A 35-year-old woman with Graves' disease fails antithyroid drugs after 18 months. She has a large diffuse goiter compressing the trachea and active severe ophthalmopathy. Which management is most appropriate?
- A Total thyroidectomy after achieving euthyroid state ✓
- B Radioiodine (RAI) therapy
- C Long-term carbimazole without surgery
- D Near-total thyroidectomy without preoperative preparation
Correct answer: A. Total thyroidectomy after achieving euthyroid state
Explanation
Active significant Graves' ophthalmopathy is a relative contraindication to radioiodine because RAI can worsen ophthalmopathy by releasing thyroid antigens and increasing TSH receptor antibody titers. Total thyroidectomy eliminates the antigen drive and is preferred when there is compressive goiter and active ophthalmopathy. RAI is avoided or requires prophylactic steroids when ophthalmopathy is active. Near-total thyroidectomy without preparation risks thyroid storm. Long-term carbimazole is inferior once compliance issues and disease activity are established.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.