**Conflict of interest**

*Goiter - Causes and Treatment*

**6.8 Surgical management**

Underlying thyroid carcinoma Suspicious/malignant nodules on FNAC

ablation therapy

*Indications of surgery.*

**Table 7.**

**6.9 Newer agents**

**7. Conclusion**

Block synthesis (anti thyroid drugs)

Block enterohepatic circulation (cholestyramine)

Block release (iodine)

Beta blocker

*Five B's of thyroid storm.*

Achieving a euthyroid state is first and foremost requisite prior to surgical management using the above-mentioned medical treatment strategies [27]. However, there is a subset of patients who fail medical management despite all of the most aggressive treatment modalities. This occurs more commonly in iodine-deficient areas, where thyroid storm is mostly related to iodine contamination in patients with thyroid autonomy. These patients are particularly resistant to even high-dose thionamides or iodine therapy because of the large intrathyroidal iodine pool [90].

**Absolute indication Relative indication** Failed medical therapy Symptomatic goiter

Not a candidate for radio ablation therapy Severe Grave's ophthalmopathy

Refractory thyroiditis Amiodarone

related Toxic adenoma

Severe reaction to antithyroid drugs Pregnancy

Persistent thyrotoxicosis despite maximum antithyroid drug/radio

All measures should be employed to stabilize the patient prior to considering emergent surgical management. Surgical team should be involved early (within 12–72 h) if the patient is not responding to medical therapy. The surgical options involve a subtotal or near-total thyroidectomy [73]. The surgery produces rapid resolution of the hyperthyroidism as very little thyroid tissue remains. This allows cessation of the thionamides soon after the surgery. Corticosteroid and β-blocker should be continued

Biological agent Rituximab (anti-CD20 monoclonal antibody which depletes B lymphocytes) and various other emerging therapies have shown promise in the treatment of Graves' ophthalmopathy, but the role of these agents in the manage-

Thyroid storm is an endocrine emergency that is associated with high morbidity and mortality if not promptly recognized and treated. Multidisciplinary treatment

The broad indications of surgery have been listed in **Table 7**.

perioperatively and slowly weaned off over the ensuing weeks [27].

ment of the thyrotoxic state is less clear [17, 91–93].

Block T4 to T3 conversion (high dose PTU, propranolol, corticosteroid)

**124**

**Table 8.**

The authors declare no conflict of interest.
