**6.8 Surgical management**

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

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

## **6.9 Newer agents**

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