Levothyroxine medication is used to replace the thyroid hormones that the body is no longer able to produce in sufficient quantities.


Treatment results
Hypothyroidism is a chronic condition, so patients will require continuous medication for the duration of their lives. However, once thyroid hormone levels return to normal, the associated symptoms will go away.

Hypothyroidism

If left untreated or in severe cases, hypothyroidism can result in the patient going into what is known as a “myxedema coma”, which is characterized by the failure of various physical systems, including:

• The neurological system, which can lead to confusion, sluggishness, loss of consciousness, seizures, or a coma
• The respiratory system, which can slow breathing down, causing an oxygen deficiency, fluid buildup in the lungs, and respiratory failure
• The renal system, which can cause kidney failure
• The cardiovascular system, which can cause a drop in blood pressure, severely reduced pulse, irregularities in the heart’s electrical system, and a buildup of pericardial fluid
• Hypoglycemia
• The digestive system, which can cause severe constipation and impaired intestinal function

Death rates resulting from such an occurrence are between 30 – 50%, with elderly patients and those with underlying health conditions most at risk.

Warning signs of hyperthyroidism

• Protrusion of the eyeball
• Other eye problems, such as redness, dryness, or swelling eyelids
• Some cases may involve blurred vision
• An enlarged thyroid gland
• An irregular or unusually fast heart rate
• Smoothing of the skin
• An increased risk of osteoporosis

Symptoms

• A rapid heart rate that causes fatigue and shallow breathing
• Irritability, nervousness and anxiety
• Weight loss
• Muscle weakness and shaking hands
• Hair loss
• Frequent bowel movement
• Irregularities affecting the menstrual period
• Sensitivity to heat
• An increased risk of miscarriages
• Difficulty sleeping

• Blood tests to analyze TSH, free T3, and free T4 hormone levels
• Blood tests to ascertain thyroid antibody strength, assessed through analysis of Anti-TPO (anti-thyroid peroxidase), Anti-Tg (anti-thyroglobulin antibodies), and TSH receptor antibody (TRAb) levels, which are the antibodies responsible for impairing thyroid function
• For cases suspected of suffering thyroiditis, physician may order radioactive iodine uptake (RAIU) to distinguish thyroiditis from hyperthyroidism.
• Patients who have hyperthyroidism and palpable thyroid nodule(s), physician may order the following tests:
  • A thyroid scintigraphy (thyroid scan) to assess for possible hyper functioning thyroid nodule(s)
  • Thyroid ultrasound

There are 3 main treatment options that can be used to treat hyperthyroidism, as follows:

• Anti-thyroid medicines, which are methimazole and propylthiouracil (PTU)
• Radioactive iodine therapy  (I-131)
• Thyroidectomy or surgical removal of thyroid gland, which can be performed using either of the following techniques:
  • Open surgery
  • Endoscopic surgery
• Patients with severe thyroid eye disease (proptosis, strabismus, or blurred vision owing to hyperthyroidism) will require ophthalmology consultation. The ophthalmologist may perform one or all of the following surgeries:
  • Orbital decompression to prevent blindness resulting from elevated intraocular pressure
  • Eye muscle surgery to correct strabismus
  • Eyelid surgery used to treat external eye issues or eyelid disorders involving bulging to return the eyeball and eyelid to their former positions

Generally, medical staff will first try medication, but should the patient’s condition not show signs of improvement or the disease persists or reoccurs after antithyroid medicine discontinuation, radioactive iodine therapy or surgery may be required. Surgery, also, may be necessary in cases suspected of suffering with thyroid cancer or suspicious thyroid nodule alongside hyperthyroidism.


Treatment results

• The condition may improve significantly, but there is usually a need for continuous medication lasting approximately 1 ½ to 2 years. Around 30–40% of patients experience hyperthyroidism recurrence, especially those with severely elevated thyroid hormone at the diagnosis, large goiter or smoking
• If radioactive iodine therapy treatment is used, the thyroid gland size will decrease due to the treatment helping to destroy the overactive thyroid glands and restoring normal thyroid function. However, patients may experience permanently impaired thyroid function, which requires lifelong thyroid hormone replacement.
• Patients undergoing surgical forms of treatment will also likely need to take thyroxine medication for the rest of their lives.

Hyperthyroidism

Thyroid storm – which is severe life-threatening hyperthyroidism can cause any of the following symptoms: the failure of various organs systems, fever, an elevated heart rate, an irregular heart rate, heart failure, anxiety, confusion, coma, jaundice, or hepatomegaly. Death rates resulting from this condition reach approximately 20–30%.

Symptoms

People suffering with nodular thyroid diseases tend not to experience any symptoms, although some may experience the following:

• A noticeable enlargement of the thyroid gland
• A raspy voice and difficulties swallowing, which may happen if the nodule is cancerous and has involved the nearby nerve supplying the voice box or invaded the esophagus
• A tightness in the throat
• Symptoms synonymous with hypothyroidism or hyperthyroidism

• A thyroid ultrasound
• Thyroid scintigraphy (thyroid scan) for patients who with low TSH (Thyroid Stimulating Hormone) and thyroid nodule(s)
• Fine needle aspiration (FNA) in cases where an ultrasound shows a nodule that is suspicious for cancer. The procedure begins with a local anesthetic injections into the skin before an ultrasound is performed to help doctors accurately locate the nodule. This generally takes no longer than 30 minutes to complete and involves no scarring, with patients able to return home straight away. Pathologists are then responsible for interpreting the results for the patients after careful inspection of the cells, which takes approximately 2–3 days in most cases.
• A cervical lymph node mapping ultrasound is a highly detailed ultrasound to examine lymph nodes in the patient’s neck. It is usually ordered by the doctor when the nodule is highly suspicious and confirmed to be cancerous.
• CT scans or MRI scans may be necessary in patients with large nodules that doctor’s suspect could be pressure effect, compress or invade nearby organs (i.e. trachea or esophagus).

• A thyroidectomy (partial or total removal of thyroid gland) using either of the following techniques:
  • Open surgery
  • Endoscopic surgery using either a trans-axillary thyroidectomy or trans-oral endoscopic thyroidectomy procedure
• Typically surgery is recommended when the thyroid nodule is very suspicious or confirmed by FNA to be cancerous, or it causes compression symptoms to the patient (for example, difficulty breathing or swallowing). If the nodule is not cancerous but causes symptoms and patients wants to avoid surgery, the following options are available
  • Thyroid radiofrequency ablation (RFA) is a minimally invasive form of treatment that utilizes high frequency sound waves to reduce the nodule’s size. It involves inserting electrodes into the skin to the depth of the nodule before releasing sound waves through those electrodes, causing heat that helps to reduce the nodule’s size.
  • A high-intensity focused ultrasound (HIFU). This is a non-invasive procedure that utilizes sound waves at 0.8 3.5 MHz instead of using needles. The procedure involves placing a probe that emits the sound waves against the skin to cause vibrations and heat in the nodule tissue, which can be effective in reducing its size.
  • Ethanol ablation involves injecting ethyl alcohol into the nodule to reduce its size. This procedure is most suited to predominantly cystic thyroid nodule cases.

There are 3 main benefits to such forms of treatment, as follows:

• There is no need for general anesthesia as local anesthetic is sufficient.
• These are non-surgical techniques, so there is no scarring or need to stay overnight in hospital.
• These procedures eliminate the need for a thyroidectomy, which removes the risk of thyroid hormone deficiencies occurring following treatment.

Nodular thyroid diseases

Generally, thyroid cancer is found in about 5-10 % of thyroid nodules. If it is left untreated thyroid cancer could spread to nearby organs, such as the trachea, larynx, and esophagus. Cancer can cause any of the following issues: difficulties or pain when swallowing, increased choke risk, breathing difficulties, or a raspy voice. Nonetheless, the cancer could also spread to lymph nodes located in the neck, with some cases spread to blood stream to lung and bone.

• Thyroid ultrasoundThyroid ultrasound
  Objectives: To assess the size and tissue state of the thyroid, and to check for the presence of thyroid nodules and cysts, or a combination of the two. Additionally, this screening can analyze the calcification within the nodule, which helps to assess the risk of cancer as well as helping assess the lymph nodes in the neck region.
  Time required: The task takes 30 minutes and results are available after 1 ½ hours.
• Cervical lymph node mapping ultrasound Utilizes ultrasound waves to provide highly accurate and comprehensive screening for the lymph nodes located in the neck, which usually consist of 6 distinct zones on each side (totaling 12 zones on both sides). This form of imaging is therefore considered an effective and highly accurate method of comprehensively mapping the nodes at the neck, although doing so requires the expertise of a specialist in radiotherapy. Bumrungrad is the first hospital in Thailand to offer cervical lymph node mapping ultrasound screening.
  Objectives:The screening greatly aids medical staff in mapping out the lymph nodes and thyroid glands located in the neck. This procedure helps our medical team to have great success in thyroid cancer surgery, reducing the likelihood of the cancer making a return as well as the chances that a repeat surgery will be required.
  Time required: Screening takes 50 minutes and results are available within 2–3 hours.
• Radioactive Iodine Uptake (RAIU) It is usually ordered by an endocrinologist to differentiate truly overactive thyroid gland and inflammation of thyroid.
  Time required: Screening takes a total of 2 days because iodine uptake levels are recorded at 4 hours and then 24 hours following the iodine’s administration, this test is an outpatient procedure.
• Thyroid scintigraphy(Thyroid scan) The thyroid is scanned using a substance called technetium (Tc – 99 m), which is used to evaluate the thyroid nodules in the setting of hyperthyroidism. The thyroid scan imaging helps to identify the toxic or hyper functioning nodule.

• Blood tests performed in internationally accredited laboratories enable the utmost accuracy and involve the following forms of screening:
  • Thyroid hormones: TSH, free T4, free T3, total T4, and total T3
  • Thyroid antibodies: Anti-TPO (Anti-Thyroid peroxidase), Anti-Tg (Anti-thyroglobulin) and Anti-TSH receptor (TRAb)
• The following forms of ultrasound:
  • Thyroid ultrasound
  • Cervical lymph node mapping ultrasound
• The following nuclear medicine techniques:
  • Radioactive Iodine Uptake (RAIU)
  • Thyroid scintigraphy (Thyroid scan)
• Fine needle aspiration (FNA), which requires advance booking but can be performed on the same day or the day after the booking is made
• Cytopathological screening performed by a highly experienced pathologist specializing in the field, who will be able to diagnose thyroid nodule cells with the utmost accuracy

Effective treatment for patients with thyroid diseases requires the seamless cooperation between expert professionals, each specializing in their own field of medicine. Fortunately, Bumrungrad Hospital has established such a team, which consists of the following specialists:

• Endocrinologists
• Otolaryngologist (Ear, Nose, and Throat specialists)
• Endocrine & Head-Neck surgeons
• Radiologists
• Pathologists
• Nuclear medicine specialists
• Oncologists
• Ophthalmologists
• Radiographers
• Dietitians

The roles performed by each specialist are as follows:

• Endocrinologists are the main doctors responsible for treating patients and organizing the whole multidisciplinary team. They review the patient’s medical history, perform physical assessments, plan diagnosis and treatment, and monitor patients in the long-term.
• Otolaryngology (Ear, Nose, and Throat) specialists or endocrine & head-neck surgeons perform surgeries in their specific field. Fortunately, the team of surgeons at Bumrungrad are highly experienced in minimizing the risks of post-surgery complications, while they are also highly experienced in removing nodules for cases involving cancer that has spread to lymph nodes. Indeed, their experience combined with the latest technologies at their disposal have led to high success rates. All of this reduces the likelihood of injuries or post-operative complication decreasing hospital stays to just 1–2 nights, and significantly reducing costs involved with surgery.
• Diagnostic Radiologists with high levels of expertise in thyroid ultrasound cervical lymph node mapping ultrasound, CT scan and MRI
• Interventional radiologist who performs thyroid FNA and also non-surgical treatments of thyroid nodule, such as HIFU, RFA, and ethanol ablation
• Pathologists report on the results of thyroid FNA cytology using the Bethesda system (an internationally recognized system used to report on results of a fine needle aspiration biopsy). The results are classified into 6 categories depending on the level of cancer risk. This then enables the effective planning of treatment, including whether and when there is a need for surgery or an additional FNA procedure. Additionally, in cases where a thyroidectomy has been performed, pathologists are responsible for analyzing the removed thyroid to check if the nodules are benign or malignant and, in the latter cases, identifying which type of cancer is present. They also analyze any removed lymph nodes to assess whether the cancer has spread to these nodes from the thyroid. All such procedures are only effective if carried out by highly experienced experts in the field.
• Nuclear medicine therapists assist in the diagnosis and treatment of thyroid diseases by performing thyroid uptake and thyroid scan for diagnostic purposes. They also perform radioactive iodine therapy in the treatment of hyperthyroidism cases and in post-surgery thyroid cancer cases to reduce the likelihood of the cancer recurrence, as well as to manage any cancer that has spread beyond the thyroid. Nuclear medicine specialists are also responsible for undertaking radioactive iodine whole body scans to assess where thyroid cancer may have spread to.
• Oncologists play a key role in treating the aforementioned thyroid cancer types that do not respond to treatment. This includes in patients who have undergone multiple surgeries and radioactive iodine therapy sessions to reduce the nodule’s size as much as possible but for whom the cancer is still present. In such cases, our expert oncologists may turn to targeted therapy or chemotherapy techniques.
• Ophthalmologists help to treat proptosis caused by hyperthyroidism, including performing orbital decompression and strabismus surgery. They are also instrumental in treating patients for whom there is a partial or complete impairment of eye muscle function, and who require surgery to treat external eye issues or eyelid disorders involving bulging.
• Dietitians assist patients who require a low-iodine diet, preparation of radioactive iodine treatment for thyroid cancer or hyperthyroidism. Our dietitians also provide advice regarding pre-treatment dietary preparations necessary to achieve the best results.

• The comprehensive nature of our expert medical teams, who are highly experienced in the treatment of thyroid diseases
• International standards of care, making us the best choice for patients of all types
• Our level of readiness in terms of the latest medical devices and equipment