The indications for subtotal thyroidectomy are decreasing because of the lower incidence of endemic goiters, both colloid and nodular, and the increasing effectiveness of medical therapy in patients who present with thyrotoxicosis, whether this is due to Graves’ disease or to nodular toxic goiter.
A definite indication for subtotal thyroidectomy is the removal of a solitary nodule in a young person, especially female, when the mass does not take up radioiodide on thyroid scan and hence is suspected of being malignant. A simple fine needle aspiration may yield a suspicious cytology. Total lobectomy ensures a better margin and allows pathologic examination of the excised thyroid lobe for multicentric foci should a malignant tumor be found. Many surgeons combine a total lobectomy on the involved side with a subtotal lobectomy on the alternate side.
The controversy as to whether surgical or medical treatment for thyrotoxicosis is desirable in patients younger than 35 to 40 years and in pregnant patients has yet to be resolved, but it is generally agreed that the use of radioactive iodine is contraindicated. Surgical removal should be considered if antithyroid drugs are tolerated poorly or required in large, prolonged doses and if thyrotoxicosis recurs after an apparently successful medication regimen. In the poor-risk patient or one who has had a recurrence of toxicity following previous thyroid surgery, medical therapy is usually the treatment of choice. Also, some pregnant patients may be best treated with antithyroid drugs in order to defer surgery until after the patient has delivered. However, thyroid replacement is given daily once the patient is euthyroid to prevent the development of a goiter in the fetus.
Subtotal thyroidectomy or total thyroidectomy is performed for an enlarged thyroid gland that produced pressure symptoms or an undesirable cosmetic effect (endemic goiter), for toxic goiters, and occasionally for inflammatory conditions such as Riedel’s struma and Hashimoto’s disease.
The only indication for emergency thyroidectomy is in that exceedingly rare situation where pressure symptoms develop rapidly due to intrathyroid hemorrhage. In all other situations thyroidectomy should be considered an elective procedure performed when the patient is in optimal physical health. This is true particularly in thyrotoxicosis.
Patients with thyrotoxicosis should be treated with antithyroid drugs preferentially until they are euthyroid. Because the (thiourea) compounds block the synthesis of thyroxine but do not inhibit the release of the hormone from existing colloid stores, the time required for symptomatic improvement may vary widely from 2 weeks to as long as 3 months. The variability is in part related to the size of the gland, since large goiters usually contain more colloid. When the patient has become euthyroid, iodine—given as Lugol’s solution, potassium iodide solution, or tablets or syrup of hydriodic acid—can be administered for 10 days before surgery (optional). If this procedure is followed, almost any thyroidectomy can be performed under ...