2022 European Thyroid Association Guideline for the management of pediatric Graves’ disease

Hyperthyroidism caused by Graves’ disease (GD) is a relatively rare disease in children. Treatment options are the same as in adults – antithyroid drugs (ATD), radioactive iodine (RAI) or thyroid surgery, but the risks and benefits of each modality are different. The European Thyroid Association guideline provides new recommendations for the management of pediatric GD with and without orbitopathy. Clinicians should be alert that GD may present with behavioral changes or declining academic performance in children. Measurement of serum TSH receptor antibodies is recommended for all pediatric patients with hyperthyroidism. Management recommendations include the first-line use of a prolonged course of methimazole/carbimazole ATD treatment (3 years or more), a preference for dose titration instead of block and replace ATD, and to avoid propylthiouracil use. Where definitive treatment is required either total thyroidectomy or RAI is recommended, aiming for complete thyroid ablation with a personalized RAI activity. We recommend avoiding RAI in children under 10 years of age but favor surgery in patients with large goiter. Pediatric endocrinologists should be involved in all cases.

Status of Alternative Approaches for Thyroidectomy: Is There Any Evidence to Substitute in Place of Conventional Surgery?

Over the past 20 years, various alternative cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed. All of these alternative access methods aim at optimizing the cosmetic results. In principle, the indication for the use of alternative access procedures does not differ from that for conventional surgery. Nonetheless, appropriate experience in traditional thyroid surgery and suitable patient selection, taking into account thyroid volumes and the underlying pathology, are important prerequisites. General contraindications for an alternative approach are large goiter with symptoms of compression, advanced thyroid carcinoma, recurrent interventions or previous radiotherapy in the operating area. The alternative surgical approaches to the thyroid can be divided into cervical minimally invasive, extracervical endoscopic (robot-assisted) and transoral procedures. This article gives an overview of the clinically used alternative approaches in thyroid surgery. The desire for an optimal cosmetic result should not be prioritized over patient safety. Only a few alternative procedures (minimally invasive video-assisted thyroidectomy, transaxillary robot-assisted thyroidectomy) can currently be viewed as a useful addition to conventional thyroid surgery, even when in responsible, experienced hands for a selected group of patients.

Hashimoto‘s thyroiditis

Hashimoto thyroiditis is a chronic organ-specific autoimmune disease. It is characterized by the production of autoantibodies against thyroid gland antigens with lymphocytic infiltration of the gland, leading to gradual destruction of a functional parenchyma. The disease is a leading cause of hypothyreosis in the areas with sufficient iodine supplementation. Etiology is currently unknown, occurence of other autoimmune diseases is common and familiar occurence was noted. The disease is associated with higher risk of thyroid gland malignancy. The treatment is usually conservative, surgery is indicated in suspicion for malignant tumor or in cases of a large goiter with mechanical compression.

Nasogastric tube insertion difficulty in a patient with a large goiter: A case report

Airway management under anesthesia is given special attention in patients who have large goiters. Nasogastric tube insertion may be difficult in intubated patients with large goiters. Several methods have been proposed to facilitate the insertion of nasogastric tubes in patients with endotracheal intubation; however, a standard insertion method has not been established. A 33-year-old man was admitted to our otolaryngology department for right thyroid lobectomy to remove a larger goiter. A thyroid computed tomography scan revealed a huge cystic mass with tracheal displacement. Although difficult intubation was expected, endotracheal intubation was performed successfully. An anesthesiologist attempted nasogastric tube insertion via the right nostril; however, this was not successful. Next, an angiography catheter was placed in a nasogastric tube, and the nasogastric tube was gently inserted with the patient’s neck in mild flexion. This attempt also failed. Finally, the nasogastric tube was gently inserted via anterior displacement of the cricoid cartilage. The nasogastric tube advanced up to 60 cm. Surgery was performed, and the patient was discharged with no complications on postoperative day 8.

SUN-522 A Case of Diabetic Ketoacidosis Associated with Thyroid Storm

Background: Thyrotoxic crisis is a rare complication of diabetic ketoacidosis (DKA). We herein report a case of DKA and subsequent thyroid storm which required emergent tracheostomy possibly due to large goiter and post-intubation obstruction. Clinical Case: A 26-year-old woman was admitted to our emergency department complaining fever (38.2℃) and palpitation. There was no history of autoimmune disease. Physiological examination revealed tachycardia (pulse rate 164/min), tachypnea (55/min), impaired consciousness with a GCS score of 13 (E3V4M6) and goiter. Endotracheal intubation was performed. Her laboratory tests showed metabolic acidosis (pH 7.255), marked high plasma glucose of 1,672 mg/dL, elevated HbA1c of 9.2%, elevated FT3 and FT4 with suppressed TSH. She scored 55 on the diagnostic criteria for thyroid storm of Burch & Wartofsky. Based on these findings, she was diagnosed as having DKA and thyroid crisis. The patient responded well to standard treatment which involves intravenous insulin infusion with pump, correction of electrolyte disturbances, use of methimazole, as well as propranolol. Meanwhile, the patient was positive for anti-glutamic acid decarboxylase (GAD) antibody, TSH receptor antibody, as well as thyroid stimulating antibody, indicating type 1 diabetes and Graves’ disease. She underwent extubation on day 5, however, she developed wheezing around day 30. Imaging analysis demonstrated remarkable tracheal stenosis that is possibly due to large goiter and airway injury by intubation. Emergent tracheostomy was performed on day 50, because the dyspnea became progressively worse. Later, she was successfully treated by tracheal stent placement. At the follow-up period, the patient was found to be doing well, with no severe hyperthyroidism or changes in bronchoscopic findings. Conclusion: Thyroid storm is a rare but serious complication of DKA. Our report highlights the importance of considering airway obstruction due to large goiter especially in patients with a past history of prolonged ventilation.

Tracheomalacia due to trachea compression related to benign goiter

Introduction: Tracheomalacia can result from long-standing compression by a large goiter. The cartilaginous rings of the trachea may be weakened or destroyed by long-standing compression, causing loss of structural support. Tracheomalacia after resectioning of benign goiter compressing trachea was an important issue. It has extended the time of mechanical ventilation, increased the risk of failure extubating and mortality. Materials and Methods: Descriptive and prospective study. From November 2014 to January 2017, we have collected 102 patients who had benign goiter compressing trachea and had thyroidectomy. Tracheomalacia was diagnosed and managed intra and postoperatively. Results: Recognition of women accounted for the majority of 81.4%. The average age was 54.5 years old and the average duration of goiter was 5 years. The patients were hospitalized with the main symptom of dysphagia accounting for 21.6% and difficulty breathing when lying down was 16.7%. On CT scan, the average Goiter was 270g, the average narrow airway diameter was 8.4 mm, of which 12.7% of patients had narrow tracheal diameter <5mm. The rate of tracheomalacia was 4.9%. There were statistically significant differences between the 2 groups with and without tracheomalacia: elderly patients (p = 0.041); goiter long-standing time (p = 0.07); symptoms of positional dyspnea on lying (p = 0.003) and tracheal diameter compressed (p = 0.001). Conclusion: Tracheomalacia should be noted in patients older than 65 years old, goiter exist longer than 5 years and goiter is over 200g.

Goiter in a Patient with Pulmonary Arterial Hypertension Treated with Epoprostenol

A 35-year-old female with pulmonary arterial hypertension (PAH) who presented with complaints of progressively worsening dysphagia, facial swelling, and shortness of breath, was found to have a large goiter. In patients treated with epoprostenol for long periods of time, thyroid disease is common. Most cases of thyroid disease describe thyrotoxicosis and hyperthyroid statues, but our case was a patient on long term IV epoprostenol presenting with a superior vena cava-syndrome (SVC) like appearance and airway compromise found to have a goiter incidentally during workup.