INTRODUCTION

Hyperthyroidism, a term for overactive tissue within the thyroid gland, resulting in
overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4),
triiodothyronine (T3) or both. Thyroid hormone is important at a cellular level,
affecting nearly every type of tissue in the body. It functions as a stimulus tometabolism,
and is critical to normal function of the cell.

Hyperthyroidism, considered as the second most common endocrine disorder.

It results from an excessive output of thyroid hormones due to abnormal
stimulation of the thyroid gland by circulating immunoglobulin. This disorder affects
women eight times more frequently than men and peaks between the second and fourth
decades of life. It generally occurs between 20 and 40 years old and is more common in
females.

PREDISPOSING FACTORS

Hyperthyroidism occurs when the thyroid releases too much of its hormones over a
short (acute) or long (chronic) period of time. Many diseases and conditions can cause
this problem, including:

• Getting too much iodine

• Graves disease (accounts for most cases of hyperthyroidism)
• Inflammation (thyroiditis) of the thyroid due to viral infections or other causes
• Noncancerous growths of the thyroid gland or pituitary gland
• Taking large amounts of thyroid hormone
• Tumors of the testes or ovaries

CLINICAL MANIFESTATIONS

Symptoms

• Difficulty concentrating
• Fatigue
• Frequent bowel movements
• Goiter (visibly enlarged thyroid gland) or thyroid nodules
• Heat intolerance
• Increased appetite
• Increased sweating
• Irregular menstrual periods in women
• Nervousness
• Restlessness
• Weight loss (rarely, weight gain)

Other symptoms that can occur with this disease:

 • Breast development in men
• Clammy skin
• Diarrhea
• Hair loss
• Hand tremor
• Weakness
• High blood pressure
• Itching - overall
• Lack of menstrual periods in women
• Nausea and vomiting
• Pounding, rapid, or irregular pulse
• Protruding eyes (exophthalmos)
• Rapid, forceful, or irregular heartbeat (palpitations)
• Skin blushing or flushing
• Sleeping difficulty

ANATOMY AND PHYSIOLOGY

Thyroid Gland

The thyroid is one of the largest endocrine glands in the body. This gland is
found in the neck inferior to (below) the thyroid cartilage (also known as the Adam's
apple in men) and at approximately the same level as the cricoid cartilage. The thyroid
controls how quickly the body burns energy, makes proteins, and how
sensitive the body should be to other hormones. The thyroid participates in
these processes by producing thyroid hormones, principally thyroxine (T4) and
triiodothyronine (T3). These hormones regulate the rate of metabolism and affect
the growth and rate of function of many other systems in the body. Iodine is
an essential component of both T3 and T4. The thyroid also produces the
hormone calcitonin, which plays a role in calcium homeostasis.

The thyroid is controlled by the hypothalamus and pituitary. The gland gets its
name from the Greek word for "shield", after the shape of the related thyroid
cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism
(underactive thyroid) are the most common problems of the thyroid gland.
Anatomy

The thyroid gland is butterfly-shaped organ and is composed of two cone-

like lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe),
connected with the isthmus. The organ is situated on the anterior side of the
neck, lying against and around the larynx and trachea, reaching posteriorly
the oesophagus and carotid sheath. It starts cranially at the oblique line on the thyroid
cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly
to the fourth to sixth tracheal ring. It is difficult to demarcate the gland's upper and
lower border with vertebral levels as it moves position in relation to
these during swallowing.

The thyroid gland is covered by a fibrous sheath, the capsula glandulae thyroidea,
composed of an internal and external layer. The external layer is anteriorly continuous
with the lamina pretrachealis fasciae cervicalis and posteriorolaterally continuous with
the carotid sheath. The gland is covered anteriorly with infrahyoid muscles and laterally
with the sternocleidomastoid muscle. Posteriorly, the gland is fixed to the cricoid and
tracheal cartilage and cricopharyngeus muscle by a thickening of the fascia to form
the posterior suspensory ligament of Berry. In variable
extent, Zuckerkandl's tubercle, a pyramidal extension of the thyroid lobe, is present
at the most posterior side of the lobe. In this region the recurrent laryngeal nerve and
the inferior thyroid artery pass next to or in the ligament and tubercle.
Between the two layers of the capsule and on the posterior side of the lobes there are
on each side two
parathyroid glands.
The thyroid isthmus is variable in presence and size, and can encompass a cranially
extending pyramid lobe (lobus pyramidalis or processus pyramidalis),
remnant of the thyroglossal duct. The thyroid is one of the larger
endocrine glands, weighing 2-3 grams in neonates and 18-60 grams in adults, and is
increased in pregnancy

The thyroid is supplied with arterial blood from the superior thyroid artery, a
branch of the external carotidartery, and the inferior thyroid artery, a
branch of the thyrocervical trunk, and sometimes by the thyroid
ima artery,branching directly from the aortic arch. The venous blood is drained via
superior thyroid veins, draining in the internal jugular vein, and via inferior thyroid veins,
draining via the plexus thyroideus impar in the left brachiocephalic vein. Lymphatic
drainage passes frequently the lateral deep cervical lymph nodes and the pre- and
parathracheal lymphnodes. The gland is supplied by sympathetic
nerve input from the superior cervical ganglion and
the cervicothoracicganglion of the sympathetic trunk, and by parasympathetic
nerve input from the superior laryngeal nerve and there current laryngeal nerve.

Physiology

The primary function of the thyroid is production of the hormones thyroxine (T4),
triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to
T3 by peripheral organs such as the liver, kidney and spleen. T3 is
about ten times more active than T4. T3 and T4 production and action

Thyroxine (T4) is synthesised by the follicular cells from free tyrosine and
on the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with
the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid
peroxidase (TPO) and linked to the 3' and 5' sites of the benzene
ring of the tyrosine residues on TG, and on free tyrosine.
Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells reabsorb
TG and proteolytically cleave the iodinated tyrosines from TG, forming T4 and T3 (in T3,
one iodine is absent compared to T4), and releasing them into
the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted from
the gland is about 90% T4 and about 10% T3.

Cells of the brain are a major target for the thyroid hormones T3 and T4. Thyroid
hormones play a particularly crucial role in brain maturation during fetal development. A
transport protein (OATP1C1) has been identified that seems to be important
for T4 transport across the blood brain barrier. A second transport protein (MCT8) is
important for T3 transport across brain cell membranes.

In the blood, T4 and T3 are partially bound to thyroxine-

binding globulin, transthyretin and albumin. Only avery small
fraction of the circulating hormone is free (unbound) - T4 0.03% and T3 0.3%. Only
the free fraction hashormonal activity. As with the steroid hormones and retinoic
acid, thyroid hormones cross the cell membrane andbind to intracellular receptors (α1,
α2, β1 and β2), which act alone, in pairs or together with the retinoid X-
receptor astranscription factors to modulate DNA transcription.

T3 and T4 regulation

The production of thyroxine and triiodothyronine is regulated by thyroid-

stimulating hormone (TSH),
released by the anterior pituitary (that is in turn released as a result of TRH
release by the hypothalamus). The
thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed
when the T4 levels are high,
and vice versa. The TSH production itself is modulated by thyrotropin-
releasing hormone (TRH), which is produced by
the hypothalamus and secreted at an increased rate in situations such as cold (in
which an accelerated metabolism would generate more heat). TSH production is
blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones
(estrogen and testosterone), and excessively high blood iodide concentration.

Calcitonin

An additional hormone produced by the thyroid contributes to the regulation of blood

calcium levels. Parafollicular cells produce calcitonin in response to
hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to
the effects of parathyroid hormone (PTH). However, calcitonin seems far less
essential than PTH, as calcium metabolism remains clinically normal
after removal of the thyroid, but not the parathyroids.
LABORATORY AND DIAGNOSTIC EXAMS

Physical examination may reveal thyroid enlargement, tremor, hyperactive reflexes, or

an increased heart rate. Systolic blood pressure (the first number in a blood pressure
reading) may be high.

Subclinical hyperthyroidism is a mild form of hyperthyroidism that is diagnosed by

abnormal blood levels of thyroid hormones, often in the absence of any symptoms.

Blood tests are also done to measure levels of thyroid hormones.

• TSH (thyroid stimulating hormone) level is usually low

• T3 and free T4 levels are usually high

This disease may also affect the results of the following tests:

• Cholesterol test
• Glucose test
• Radioactive iodine uptake
• T3RU
• Triglycerides
• Vitamin B12 (in rare cases)

TREATMENT AND MEDICATIONS

How the condition is treated depends on the cause and the severity of symptoms.
Hyperthyroidism is usually treated with one or more of the following:

• Antithyroid medications includes methimazole (Tapazole) or propylthiouracil

(PTU) pills These drugs block the amount of thyroid hormone in the blood and
make it more difficult for iodine to get into the thyroid gland.
• Radioactive iodine (which destroys the thyroid and stops the excess production
of hormones)
• Surgery to remove the thyroid

If the thyroid must be removed with surgery or destroyed with radiation, you must take
thyroid hormone replacement pills for the rest of your life.

Beta-blockers such as propranolol are used to treat some of the symptoms, including
rapid heart rate, sweating, and anxiety until the hyperthyroidism can be controlled.
SURGICAL MANAGEMENT

Thyroidectomy

Thyroidectomy is a surgical procedure in which all or part of the thyroid gland is

removed. The thyroid gland is located in the forward (anterior) part of the neck just
under the skin and in front of the Adam's apple. The thyroid is one of the body's
endocrine glands, which means that it secretes its products inside the body, into the
blood or lymph. The thyroid produces several hormones that have two primary
functions: they increase the synthesis of proteins in most of the body's tissues, and they
raise the level of the body's oxygen consumption.

Purpose

All or part of the thyroid gland may be removed to correct a variety of

abnormalities. If a person has a goiter, which is an enlargement of the thyroid gland that
causes swelling in the front of the neck, the swollen gland may cause difficulties with
swallowing or breathing. Hyperthyroidism (over activity of the thyroid gland) produces
hypermetabolism, a condition in which the body uses abnormal amounts of oxygen,
nutrients, and other materials. A thyroidectomy may be performed if the
hypermetabolism cannot be adequately controlled by medication, or if the condition
occurs in a child or pregnant woman. Both cancerous and noncancerous tumors
(frequently called nodules) may develop in the thyroid gland. These
growths must be removed, in addition to some or the entire gland itself.
Demographics

Screening tests indicate that about 6% of the United States population has some
disturbance of thyroid function, but many people with mildly abnormal levels of thyroid
hormone do not have any disease symptoms. It is estimated that between 12 and 15
million people in the United States and Canada are receiving treatment for thyroid
disorders as of 2002. In 2001, there were approximately 34,500 thyroidectomies
performed in the United States. Females are somewhat more likely than males to
require a thyroidectomy.

Description

A thyroidectomy begins with general anesthesia administered by an

anesthesiologist. The anesthesiologist injects drugs into the patient's veins and then
places an airway tube in the windpipe to ventilate (provide air for) the person during the
operation. After the patient has been anesthetized, the surgeon makes an incision in the
front of the neck at the level where a tight-fitting necklace would rest. The surgeon
locates and takes care not to injure the parathyroid glands and the recurrent laryngeal
nerves, while freeing the thyroid gland from these surrounding structures. The next step
is clamping off the blood supply to the portion of the thyroid gland that is to be removed.
Next, the surgeon removes all or part of the gland. If cancer has been diagnosed, all or
most of the gland is removed. If other diseases or nodules are present, the surgeon
may remove only part of the gland. The total amount of glandular tissue removed
depends on the condition being treated. The surgeon may place a drain, which is a soft
plastic tube that allows tissue fluids to flow out of an area, before closing the incision.
The incision is closed with either sutures (stitches) or metal clips. A dressing is placed
over the incision and the drain, if one has been placed. People generally stay in the
hospital one to four days after a thyroidectomy.

Diagnosis/Preparation

Thyroid disorders do not always develop rapidly; in some cases, the patient's
symptoms may be subtle or difficult to distinguish from the symptoms of other disorders.
Patients suffering from hypothyroidism are sometimes misdiagnosed as having a
psychiatric depression. Before a thyroidectomy is performed, a variety of tests and
studies are usually required to determine the nature of the thyroid disease. Laboratory
analysis of blood determines the levels of active thyroid hormones circulating in the
body. The most common test is a blood test that measures the level of thyroid-
stimulating hormone (TSH) in the bloodstream. Sonograms and computed
tomography scans (CT scans) help to determine the size of the thyroid gland and
location of abnormalities. A nuclear medicine scan may be used to assess thyroid
function or to evaluate the condition of a thyroid nodule, but it is not considered a
routine test. A needle biopsy of an abnormality or aspiration (removal by suction) of fluid
from the thyroid gland may also be performed to help determine the diagnosis.
 If the diagnosis is hyperthyroidism, a person may be asked to take anti thyroid
medication or iodides before the operation. Continued treatment with anti thyroid drugs
may be the treatment of choice. Otherwise, no other special procedure must be followed
prior to the operation.

Aftercare

A thyroidectomy incision requires little to no care after the dressing is removed.

The area may be bathed gently with a mild soap. The sutures or the metal clips are
removed three to seven days after the operation.

Risks

There are definite risks associated with the procedure. The thyroid gland should be
removed only if there is a pressing reason or medical condition that requires it. As with
all operations, people who are obese, smoke, or have poor nutrition are at greater risk
for developing complications related to the general anesthetic itself.

Hoarseness or voice loss may develop if the recurrent laryngeal nerve is injured
or destroyed during the operation. Nerve damage is more apt to occur in people who
have large goiters or cancerous tumors.

Hypoparathyroidism (underfunctioning of the parathyroid glands) can occur if the

parathyroid glands are injured or removed at the time of the thyroidectomy.
Hypoparathyroidism is characterized by a drop in blood calcium levels resulting in
muscle cramps and twitching.

Hypothyroidism (underfunctioning of the thyroid gland) can occur if all or nearly

all of the thyroid gland is removed. Complete removal, however, may be intentional
when the patient is diagnosed with cancer. If a person's thyroid levels remain low,
thyroid replacement medications may be required for the rest of his or her life.

A hematoma is a collection of blood in an organ or tissue, caused by a break in

the wall of a blood vessel. The neck and the area surrounding the thyroid gland have a
rich supply of blood vessels. Bleeding in the area of the operation may occur and be
difficult to control or stop. If a hematoma occurs in this part of the body, it may be life-
threatening. As the hematoma enlarges, it may obstruct the airway and cause a person
to stop breathing. If a hematoma does develop in the neck, the surgeon may need to
perform drainage to clear the airway. Wound infections can occur. If they do, the
incision is drained, and there are usually no serious consequences.

PROCEDURE:

-A thyroid surgery begins with the administration of general anesthesia. Once the
anesthesia takes effect, the procedure begins with an incision 2 inches to 4 inches
long that stretches horizontally over the thyroid. Based on the tests performed
before the procedure and the appearance of the thyroid, the final determination of
how much of the thyroid should be removed is made.

-At this point, the portion or portions of the thyroid are removed using a scalpel.Special
care is taken not to harm or disturb the parathyroid glands and the vocalcords, both of
which rest in the neck near the thyroid.

-A biopsy may also be done to examine the tissues of the thyroid, the parathyroid
and, in rare cases, nearby lymph nodes. This is done to make sure that the portion
of the thyroid that is left, if any, is not diseased. In some cases, the tissue is
examined by a pathologist immediately, so that a second surgery to remove a
diseased portion of the thyroid is not necessary.

-Once the thyroid has been removed and any necessary samples have been taken,
the area is examined for bleeding. Once the surgeon is confident that there is no
bleeding present, the incision is closed. It may be closed with staples or sutures,
and in some cases, a surgical drain may be placed to remove fluid from the area in
the days after surgery. Once a sterile bandage is applied to the incision, the surgery is
completed. Anesthesia is discontinued and medication is given to wake the patient. The
patient is then taken to the recovery room to be closely monitored while the remaining
anaesthetic wears off.

NURSING MANAGEMENT

•Obtain a complete history and asking questions concerning weight, appetite, activity,
heat tolerance, and bowel activity

•Provide the client with a well-balanced diet high in calories, protein, carbohydrates, and
minerals.
•Discourage the ingestion of foods that increase peristalsis and thus result in diarrhea,
suchas highly seasoned, bulky and fibrous foods.

For exophthalmos:
•Instruct the client to wear dark eye glasses.
•Warn the client to avoid getting dust or dirt in the eyes.
•If the eyelids cannot be closed easily or at all, have the client wear a sleeping mask or
lightly tape the eyes shut with non-allergic tape.
•Elevate the head of the bed at night, and have the client restrict salt intake to relieve
edema.

MEDICAL MANAGEMENT
•Curtail the excessive secretion of TH and prevent and treat complications.
•Choice of intervention is based on age, goiter size, and whether the client has other
health problems.
•The three major forms of therapy are antithyroid medication, radio-iodine therapy, and
surgery.
•Iodide, propylthiouracil, and methimazole- major medications used to control
hyperthyroidism.
•Adrenergic blocking agents may be administered as adjunctive therapy.
For exophthalmos:
•Diuretics- may alleviate some periorbital edema.
•Methyl-cellulose eye drops help reduce eye irritation

PROGNOSIS

Hyperthyroidism is generally treatable and only rarely is life threatening. Some of its
causes may go away without treatment.

Hyperthyroidism caused by Graves disease usually gets worse over time. It has many
complications, some of which are severe and affect quality of life.

POSSIBLE COMPLICATIONS

Thyroid crisis (storm), also called thyrotoxicosis, is a sudden worsening of

hyperthyroidism symptoms that may occur with infection or stress. Fever, decreased
mental alertness, and abdominal pain may occur. Immediate hospitalization is needed.

Other complications related to hyperthyroidism include:

• Heart-related complications including:

o Rapid heart rate
o Congestive heart failure
o Atrial fibrillation
• Increased risk for osteoporosis, if hyperthyroidism is present for a long time
• Surgery-related complications, including:
o Scarring of the neck
o Hoarseness due to nerve damage to the voice box
o Low calcium level due to damage to the parathyroid glands (located near
the thyroid gland)
• Treatments for hypothyroidism, such as radioactive iodine, surgery, and
medications to replace thyroid hormones can have complications.