Preparation of hyperthyroid patients for surgery can be satisfactorily achieved by making them euthyroid with one of the above drugs plus a P-adrenoceptor blocker for comfort (see below) and safety,3 and adding iodide for 7-10 days before operation (not sooner) to reduce the surgically inconvenient vascularity of the gland.
In an emergency, the patient is prepared with a (^-adrenoceptor blocker (e.g. propranolol 6-hourly, with dose titration to eliminate tachycardia) for 4 days. This is continued through the operation and for 7-10 days after. Iodide should also be given, as above (see p. 703). The important differences with this second technique are that the gland is smaller and less friable, although the patient's tissues are still
There are three possible lines of treatment, each with its special advantages and disadvantages:
• Antithyroid drugs
• Surgery, after preparation as below.
Antithyroid drugs are generally preferred provided the goitre is small and diffuse. A nodular goitre is generally large enough to be a source of complaint, relapses when drug the rap/ is withdrawn (nodules arc autonomous)! and is best treated surgically. These drugs do not decrease thyroid size: it may even increase (see above).They may be used in pregnancy.
Radioiodine is now commonly used for adult patients of all ages: but not In pregnancy. It affects both diffuse and nodular goitre.The goitre becomes smaller. Monitoring indefinitely for subsequent hypothyroidism is essential. Hyperthyroidism due to a single hyperfunctioning adenoma ('hot nodule') is also suitable for this treatment, and higher doses may be used since the function of the rest of the gland is already suppressed by the familiar negative feedback regulatory process.
Surgery is generally a second choice for thyrotoxicosis. It may be indicated if obstruction of neck veins or trachea exists or is thought to be likely in the future, if the thyroid contains a nodule of uncertain nature, or in young patients with relapsing thyrotoxicosis, with preference for surgery.
hyperthyroid, and it is essential, in order to avoid a hyperthyroid crisis or storm, that the adrenoceptor blocker be continued as above without the omission of even a single 6-hourly dose of propranolol.
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