Structure and location of thyroid gland

1. Thyroid gland diseases. Ethiology. Pathogenesis. Diagnostics. Clinical pattern. Complications. Principles of treatment. The role of  a doctor-dentist   in early diagnostics and prophylaxisN. Bilkevych

2. Structure and location of thyroid gland

3. Influence of thyroid hormones on an organism: Nervous system and psychic Cardiovascular system Digestive system Reproductive system Skin and intertguments Musculosceletal apparatus

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

5. Ethiology • Iodine deficiency is the main obvious factor • Additional factors: • deficiency of microelements cobalt, copper, fluorine, zinc, molybdenum (participate in iodine metabolism);Influence of strumogens – substances which decelerate biosynthesis of thyroid hormonesHypersecretionof thyrotrophic hormone (TTH) by hypophysis • Diseases of digestive tract, a liver with disordered iodine absorption.

6. 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

7. Classification of thyroid gland enlargement (WHPO, 2001)

12. Nodal goitre

13. Treatment • 1. Thyroid hormones – L-thyroxin - 50-100 мcg/d;2. Iodinum preparations – 100-200 мcg/d • Prophylaxis of iodine defficiensy • Iodinum-containing products (salt, bred, milk); 2. Iodinum preparations:iodide potassium, lipiodol 100-200 мcg/d.

14. Ethiology and provoking factors stress; Infectious diseases; insolation; smocking; Inflammatory processes in thyroid gland Hormonal disbalance heredity Diffuse toxic goitre (DTG)

15. 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 - increasedappetite; abdominal pain; periodical diarrhoea Ophthalmopathy – feeling of protrusion of eyes, dacryagogue; photophobia Interguments – brittle hair, loosing hair.

16. 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). Objective examination

17. 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

18. Ophthalmopathy • Exophthalmos* Dalrimpl’s sign (wide eye slits)* Graefe’s sign • * Mebiussign (convergention disorders)* Elinek’ssign (hyperpigmentation)* Stellwag’ssign (rareblinking)* Rosenbach’ssign (tremor of closed eyelids)* Kocher’s sign

19. 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

23. Diagnostics of DTG Anamnesis Provoking factors Clinical pattern Signs of thyrotoxicosis and diffuse enlargement of thyroid gland Laboratory tests 1) Common and free Т3 і Т4are increased; 2) Increased level of common Т3and normal Т4 (Т3 – thyrotoxicosis) 3) Decreased level of thyrotrophic hormone (TTH) 4) Increased consumption of radioactive iodinumJ131with thyroid gland 5) High level of antibodies to TTH receptors

24. Instrumental diagnostics • 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

25. 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

26. Ultrsound examination of thyroid gland

27. Radioisotopic scanogrm of thyrid gland

28. Puncture biopsy of thyroid gland

30. Treatment Antithyroid preparations (propilthiouracil, tiamazol (merkasolil) within 1-2 years Mercasolil (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

31. Hypothyreosis A disease caused by prolobged permanent thyroid hormones deficiency with following decrease of metabolism and functional disorders in different organs and systems

33. Face in hypothyreosis

34. Hypothyreosis in bnewborns

36. Pretibial myxedema

37. 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.

38. 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.

39. Objective examination • Metabolism - hypothermia, overweight Skin – 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

40. 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.

41. 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.

42. 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.

43. 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.

44. Dry hear Falling of external eyebroves hair Periorbital edema Edematous face dry skin

46. 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 Tertiaryhypothyreosis – decreased TTH, decreased Т4 thyroliberin test is positive

47. 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.

49. Treatment Corticosteroids– for prevention of adrenal insufficiency(hydrocortison 100-150 mg or prednisolon 30-50 mgi/v. 200 мcг of thyroxin, glucous 40% - 60 ml, ISS500 мл, 5% ascorbic acid 5 0 i/v. Oxygen. Artificial lung ventilation. In edema and high BP – diuretics (lasix 2 ml i/m), in hypotesion - mesaton 1% - 0,5-1,0 mli/v, corglivon 0,06% - 1,0. Antibiotics.

50. Thank you!