How to manage a patient with Graves' disease on Carbimazole 10 mg twice daily and Propranolol 40 mg once daily, presenting with nasal regurgitation of food, increased thyroid swelling, active thyroiditis, elevated Free T3, and suppressed TSH?

Management of Graves' Disease with Nasal Regurgitation and Thyroid Swelling

The patient with Graves' disease presenting with nasal regurgitation, increased thyroid swelling, active thyroiditis on ultrasound, elevated Free T3, and suppressed TSH requires immediate referral for surgical evaluation (thyroidectomy) due to compressive symptoms affecting the esophagus.

Clinical Assessment of Current Status

The patient's presentation shows several concerning features:

1. Compressive symptoms:

   • Nasal regurgitation of food suggests compression of the esophagus
   • Increased thyroid swelling indicates disease progression

2. Laboratory findings:

   • Free T3 elevated at 5.9 (hyperthyroid)
   • TSH suppressed (<0.01)
   • Free T4 at 1.1 (within normal range)

3. Imaging findings:

   • Ultrasound showing active thyroiditis
   • Bulky gland (10cc each lobe)

4. Current treatment:

   • Carbimazole (Neomercazole) 10 mg twice daily
   • Propranolol (Ciplar LA) 40 mg once daily

Treatment Algorithm

Step 1: Address Compressive Symptoms

The nasal regurgitation indicates compression of the esophagus, which is a concerning symptom requiring urgent intervention. This is a clear indication for surgical consultation.

Step 2: Optimize Medical Management While Awaiting Surgery

• Increase antithyroid medication: Consider increasing carbimazole dose to control hyperthyroidism more effectively
• Adjust beta-blocker: Ensure adequate symptom control of adrenergic symptoms
• Add anti-inflammatory treatment: Consider prednisolone for thyroiditis component

Step 3: Definitive Treatment

• Surgical consultation: Refer for thyroidectomy evaluation due to compressive symptoms
• Consider radioactive iodine therapy as an alternative if surgery is contraindicated

Evidence-Based Rationale

The presence of compressive symptoms (nasal regurgitation) along with increased thyroid swelling indicates a need for definitive treatment. While the evidence provided doesn't directly address this specific presentation, clinical judgment based on the severity of symptoms supports surgical intervention.

Case reports have documented instances where Graves' disease can present with painful thyroiditis 1, and some patients may be resistant to standard medical therapy 2. In one reported case, emergency thyroidectomy was required when medical management failed 3.

Important Considerations

• Monitor for thyroid storm: The combination of active thyroiditis and elevated T3 puts the patient at risk for thyroid storm
• Assess for other causes of thyroiditis: While Graves' disease is the primary diagnosis, concomitant conditions like painful thyroiditis can occur 4
• Medication compliance: Ensure the patient has been taking medications as prescribed, as non-compliance can lead to treatment failure 3

Pitfalls to Avoid

1. Delaying surgical referral: Compressive symptoms require prompt evaluation for definitive treatment
2. Focusing only on biochemical control: While normalizing thyroid function is important, addressing structural complications is equally critical
3. Missing concomitant conditions: Graves' disease can occur simultaneously with other thyroid conditions that may require specific management 4, 2

The patient's current antithyroid medication dose may be insufficient, as evidenced by the elevated Free T3 despite treatment. However, medication adjustments alone will not address the compressive symptoms, which are the primary concern in this case.