Surgical management of Graves
disease in childhood and adolescence:
an institutional experience
Jonathan Sherman, BS,
a
Geoffrey B. Thompson, MD,
a
Aida Lteif, MD,
b
W. Frederick Schwenk II, MD,
b
Jon van Heerden, MD,
a
David R. Farley, MD,
a
Seema Kumar, MD,
Donald Zimmerman, MD,
c
Marilyn Churchward,
a
and Clive S. Grant, MD,
a
Rochester, Minn,
and Chicago, Ill
Background. Graves disease is the most common cause of hyperthyroidism in children. Medical
therapy, radioiodine ablation, and thyroidectomy are all treatment options. To evaluate the safety and
efficacy of operative therapy, we updated our operative experience with pediatric Graves disease at a
single tertiary care center.
Methods. The medical records of children Ͻ18 years old who underwent thyroidectomy for Graves
disease between 1986-2003 were reviewed.
Results. We identified 78 patients (median age, 13.8 years; 87% female). The most common
presenting signs and symptoms included heat intolerance (61%), decreased academic performance
(50%), tremor (49%), and ophthalmopathy (43%). All patients had clinical and laboratory evidence
of autoimmune thyrotoxicosis. Sixty-nine percent chose operative therapy because of failure of medical
therapy or adverse drug reactions. Near-total thyroidectomy was the most common surgical procedure
performed (65%). Pathology demonstrated previously unrecognized thyroid malignancies in 4 (5%)
patients. Operative morbidities were transient and included hypoparathyroidism (6%) and recurrent
laryngeal nerve neuropraxia (1%). Three (4%) patients who underwent subtotal thyroidectomy
developed recurrent hyperthyroidism; all were treated successfully with radioiodine ablation. Of patients
presenting with ophthalmopathy, 85% noted improvement postoperatively, while 1 (3%) patient experienced
worsening of symptoms. Only 5% developed new-onset Graves ophthalmopathy after operation.
Conclusions. Near-total thyroidectomy for Graves disease in children is safe and effective when
performed by experienced thyroid surgeons. In addition to relief of systemic symptoms, the majority of
patients presenting with Graves ophthalmopathy experienced improvement of their ocular disease after
operation. In 5% of patients, surgical management allowed for detection and treatment of clinically
occult thyroid malignancies. (Surgery 2006;140:1056-62.)
From the Division of Gastroenterologic and General Surgery
a
and the Division of Pediatric Endocrinology and
Metabolism,
b
Mayo Clinic, Rochester, and Children’s Memorial Hospital,
c
Chicago
Graves disease is the most common cause of thy-
rotoxicosis in children and adolescents affecting
0.02% of all children.
1
Many young patients
present with a constellation of symptoms similar to
that of adults, including heat intolerance, palpita-
tions, ophthalmopathy, and tremor. In children,
more so than in adults, it is common for nervous-
ness, fatigue, sleep disturbances, and behavioral or
learning disorders to be the presenting signs and
symptoms. Graves disease in childhood can have a
profound impact on quality of life, learning, and
development.
The management of Graves disease in these chil-
dren remains controversial because no single treat-
ment modality consistently restores euthyroidism
without risk. Three modalities are available: medi-
cal therapy (antithyroid drugs), radioactive iodine
thyroid ablation, and thyroidectomy. Antithyroid
drugs are associated with a number of acute ad-
verse reactions.
2
In addition, use of antithyroid drugs is associ-
ated with high relapse rates, even after long-term
therapy.
2
Radioactive iodine is often employed in
Presented at the 27th Annual Meeting of the American Association
of Endocrine Surgeons, New York, New York, May, 2006.
Reprint requests: Geoffrey B. Thompson, MD, Mayo Clinic, 200
First St SW, Rochester, MN 55905. E-mail: thompson.geoffrey@
mayo.edu.
0039-6060/$ - see front matter
© 2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.surg.2006.07.040
1056 SURGERY