Graves’ disease is rare in children with a prevalence of 1 in 10,000 [9, 10]. Because only a minority of pediatric patients achieve remission [11–14], the majority of patients will require either radioactive iodine or surgery [4, 9]. Our observations support the notion that in the hands of high volume thyroid surgeons, thyroidectomy is an appropriate treatment option for pediatric patients.
To date the largest series detailing the surgical treatment of GD in children is from the Mayo Clinic . Seventy-eight pediatric patients, ages 3.1 to 17.9 years, with GD underwent surgical treatment . Sixty patients (77%) underwent total or near-total thyroidectomy; 18 patients (23%) underwent bilateral subtotal thyroidectomy . When a sub-total thyroidectomy is performed, a small amount of thyroid tissue is left behind in the region of the RLN or parathyroid glands in the hope of minimizing risks of RLN injury or hypoparathyroidism .
In the Mayo Clinic series, no RLN injuries, hematomas, nor instances of permanent hypoparathyroidism were reported . One patient (1%) developed transient RLN neuropraxia, and 5 patients (6%) had transient hypoparathyroidism . Five microcarcinomas (6%) were identified in the pathological specimens . Of note, 4 of the 18 patients (22%) who underwent bilateral subtotal thyroidectomy experienced recurrence of their hyperthyroidism .
Recognizing the high recurrence rate associated with subtotal thyroidectomy, we adopted an aggressive surgical approach for the management of GD in children and adults by performing total or near-total thyroidectomies in all patients. Supporting the utility of our approach in curing the disease, no patient in our series experienced relapse of their GD.
HCUP-NIS data show that pediatric patients suffer complications more frequently following thyroidectomy than adults (9.3% vs. 6.1%, p < 0.01) [1, 2]. In our cohort, we observed transient hypocalcemia, presumable due to transient hypoparathyroidism, as the most common minor complication in pediatric patients. However, with preoperative calcitriol therapy, the need for post-operative calcium infusions was reduced from 50% to 16% and the duration of intravenous calcium infusion was shortened by more than 50%.
RLN injury was observed in two of the children in our cohort. In one child, a soft voice was observed shortly after surgery, and direct laryngoscopy performed two months after surgery revealed unilateral vocal cord paresis. At six months after surgery, there was normal bilateral vocal cord function and the voice was normal.
One child, 4 years of age, had transection of one RLN during surgery that was immediately recognized and repaired. At 6 months after surgery, unilateral vocal cord paresis was observed by direct laryngoscopy. At 18 months after surgery, direct laryngoscopy revealed bilateral vocal cord movement and the voice was normal. Of note, the RLN injury occurred in the lone patient who could not be treated preoperatively with SSKI due to an anaphylactic reaction to the medication.
It is interesting that occult malignancy was seen in 12 of 68 adult patients and in 1 of 32 pediatric patients. Ten of the 12 malignancies seen in adults were unifocal papillary microcarcinomas, and one case was a multifocal papillary carcinoma that was 2.5 cm in the greatest diameter. A papillary microcarcinoma of 0.4 cm confined to the thyroid capsule was seen in one pediatric patient. These observations highlight the need for clinicians to obtain sonographic imaging of the thyroid gland if asymmetry or gland size change is noted in the setting of GD. Should nodules be observed, they should be evaluated per recent guidelines .
The observation of microcarcinomas in the setting of GD, which will be difficult to identify by preoperative ultrasound, should not be construed as an argument to in favor of surgery over radioactive iodine in the definitive treatment of GD. If GD patients with microcarcinomas are treated with recommended activities of radioactive iodine that are intended to ablate thyroid tissue [4, 17, 18], it is anticipated that microcarcinomas will be destroyed along with normal thyroid tissue. Support for this notion come from data from the Thyrotoxicosis Study Group follow-up data showing that rates of differentiated thyroid cancer in patients with GD are substantially lower in those treated with radioactive iodine or surgery than in individuals treated with antithyroid medications alone who underwent spontaneous remission .
Overall, we demonstrate that total or near-total pediatric thyroidectomy can be performed safely in experienced hands and is not associated with GD recurrence. A multidisciplinary team consisting of a high volume endocrine surgeon, a pediatric surgeon, pediatric endocrinologists, pediatric anesthesiologists, and experienced endocrine nurses can achieve excellent outcomes with very low complication rates. These observations support recent recommendations that children and adults requiring surgery for GD should be operated on by high volume endocrine surgical teams [4, 5].