Surgical Considerations for Graves' Disease and Thyroid Nodules

1. Graves’ and Thyroid Disease: The Journey CHASE LAY MD ENT – OCULOPLASTICS – SKULL BASE Cupertino, CA

2. Grave’s Disease Surgical Considerations

3. Thyroid hormone is critical for regulating mood, weight, and mental and physical energy levels. • If the body makes too much thyroid hormone, the condition is called hyperthyroidism. (An underactive thyroid leads to hypothyroidism.) • Graves disease is the most common cause of hyperthyroidism. • Caused by an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormones. • Body actually produces antibodies that activate thyroid hormone production The Thyroid & Grave’s

4. Grave’s Eye Disease - Inflammation

5. Signs & Symptoms • Anxiety • Breast enlargement in men (possible) • Double vision • Eyeballs that stick out (exophthalmos) • Eye irritation and tearing • Frequent bowel movements • Heat intolerance • Increased appetite • Menstrual irregularities in women • Muscle weakness • Nervousness • Rapid or irregular heartbeat (palpitations or arrhythmia) • Restlessness and difficulty sleeping • Tremor • Weight loss (rarely, weight gain)

6. Testing for Graves • Simple blood test • TSH, T3, T4 • TSH receptor antibody; Thyroid stimulating immunoglobulin or “TSI” • Ultrasound of the neck if thyroid is enlarged or mass felt

7. Surgical Grave’s Disease • Hyperthyroidism or progressing eye disease in patients who can’t be treated with radioactive iodine therapy • Rapidly worsening Thyroid Eye Disease • Enlarged thyroid or Goiter causing difficulty breathing or swallowing • Women interested in becoming pregnant • Nodule in a patient with Grave’s or a family history of thyroid cancer • Suspicious thyroid nodules • Change of malignancy in thyroid nodules is double in context of Graves

8. Thyroid nodules are common • Can be found in 5% of the general population • Mostly benign • Can be observed if there are no risk factors www.mythyroid.com

9. Detecting Thyroid Nodules • Physical Exam • Ultrasound

10. What is a suspicious thyroid nodule? • A large nodule, >1cm • Any nodule over 0.5cm in size in a Grave’s patient • A thyroid nodule in a patient with • A family history of thyroid cancer • A history of radiation exposure • Age younger than 20 • Age older than 50

11. Surgery & Risks • General anesthesia • Small incision in the lower neck • Hoarse voice • Vocal cord weakness • Visible incision • Bleeding • Low Calcium (Total thyroidectomy)

12. After Surgery • Small incision – Quick healing • Typically stay in the hospital overnight • Back to work in a 2 to 6 days. • Complications with nerve weakness, post-operative bleeding, or calcium regulation may delay return to work.

13. Surgical Treatment of Eye Disease

14. Marty Feldman

15. Grave’s Eye Disease - Inflammation

16. Combination of compression of the optic nerve and inflammation of the nerve

18. Performed both endoscopically and externally • Surgical treatment to save or restore vision • Should be thought of as a medical necessity • Additional corrective surgeries are often required • Typically outpatient procedures Orbital Decompression &Fat Removal

21. Endoscopic Decompression Extended or Advanced Sinus Surgery

25. External Decompression

29. CSF leak during endoscopic surgery • Diplopia or Double Vision (often pre-existing) • Bleeding • Infection • Eyelid retraction or drooping Risks of Decompression Surgeries

30. Droopy eyelid repaired

32. Thank you for your time