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Surgical management of hyperthyroidism

Surgical management of hyperthyroidism
Literature review current through: Jan 2024.
This topic last updated: Sep 19, 2023.

INTRODUCTION — The treatment of hyperthyroidism consists of both symptomatic relief and decreasing the production of thyroid hormone. The use of surgery as definitive therapy for hyperthyroidism varies with the cause of the disease and the characteristics of the patient.

Indications for surgical management of hyperthyroidism and preoperative preparation are reviewed here. Thyroidectomy is reviewed in detail elsewhere (see "Thyroidectomy"). Other treatment options are also discussed elsewhere. (See "Radioiodine in the treatment of hyperthyroidism" and "Treatment of toxic adenoma and toxic multinodular goiter" and "Graves' hyperthyroidism in nonpregnant adults: Overview of treatment", section on 'Selection of therapy'.)

ROLE OF SURGERY — The approach outlined below is consistent with Hyperthyroidism Management Guidelines from the American Thyroid Association (ATA) [1] and the American Association of Endocrine Surgeons [2].

Graves' disease — Patients with Graves' disease can be treated with antithyroid drugs, radioiodine, or surgery. In the only randomized, prospective trial comparing these three therapies, each was equally effective in normalizing serum thyroid hormone concentrations within six weeks; after treatment, 95 percent or more of the patients were satisfied with their therapy [3]. Therefore, the choice of therapy should involve active discussion between clinician and patient (table 1) [4]. The therapeutic approach to Graves' hyperthyroidism is reviewed in more detail elsewhere. (See "Graves' hyperthyroidism in nonpregnant adults: Overview of treatment", section on 'Selection of therapy'.)

A patient may prefer surgery over other modalities because of a desire to avoid radioiodine, avoid the potential side effects of antithyroid drugs, and to obtain rapid correction of hyperthyroidism. In addition, the following patients with Graves' hyperthyroidism may be better served by surgery:

Patients with very large goiters (≥80 g) who may require multiple doses of radioiodine, which can result in asymmetric and limited shrinkage of the goiter.

Patients with goiters causing upper airway obstruction or severe dysphagia.

Patients who also have a nonfunctional thyroid nodule with indeterminate, suspicious, or positive cytology on fine-needle aspiration, in whom surgery can both cure the hyperthyroidism and provide a definitive diagnosis of the nodule.

Patients with coexisting hyperparathyroidism who are surgical candidates for parathyroidectomy, in whom surgery can cure the hyperthyroidism and hyperparathyroidism.

Patients with moderate to severe thyroid eye disease in whom surgery is preferred over radioiodine since radioiodine may exacerbate thyroid eye disease, presumably by transiently increasing thyrotropin receptor antibody (TRAb) levels. Coadministering corticosteroids with radioiodine may prevent exacerbation of thyroid eye disease when it is mild. (See "Treatment of thyroid eye disease".)

Pregnant women who are allergic to antithyroid drugs and are tolerating hyperthyroidism poorly have no alternative to surgery.

Hyperthyroid women who want to get pregnant within the year, who wish to avoid the teratogenicity associated with propylthiouracil (PTU), and the increased risk of fetal hyperthyroidism due to the transient increase in TRAb levels after radioiodine.

Patients who have persistent hyperthyroidism despite treatment with antithyroid medication and radioiodine.

Additionally, the increased all-cause mortality and cardiovascular-related events associated with Graves' disease are correlated with persistent TSH suppression independent of treatment option [5]. Surgery typically results in more rapid correction of hyperthyroidism and also more effectively lowers TRAb [6].

Toxic adenoma and toxic multinodular goiter — Surgery is used more commonly for the treatment of patients with a toxic adenoma or toxic multinodular goiter (MNG) than it is for Graves' hyperthyroidism. It is indicated for patients with obstructive goiters or very large goiters, those who need rapid and definitive correction of hyperthyroidism, and for patients with coexisting malignancy or primary hyperparathyroidism. (See "Treatment of toxic adenoma and toxic multinodular goiter", section on 'Therapeutic approach'.)

Surgery could also be considered in children and adolescents and, as noted above, may be preferable in patients with coexistent nonfunctioning nodules, especially if the goiters are large. Surgery is increasingly preferred by patients who have nodules in order to avoid the need for future assessments and interventions. Nodular thyroid tissue that remains following radioiodine treatment may develop calcifications over time, which may be interpreted as suspicious by radiologists on subsequent imaging and lead to thyroidectomy a decade or more after radioiodine treatment [7]. Substernal extension of the goiter is another possible indication for surgery [8]. (See "Treatment of benign obstructive or substernal goiter", section on 'Substernal goiter' and "Treatment of toxic adenoma and toxic multinodular goiter", section on 'Indications'.)

CONTRAINDICATIONS — The presence of substantial comorbidity, including cardiopulmonary disease or other debilitating disease, is a relative contraindication to surgery. Surgery during pregnancy is associated with an increased risk of spontaneous abortion or premature delivery. For pregnant women who require surgery because of an inability to tolerate thionamides, the risks of surgery are minimized by operating during the second trimester. (See "Hyperthyroidism during pregnancy: Treatment", section on 'Thionamide intolerance'.)

EXTENT OF RESECTION

Graves' disease – Most experts agree that total or near-total thyroidectomy rather than subtotal thyroidectomy is considered the optimal procedure [1,2]. The extent of surgery for Graves' hyperthyroidism was an area of controversy that paralleled the arguments for low versus high doses of radioiodine therapy; more aggressive surgery (total thyroidectomy) had a higher likelihood of inducing hypothyroidism, while less aggressive surgery (subtotal thyroidectomy) had a higher likelihood of recurrent hyperthyroidism. Surgical complications are lower when performed by surgeons with expertise in thyroid surgery [1,2,9,10].

Total thyroidectomy – Total thyroidectomy involves removal of all thyroid tissue. Total thyroidectomy has a nearly 0 percent risk of recurrence; however, these patients require lifelong thyroxine (T4) replacement therapy [11].

Subtotal thyroidectomy – Subtotal thyroidectomy is defined as either bilateral subtotal (leaving posterior rim on each thyroid lobe) or as the Hartley-Dunhill procedure (unilateral total lobectomy with contralateral subtotal lobectomy). Up to 60 percent of patients can maintain adequate thyroid function without thyroid hormone supplementation when there is a four- to seven-gram remnant [1], an important feature for patients without good access to thyroid hormone. However, the remnant predisposes to persistent or recurrent hyperthyroidism, as illustrated by the findings of a retrospective review of 415 patients who had subtotal thyroidectomy for Graves' disease; persistent or recurrent disease occurred in 28.7 percent with a median time to recurrence of 36 months [12]. Hypothyroidism developed in over 50 percent of patients.

In a randomized trial of subtotal versus total thyroidectomy for Graves' disease involving 191 patients followed over five years, recurrent hyperthyroidism occurred in 4.7 percent of patients after subtotal versus none after total thyroidectomy, while transient hypoparathyroidism was seen in 6.8 and 12.6 percent, respectively, and permanent hypoparathyroidism in 0 and 0.5 percent, respectively [13].

In a randomized trial comparing near total and total thyroidectomy in 205 patients with Graves' disease, there was no difference in the rate of transient hypoparathyroidism, an increased rate of reoperations for bleeding (3 versus 0 percent), and a higher rate of inadvertently removed parathyroid glands (13 versus 3 percent) in the near total thyroidectomy group [14].

Toxic multinodular goiter – For patients with toxic multinodular goiter (MNG), total thyroidectomy should be performed [1]. (See "Treatment of toxic adenoma and toxic multinodular goiter", section on 'Extent of resection'.)

Toxic adenoma – For patients with toxic adenoma without evidence of nodules in the contralateral lobe, ipsilateral lobectomy (or isthmusectomy if the adenoma is in the thyroid isthmus) is adequate. For patients with toxic adenoma and a coexisting nonfunctioning nodule in the contralateral lobe, total thyroidectomy may be warranted. The decision should be based upon results of fine-needle aspiration biopsy of the nonfunctioning nodule(s). (See "Treatment of toxic adenoma and toxic multinodular goiter", section on 'Surgery'.)

PREOPERATIVE PREPARATION

Management of hyperthyroidism — Patients with hyperthyroidism who are to undergo thyroid surgery should be treated with an antithyroid drug until the free T4 and T3 are normal [1]. It is not necessary to wait for the TSH to become normal, as this typically takes several additional weeks. Beta blockers can be used to control hyperthyroid symptoms in addition to thionamides. In patients with thionamide intolerance, beta blockers can be used alone or in conjunction with iodine, glucocorticoids, and possibly cholestyramine. Glucocorticoids have been used in conjunction with beta blockers and, in Graves' disease, iodine drops or iopanoic acid (if available) to prepare thyrotoxic patients for emergency surgery [15]. (See 'Beta blockers' below and 'Thionamide therapy' below and 'Iodine' below and 'Patients unable to take a thionamide drug' below.)

Patients with hyperthyroidism are at risk for developing thyroid storm, a rare and potentially fatal condition that usually occurs during surgery or in the first 18 hours after the procedure [16,17]. Treating hyperthyroidism prior to thyroid surgery reduces this risk. Some retrospective studies suggest surgery in patients with uncontrolled hyperthyroidism may be performed safely [18,19]. However, one study demonstrated a higher requirement for intraoperative beta blockers and another used a more stringent definition for the diagnosis of thyroid storm, potentially underestimating its occurrence.

There are some patients in whom euthyroidism cannot be achieved, or is not expected to be achieved, with thionamide therapy due to poor compliance or other patient-related factors. In such patients, the risk of thyroid storm may well be higher if thyroidectomy is deferred [19,20]. Surgery in a thyrotoxic patient ideally should be done at a center with experienced anesthesiologists.

Beta blockers — Beta blockers ameliorate many of the symptoms of hyperthyroidism. They are often started as soon as the diagnosis of hyperthyroidism is made, even before obtaining a 24-hour radioiodine uptake or scan or the results of a thyrotropin receptor antibody (TRAb) level. In the absence of contraindications, we usually give atenolol (25 to 50 mg/day), which has the advantages of single daily dosing and beta-1 selectivity, but all drugs of this class effectively reduce symptoms in patients with hyperthyroidism.

In addition, for patients who are allergic to or cannot tolerate thionamides, beta blockers administered preoperatively may be as safe as a thionamide for preoperative preparation of the hyperthyroid patient [18,21-23]. As an example, in a randomized trial of methimazole versus metoprolol in 30 patients with newly diagnosed and untreated hyperthyroidism undergoing thyroid surgery, there was no difference in anesthesiologic or cardiovascular complications during surgery or in postoperative complications postsurgery [21]. (See "Beta blockers in the treatment of hyperthyroidism" and 'Patients unable to take a thionamide drug' below.)

Beta blockers may be tapered and discontinued after thyroid function tests have returned to normal.

Thionamide therapy — Once the diagnosis of hyperthyroidism associated with an elevated TRAb level or a normal or increased radioiodine uptake is established, thionamides should be initiated with the aim of controlling hyperthyroidism prior to surgery. Thionamides alone are sufficient to achieve euthyroidism in approximately three to eight weeks. Prior to initiating thionamides, we obtain baseline blood tests, including a complete blood count (white count with differential) and a liver profile (bilirubin and transaminases). We do not use thionamides in patients with a baseline absolute neutrophil count <1000 mm3 or elevated liver transaminases (more than fivefold the upper limit of normal), except in selected patients after careful assessment of alternatives and risks. (See "Thionamides in the treatment of Graves' disease".)

Methimazole is recommended over propylthiouracil (PTU), except during the first trimester of pregnancy, because of its longer duration of action (allowing for single daily dosing) and a lesser degree of toxicity. (See "Thionamides in the treatment of Graves' disease", section on 'Choice of drug'.)

The initial dose of methimazole is 5 to 40 mg once daily depending upon disease severity [1]. For patients with larger goiters and/or more severe hyperthyroidism, we typically administer 20 or 30 mg daily. Patients should have their thyroid function assessed at four- to six-week intervals. The dose can be adjusted if the hyperthyroidism (as assessed clinically and by measurements of serum thyroid-stimulating hormone [TSH], T4, and T3) is not ameliorated within four to six weeks. (See "Thionamides in the treatment of Graves' disease", section on 'Dosing'.)

Methimazole can be discontinued on the day of surgery.

Patients unable to take a thionamide drug — Patients with toxic nodular goiter or toxic adenoma who are intolerant or unable to take thionamides should be pretreated with beta blockers alone, whereas patients with Graves' hyperthyroidism who are allergic to or are intolerant of thionamides can be treated with the combination of beta blockers and iodine [18,21-24]. (See 'Iodine' below.)

In the absence of contraindications, if blood pressure allows, a beta-adrenergic antagonist drug should be given in sufficient dose to maintain a pulse rate below 80 beats/minute with exercise [23]. Longer-acting drugs of this type, such as atenolol, are preferable because an oral dose taken one hour before surgery will maintain adequate blockade until the patient is able to take oral medications postoperatively. Supplemental intravenous propranolol can be administered as needed. (See "Beta blockers in the treatment of hyperthyroidism".)

Although some studies suggest that cholestyramine (4 g by mouth three times daily) may help lower thyroid hormone levels during the preoperative management of refractory hyperthyroidism (eg, for people who cannot tolerate or who are resistant to thionamides) [25,26], it is rarely needed in this setting. (See "Thyroid storm", section on 'Other therapies'.)

Iodine — In patients with Graves' disease, we administer inorganic iodine (eg, saturated solution of potassium iodide [SSKI]) for up to 10 days before surgery to decrease thyroid hormone secretion and to decrease the vascularity of the thyroid gland and subsequent surgical blood loss [1,27]. Preoperative iodine should not be used in patients with toxic multinodular goiter (MNG) or toxic adenoma, whose thyroid glands tend to be less hypervascular than in patients with Graves' disease, since iodine may actually exacerbate hyperthyroidism, especially in those patients not concurrently treated with antithyroid drugs preoperatively. (See "Iodine in the treatment of hyperthyroidism".)

In a study comparing 28 patients who received iodine preoperatively with 31 who did not, rates of transient hypoparathyroidism (7 versus 26 percent) and transient hoarseness (0 versus 16 percent) were lower in the iodine group, suggesting that iodine also improves the safety of the surgery [28]. However, in a meta-analysis that included 223 patients given preoperative radioiodine and 287 controls, the iodine-treated patients had reduced vascularity and reduced intraoperative blood loss, but no change in recurrent laryngeal nerve damage, hypoparathyroidism, or postoperative hematoma [29].

Iodine can be given as SSKI (50 mg iodide per drop [0.05 mL], 1 to 2 drops three times daily [approximately 300 mg daily]) or potassium iodide-iodine solution (Lugol's) 8 mg iodide/iodine per drop, 5 to 7 drops three times daily. These solutions can be irritating and should be diluted in 240 mL or more of beverage and taken with food (see "Iodine in the treatment of hyperthyroidism"). Alternatively, the patient with Graves' disease can be given sodium ipodate or iopanoic acid (iodinated radiographic contrast agents) that not only contain iodine but also inhibit the extrathyroidal conversion of T4 to T3 and therefore rapidly lower serum T3 concentrations [15]. Neither is available in the United States. (See "Iodinated radiocontrast agents in the treatment of hyperthyroidism".)

Measures to prevent postoperative hypocalcemia — Calcium and 25-hydroxyvitamin D should be measured preoperatively and repleted if low or given prophylactically [1]. (See "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment" and 'Hypocalcemia' below.)

Transient biochemical hypocalcemia is common after thyroidectomy for Graves' disease [30,31]. Rates of symptomatic and biochemical postoperative hypocalcemia were reduced in one study when 1 g calcium carbonate was given three times daily for two weeks preoperatively [32]. Hypocalcemia was also less common when vitamin D levels were >20 ng/mL prior to surgery [33]. In patients at high risk for hypoparathyroidism, calcitriol can be started pre- or perioperatively [34-36]. Since the onset of action for calcitriol may be several days, starting calcitriol three days prior to scheduled surgery in patients at high risk for postoperative hypoparathyroidism may prevent a delay in hospital discharge. (See 'Hypocalcemia' below.)

COMPLICATIONS — Complications of thyroid surgery include wound infection, keloid formation at the site of the incision, transient and permanent hypoparathyroidism, and recurrent or superior laryngeal nerve palsy. (See "Thyroidectomy", section on 'Complications'.)

Permanent problems should occur in less than 1 to 2 percent of patients, although slightly higher complication rates have been described. As an example, in a series of 380 patients with hyperthyroidism who underwent surgery (98 percent subtotal thyroidectomy), complications included [37]:

Transient vocal cord paralysis in 3 percent

Prolonged postoperative hypocalcemia in 3 percent

Permanent hypoparathyroidism in 1 percent

Recurrent hyperthyroidism in 2 percent

In the Nationwide Inpatient Sample database, complications of total thyroidectomy were higher in surgeries done for Graves' disease than for thyroid cancer and multinodular goiter [38].

POSTOPERATIVE MANAGEMENT — Beta blockers, if administered, should be tapered and discontinued after thyroidectomy. Antithyroid drugs can be discontinued at the time of thyroidectomy.

Hypocalcemia — In the first 24 hours after total thyroidectomy for hyperthyroidism, transient biochemical hypocalcemia is common, occurring in 60 to 90 percent of patients [11,30,31,39]. Permanent hypoparathyroidism is uncommon, occurring in approximately 1 percent of patients [11].

Patients should be monitored for postoperative hypocalcemia and provided with education on the signs and symptoms of hypocalcemia. Some patients are routinely given calcium and calcitriol supplementation, whereas others are supplemented if the calcium level declines. When the risk of post-thyroidectomy hypocalcemia is high (eg, if the surgery was difficult and the surgeon feels the parathyroids may have been compromised or if the intraoperative or postoperative PTH levels are less than 10 to 15 pg/mL), routine supplementation with calcium and calcitriol is preferred.

Routine supplementation – Routine postoperative supplementation of calcium and calcitriol may decrease the development of hypocalcemia symptoms and allow for earlier discharge [40]. In many centers, a serum parathyroid hormone (PTH) level is checked in the immediate postoperative period and is used to predict risk of hypocalcemia [41,42]. In several studies, a postoperative (one to six hours) serum PTH level <10 to 15 pg/mL was predictive of postoperative hypocalcemia [43-45].

A typical prophylactic dose of oral calcium carbonate is approximately 2 to 3 g of elemental calcium given in two to four divided doses daily. This can be tapered over two to six weeks depending upon hypocalcemic symptoms and serum calcium determinations. Calcitriol is initially administered at a dose of 0.5 mcg daily for one to two weeks and increased or decreased thereafter depending upon the calcium and intact PTH levels [1]. Patients can be discharged if they are asymptomatic and have stable serum calcium levels (at least 7.8 mg/dL [1.95 mmol/L]).

Supplementation as needed – If calcium is not routinely administered after near-total or total thyroidectomy, serum calcium and albumin should be measured on the evening of surgery and the next morning. Oral calcium and calcitriol supplementation should be administered based upon the results of the serum calcium corrected for albumin (table 2).

The management of post-thyroidectomy hypoparathyroidism is reviewed in more detail separately. (See "Differentiated thyroid cancer: Surgical treatment", section on 'Hypoparathyroidism'.)

Hypothyroidism — The frequency of postoperative hypothyroidism is dependent upon the size of the surgical remnant. For patients with Graves' disease or toxic multinodular goiter (MNG) who had near-total or total thyroidectomy, thyroid hormone replacement (T4) should be initiated prior to discharge in a euthyroid patient at a dose of approximately 1.6 mcg/kg body weight daily. If the patient was still hyperthyroid at the time of surgery, thyroid hormone replacement should be delayed until levels fall into the normal range; the interval can be estimated based on the week-long half-life of T4. Older patients and those with coronary disease or multiple coronary risk factors should initially be treated with approximately 20 percent less than the full calculated replacement dose to avoid the potential complications of overtreatment.

Serum TSH should be measured approximately six weeks after discharge and the dose increased by 12 to 25 mcg/day if the TSH remains above the normal reference range. Serum TSH should be remeasured approximately six weeks after each dose adjustment. (See "Treatment of primary hypothyroidism in adults", section on 'Dose and monitoring'.)

Patients with Graves' disease who have subtotal thyroidectomy and are not hypothyroid soon after surgery need to be monitored for possible hypothyroidism (or recurrent hyperthyroidism) for the rest of their lives.

Hypothyroidism is less common after lobectomy or isthmusectomy for toxic adenoma. Serum TSH and free T4 levels should be measured four to six weeks after surgery. Thyroid hormone should be initiated only if the TSH rises and remains above the normal reference range.

Persistent hyperthyroidism — If hyperthyroidism persists or recurs after near-total thyroidectomy for Graves' disease, patients should be treated with radioiodine because repeat surgery is associated with a high risk of complications. (See "Radioiodine in the treatment of hyperthyroidism", section on 'Indications'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hyperthyroidism".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Hyperthyroidism (overactive thyroid) (The Basics)")

Beyond the Basics topics (see "Patient education: Hyperthyroidism (overactive thyroid) (Beyond the Basics)" and "Patient education: Antithyroid drugs (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Role of surgery – The treatment of hyperthyroidism consists of both symptomatic relief and decreasing the production of thyroid hormone. The use of surgery as definitive therapy for hyperthyroidism varies with the cause of the disease and the characteristics of the patient. A patient may prefer surgery over other modalities to treat hyperthyroidism because of a desire to avoid radioiodine, avoid the potential side effects of antithyroid drugs, and obtain rapid correction of hyperthyroidism. Patients with symptoms or signs of compression/obstruction, a need for rapid return to euthyroidism, or coexisting thyroid cancer require surgery. (See 'Role of surgery' above.)

Contraindications to surgery – The presence of substantial comorbidity, including cardiopulmonary disease or other debilitating disease, is a relative contraindication to surgery. Surgery during pregnancy is associated with an increased risk of spontaneous abortion or premature delivery. For pregnant women who require surgery because of an inability to tolerate thionamides, the risks of surgery are minimized by operating during the second trimester. (See 'Contraindications' above.)

Preoperative preparation

Beta blockers – Assuming there are no contraindications to its use, we recommend using a beta blocker for patients with moderate to severe hyperadrenergic symptoms until euthyroidism is achieved by thionamides or surgery (Grade 1B). We typically start with atenolol 25 to 50 mg daily and increase the dose as needed (up to 200 mg daily) to reduce pulse to less than 90 beats per minute if blood pressure allows. (See "Beta blockers in the treatment of hyperthyroidism".)

Thionamides – Patients with hyperthyroidism are at risk for developing thyroid storm, a rare condition that usually occurs during surgery or in the first 18 hours after the procedure.

For patients with hyperthyroidism associated with an elevated thyrotropin receptor antibody (TRAb) level or a normal or elevated radioiodine uptake who are to undergo thyroidectomy, we suggest treating with a thionamide (Grade 2C). Methimazole is preferred over propylthiouracil (PTU), except during the first trimester of pregnancy, because of its longer duration of action (allowing for single daily dosing) and a lesser degree of toxicity. The initial dose of methimazole is 5 to 40 mg once daily. For patients with larger goiters and/or more severe hyperthyroidism, we typically administer 20 or 30 mg daily. Thionamides alone are sufficient to achieve euthyroidism in approximately three to eight weeks. (See 'Preoperative preparation' above and "Thionamides in the treatment of Graves' disease" and "Thionamides in the treatment of Graves' disease", section on 'Choice of drug'.)

Thionamide intolerance – Patients with toxic nodular goiter or toxic adenoma who are intolerant or unable to take thionamides should be pretreated with beta blockers alone, whereas patients with Graves' hyperthyroidism who are allergic to or are intolerant of thionamides can be treated with the combination of beta blockers and iodine. (See 'Patients unable to take a thionamide drug' above.)

Iodine if Graves' disease – For patients with Graves' hyperthyroidism, we suggest adding potassium iodine solution to decrease the vascularity of the thyroid gland and surgical blood loss (Grade 2C). We typically use saturated solution of potassium iodide (SSKI, 50 mg iodide per drop [0.05 mL], 1 to 2 drops three times daily [approximately 300 mg daily]) for up to 10 days before surgery. (See 'Preoperative preparation' above and "Iodine in the treatment of hyperthyroidism", section on 'Role of iodine'.)

Preoperative iodine should not be used in patients with toxic MNG or toxic adenoma, whose thyroid glands tend to be less hypervascular than in patients with Graves' disease, since iodine may actually exacerbate hyperthyroidism especially in those patients not concurrently treated with antithyroid drugs preoperatively.

Calcium and vitamin D supplementation for prevention – To prevent postoperative hypocalcemia, serum calcium and 25-hydroxyvitamin D should be assessed preoperatively and replaced, if necessary. (See 'Measures to prevent postoperative hypocalcemia' above.)

Postoperative management

Hypocalcemia – Patients should be monitored for postoperative hypocalcemia and either routinely provided with calcium and calcitriol supplementation or supplemented if the calcium level declines. When the risk of post-thyroidectomy hypocalcemia is high (eg, if the surgery was difficult and the surgeon feels the parathyroids may have been compromised or if the intraoperative or postoperative PTH levels are less than 10 to 15 pg/mL), routine supplementation of calcium and calcitriol is preferred. (See 'Hypocalcemia' above.)

A typical prophylactic dose of oral calcium carbonate is approximately 2 to 3 g of elemental calcium by mouth given in two to four divided doses daily. This can be tapered over two to six weeks depending upon hypocalcemic symptoms and serum calcium determinations. Calcitriol is administered at a dose of 0.5 mcg daily for one to two weeks and increased or decreased thereafter depending upon the calcium and intact PTH levels.

If calcium is not routinely administered after near-total or total thyroidectomy, serum calcium and albumin should be measured on the evening of surgery and the next morning. Oral calcium and calcitriol supplementation should be administered based upon the results of the serum calcium corrected for albumin (table 2). (See 'Hypocalcemia' above and "Differentiated thyroid cancer: Surgical treatment", section on 'Hypoparathyroidism'.)

Thyroid hormone replacement

-Graves' disease or toxic MNG – For patients with Graves' disease or toxic MNG who had near-total or total thyroidectomy, thyroid hormone replacement (T4) should be initiated prior to discharge in euthyroid patients at a dose of approximately 1.6 mcg/kg body weight daily. If the patient was still hyperthyroid at the time of surgery, thyroid hormone replacement should be delayed until levels fall into the normal range; the interval can be estimated based on the week-long half-life of T4. Older patients and those with coronary disease or multiple coronary risk factors should initially be treated with approximately 20 percent less than the calculated full replacement dose to avoid overtreatment. (See 'Hypothyroidism' above.)

Serum thyroid-stimulating hormone (TSH) should be measured in approximately six weeks and the dose increased by 12 to 25 mcg/day if the TSH remains above the normal reference range. (See 'Hypothyroidism' above.)

Patients with Graves' disease who have subtotal thyroidectomy and are not hypothyroid soon after surgery need to be monitored for possible hypothyroidism (or recurrent hyperthyroidism) for the rest of their lives.

-Toxic adenoma – Hypothyroidism is less common after lobectomy or isthmusectomy for toxic adenoma. Serum TSH and free T4 levels should be measured four to six weeks after surgery. Thyroid hormone should be initiated only if the TSH rises and remains above the normal reference range. (See 'Hypothyroidism' above.)

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Topic 7880 Version 23.0

References

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