hipertiroidii
DESCRIPTION
HIPERTIROIDII. HYPERTHYROIDISM. Increased serum levels of thyroid hormones, - Surgical correction is frequently appropriate. NORMAL THYROID FUNCTION. The follicular cells- T3, T4 T3, T4 bind with thyroglobulin, stored on the gland until released onto the bloodstream - PowerPoint PPT PresentationTRANSCRIPT
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HYPERTHYROIDISM
- Increased serum levels of thyroid hormones,
- Surgical correction is frequently appropriate
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NORMAL THYROID FUNCTIONThe follicular cells- T3, T4
T3, T4 bind with thyroglobulin, stored on the gland until released onto the bloodstream
Release is under the control of TSH and TRH
A feed-back mechanism regulating T3, T4 release is related to the level of circulating T3, T4.
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HORMONAL ACTION
The thyroid hormones:
- increase the metabolic rate,
- increase the O2 consumption,
- increase glycogenolysis,
- enhance the actions of catecholamines
The result is:Increase in the PR, CO. Nervousness,
irritability, muscular tremor, muscle wasting
These effects can be blocked by the use of beta-blockers
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HORMONAL ACTIONThe parafollicular or C-cells- produce
thyrocalcitonin
Thyrocalcitonin action:- to lower serum calcium and phosphate
concentration,- reduces bone resorption- in the kidney accelerates calcium and
phosphate excretion:
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THYROID GLANDCLINICAL EXAMINATION
HyperthyroidismSymptoms: dyspnea on effort, palpitation, tiredness, preferance for cold, sweating, nervousness, weight loss, good appetite
Signs: palpable thyroid, exophtalmos, lid lag, hyperkinesis, finger tremor, hot and moist hands, rapid PR
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INVESTIGATIONSTSH- raised in primary hypothyroidism and
after treatment of thyrotoxicosis by surgery or radioiodine, - reduced in hyperthyroidism
Free T3, T4- radioimmunoassays,Radioiodine uptake,Thyroid isotope scanningUltrasonography, CT, MRIFine needle aspiration cytologyThyroid autoantibodies (ab.to thyroglobulin)
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Thyroid scintigramAutonomous adenoma in the
right lobe of the struma.
The test substance accumulates almost exclusively in the range of the autonomous adenoma.
The other areas of the struma show a considerable reduced accumulation of activity.
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GOITERENLARGEMENT OF THE THYROID GLANDSimple goiter - diffuse hyperplastic goitre,
- nodular goitreToxic goiter - diffuse (Grave’s disease),
- toxic multinodular goitre, - toxic solitary nodule
Neoplastic goiter - benign, - malignant
Thyroiditis - subacute (de Quervain’s), - autoimmune(Hashimoto’s), - invasive fibrous thyroiditis (Riedel’s) - acute suppurative
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HYPERTHYROIDISM
Common causes:
- diffuse toxic goitre (Graves’s disease),- toxic multinodular goitre (Plummer’s
disease),- toxic solitary nodule,- exogenous thyroid hormone excess,- thyroiditis
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HYPERTHYROIDISMRare causes: - metastatic thyroid carcinoma, - pituitary tumour secreting TSH
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GRAVE’S DISEASE
The most common cause of hyperthyroidismIt is an immunological disordersThyroid stimulating antibodies (IgG type)
bind to the TSH receptor of the thyroid cells- excess of the thyroid hormones
The thyroid gland hypertrophiesDiffuse enlargement
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GRAVE’S DISEASEClinical Diagnosis
Symptoms and signs of thyrotoxicosis result from excess thyroid hormones:Cardio vascular Neurological Metabolic ExophtalmosDiffuse enlargement of the thyroid
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GRAVE’S DISEASEOphthalmopathy- two major components:-Non-infiltrating ophthalmopathy-sympathetic
activity:- upper lid retraction, - a stare,- infrequent blinking
-Infiltrative ophthalmopathy- edema of the orbital contents, lids, periorbital tissue, cellular infiltration within the orbit
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HYPERTHYROIDISMPREOPERATIVE PREPARATION
Surgery must be done in the euthyroid state ATD for a period then discontinueBetablockers to control cardiac symptomsLugol’s solution, 10 days, will diminish the
peroperative hemorrhagic risk
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GRAVES’ DISEASETREATMENT
To restore the euthyroid state:Antithyroid drugs + beta-blockersRadioactive iodine - distroys overactive tissue
Surgery - bilateral subtotal/total thyroidectomy
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Grave’s diseaseMultiple nodules and hypervascularity
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Grave’s diseasePressure symptoms
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Recurrent Grave’s disease after subtotal thyroidectomy, nodule at the piramidal lobe
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Right thyroid nodules after subtotal thyroidectomy
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Nodules with cystic degeneration after subtotal thyroidectomy
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Left upper nodule with cystic degeneration
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MULTINODULAR GOITREMANAGEMENT
Hyperthyroid- iodine scanLarge- ATD & surgerySmall- iodine therapy
EuthyroidNo dominant nodule-observeDominant nodule-FNAC
Benign, no sy-observeMalignant- surgerySuspicious- surgeryInadequate- repeat FNACRetrosternal- surgeryCosmetic- surgery
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SOLITARY THYROID NODULEMANAGEMENT
Hyperthyroid- FNAC & isotope scanGreater than 3 cm.- surgeryLess than 3 cm.- iodine therapy
Euthyroid- FNACBenign-no pressure sy.-observe, repeat FNAC in 6
monthsBenign- with pressure sy.- surgeryThyoiditis- T4 treatmentSuspicious- surgeryMalignant- surgeryInadequate FNAC- repeatCystic benign- observe, review in 6 weeksCystic malignant- surgery
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TOXIC SOLITARY NODULETREATMENT
This condition is caused by a single autonomous thyroid nodule
Best option- surgery- unilateral thyroid lobectomy
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Toxic compressive goiter
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POSTOPERATIVE COMPLICATIONS
1. Postoperative bleeding2.Postoperative thyrotoxic crisis3.Postoperative voice changes4. Hypoparathyroidism5. Hypothyroidism
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POSTOPERATIVE BLEEDINGPostoperative bleeding
there is always a risk of postop .bleeding,it is rare but sometimes dramatic
The bleeding may occur in one of two sites,- deep to the myofascial layer in relation to
thyroid vessels-evacuation must be done quickly
- deep to the skin flaps, from veinsCompressive hematoma- respiratory
embarrasment- evacuation is mandatory
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POSTOPERATIVETHYROTOXIC CRISISSerious complication-where there has not
been adequate preop.preparation
It occurs within the first 24 hours of thyroidectomy
Symptoms: confusion, hyperactive, fever, profuse sweating, rapid PR.
Treatment: beta-blockers, iv steroids, iodine
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POSTOPERATIVE VOICE CHANGES
Rare due to any damage to recurrent laryngeal nerves- this occurs in less than 1%
Probably minor changes in the muscles around the cricoid and thyroid cartilages are the most important, inevitable with the mobilization of the gland
Trauma to external laryngeal nerve- cricothyroid muscle- voice change- difficulty in achieving vocal cord tension
Trauma t the internal laryngeal nerve can occur where there is difficulty in mobilizing the superior pole
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POSTOPERATIVE HYPOPARATHYROIDISMHypocalcemia- usually a consequance of a
metabolic changes- re-entry of calcium into bone demineralized by hyperthyroidism (“hungry bones”)
Parathyroids are small and are not always easy to identify
The incidence of hypoparathroidism after surgery shoud be less than 1%
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POSTOPERATIVE HYPOTHYROIDISM
All forms of treatment for thyrotoxicosis will produce a population of patients prone to develop hypothyroidism
Greatest risk after radioiodine therapy