Medical Care
Acute thyroiditis
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Acute thyroiditis requires immediate parenteral antibiotic therapy before abscess formation begins. For initial antibiotic therapy, administer penicillin or ampicillin to cover gram-positive cocci and the anaerobes that are the usual causes of the disease.
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In patients who are allergic to penicillin, cephalosporins are appropriate.
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Patients with acute thyroiditis may require inpatient care to complete 10-14 days of antibiotics.
Subacute thyroiditis
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Subacute thyroiditis is self-limiting; therefore, the goals of treatment are to relieve discomfort and to control the abnormal thyroid function. The discomfort can usually be relieved with low-dose aspirin (divided every 4-6 h). In the rare cases that aspirin does not relieve the discomfort, administer prednisone for 1 week and then taper.
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Propranolol can be used to reduce signs and symptoms of hyperthyroidism.
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Low-dose levothyroxine may be necessary in some patients who develop hypothyroidism.
Chronic autoimmune thyroiditis
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Treatment for chronic autoimmune thyroiditis depends on the results of the thyroid function tests. Patients with overt hypothyroidism who have high thyroid-stimulating hormone (TSH) and low free T4 levels require treatment with levothyroxine. The dose is age dependent. TSH levels should be monitored and the dose should be adjusted to maintain levels within the reference range.
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The treatment of subclinical hypothyroidism in patients with elevated TSH and normal free T4 levels is controversial. These children may enter a remission phase and may not have permanent hypothyroidism. This appears to be a minority of subjects. One study found that 4 of 14 subjects had normalization of TSH after a follow-up of 3-12 years. Most pediatric endocrinologists recommend treatment of subclinical hypothyroidism during childhood to ensure normal growth and development. If thyroxine administration may not be permanently required, treatment may be stopped once the patient has completed pubertal development, and thyroid function then can be reassessed. Guidelines for the diagnosis and management of subclinical thyroid disease have been established.
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The use of thyroxine treatment in patients with a goiter due to autoimmune thyroiditis who have normal TSH and free T4 levels is even more controversial. Some studies have suggested that treatment may decrease gland size, [23, 24] but other studies suggest that reduction in gland size is likely only in children with initially elevated TSH levels. [17]
Surgical Care
In acute thyroiditis, surgery may be necessary to drain the abscess and to correct the developmental abnormality responsible for the condition.
The surgical service consulted depends on the institution and the physician who has the most experience with thyroid surgery. Options include the following:
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Pediatric surgery
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Otolaryngology
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A specialized endocrine surgery service
Consultations
Acute thyroiditis: Consulting with a pediatric infectious disease specialist may be useful for selecting appropriate antibiotic therapy.
Subacute and chronic thyroiditis: Consulting with a pediatric endocrinologist should be considered in treating children with these disorders. This is particularly true if the child has experienced poor growth possibly due to hypothyroidism, has symptoms of overt hyperthyroidism, or has a discrete thyroid nodule.
Diet
No dietary limitations are necessary.
Activity
Children with overt hyperthyroidism or hypothyroidism have poor exercise tolerance. These children usually limit their own activity. As treatment progresses and thyroid function levels return to normal, their exercise tolerance should increase.
Long-Term Monitoring
Subacute thyroiditis
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This is a self-limiting disease that may last 2-7 months.
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During this time, monitor thyroid function and adjust medications as needed.
Chronic autoimmune thyroiditis
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Outpatient care involves monitoring thyroid function tests. Patients with normal thyroid function test results should be examined every 6 months to ensure that they do not develop hypothyroidism. After a year, these visits may be annual.
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Children who require thyroxine therapy should undergo thyroid function tests every 3-12 months, depending on age. More frequent testing is required in younger children. Thyroid-stimulating hormone (TSH) and free T4 levels should be checked 1 month after any change in dosage.
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Three multinuclear, giant cell granulomas observed in a fine-needle aspiration biopsy of the thyroid; from a patient with thyrotoxicosis from lymphocytic or subacute granulomatous thyroiditis.
