Thyroid gland diseases. Ethiology. Pathogenesis.

Diagnostics. Clinical pattern. Complications. Principles of

treatment. The role of  a doctor-dentist   in early diagnostics and

prophylaxis N. Bilkevych

Structure and location of thyroid gland

Influence of thyroid Influence of thyroid hormones on an hormones on an

organismorganism::Nervous system and psychicNervous system and psychic

Cardiovascular systemCardiovascular system

Skin and intertgumentsSkin and intertguments

Digestive systemDigestive system

Musculosceletal apparatusMusculosceletal apparatus

Reproductive systemReproductive system

Endemic goitreEndemic goitre

This is a disease manifested This is a disease manifested with thyroid gland enlargement. with thyroid gland enlargement. It develops in certain It develops in certain biogeochemical regions biogeochemical regions characterized by iodine characterized by iodine deficiency in the environmentdeficiency in the environment

EthiologyEthiology• Iodine deficiency is the main obvious factorIodine deficiency is the main obvious factor• Additional factors:Additional factors:• deficiency of microelements deficiency of microelements cobalt, copper, fluorine, cobalt, copper, fluorine,

zinc, molybdenumzinc, molybdenum (participate in iodine metabolism) (participate in iodine metabolism);;Influence of Influence of strumogensstrumogens – – substances which decelerate substances which decelerate biosynthesis of thyroid hormonesbiosynthesis of thyroid hormones HHypersecretionypersecretion of of thyrotrophic hormone (TTH) by thyrotrophic hormone (TTH) by hypophysishypophysis

• Diseases of digestive tract, a liver with disordered iodine Diseases of digestive tract, a liver with disordered iodine absorption.absorption.

Palpation may be performed, if a doctor

stands behind or before the patient, his arms are put at

the zone of projection of the gland

Classification of thyroid gland Classification of thyroid gland enlargementenlargement ( (WHPOWHPO, , 20012001))

Degree of enlargement – 0Goitre is absent (sizes of both lobules

don’t exceed medial phalange of human’s

thumb

Degree of enlargement - І Thyroid gland is palpable but is not

visible in normal position of patient’s

neck: nodal formations which don’t cause

thyroid gland enlargement

Degree of enlargement - ІІ Thyroid gland is visible in any position of

the patient

Nodal goitre

Treatment

• 1. 1. Thyroid hormonesThyroid hormones – – L-thyroxinL-thyroxin - 5 - 500-100 -100 ммcgcg//dd;;2. 2. Iodinum preparationsIodinum preparations – 1 – 10000-200-200 м мcgcg//dd

• Prophylaxis of iodine defficiensyProphylaxis of iodine defficiensy• Iodinum-containing productsIodinum-containing products ( (saltsalt, , bredbred, , milkmilk); );

22. . Iodinum preparationsIodinum preparations:: iodide potassiumiodide potassium, , lipiodollipiodol 100-200 100-200 ммcgcg//dd..

Ethiology and provoking factorsstress;Infectious diseases;insolation;smocking;Inflammatory processes in thyroid

glandHormonal disbalanceheredity

Diffuse toxic goitre (DTG)

Clinical patternComplaints

• Nervous system –tearfulness, depression, deranged sleep, irritability, oversweating

Cardiovascular system – Permanent palpitation, periodical intermissions, dyspnea

• Metabolism – poor tolerance to heat, low body weight while appetite is increased, muscular weakness

Digestive tract - increased appetite; abdominal pain; periodical diarrhoea

Ophthalmopathy – feeling of protrusion of eyes, dacryagogue; photophobia

Interguments – brittle hair, loosing hair.

Objective examination Red dermographism. Cardiovascular system –

tachicardia, extrasystoly, atrial fibrillation;

Intensification of І heart sound, systolic murmur,

Heart failure; Systolic arterial hypertension Sex glands – Disorders of

menstrual function and problems with pregnancy in females, impotence in males

Nervous system – Emotional lability, irritability;

Tremor of the body (symptom of «telegraph post») especially nails of hands (Mary symptom).

• Metabolism – subfebrile body temperature, skin is warm

Low body weight.

Ostheoporosis.

Skin is warm and moist, mild, velvet-like;

Pretibial myxedema• Thyroid gland is enlarged, of solid-elastic

consistency, systolic murmur above it• Sex glands – mastopathy, gynecomastia

Ophthalmopathy• Exophthalmos

* Dalrimpl’s sign (wide eye slits)* Graefe’s sign

• * Mebius sign (convergention disorders)* Elinek’s sign (hyperpigmentation)* Stellwag’s sign (rare blinking)* Rosenbach’s sign (tremor of closed eyelids)* Kocher’s sign

Laboratory and instrumental examination

• ECG: synus tachicardia, extrasystoly, paroxysmal tachycardia, atrial fibrillation;

Ultrasound examination of a heart: high heart output;

Rogr - cardiomegaly• Metabolism – Increased serum Ca, excretion

of Ca with urine • Digestive tract – Changes of indexes of liver

function

Diagnostics of DTGAnamnesisProvoking factorsClinical patternSigns of thyrotoxicosis and diffuse enlargement of thyroid glandLaboratory tests1) Common and free Т3 і Т4 are increased;2) Increased level of common Т3 and normal Т4 (Т3 – thyrotoxicosis)3) Decreased level of thyrotrophic hormone (TTH)4) Increased consumption of radioactive iodinum J131 with thyroid gland5) High level of antibodies to TTH receptors

Instrumental diagnostics

1) Ultrasound examination of thyroid gland (enlargement and diffuse

decreased density);2) Scintigraphy (insuspiction on retrosternal

goitre and in nodal goitre)

3) Puncture biopsy of thyroid gland is executed for diagnostics of all nodal formations in the gland

Laboratory and instrumental examination

• ECG: synus tachicardia, extrasystoly, paroxysmal tachycardia, atrial fibrillation;

Ultrasound examination of a heart: high heart output;

Rogr - cardiomegaly• Metabolism – Increased serum Ca, excretion

of Ca with urine • Digestive tract – Changes of indexes of liver

function

Ultrsound examination of thyroid gland

Radioisotopic scanogrm of thyrid gland

Puncture biopsy of thyroid gland

Treatment

Antithyroid preparations (propilthiouracil, tiamazol (merkasolil) within 1-2 yearsMercasolil (5 mg) – 30-60 mg per os, gradually decrease dosage till 5-15 mg.Beta-adrenobloquers (metoprolol 50-200 mg/d, bisoprolol 5-10 mg/d, propranolol 80-120 mg/d

Hypothyreosis A disease caused by prolobged

permanent thyroid hormones deficiency with following decrease of metabolism and functional disorders in different organs and systems

Face in hypothyreosis

Hypothyreosis in bnewborns

Pretibial myxedema

Clinical patternComplaints

• Metabolism – body mass gain• Skin – dryness, induration and

change of color (“wax-like”), rugged face features, enlargement of foots, speech is not clear, decreased hearing.

• Nervous system - somnolence, indisposition, depression, decreased memory and intellect, frequent headaches, dizziness; sensitiveness to cold, parestesias, deranged vision.

• Musculoskeletal system – musculaer pains and crumps, weakness.

• Cardiovascular system – pain in heart region, dyspnea in physical load.

• Digestive system – constipation, decrease appetite, nausea

• Respiratory system – frequent bronchitis exacerbations, pneumonias (body temperature is normal).

• Urogenital system – decreased diuresis, pyelonephritis, decreased potention in males, menstrual-ovarial cycle disorders in females.

Objective examination• Metabolism - hypothermia,

overweightSkin – dry, cold, yellow, it is nit

possible to make skin fold, symptom of dirty elbows and колін; dryness and brittlessness of hair, psilosis, loosing of external parts od eyebroves; nails are sick, with streaks; face is pastous, enlarged lips and a tongue with teeth pattern, hoarse voice

Myxedematous edema (myxaedema)– accumulation of gucosaminoglacals (hialuronic and chondroitinsulfate acids), with accumulation of liquid and sodium in tissues (skin, subcutaneous fat, vocal slits, mucous memvranes.

Nervous system – disordered coordination, poor vision.

Digestive system –tonque enlqrgement with teeth patter on its sides, hepatomegaly, dyskinesia of bile dicts and intestine, ascites.

Cardiovascular system - bradicardia, extrasystoly

Apex beat is low, relative cardiac dullness borders are displaced, weak heart sounds, systolic murmur at the apex, signs of heart failure. BP low or normal.

Respiratory system – superficial breathing, pleuricy.

Thyroid gland – is of normal size or slightly enlarged,mild or of moderat density, painless.

Laboratory and instrumental diagnostics

• Blood – hyperlipoproteidemia, increased level of cholesterol and triglicerides. Anemia (normochromic, hypochromic iron-deffiicency or В12- iron-deffiicency)

Nervous system - Eectroencephalography: decreased amplitude of waves, narroving of vision fields, increased intraocular pressure.

Musculoskeletal system – osteoporosis, sinovial fluid.

Cardiovascular system - ECG: low voltage, sinus

bradicardia, disordered conduction ( P-Q prolongation),

extrasystoly.

Ultrasound of a heart – pericardial effusion, left

ventricular wall sickness.

Digestive system – achlorhydria and authimmune

gastritis.

Urogenital system - decreased diuresis, renal blood

flow and glomerular filtration, moderate proteinuria.

Dry hear

Falling of external eyebroves hair

Periorbital edema

Edematous face dry skin

Diagnostics

Changes of Т3, Т4, ТТH.

Subclinical hypothyreosis – increased TTH, normal Т4.

Primary hypothyreosis – increased TTH, decreased Т4.

Secondary hypothyreosis – decreased TTH, decreased Т4 thyroliberin test is negative

Tertiary hypothyreosis – decreased TTH, decreased Т4 thyroliberin test is positive

Treatment Ethiological treatment of the cause Pathogenetic thyroid hormones 1) poor Т4 (levothyroxin, L-thyroxin, euthirox) – for

prolonged замісної treatment;2) poor Т3 (thriiodtironin) – is used for diagnostics;3) Combined preparations (tireocomb, tireotom, novotirol) –

is difficult to choose proper dosage.

Treatment

1. Corticosteroids – for prevention of adrenal insufficiency

(hydrocortison 100-150 mg or prednisolon 30-50 mg i/v.

2. 200 мcг of thyroxin, glucous 40% - 60 ml, ISS 500 мл, 5%

ascorbic acid 5 0 i/v.

3. Oxygen. Artificial lung ventilation.

4. In edema and high BP – diuretics (lasix 2 ml i/m), in hypotesion

- mesaton 1% - 0,5-1,0 ml i/v, corglivon 0,06% - 1,0.

5. Antibiotics.

•Thank you!