Diseases of the thyroid gland

Thyroid syndrome is a symptom complex due to the thyroid pathology. There are a lot of diseases, but thyroid diseases that give a pronounced clinical picture come to the fore. Given the law of feedback for all endocrine diseases, the syndrome should be tested together with an endocrinologist, gynecologist, mammologist and other narrow diagnostic specialists, in particular a therapist and neurologist, since thyroid disorders are accompanied by a violation of cardiac activity and nervous system function. Zobs can be sporadic in nature, when the cases are unique for this locality and endemic; when the disease occurs in 10% of the adult population and in 20% of adolescents.

[1], [2]

Forms

[3]

Adenomas of the thyroid gland

Benign thyroid gland diseases, often pathogenetically closely related to breast pathology and gynecological diseases, in particular adenomas and fibroadenomas.

Depending on the secretion of the thyroid hormone, the adenoma can have a hyperthyroid (toxic), normothyroid and hypothyroid forms. With toxic adenoma, unlike  diffusively toxic goiter, there is no ophthalmopathy. In most cases, subjective sensations in this thyroid disease are absent and when external examination of functional disorders is not detected. Palpatorically reveals an elastic soft formation (rarely several) of round or oval shape, clearly delimited from surrounding tissues by a capsule, smooth, elastic, mobile, painless. Consistency depends on the timing of the adenoma: at first soft, in the future, as the capsule is fibrous, more dense. The presence, location of the adenoma, the state of its capsule makes it possible to know ultrasound, magnetic resonance imaging. The functional state is judged by a thyreogram using the iodine-131 isotope (both scintigraphy is carried out simultaneously) and the maintenance of thyroid hormones in the blood plasma. The morphological form (microfollicular, macrofollicular, tubular) is determined from the data of a puncture biopsy.

Tactics are individual for each case, coordinated with an endocrinologist, absolutely operative treatment is indicated for large adenoma sizes, toxic form, the presence of any complications.

[4], [5]

Diffuse toxic goiter

Autoimmune diseases of the thyroid gland, accompanied by its hyperfunction and hypertrophy. When examined and palpated, it is enlarged, diffuse, mobile, of varying density.

Under the law of feedback, with thyrotoxicosis, the function of other organs of internal secretion is inhibited. First of all, the function of the pituitary gland is inhibited, which leads to a violation of neurohumoral regulation and dysfunction of the nervous system, both sympathetic and vegetative. Sexual organs in women - various forms of dysmenorrhea, mastopathy; in men testicular form of impotence, gynecomastia. Adrenal glands - decrease in function up to the development of hypocorticism. Liver and kidneys - decreased function and morphological changes up to the development of fatty or granular dystrophy. Pancreas - lability of insulin formation with transition to insufficiency, dystrophic changes in tissue. This determines the development of dyspepsia disorders in the form of diarrhea, nausea, vomiting, weight loss. At the same time there is hyperemia of the thymus, which first gives a picture of myopathy, accompanied by severe muscle weakness, right up to the development of myasthenia gravis.

Symptomocomplex of the nervous system is manifested most early and often determines the severity - and the prognosis of thyroid disease: emotional lability, insomnia, headache, dizziness; anxiety, sweating, palpitations and tachycardia, shortness of breath, tremors of hands and whole body. In patients with thyrotoxicosis, ophthalmopathy is formed: the eyes are widely open (Dalrymple's symptom), on the rollout, shiny, flashing rare (Stelvag's symptom), the eyes remain wide open even during laughter (Bram's symptom), eyeballs movements faster than the eyelids, therefore when looking down between the upper eyelid and the iris, the scleral band (Eocher's symptom) is seen, the upper eyelid lags behind the iris when looking down behind the subject (Gref's symptom), the convergence of the eyeballs is broken (Moebius symptom), the eyelids are pigmented (Jellinek symptom ), their jerking and uneven downward movement, not parallel to the eyeballs (Boston's symptom), the upper eyelid descending jumpwise and lagging behind the eyeball (Popov's symptom), are swollen, and the edema in the upper eyelid region has a characteristic "fluffy" appearance, and the lower eyelid forms a sack-like edema (Enroth's symptom), and swelling is dense and the upper eyelid is difficult to unscrew (Gifford's symptom).

Tactics: the endocrinologist conducts a complex of medicamental therapy before the cupping of thyrotoxicosis, in the future the question is solved individually:

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

The operation is indicated for large organ sizes, with intolerance of drugs for drug treatment, the inability of long-term therapy, and the lack of the effect of conservative therapy.

[6], [7], [8], [9]

Nodular goiter

The most frequent diseases of the thyroid gland, which is based on a lack of intake of iodine. More often it is endemic.

According to the law of feedback, chronic insufficiency of iodine intake activates the pituitary gland, stimulating the thyroid function, which leads to its hyperplasia in certain areas in which cysts and fibrous calcifications are formed, which cause the formation of nodes. The adrenal cortex is oppressed, which is manifested by the lability of the psyche, especially during stressful situations, increased pain sensitivity. The functions of the thyroid gland are not disturbed for a long time. Growth is very slow (for years and decades), which is different from cancer.

Hyperplasia can be diffuse,  nodular  and mixed. Palpator for diffuse hyperplasia, the organ has a smooth surface, an elastic consistency; with the nodular form a dense, painless, mobile elastic formation is defined in the thickness; with a mixed form, the nodes or node is detected against the background of hyperplasia. Regional lymph nodes are not involved in the process.

The main clinical sign of thyroid disease is an increase in the body according to which the degree of nodular goiter is determined:

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

Confirm the diagnosis of ultrasound and magnetic resonance imaging. With thyreography, increased iodine uptake is determined, and on scannograms, a uniform increase in the thyroid gland is revealed in the diffuse form, in the presence of nodes, "cold" and "hot" areas are identified. Indicators of protein-bound iodine and thyroxine are normal, and triiodothyronine is usually elevated.

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

Sporadically, Asher syndrome can occur. The presence of goiter without a functional disorder, which is accompanied by recurrent edema of the upper lip and upper eyelids. Treatment does not require, the edema disappears on its own within a week.

Thyroiditis

Acute purulent thyroiditis - these diseases of the thyroid gland are extremely rare, usually with direct injury of the organ or as a complication of puncture biopsies, less often in the form of a transitional form with submandibular abscesses or erysipelas of the neck, even less often with anginas; when the infection penetrates the lymphogenous way, but it can also be in other purulent processes, when the embolus is injected into the organ by the hematogenous way.

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

The local process can take the form of an abscess or phlegmon. Pain sharply expressed, radiates into ears, back of head, collarbone. The skin above the inflammation zone is hyperemic, edematic, densified, palpation is sharply painful, fluctuations can occur, regional lymph nodes are enlarged, dense, painful on palpation. The process can extend to the trachea and larynx, mediastinum.

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

Thyroiditis subacute (de Kervena) - 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 antigen B-15 is characteristic.

The current is distinguished: a rapidly progressing form; forms with a slow course of the disease; with signs of thyrotoxicosis: pseudoplastic form with pronounced compaction and increase.

These thyroid disorders start acutely against the background of an existing or transferred respiratory infection. There are no signs of purulent intoxication, the general condition of patients varies little. Disturb pain, worse when swallowing, turning the neck, can be irradiation in the ears and head. The thyroid gland is enlarged in size, dense, painful on palpation, it is mobile, the skin above it can be somewhat hyperemic, moist. Regional lymph nodes are not enlarged, the level of protein bound iodine and thyroidin in the blood rises, but absorption of iodine isotopes, on the contrary, decreases.

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

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

A distinctive feature is the functional phase of the disease of the thyroid gland: hyperthyroidism is replaced by an euthyroid condition that changes into a hypothyroid state. The flow is slow. Therefore, the clinic is diverse and nonspecific in its manifestations. Subjective sensations are mainly in the form of a feeling of squeezing the neck, perspiration and coma in the throat when swallowing, the hoarseness of the voice. At the beginning of thyroid disease, symptoms of hyperthyroidism: irritability, weakness, palpitations, may be ophthalmopathy. In the late stage of hypothyroidism: chilliness, dry skin, memory loss, sluggishness.

At objective research the increased shchitovidka with single or multiple consolidations is revealed, it is mobile and not soldered with surrounding tissues, it is painless, regional lymphonoduses can be enlarged and condensed. The blood is characterized by changes in the leukocyte formula: lymphocytic and monocyte reduction, 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 punctate, clusters of lymphocytes, lymphoblasts, plasma cells are detected, and degeneration of follicular cells is noted. Immune study (Boyden Reaction) reveals a high antibody titer to thyroglobulin. For differential diagnosis, a sample with prednisolone (15-20 mg per day - 7-10 days) is performed, at which there is a rapid decrease in density, which does not give any of its other pathologies.

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

Thyroiditis chronic fibrosis (Riedel's goiter) - these thyroid diseases are extremely rare and, according to many endocrinologists, is the final stage of thyroiditis Hashimoto. It flows slowly, the symptomatology is not highly expressed and manifests itself only when the trachea, esophagus, vessels and nerves of the neck are squeezed. Shchitovidka is characterized by the formation of a very dense ("stony" consistency) goiter, which is soldered to surrounding tissues, immovable. From cancer only slow growth and the absence of an oncosyndrome.

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

Hypothyroidism

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

Hypothyroidism  can be: congenital - with aplasia or hypoplasia; acquired after sciromectomy, thyroiditis and struma, autoimmune diseases, exposure to ionizing radiation and certain medications (mercazolil, iodides, corticosteroids, beta-blockers); tertiary - with damage to the hypothalamus and pituitary gland (inhibition of the function according to the law of feedback). On the part of other organs of internal secretion, oppression of the adrenal cortex is noted with the development of hypocorticism. Pathogenesis is caused by a violation of intracellular metabolism of proteins, fats and carbohydrates.

The clinic of thyroid disease develops gradually, malosymptomatically, and pronounced changes in the body are formed only in the late stages of the development of the disease. Subjectively manifested by chilliness, decreased memory and attention, inhibition, drowsiness, difficulty speaking. The examination reveals an increase in body weight, pallor and dryness of the skin, amemia, pasty and puffiness of the face, dry skin, often hair loss on the head and hairlessness of the body, increased and swelling of the tongue, the presence of dense non-pressured edema. This symptom of the thyroid gland is characterized by the Bera symptom - excessive keratinization and thickening of the epidermis on the knees, elbows, rear of the feet and inner ankles, while the skin becomes dirty gray. The voice is low, "creaky". Arterial blood pressure is prone to hypotension, but there may be hypertension, cardiac deafness, bradycardia. Often formed cholecito-pancreato-duodenal syndrome

With expressed hypothyroidism, there is a decrease in free thyroxin and protein-bound iodine, triiodothyronine. The level of thyrotropin rises. To obtain reliable results of the absorption capacity of iodine isotopes, it is necessary to stop taking drugs for several days, and a significant decrease in function is revealed. In blood tests revealed: normochromic anemia, leukopenia, lymphocytosis. The level of cholesterol is increased. In the subclinical stage of the thyroid gland disease, a test with tyroliberin (intravenously 500 μg) is performed to confirm the diagnosis, which causes an even higher increase in the plasma blood titropin level.

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

Differential diagnosis of this disease of the thyroid gland is carried out with pathological processes, accompanied by its increase and compaction.