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COMMON THYROID DISORDERS

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					COMMON THYROID
   DISORDERS
  Done by: Abdullah Al-Twal
           Shadi Al-Khzouz
           Feras Hamati

                              1
                  ANATOMY
   Butterfly-shape organ.
   Composed of two lobes connected by isthmus.
   The organ is situated on the anterior side of the
    neck, lying against and around the larynx and
    trachea, reaching posteriorly the esophagus and
    carotid sheath.



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               PHYSIOLOGY
   Production of triiodothyronine T3, thyroxine T4
    and calcitonin
   Up to 80% of T4 is converted to T3 in
    peripheral organs such as liver, kidney and
    spleen.
   T3 is several times more powerful than T4



                                                  4
5
Thyroid Disorders




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       HyperThyroidism
            (Thyrotoxicosis)

Definition:
Excessive secretion of T3, T4

Affects metabolic processes in all body
organs



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       Hyperthyroidism

Four to ten times more prevalent in
women.

 Second only to Diabetes as the most
common occurring endocrine disease.

   Usually occurs in ages 30-50.       8
Most common types
   Graves‟ Disease.

   Multinodular Goiter.
    (Toxic Adenoma)



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      Graves’ Disease
Pathophysiology:
 Thyroid stimulated by immunoglobulins.



 Causes gland to enlarge and hypersecrete
hormones.



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    Graves’ Disease
 Incidence
20-40 years of age
Women
Heridity
Stress
Infection

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Signs & Symptoms
Cardiac
Systolic hypertension
Tachycardia
Palpitations
Dysrhythmias
Atrial Fibrillations
Angina , Heart failure
Dyspnea


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Signs & Symptoms
   Neuromuscular.
Fine tremors
Nervousness
Hyperactive DTR‟s
 Exophthalmos.
 Periorbital Edema.

 Fine, Soft, Silky Hair.

                            13
Signs & Symptoms
   GI
Increased appetite
Weight loss
Thirst
Diarrhea
Hyperactive Bowel sounds




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Signs & Symptoms
• Other
– Amenorrhea
– Increased libido
– Weakness
– Fatigue
– Smooth moist skin
– Goiter
– ↑ Temp
– Insomnia



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Proptosis & Goiter




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             Diagnostics

����   Increased T3, T4
����   Decreased TSH
����   No response to TRH
����   Thyroid Scan (RAI Uptake)
����   Increased uptake of iodine
����   Enlarged gland
����   Ultrasound
                                  18
   Treatment of
  Hyperthyroidism
• Medications
– Antithyroid meds
• Propylthioracil (PTU)
• Tapazol (methimazole)
– Iodine
• Lugol’s Solution
• Radioactive Iodine Therapy


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   Treatment of
  Hyperthyroidism
• Medications Continued:



– Beta Adrenergic Blockers
• Inderal (Propranolol)




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Surgical Treatment of
  Hyperthyroidism
• Procedure: thyroidectomy

• Preoperatively
– Euthyroid
– Nutrition
– Decrease stress
– Teaching



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               Postoperative
               Management
����   Support head and neck
����   Hemorrhage
����   Respiratory Obstruction
����   Humidified Air
����   Oral/tracheal suctioning
����   Voice checks every 1 to 2 hours
����   Eye Care
����   Home Care


                                       22
            Post Op Electrolytes
• Monitor for Hypocalcemia

– Tetany
– Chvostek’s Sign ; a spasmodic muscular contractions after
   nerve stimulation.

– Trousseau’s Sign




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          Complications of
          Hyperthyroidism
• Thyroid Storm or Crisis
– Acute exacerbation of S & S
• Heart failure
• Shock
• Hyperthermia
• Tachycardia, Hypertension
• Confusion
• Seizures … Coma


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                 Hypothyroidism
Hypothyroidism   is a disorder with multiple causes in
which the thyroid fails to secrete an adequate amount of
thyroid hormone.

      Usually caused by primary thyroid gland failure.
      Also may result from diminished stimulation of the thyroid
       gland by TSH.




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             Hypothyroidism
• Severe state: myxedema
• Usually seen in age 50+ but can
happen at any age
• Results from deficiency of
 thyroid hormones
• Called “Cretinism” in children



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            Hypothyroidism
• Primary
– Defect in thyroid gland
– Congenital
– Post treatment of hyperthyroidism
– Thyroiditis
• Secondary
– Deficiency in TSH
– Peripheral resistance to thyroid hormones

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             Hypothyroidism
- Decreased T3 and T4
- Increased TSH if cause is thyroid
- Decreased TSH if cause is pituitary or
hypothalamus




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Clinical features of hypothyroidism
           Fatigue                       Puffy Eyes

Forgetfulness/Slower Thinking         Swelling (Goiter)

   Moodiness/ Irritability
                                      Hoarseness/
                                    Deepening of Voice
         Depression
                                Persistent Dry or Sore Throat
   Inability to Concentrate

                                   Difficulty Swallowing
  Thinning Hair/Hair Loss

     Loss of Body Hair               Slower Heartbeat


      Dry, Patchy Skin            Menstrual Irregularities/
                                      Heavy Periods
        Weight Gain
                                         Infertility
      Cold Intolerance
                                        Constipation
    Elevated Cholesterol
                                     Muscle Weakness/
                                         Cramps




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            Hypothyroidism
Cardiovascular signs & symptoms :
• Bradycardia
• Decreased Cardiac Output
• Chest Pain
• Hypotension
• Atherosclerosis
• Cardiomegaly

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            Hypothyroidism
  GI Signs and Symptoms :
• Constipation
• Decreased Appetite
• Slight Weight Gain
• Thick Tongue




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            Hypothyroidism
  Reproductive Signs & symptoms :
 • Decreased Libido
• Altered Mensese




                                     33
           Hypothyroidism
 Hemopoietic signs & symptoms :
• Anemia
• Decreased Serum Iron
• Decreased Serum Folate
• Results in Increased Bruising




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            Hypothyroidism
  Other Signs and Symptoms :
• Fatigue, lethargy, weakness
• Intolerance to cold
• Joint pain
• Edema
• Depression
• Thick brittle nails
• Dry course hair

                                35
    Hypothyroidism Risk Factors :
   Risk Factors
       Age (> men 60 yrs, women > 35 yrs)
       Sex (female, 5% prevalence)
       Presence of Goiter
       History of hyperthyroidism
       History of thyroiditis
       Family history
       History of head or neck cancer or thyroid surgery
       Autoimmune disease
       Drugs (lithium, amiodarone, steroids, interferon)
       Hypercholesterolemia

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                Treatment of
               Hypothyroidism
   Levothyroxine (Synthyroid) :
   Low dose therapy with gradual increase
   Evaluate patient response
   Watch for CV adverse reactions
   Partial thyroidectomy :
   Large goiter



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Pregnancy and
Thyroid disease



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         Thyroid disease in Pregnancy
   Hypothyroidism in pregnancy may be difficult to diagnose
     Signs and symptoms overlap with common pregnancy
      complaints
     Among pregnant hypothyroid patients
            33% have few or no symptoms
            33% have moderate symptoms
            33% have classical presentation of hypothyroidism
       Maternal thyroid deficiency has been linked to reduced fetal
        neuropsychological development


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      Hypothyroidism: Maternal and
              Fetal Risks

Maternal                  Fetal
 Miscarriages            SGA
 PIH                      IUGR
 Preterm delivery        Prematurity
 Postpartum hemorrhage   Transient Hypothyroidism



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          THYROIDITIS
PAINFUL                                PAINLESS

INFECTIOUS                POSTVIRAL
                          Subacute granulomatous
ACUTE                CHRONIC
  (Immunocompromised)
Staphylococcus,    Mycobacteria
Streptococcus      Pneumocystic carinii
Pnuemococcus       Fungal



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             PAINLESS
1.   HASHIMOTOS THYROIDITIS
2.   SUBACUTE THYROIDITIS
3.   REIDEL’S THYROIDITIS
4.   CHRONIC NONSPECIFIC
     THYROIDITIS




                              42
        HASHIMOTO
    THYROIDITIS / CHRONIC
       LYMPHOCYTIC
        THYROIDITIS
   Autoimmune disease
   Most common cause of hypothyroidism
   Gradual thyroid failure
   Age: 40-65yrs
   F>M
   Major cause of non-endemic goiter (in children)
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          ETIOLOGY

 Genetic component
 Non-Mendelian pattern of inheritance

 Concordance rate in monozygotic
 twins: 30%-60%
 Association: Turner syndrome, Downs
 syndrome
 HLA-DR3 AND HLA-DR5

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         CLINICALLY
 Hypothyroidism
 Sometimes: Hashitoxicosis

 Increased risk for developing other
 autoimmune diseases as well as B-cell
 NHL



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            Thyroid malignancies
   Follicular cell origin
     Papillary carcinoma - 70%
     Follicular carcinoma - 25%

     Anaplastic carcinoma - rare

   Parafollicular „C‟ cell origin
       Medullary carcinoma - 5%




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               Papillary carcinoma
   Follicular cell origin
   Well-differentiated
   Arises mostly in young adults
   Often multifocal
   Metastasises via lymphatics to neck nodes
   Slow-growing
   Excellent prognosis
   Treatment
       Surgery - lobectomy/thyroidectomy
       Iodine-131
       ± EBRT

                                                47
               Follicular carcinoma
   Follicular cell origin
   Most common in middle age
   Metastasises via blood stream
       Characteristically spreads to bone, lung
   Good prognosis
   Treatment
       Surgery
       Iodine-131
       ± EBRT


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             Anaplastic carcinoma
   Follicular cell origin
   Occurs exclusively in the elderly
   Poorly differentiated
   Rapidly progressive with direct invasion of adjacent
    structures
   Very poor prognosis
   Treatment - poor response
       Surgery?
       EBRT?
       (Iodine-131?)

                                                           49
              Medullary carcinoma
   Arises in parafollicular „C‟ cells
   Sporadic or part of MEN syndrome
   Small cells containing neuro-endocrine granules
   Occurs in middle-aged and elderly
   Slow-growing
   Metastasises to lymph nodes
   Secretes calcitonin (blood test)
   Treatment
       Surgery
       EBRT (but relatively radio-resistant)
       Low uptake of iodine-131 - limited role

                                                      50
                 Diagnostic tools

   History and examination
   Thyroid function tests
       T3, T4, TSH
   Tumour markers
       Thyroglobulin
       Anti-TG antibodies
   Iodine-123 or 131 scan
   Ultrasound
   Biopsy


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