Hyperthyroidism

Population Covered By The Guidance

This pathway provides guidance on the investigation of adult patients with hyperthyroidism.

Lead Researcher: Sian Chin, Arjun Shivananda

Experts & Contributors: Ravinder Dhillon, David Hurley, Anita Kothapalli, Kyaw Thura

Editorial Panel: Core membership
Link to Editorial Panel

Date reviewed: February 2018

Date Published: June 2018

Image 1a and 1b (Thyroid Scintigraphy - Tc99m Pertechnetate): The thyroid gland has taken up 6.3% of the administered dose (normal between 0.6-2.7%). This is evenly distributed throughout both lobes of the thyroid gland. No focal abnormalities are demonstrated. The appearances are typical of Graves' Disease.

Graves' Disease

Image 1a and 1b (Thyroid Scintigraphy - Tc99m Pertechnetate): The thyroid gland has taken up 6.3% of the administered dose (normal between 0.6-2.7%). This is evenly distributed throughout both lobes of the thyroid gland. No focal abnormalities are demonstrated. The appearances are typical of Graves' Disease.

Graves' Disease

Image 2 (H&E, x10): Histological section of Graves' disease showing hyperplastic follicles with infolding of the follicular epithelium to form papillary projections (blue arrow). The colloid is pale with scalloped margins (green arrows).

Graves' Disease

Image 3a, 3b, 3c and 3d (Computed Tomography): The right lobe of the thyroid is considerably enlarged with retrosternal extension and deviation of the trachea to the left (arrows). There are a few mediastinal nodes which measure around 1cm in short axis diameter.

Retrosternal Goitre

Image 3a, 3b, 3c and 3d (Computed Tomography): The right lobe of the thyroid is considerably enlarged with retrosternal extension and deviation of the trachea to the left (arrows). There are a few mediastinal nodes which measure around 1cm in short axis diameter.

Retrosternal Goitre

Image 3a, 3b, 3c and 3d (Computed Tomography): The right lobe of the thyroid is considerably enlarged with retrosternal extension and deviation of the trachea to the left (arrows). There are a few mediastinal nodes which measure around 1cm in short axis diameter.

Retrosternal Goitre

Image 3a, 3b, 3c and 3d (Computed Tomography): The right lobe of the thyroid is considerably enlarged with retrosternal extension and deviation of the trachea to the left (arrows). There are a few mediastinal nodes which measure around 1cm in short axis diameter.

Retrosternal Goitre

Image 4a: Total thyroidectomy showing a multinodular goitre with marked asymmetrical enlargement of the right lobe due to a massive dominant nodule

Multinodular (Colloid) Goitre

Image 4b (H&E, x2.5): Histological section of a multinodular (colloid) goitre showing the usual features of variously sized, colloid-containing follicles lined by uniform epithelial cells, patchy areas of haemorrhage and fibrosis.

Multinodular (Colloid) Goitre

  • Graves' disease can often be diagnosed clinically and appropriate medication commenced
  • If the aetiology of hyperthyroidism is uncertain, isotope scan may aid in the diagnosis based on the pattern and location of radionuclide uptake

Date of literature search: September 2017

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388(10047):906-18. (Review article). View the reference
  2. Lacka K, Fraczek MM. Classification and etiology of hyperthyroidism. Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego. 2014;36(213):206-11. (review article). View the reference
  3. Meller J, Becker W. The continuing importance of thyroid scintigraphy in the era of high-resolution ultrasound. Eur J Nucl Med Mol Imaging. 2002;29 Suppl 2:S425-38. (Review article). View the reference
  4. Summaria V, Salvatori M, Rufini V, Mirk P, Garganese MC, Romani M. Diagnostic imaging in thyrotoxicosis. Rays. 1999;24(2):273-300. (Review article). View the reference
  5. Alimanovic-Alagic R, Brkovic A, Kucukalic-Selimovic E, Skopljak-Beganovic A. Thyroid scintigraphy as diagnostic method evaluation of thyroid diseases. Med Arh. 2008;62(2):114-6. (Review article). View the reference
  6. Smith JR, Oates E. Radionuclide imaging of the thyroid gland: patterns, pearls, and pitfalls. Clin Nucl Med. 2004;29(3):181-93. (Review article). View the reference
  7. Intenzo CM, dePapp AE, Jabbour S, Miller JL, Kim SM, Capuzzi DM. Scintigraphic manifestations of thyrotoxicosis. Radiographics. 2003;23(4):857-69. (Review article). View the reference
  8. Kusic Z, Becker DV, Saenger EL, Paras P, Gartside P, Wessler T, et al. Comparison of technetium-99m and iodine-123 imaging of thyroid nodules: correlation with pathologic findings. J Nucl Med. 1990;31(4):393-9. (Level III evidence). View the reference
  9. Gupta V. Physiopathologic atlas of thyroid scintigraphy. Kathmandu University medical journal (KUMJ). 2007;5(4):583-90. (Review article). View the reference
  10. Meng Z, Zhang G, Sun H, Tan J, Yu C, Tian W, et al. Differentiation between Graves' disease and painless thyroiditis by diffusion-weighted imaging, thyroid iodine uptake, thyroid scintigraphy and serum parameters. Experimental and Therapeutic Medicine. 2015;9(6):2165-72. (Level III evidence). View the reference

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SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Endocrine