d that they will need this treatment for life, and that they should re regularly checked, and consistent in their daily dosage.
Long Term Follow-Up
Probably the thyroid remnant is not normal. It has a rapid 131-I turnover rate and a small pool of stored organic iodine. Suppressibility by T3 administration returns within a few months of operation in some patients. TSAb tend to disappear from the blood in the ensuing 3 – 12 months [208-210]. After subtotal thyroidectomy, thyrotoxicosis recurs in 5 – 10% of patients, often many years after the original episode. The long term outcome of thyroid surgery for hyperthyroidism was reviewed by the Department of Surgery at Karolinska Institute. Of 380 patients observed and treated by surgery for thyrotoxicosis, primarily by subtotal thyroidectomy, 1% developed permanent hypoparathyroidism. Recurrent disease occurred in 2%. The operators intended to leave less than two grams of thyroid tissue, which presumably accounts for the low recurrence rate (210.1).
Finally, adequate follow-up must be carried out after any kind of treatment of Graves’ disease. Recurrence is always possible, either early or late, and there is always the threat that the ophthalmopathic problems may worsen when all else in the progress of the patient seems favorable. A surprisingly large proportion of patients who have had subtotal thyroidectomy for Graves’ disease and who are clinically euthyroid can be shown to have an abnormal TRH response (excessive or depressed), and up to a third have elevated serum TSH levels [210, 211]. Some of them are undoubtedly mildly hypothyroid, whereas others are close to euthyroid but require the stimulation of TSH to maintain this state. These patients should have replacement T 4therapy if the elevated TSH persists. Over subsequent years the residual thyroid fails in more patients, due either to reduced blood supply, fibrosis from trauma, or continuing autoimmune thyroiditis. After 10 years, and depending on the extent of the original surgery, 20 – 40% are hypothyroid. This continuing thyroid failure is also seen after antithyroid drug therapy with 131-I and represents the natural evolution of Graves’ disease.
SPECIAL CONSIDERATIONS IN THE TREATMENT OF THYROTOXICOSIS IN CHILDREN
Thyrotoxicosis may occur in any age group but is unusual in the first five years of life. The same remarkable preponderance of the disease in females over males is observed in children as in the adult population, and the signs and symptoms of the disease are similar in most respects. Behavioral symptoms frequently predominate in children and produce difficulty in school or problems in relationships within the family. Thyrotoxic children are tall for their age, probably as an effect of the disease. These children are restored to a normal height/age ratio after successful therapy for the thyrotoxicosis. Permanent brain damage and craniosynostosis are reported as complications of early childhood thyrotoxicosis ( 211.1). Bone age is also often advanced . No more is known about the cause of the disease in children than in adults. Diagnosis rests upon eliciting a typical history and signs and upon the standard laboratory test results. Normal values for children are not the same as for adults during the first weeks of life, and these differencesshould be taken into account.
Therapy of Childhood Graves’ Disease 131-I Treatment- In some clinics, RAI is used in the treatment of thyrotoxicosis in children. In one report, 73 children and adolescents were so treated. Hypothyroidism developed in 43. Subsequent growth and development were normal. In another group of 23 treated with 131-I, there were 4 recurrences, at least 5 became hypothyroid, and one was found to have a papillary thyroid cancer 20 months after the second dose . Safa et al.  reviewed 87 children treated over 24 years and found no adverse effects except the well-known occurrence of hypothyroidism. Hamburger has examined therapy in 262 children ages 3 – 18 and concludes 131-I therapy to be the best initial treatment . Read et al (214.1) reviewed there ex