious doubt (Wilkin et al 1977a;Wilkin et al 1980;Young et al 1976;Hedley étal.…”

Hyperthyroidism and the heart.

“…Nevertheless, beta-blockers have gained popularity in recent years because they reduce the tachycardia and other troublesome symptoms mediated by beta-adrenoceptors without obscuring the progressive fall in serum concentrations of T4 which indicates successful response to treatment with radioactive iodine.27 In this context the use of beta-blockers is short term, and the practice is unlikely to change as a result of the Edinburgh findings.16 The use of propranolol alone in the accelerated preparation of patients with Graves' disease for subtotal thyroidectomy is similarly short term. 28 Thyroid hormones have long been known to exert profound effects on cardiac rate and rhythm. Cardiomyopathy was described in myxoedema over 100 years ago,29 and there is now convincing evidence that myocardial performance is compromised in hyperthyroidism as well.…”