DIFFUSED TOXIC GOITER: A FIVE YEAR EXPERIENCE€¦ · all patients with Diffused toxic goiter ... disease in all patients with nodules in 12.94% however there was no ... DIFFUSED

International Journal of Advancements in Research & Technology, Volume 4, Issue 3, April -2015 1 ISSN 2278-7763

Copyright © 2015 SciResPub. IJOART

DIFFUSED TOXIC GOITER: A FIVE YEAR EXPERIENCE

AUTHORS: S. ALIYU, A. G. IBRAHIM

ADDRESS: DEPARTMENT OF SURGERYs UNIVERSITY OF MAIDUGURI TEACHING

HOSPITAL MAIDUGURI BORNO STATE NORTH EASTERN NIGERIA.

CORRESPONDANCE: DR SULEIMAN ALIYU DEPARTMENT OF SURGERY

UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL P.M.B1414 MAIDUGURI

BORNO STATE NIGERIA

TEL. +2348035015309

EMAIL: [email protected]

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mailto:[email protected]



ABSTRACT: Background: Grave’s disease is the commonest endocrine auto

immune disorder in women it is characterized by diffuse enlargement of the

thyroid gland associated with elevated serum thyroid hormones manifesting with

clinical features of thyrotoxicosis. Other features are opthalmopathy, and

acropachy. It is an IgG antibody mediated. Grave’s disease is one of the

indications for thyroidectomy; the study reviewed our 3 year experience in the

management of patients with the disease. Patients and Methods: We reviewed

all patients with Diffused toxic goiter (Grave’s disease) managed in the University

of Maiduguri Teaching Hospital (UMTH) between January 2010 and December

2014. Patients with emergency presentation (thyrocardia) were resuscitated and

optimized. All patients were rendered euthyroid with carbimazole and

propranolol on outpatient basis. Subtotal thyroidectomy under general

anesthesia was done in all patients. Results: A total of 85 patients were analyzed,

78 were females and 7 males with a female to male ratio of 11.14: 1. Age ranged

from 14 – 70 years with a mean of 31.84 years and SD of 10.89, mean age for

females, and males were 31.74, and 32.86 respectively. The peak age group was

20 – 29 accounting for 41.18%, and 78.82% of the patients were under the age of

40 years. The presenting clinical features were anterior neck swelling, heat

intolerance, and hair loss/darkening of skin in all patients. Associated

autoimmune diseases were type 1 diabetic mellitus in 5.88%, Rheumatoid

arthritis in 3.53%, and systemic lupus erythromatosis (SLE) in 1.18%.

Postoperative complications were respiratory obstruction in 11.76%, and

transient hypocalcaemia in 10.59%. Conclusion: Grave’s disease is common, with

spectrum of manifestations characterized by goiter, thyrotoxicosis, and

psychosocial problems. Subtotal thyroidectomy is still a viable option in

developing countries.

KEYWARDS: Diffused Toxic Goiter, Psychosocial problems, Subtotal

Thyroidectomy, Outcome of Management.

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Introduction: Graves’ disease owes its name to the Irish physician; Robert James

Grave’s who described the condition in 1835. It is a syndrome comprising

hyperthyroidism with a diffuse goiter, eye disease characterized by inflammation

and involvement of intra orbital structures, dermopathy refer to as pretibial

myxedema, and rare involvement of the nails, fingers and long bones known as

acropachy. Prior to Graves’ description the Greek philosopher Aristotle and the

English physician Caleb Parry had described the condition1. The disease is the

most common autoimmune disease representing 50-80% of cases of

hyperthyroidism in the U.S.A2 it occurs more commonly among women, smokers,

and patients with other autoimmune diseases or a family history of thyroid

autoimmunity3. The emergence of this autoimmune process is probably due to an

underlying genetic susceptibility with superimposed environmental factors

particularly HLA alleles on chromosome 6 namely HLA- DRB1-08, DRB3-0202, and

HLA-DQA1-0501 are known to confer an increased risk of Graves’ disease4-5. There

is always a trigger before the onset of clinical features. Such triggers include

stressful life events, infection, job loss, or bereavement, exposure to high doses of

iodine, and recent child birth. The clinical features include weight loss despite

increase appetite, heat intolerance, irritability, insomnia, sweatiness, diarrhea,

palpitations, muscular weakness, and menstrual irregularity. Others are diffused

goiter, fine resting tremor, tachycardia, hypereflexia, eyelid lag, worm smooth

skin, and proximal myopathy. Rarely atrial fibrillation and thyroid bruit reflecting

increased thyroid vascularity. Older patients are more likely to present with

depression, weight loss, and cardiovascular features like congestive cardiac failure

than younger patients6. This hyper dynamic congestive cardiac failure is also

called thyrocardia. Women may presents for cosmetic reasons, with concerns

about goiter, eye changes, or hair loss7-8. These cosmetic problems were under

reported, especially in developing countries where gender inequality, cultural

factors, poor socioeconomic status and low level of education put women at

disadvantage. Most women are dependent on men therefore loss of self esteem

and body image lead many women that are not gainfully employed in to

depression and suicidal tendency, marital separation, divorce and instability are

common among women with Graves’ disease. Total thyroidectomy with thyroxine

replacement is currently the gold standard in goiter surgery for both benign and

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malignant conditions9-10. Many developing countries have a peculiar problem of

non availability of thyroxine and where available is too expensive and

unaffordable to be taken for life. This is a strong indication for subtotal

thyroidectomy in our environment. The study reviewed our experience in Graves’

disease management.

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Patients and Methods: The study reviewed all patients with Diffused toxic goiter

(Grave’s disease) managed in the University of Maiduguri Teaching Hospital

(UMTH) between January 2010 and December 2014. Permission for the study was

granted by the Hospital Ethical and Research Committee. Written informed

consent was obtained from the patients. Information was extracted from clinical

and laboratory records and data analyzed using SPSS version 16. The diagnosis

was made from clinical and laboratory evaluation. Investigations done were

Thyroid function test (T3, T4, and TSH), urinalysis, full blood count, blood

chemistry, indirect laryngoscopy, electrocardiography, and echo cardiography

where necessary. Patients with emergency presentation (thyrocardia) were

resuscitated and optimized, and patients were rendered euthyroid with

carbimazole and propranolol on outpatient basis before surgery. All patients had

subtotal thyroidectomy under general anesthesia with endotracheal intubation.

Prophylactic antibiotic (ceftriaxone) was given at induction. Patients were

monitored postoperatively and followed up after discharge.

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Results: A total of 85 patients were analyzed, 78 were females and 7 males with a

female to male ratio of 11.14: 1. Age ranged from 14 – 70 years with a mean of

31.84 years and SD of 10.89, mean age for females, and males were 31.74, and

32.86 respectively. The peak age group was 20 – 29 accounting for 35 (41.18%),

and 67 (78.82%) of the patients were under the age of 40 years table 1. The

presenting clinical features were anterior neck swelling, heat intolerance, and hair

loss/darkening of skin in all patients table 2. Co-morbid medical conditions were

hypertension in 11 (12.94%), type one diabetic mellitus in 5 (5.88%), Rheumatoid

arthritis in 3 (3.53%), asthma in 2 (2.35%), and systemic lupus erythromatosis

(SLE) in 1 (1.18%). Histology confirmed Graves’ disease in all patients with

associated nodules in 11 (12.94%) no malignancy was found. Postoperative

complications were respiratory obstruction in 10 (11.76%), comprising of

laryngeal edema in 6 (7.06%), recurrent laryngeal nerve palsy in 1 (1.18%), and

hematoma in 3 (3.53%). Others were transient hypocalcaemia in 9 (10.59%),

recurrence in 2 (2.35%) (Who subsequently had total thyroidectomy with

thyroxine replacement for life), and keloid/hypertrophic scar in7 (8.24%). There

was no mortality. The mean hospital stay, and duration of follow up were 5 days,

and 27 months.

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Discussion: The study revealed the mean age for Graves’ disease to be 31.84

years, and the patient’s age ranged from 14 – 70 years. This indicates by far

Graves’ disease is the disease of the young in this environment compared to

similar study by Jolanta et al11 that found older patients with the mean age of

47.12years, and age range of 18 – 84 years. Similarly the mean ages for males and

females of 32.86years and 31.74years respectively were lower than their findings.

Globally however there is a rising incidence of Graves’ disease among children

especially in the Far East12. The traditionally recognized clinical features13 of

Graves’ disease were similar to our findings. However this study revealed the

depth of psychosocial disturbance associated with Graves’ disease as evidence by

the findings of hostile/quarrelsome disposition, and domestic problems of

separation or divorce in 85.88%, and 27.06% respectively. Graves’ disease

patients are found to have low self esteem and body image due to associated

poor cosmetic outlook (hair loss, goiter, extholpthalmus, and dermopathy) in

(91.76%). The fore going psychosocial problems constitute a major part of the

unreported features of Graves’ disease that the current study found. Graves’

disease is known to be associated with other autoimmune disorders like

myasthenia gravis, type 1 diabetes mellitus14-15. The current study found type 1

diabetes mellitus, and rheumatoid arthritis. The histology revealed Graves’

disease in all patients with nodules in 12.94% however there was no incidental

carcinoma in variance with study by Mishra et al16that found incidental carcinoma

in their series. The postoperative complications in our series were respiratory

obstruction in 11.76% (from hematoma 3.53%, laryngeal edema 7.06%, and

recurrent laryngeal nerve palsy 1.18%), and transient hypocalcaemia in 10.59%.

These complications were similar to complications of subtotal thyroidectomy but

lower than found in total thyroidectomy as reported in comparative study of total

versus subtotal thyroidectomy by Colak et al17. Globally there is a reduction in the

complications associated with thyroidectomy, therefore the reluctance to

recommend thyroidectomy for definitive treatment of Graves’ disease has been

challenged in recent years. A study by Pearce et al18 showed that thyroidectomy is

more cost effective than either radio iodine ablation or antithyroid medication

and offers patient a better quality of life. The argument today is which surgery is

the best? Total thyroidectomy on the one hand, and near total or subtotal

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thyroidectomy on the other hand based on variation in complications19-21. The

current study had 2.35% recurrent goiter that were offered completion

thyroidectomy. Alessandro et al22 in a 20 year follow up period found a

recurrence of 2-70% of cases, and advocated for total thyroidectomy at the initial

surgery because surgical treatment of such recurrence is associated with higher

complications.

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Tables1: Age Distribution

Age (Years) No %

<20 20-29 30-39 40-49 50-59 60-69 70+

6 7.06 35 41.18 26 30.59 10 11.76 6 7.06 1 1.18 1 1.18

Total 85 100.00

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Table 2: Clinical features

Clinical features No %

Cardinal features * Low self esteem/body image Hostile/quarrelsome Palpitations Opthalmopathy Separation/Divorce Pretibial myxedema Thyrocardia

85 100 78 91.76 73 85.88 71 83.53 49 57.65 23 27.06 17 20.00 4 4.71

NB: * Goiter, Heat intolerance, sweating, weight loss, Increase appetite, Hair

loss/Darkening of skin, present in all patients.

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DIFFUSED TOXIC GOITER: A FIVE YEAR EXPERIENCE€¦ · all patients with Diffused toxic goiter ... disease in all patients with nodules in 12.94% however there was no ... DIFFUSED