Thyroid diseases

Thyroid syndrome is a symptom complex caused by thyroid pathology. There are many diseases, but thyroid diseases come to the forefront, giving a pronounced clinical picture. Considering the law of feedback for all endocrine diseases, the syndrome should be examined together with an endocrinologist, gynecologist, mammologist and other narrow specialists-diagnosticians, in particular with a therapist and neurologist, since thyroid diseases are accompanied by a violation of cardiac activity and nervous system function. Goiters can be sporadic, when cases are isolated for a given area, and endemic; when the disease occurs in 10% of the adult population and in 20% of adolescents.

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Forms

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Thyroid adenomas

Benign diseases of the thyroid gland, often closely pathogenetically associated with breast pathology and gynecological diseases, in particular with adenomas and fibroadenomas.

Depending on the secretion of thyroid hormone, adenoma can have hyperthyroid (toxic), normothyroid and hypothyroid forms. In toxic adenoma, unlike diffuse toxic goiter, there is no ophthalmopathy. In most cases, subjective sensations with this thyroid disease are absent and no functional disorders are detected during external examination. Palpation reveals an elastic soft formation (rarely several) of a round or oval shape, clearly delimited from the surrounding tissues by a capsule, smooth, elastic, mobile, painless. The consistency depends on the duration of the adenoma: soft at first, then denser as the capsule fibrosizes. Ultrasound and magnetic resonance imaging provide information on the presence, location of the adenoma, and the state of its capsule. The functional state is assessed by the thyrogram using the iodine-131 isotope (scintigraphy is also performed simultaneously) and the content of thyroid hormones in the blood plasma. The morphological form (microfollicular, macrofollicular, tubular) is determined by the data of a puncture biopsy.

The tactics are individual for each case, agreed upon with an endocrinologist; absolutely surgical treatment is indicated for large adenomas, toxic form, and the presence of any complications.

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Diffuse toxic goiter

Autoimmune diseases of the thyroid gland, accompanied by its hyperfunction and hypertrophy. During examination and palpation, it is enlarged, diffuse, mobile, of varying density.

According to the law of feedback, the function of other endocrine organs is inhibited in thyrotoxicosis. First of all, the function of the pituitary gland is inhibited, which leads to disruption of neurohumoral regulation and dysfunction of the nervous system, both sympathetic and vegetative. The genitals in women - various forms of dysmenorrhea, mastopathy; in men - testicular impotence, gynecomastia. The adrenal glands - decreased function up to the development of hypocorticism. The liver and kidneys - decreased function and morphological changes up to the development of fatty or granular dystrophy. The pancreas - lability of insulin formation with transition to insufficiency, dystrophic tissue changes. This determines the development of dyspeptic disorders in the form of diarrhea, nausea, vomiting, weight loss. At the same time, hyperfunction of the thymus is noted, which initially gives a picture of myopathy, accompanied by severe muscle weakness, up to the development of myasthenia.

The symptom complex of dysfunction of the nervous system manifests itself earliest and often determines the severity and prognosis of thyroid disease: emotional lability, insomnia, headache, dizziness; anxiety, sweating, palpitations and tachycardia, shortness of breath, tremors of the hands and the whole body. In patients with thyrotoxicosis, ophthalmopathy develops: the eyes are wide open (Dalrymple's symptom), bulging, shiny, blinking is rare (Stellwag's symptom), the eyes remain wide open even during laughter (Brahm's symptom), the movements of the eyeballs are faster than the eyelids, so when looking down, a strip of sclera is visible between the upper eyelid and the iris (Eoher's symptom), the upper eyelid lags behind the iris when looking down behind an object (Graefe's symptom), convergence of the eyeballs is impaired (Moebius's symptom), the eyelids are pigmented (Jellinek's symptom), they twitch and move unevenly downwards, not parallel to the eyeballs (Boston's symptom), the upper eyelid drops spasmodically and lags behind the eyeball (Popov's symptom), they are edematous, and the edema in the upper eyelid has a characteristic "fluffy" appearance, and a saccular edema forms at the lower eyelid (Enroth's symptom), and the edema is dense and the upper eyelid is difficult to evert (Gifford's symptom).

Tactics: the endocrinologist carries out a complex of drug therapy until thyrotoxicosis is relieved, then the issue is resolved individually:

1. continuation of drug treatment for this thyroid disease;
2. radioactive iodine treatment;
3. performing a strumectomy.

The operation is indicated for large organ sizes, intolerance to medications for medical treatment, impossibility of long-term therapy, and lack of effect from conservative therapy.

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Nodular goiter

The most common thyroid diseases, which are based on the lack of iodine in the body. Often endemic.

According to the law of feedback, with chronic iodine deficiency in the body, the pituitary gland is activated, stimulating the thyroid function, which leads to its hyperplasia in certain areas, where cysts and fibrous calcifications are formed, causing the formation of nodes. The adrenal cortex is suppressed, which is manifested by mental instability, especially during stressful situations, and increased pain sensitivity. The functions of the thyroid gland itself are not impaired for a long time. Growth is very slow (for years and decades), which distinguishes it from cancer.

Hyperplasia can be diffuse, nodular and mixed. When palpated, diffuse hyperplasia reveals a smooth surface and elastic consistency; nodular hyperplasia reveals a dense, painless, mobile elastic formation in the thickness; mixed hyperplasia reveals nodes or a node against the background of hyperplasia. Regional lymph nodes are not involved in the process.

The main clinical sign of thyroid disease is an enlargement of the organ, which is used to determine the degree of development of nodular goiter:

• 0 degree - not visible and not determined by palpation;
• Grade I - not visible during examination, but upon palpation during swallowing, the isthmus is determined and the lobes can be palpated;
• Grade II – the thyroid gland is visible during examination during swallowing, is clearly defined by palpation, but does not change the configuration of the neck;
• Grade III - an enlarged thyroid gland changes the configuration of the neck in the form of a “thick neck”;
• IV degree - the thyroid gland is visible during examination and changes the configuration of the neck in the form of a protruding goiter;
• Grade V - the enlarged organ leads to compression of the trachea, mediastinal organs and neurovascular trunks.

The diagnosis is confirmed by ultrasound and magnetic resonance imaging. Thyreography reveals increased iodine absorption, and scanograms reveal uniform enlargement of the thyroid gland in the diffuse form, and "cold" and "hot" areas in the presence of nodes. Protein-bound iodine and thyroxine levels are normal, while triiodothyronine is usually elevated.

Tactics: treatment of this thyroid disease is mainly conservative by an endocrinologist and therapist; indications for surgery are the presence of nodes, especially "cold" ones, rapid growth of goiter, stage 4-5 goiter, suspicion of malignancy.

Usher syndrome may occur sporadically. The presence of goiter without dysfunction, which is accompanied by recurrent swelling of the upper lip and upper eyelids. It does not require treatment, the swelling disappears on its own within a week.

Thyroiditis

Acute purulent thyroiditis - these diseases of the thyroid gland are extremely rare, usually with direct injury to the organ or as a complication of puncture biopsy, less often as a transitional form with submandibular abscesses or erysipelas of the neck, even less often with tonsillitis; when the infection penetrates through the lymphogenous route, but can also occur with other purulent processes, when the embolus is carried into the organ through the hematogenous route.

It begins acutely and is accompanied by the development of purulent-resorptive fever.

The local process may occur as an abscess or phlegmon. The pain is sharply expressed, radiating to the ears, back of the head, collarbones. The skin above the inflammation zone is hyperemic, edematous, compacted, palpation is sharply painful, fluctuation may occur, regional lymph nodes are enlarged, dense, painful upon palpation. The process may spread to the trachea and larynx, mediastinum.

Tactics: these thyroid diseases require immediate hospitalization in a surgical hospital for surgical treatment.

Subacute thyroiditis (de Quervain's) is an infectious-allergic process with sensitization to a viral infection. As a rule, it occurs with other infectious-allergic HLA-dependent diseases, but the presence of the B-15 antigen is characteristic.

Depending on the course of the disease, the following are distinguished: rapidly progressing form; forms with a slow progression of the disease; with signs of thyrotoxicosis: pseudoplastic form with pronounced compaction and enlargement.

These thyroid diseases begin acutely against the background of an existing or past respiratory infection. There are no signs of purulent intoxication, the general condition of the patients changes little. They are bothered by pain, which intensifies when swallowing, turning the neck, and may radiate to the ears and head. The thyroid gland is enlarged, dense, painful to palpation, mobile, the skin above it may be somewhat hyperemic, moist. Regional lymph nodes are not enlarged, the level of protein-bound iodine and thyroidin in the blood increases, but the absorption of iodine isotopes, on the contrary, decreases.

Tactics: treatment of this thyroid disease is conservative by an endocrinologist, but the course is long, up to six months, even with active treatment.

Autoimmune thyroiditis (Hashimoto's thyroiditis) is a chronic disease of the thyroid gland that develops as a result of autoimmunization of the body with thyroid autoantigens. The pathology is very rare, if goiter develops in an unchanged organ, the process is defined as thyroiditis, when it develops against the background of a former goiter, it is defined as strumitis.

A distinctive feature is the functional phase of the course of thyroid disease: hyperthyroidism is replaced by a euthyroid state, which turns into a hypothyroid state. The course is slow. Therefore, the clinical picture is diverse and non-specific in manifestations. Subjective sensations are mainly in the form of a feeling of constriction in the neck, a sore throat and a lump in the throat when swallowing, hoarseness. At the beginning of thyroid disease, the symptoms of hyperthyroidism are: irritability, weakness, palpitations, and there may be ophthalmopathy. In the late stage of hypothyroidism, manifestations are: chilliness, dry skin, memory loss, slowness.

An objective examination reveals an enlarged thyroid gland with single or multiple compactions, it is mobile and not fused with the surrounding tissues, painless, regional lymph nodes may be enlarged and compacted. In the blood, changes in the leukocyte formula are characteristic: lymphocytosis and a decrease in monocytes, hyperproteinemia, but with a decrease in alpha and beta globulins. The content of thyroid hormones and the absorption of iodine isotopes depend on the stage of the disease. In the puncture, clusters of lymphocytes, lymphoblasts, plasma cells are detected, degeneration of follicular cells is noted. Immune testing (Boyden reaction) reveals a high titer of antibodies to thyroglobulin. For differential diagnosis, a test with prednisolone is performed (15-20 mg per day - 7-10 days), which notes a rapid decrease in density, which is not given by any other pathology.

Tactics: treatment of thyroid disease is mainly conservative by an endocrinologist. Surgical treatment is indicated if there is a suspicion of malignancy, compression of the neck organs, rapid growth, lack of effect from drug treatment.

Chronic fibrous thyroiditis (Riedel's goiter) - these thyroid diseases are extremely rare and, according to many endocrinologists, are the final stage of Hashimoto's thyroiditis. It progresses slowly, the symptoms are mild and appear only when the trachea, esophagus, vessels and nerves of the neck are compressed. The thyroid gland is characterized by the formation of a very dense ("stony" consistency) goiter, which is fused with the surrounding tissues and is immobile. It differs from cancer only in its slow growth and the absence of oncosyndrome.

Tactics: referral to a surgical hospital for surgical treatment of thyroid disease.

Hypothyroidism

A disease characterized by a decrease or complete loss of function.

Hypothyroidism can be: congenital - with aplasia or hypoplasia; acquired - after strumectomy, with thyroiditis and strumitis, autoimmune diseases, with exposure to ionizing radiation and some drugs (mercazolyl, iodides, corticosteroids, beta-blockers); tertiary - with damage to the hypothalamus and pituitary gland (inhibition of function according to the law of feedback). From other endocrine organs, inhibition of the adrenal cortex with the development of hypocorticism is noted. Pathogenesis is due to a violation of the intracellular metabolism of proteins, fats and carbohydrates.

The clinical picture of thyroid disease develops gradually, with few symptoms, and significant changes in the body are formed only in the later stages of the disease. Subjectively, it manifests itself as chilliness, decreased memory and attention, lethargy, drowsiness, and difficulty speaking. During examination, weight gain, pale and dry skin, amimia, pastosity and puffiness of the face, dry skin, frequent hair loss on the head and hairlessness of the body, enlargement and swelling of the tongue, and the presence of dense, non-pressible edema are detected. This thyroid disease is characterized by Behr's symptom - excessive keratinization and thickening of the epidermis on the knees, elbows, back of the feet and inner ankles, while the skin acquires a dirty gray color. The voice is low, "creaky". Blood pressure tends to hypotension, but there may also be hypertension, muffled heart sounds, bradycardia. Cholecysto-pancreato-duodenal syndrome often develops.

In severe hypothyroidism, a decrease in free thyroxine and protein-bound iodine, triiodothyronine is observed. The level of thyrotropin increases. To obtain reliable results of the absorption capacity of iodine isotopes, it is necessary to stop taking medications for several days, while a significant decrease in function is revealed. Blood tests reveal: normochromic anemia, leukopenia, lymphocytosis. The cholesterol level is elevated. In the subclinical stage of thyroid disease, a thyrotropin-releasing hormone test is performed to confirm the diagnosis (intravenously 500 mcg), which causes an even greater increase in the level of thyrotropin in blood plasma.

Tactics: treatment of thyroid disease is conservative by an endocrinologist. In surgical terms, detection of hypothyroidism is necessary to ensure adequate anesthetic care (preparation of the hormonal background and adrenal glands) and pathogenetic justification of cholecysto-pancreato-duodenal syndrome and decreased intestinal motility in terms of differential diagnosis with organic pathology.

Differential diagnostics of this thyroid disease is carried out with pathological processes accompanied by its enlargement and compaction.