**18. Radioiodine and thyroid nodules**

Radioiodine treatment is indicated for ablation of autonomous tissue and reduction of thyroid volume. There is disagreement whether nodules have a greater chance of malignancy in GD cases. It is then suggested that non-functioning nodules >1 to 1.5 cm undergo a fine needle suction puncture (PAAF) prior to administration of I [14].

## **19. Monitoring after radioactive iodine**

Thyroid function should be monitored 1–2 months after radioactive iodine therapy. Some suggest that it be checked after 15 days and then monthly or every 2 months; Such guidance is aimed at the early detection of hypothyroidism, especially in patients at risk of developing or worsening orbitopathy. If the patient is still thyrotoxic within two months of therapy, thyroid function should be monitored every 4–6 weeks until the patient is euthyroid or hypothyroid, remember that it may take up to 6 months or more for TSH to normalise. Substitution of levothyroxine should be initiated as soon as hypothyroidism occurs before laboratory tests proving the condition, immediately introducing L-thyroxine replacement. Patients with relapse or persistent hyperthyroidism after 6 months may re-receive radioactive iodine or those with minimal response to treatment ≤3 months [14, 50, 56].

#### **20. Thyroidectomy**

Thyroidectomy is the oldermost treatment for GD. The main objective is the rapid and definitive control of effects of excess thyroid hormones. That is achieved by removing all or almost all of the functioning tissue of the thyroid gland. Indications for surgery in the treatment of GD do not are well established in the literature, being classified by some authors in absolute and relative indications. The indications considered absolute are large goiter with compressive symptoms, suspicious nodule or malignant, pregnant woman who does not get control with DAT, refusal of treatment with 131I, woman planning pregnancy within six to 12 months

#### *Graves' Disease: Hyperthyroidism, Symptoms, Causes and Treatment DOI: http://dx.doi.org/10.5772/intechopen.97578*

and intolerance to DAT. At relative indications are large goiter, ophthalmopathy severe, poor adherence and lack of response to treatment with DAT [56, 62, 67].

The standard procedure is total thyroidectomy (TT), which provides a cure rate of around 100% for hyperthyroidism of the DG [14, 65]. The risk of recurrence is almost 0% after TT, while subtotal thyroidectomy (TST) implies a probability of 5 to 20% (8%, on average) of persistence or recurrence of hyperthyroidism in 5 years [65]. Furthermore, with the exception of hypothyroidism early, as rates of complications with TT and TST may be comparable when the patient is operated on by a surgeon experienced (more than 100 thyroidectomies/year): transient hypocalcemia, 9.6 vs. 7.4%; definitive hypoparathyroidism, 1.6 vs. 1.0%; recurrent laryngeal injury, 0.9 vs. 0.7%, respectively [65]. In a recent meta-analysis and systematic review, the risk for hypoparathyroidism (transient or permanent) survived the older ones with TT. In a few centers, there is underwent an endoscopic thyroidectomy [38].

### **21. Preoperative management and follow-up of patients who receive thyroidectomy**

Before surgery, patients should be euthyroid. Pretreatment with ATD reduces the risk of thyroid storm precipitated by surgery, and β blockers control hyperthyroid symptoms. Pretreatment with inorganic iodide, such as potassium iodide (50 mg iodide, three times daily, for 7–10 days before surgery) can also be considered in patients with Graves' Disease [67]. Inorganic iodide reduces thyroid hormone release and thyroid vascularity [68], which in turn decreases intraoperative blood loss. After surgery, levothyroxine replacement should be started and TSH concentration monitored 6–8 weeks after surgery. Oral calcium and calcitriol supplementation can be used before surgery and according to postoperative serum calcium concentrations [69].
