First examination - before surgery (first row of images)

Clinical data: A 38-year-old woman was referred for evaluation of hyperthyroidism. She had typical complaints including severe thyroid associated orbitopathy (TAO) including diplopia.

Palpation: no abnormality.

Result of blood tests: hyperthyroidism (TSH undetectable, FT4 67.4 pM/L).

Ultrasonography. Both lobes were moderately enlarged and hypoechogenic. The vascularization was significantly increased.

Thyrostatic therapy was administered. We explained the patient that considering the severe eye complaints, the only definitive resolution would be total thyroidectomy with the consequence of hypothyroidism and life-long replacement therapy with a nature-identical substance. We told her that hormonally substituted hypothyroidism will not decrease her quality of life. Thereafter, if her eye signs will not improve within a half year, eye surgery would be required. 2 months later she underwent surgery but not by the surgeon who we suggested to her.

Histopathology disclosed benign diffuse goiter.

Second examination - one year after surgery (second row of images)

Clinical data: We did not meet the patient in the previous 6 years. Then she visited us and told what happened. She was afraid of life-long replacement therapy and looked for another surgeon. She has found one who promised her not to perform total thyroidectomy. A bilateral subtotal thyroidectomy was performed, and permanent palsy of the left recurrent nerve has developed. The patient remained euthyroid for the next 5 years without any thyroid medication. She got irradiation and steroid therapy for her TAO with only temporary improvement. One year after thyroid operation she underwent on eye surgery with very good cosmetic and functional results including cessation of diplopia. 2 months before present visit a recurrent hyperthyroidism has developed and unfortunately her diplopia also come forward. Daily 20 mg methimazole was administered.

Palpation: no abnormality.

Result of blood tests: subclinical hyperthyroidism on daily 20 mg methimazole (TSH 0.05 mIU/L, FT4 20.9 pM/L).

Ultrasonography. The thyroid was moderately hypoechogenic and contained discrete areas which did not correspond to nodule in a pathological sense. The vascularization was a bit increased.

Considering the palsy of the left recurrent nerve radioiodine therapy was performed. Her eye complaints got worse 3 weeks later and large dose of steroid and external irradiation were given. The inflammatory signs decreased but the diplopia remained. The ophthalmologist excluded a repeat eye surgery.

Comments.

1. The surgery of Graves' disease requires special interest because it is technically more difficult than the surgery of benign or most malignant thyroid diseases. Moreover, the only treatment of choice can be near total or total thyroidectomy because of the regenerative capacity of the thyroid.

2. In the case of recurrent hyperthyroidism, the treatment of choice would be radioiodine therapy. Although, there is no consensus in the literature, the exceptions include severe TAO because the eye signs may worsen more often after isotope therapy than after surgery. On the other hand, we had to consider the palsy of the recurrent nerve caused by the previous surgical procedure and therefore we had to advise radioiodine therapy.

3. The discrete lesions found on second examination are consequences of previous surgery and must not held true nodules.

4. The dorsal surface of the thyroid became lobulated/spiculated. However, pathological lobulation should be referred not to a lobe but to a nodule.