total thyroidectomy for Hashimoto's thyroiditis

Hashimoto's thyroiditis is an autoimmune disorder affecting the thyroid gland that usually runs in families. It may present in a number of different ways with many different features (see symptoms of Hashimoto's). The most common symptoms,  such as hypothyroidism, pressure from thyroid nodules or an incidental thyroid cancer are readily treated. However despite treatment of specific pathology, some patients have persistent symptoms associated with the immunological pathophysiology. These symptoms have also been labelled as the "Hashimoto's Associated Syndrome" and include tiredness and lethargy, neurocognitive changes, fibromyalgia, arthralgia, and local pressure and discomfort in the neck region in the absence of large nodules. In the past there was considerable reluctance to recommend thyroidectomy in patients with Hashimoto's thyroidits in the absence of a clear cut indication such as a Hashimoto's associated thyroid cancer or compressive symptoms from a large thyroid nodule as, in most cases, the thyroid gland undergoes progressive atrophy and ends up as a shrunken fibrotic, non-functioning structure and all that is required is hormone replacement with thyroxine. A prospective randomised clinical trial from Norway (link to abstract) published in  Annals of Internal Medicine randomised 150 patents with normal thyroid function on thyroxine replacement but with significant thyroiditis (anti-TPO antibodies > 1,000) to total thyroidectomy vs continued medial management.  Patients were assessed with the SF36 Health Survey at 18 months.  Only the surgical group demonstrated any improvement with a significant increase in health score overall and reduction in fatigue score. Chronic fatigue frequency decreased from 82% to 35% and antibodies dropped from a mean of 2232 to 152. The authors concluded  that total thyroidectomy in this group improved quality of life by elimination of the underlying immunological mechanisms of the disease process. Total thyroidectomy is an operation with potential complications however the benefits in this group clearly outweighed that risk.

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