Toxic goitre (Basedow Graves, multi nodular toxic goitre and toxic adenoma).

The enlargement of the thyroid gland is called “goitre”.   If there is no nodule growth during this enlargement and if the hormones are normal, it is called "diffuse goitre" or "simple goitre". If more than 10% of the population have goitre, it is called "endemic goitre". Turkey is an endemic region. Tiroid hormonlarının fazla sentezlenmesi ve salgılanması ile zehirli guatr oluşur.


Basedow Graves' disease

It is an autoimmune thyroid disease. It is the most common cause of hyperthyroidism, in other words toxic goitre.  10% of patients have ophthalmologic findings.  Eyes may protrude outward or in mild conditions, glow can be seen in eyes.  Eye closure problems may occur.  Ophthalmologic findings develop due to oedema in the eye muscles.  Hyperthyroidism findings such as malaise, nervousness, palpitation, heat intolerance, weight loss, sweating, diarrhea, shortness of breath, weight loss despite the increased appetite, decrease in menstruation are seen.

The levels of thyroid hormones (T3 and T4) are found to be high, TSH level is found to be low. The levels of anti TPO and Anti Tg antibodies are high. TSH receptor antibody test is ordered to confirm the diagnosis, mostly it is positive in most of the patients. TSH receptor antibody test is ordered to differentiate it from other toxic goiter types.  The thyroid gland has a specific appearance in ultrasonographic examination of thyroid, its blood flow is increased.  In some patients, pseudonodule is seen.  Radioactive substance uptake is diffuse and intense in thyroid scintigraphy.

Once the diagnosis of the disease is made, first of all the hormones of the patient are reduced to normal levels with antithyroid drugs.  These drugs can be used at very high doses in some patients. Some severe toxic goitres are treated in the hospital since drugs may have side effects.  Smoking exacerbates the disease and causes ophthalmologic findings to increase. Anti-thyroid drug is used between 6 months and 1 year.  Beta blockers that reduce heart rate are also used.  Foods containing iodized salt and iodine are prohibited.  Toxic goitre treatment in pregnant patients is very specific.  The patients are followed up at close intervals to ensure the development of the baby in the mother's womb.

If the disease recurs after the medication is stopped, in other words if hyperthyroidism reoccurs, permanent treatment alternatives come to the fore. Permanent treatments are radioactive iodine therapy and surgery.

  • If there are ophthalmologic findings, surgery is recommended because radioactive iodine therapy may cause eye problems to increase.
  • If there is no ophthalmologic findings and if the thyroid gland is small, radioactive iodine therapy is appropriate.
  • If the thyroid is large, surgery is recommended.  Both thyroid glands are removed during the surgery, in other words total thyroidectomy is performed. The patient uses thyroid hormone for life after the surgery.
  • Radioactive iodine therapy and surgery decision may vary according to the characteristic of the patient's disease, and these decisions should usually be taken by experienced physicians.
  • If there is a nodule development and this nodule is found to be suspicious as a result of needle biopsy, surgery is recommended.

Ophthalmologic findings progress independently of the disease of the thyroid gland. Since it is an autoimmune disease, the ophthalmologic findings do not completely heal, even if the thyroid gland is removed. However, after surgical treatment, ophthalmologic findings regress. Therefore, radioactive iodine therapy is not recommended for the patients with ophthalmologic findings. Hormones should be at normal levels before radioactive iodine therapy or surgical treatment.  The first treatment in toxic goitre is the use of anti-thyroid drugs.


Toxic multinodular goiter

There are multiple nodules in the thyroid gland, and some of these nodules cause toxic goitre, secreting excessive amount of hormones. The levels of T3 and T4 hormones are high, TSH level is low.   Antibodies are negative. The nodules in the thyroid gland may be palpated during the examination. The patient's nodular goitre may transform into toxic nodular goiter over time. The signs of hyperthyroidism are also seen in this disease.

First of all hormones are regulated to be at normal levels with antithyroid drugs.  The treatment of toxic multinodular goiter is surgery and the thyroid gland is removed bilaterally during surgery.  Since it is not possible to use anti-thyroid drugs for life as is in all toxic goiters, permanent treatment is necessary.  Permanent treatment of toxic multinodular goiter is the removal of the bilateral thyroid gland, in other words total thyroidectomy.


Toxic adenoma

It is rare. It is a condition in which there is only one nodule in the thyroid gland and excessive amount of hormone is secreted from this nodule.  It causes toxic goitre.  The levels of T3 and T4 hormones are high, TSH level is low.    Antibodies are negative. The nodules in the thyroid gland may be palpated during the examination.  First of all hormones are regulated to be at normal levels with antithyroid drugs. If the diameter of the nodule is less than 3 cm, radioactive iodine therapy can be administered. If the diameter of the nodule is greater than 3 cm, removal of the unilateral thyroid gland, in other words lobectomy, is performed.