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Endocrinology & Diabetes > The Medical and Surgical Management of Thyroid, Pituitary & Adrenal Disorders > Flashcards

The Medical and Surgical Management of Thyroid, Pituitary & Adrenal Disorders Flashcards

1
Q

What does the thyroid gland do

A

• Produces hormones:

  • Thyroxine (T4) & Tri-iodothyronine (T3) regulate basal metabolic rate
  • Calcitonin which regulates blood calcium levels

• Able to store large amounts of inactive hormone within extracellular follicles (unique among other endocrine glands)

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2
Q

Describe the hypothalamus-pituitary-thyroid axis (HPT)

A
  • Hypothalamus senses low T3 & T4 and responds by releasing TRH (thyrotropin-releasing hormone)
  • The TRH stimulates the the anterior pituitary to produce TSH (stimulating)
  • The TSH then stimulates the thyroid to produce thyroid hormone until levels in the blood return to normal
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3
Q

If a thyroid problem is suspected which three hormones would you measure

A
  • T4
  • T3
  • TSH (tested first) - High TSH could mean low levels of T4 and so the body is producing more TSH to compensate and try to produce more T4 which is still low - malfunction
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4
Q

What could low levels of TSH AND T4 indicate?

A

• Pituitary tumour

- means that pituitary gland cannot produce much TSH which means T4 is not produced also

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5
Q

Describe the hormone concentrations in someone with primary thyroid gland failure (hypo)

A
  • LOW T3 & T4
  • HIGH TSH
  • WITH GOITRE
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6
Q

Describe the hormone concentrations in someone with secondary hypothalamic or pituitary failure (hypo)

A
  • LOW TSH, T4, T3

* NO GOITRE

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7
Q

Describe the hormone concentrations in someone with iodine deficiency (hypo)

A
  • LOW T3 & T4
  • HIGH TSH
  • WITH GOITRE
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8
Q

What are the clinical features of hypothyoidism

A
  • Weight gain
  • Lethargy
  • Increased sleep
  • Constipation
  • Dry skin
  • Hair loss
  • Muscle weakness
  • Facial puffiness
  • Periorbital oedema
  • Hoarseness
  • Delayed reflexes
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9
Q

What are the primary causes of Hypothyroidism

A
  • Dyshormonogenesis
  • Iodine deficiency
  • Autoimmunity
  • Post radioactive iodine
  • Post thyroidectomy
  • Iodine excess
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10
Q

What are the secondary and tertiary causes of hypothyroidism

A

• Pituitary tumours/granulomas

  • Hypothalamic disorders
  • Isolated TRH deficiency
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11
Q

When would you screen for hypothyroidism

A
  • Neck irradiation
  • Patients on lithium and amiodarone
  • Congenital hypothyroidism
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12
Q

How would we investigate and manage hypothyroidism

A
  • Thyroid function tests, thyroid antibodies

* Treat with levothyroxine

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13
Q

What are the dental complications in hypothyroidism

A
  • Delayed eruption
  • Enamel hypoplasia
  • Macroglossia
  • Micrognathia
  • Thick lips
  • Dysgeusia (taste distortion)
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14
Q

In someone with hyperthyroidism - what hormone abnormalities would you expect

A
  • HIGH TSH

* HIGH T3 & T4

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15
Q

In someone with abnormal thyroid-stimulating immunoglobulin (Grave’s disease) what hormone abnormalities would you expect

A
  • HIGH T3 & T4
  • LOW TSH
  • WITH GOITRE
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16
Q

In someone with hyper secreting thyroid tumour what hormone abnormalities would you expect

A
  • HIGH T3 & T4

* LOW TSH

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17
Q

What are the causes of hyperthyroidism

A
  • Autoimmune thyroid disease (grave’s disease)
  • Toxic nodular goitre
  • Toxic adenoma

RARE:

  • hCG hyperthyroidism
  • Thyrotroph adenoma
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18
Q

What are the clinical features of hyperthyroidism

A
  • Weight loss
  • Anxiety
  • Increased sweating
  • Increased appetite
  • Lid Lag
  • Goitre
  • Tachycardia
  • Atrial fibrillation
  • Muscle weakness
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19
Q

What is typical of patients with graves disease

A
  • Diffuse goitre
  • Eye signs (protruded eyeballs)
  • Pretibial myxoedema (red shins)
  • Vitiligo and features of other autoimmune disease
20
Q

How do we investigate for graves disease

A
  • TSH receptor Antibodies
  • TPO antibodies
  • Thyroglobulin antibodies
  • Thyroid radioisotope scan
21
Q

How do we treat graves disease

A
  • Medical
  • Surgical
  • Radioactive iodine
22
Q

What are the dental complications of hyperthyroidism

A
  • Accelerated dental eruption
  • Increased susceptibility to caries
  • Perio disease
  • Increased sensitivity to epinephrine may result in arrhythmias or palpitations
  • Surgery, oral infection and stress may precipitate thyroid crises
23
Q

How do people with pituitary dysfunction present

A
  • Tumour mass effects
  • Hormone excess
  • Hormone deficiency
24
Q

How can we investigate for pituitary dysfunction

A
  • Hormonal tests

* If hormonal tests abnormal or tumour mass effects - perform MRI pituitary

25
Q

What are some of the complications of Local Mass Effects

A
  • Headaches
  • Visual field defects
  • CSF rhinorrhoea
  • Cranial nerve palsy and temporal lobe epilepsy
26
Q

What does a lack of production of ADH mean

A

• Diabetes insipidus

- ADH deficiency means decreased water absorption in kidney resulting in polyuria & polydipsia)

27
Q

What are the causes of hypopituitarism

A
  • Pituitary tumours
  • Radiotherapy
  • Trauma
  • Infarction
  • Infection (TB, syphilis)
28
Q

What is Acromegaly

A
  • Excessive growth hormone secretion with high IGF-1 levels

* Delayed diagnosis by 7-10 years

29
Q

What are the clinical features of Acromegaly

A
  • Enlargement of supraorbital ridges
  • Macroglossia
  • Headaches
  • Spade-like hands
  • Joint pain
  • Hypertension
  • Impaired glucose tolerance
  • Impaired glucose tolerance
30
Q

How do we investigate for acromegaly

A

• Investigate:
- IGF-1 levels (GH stimulates liver to produce IGF-1)

  • dynamic tests
  • MRI pituitary
31
Q

How do we treat patients with acromegaly

A
  • Surgical resection - TSS, TFS
  • Biochemical control
  • Somatostatin - from hypothalamus & inhibits production of GH
  • Pegvisomant reduces IGF-1 to levels >90%
  • Radiotherapy in unsuccessful surgery
32
Q

What are the dental related complications of Acromegaly

A
  • Jaw malocclusion
  • Teeth mobility
  • Speech difficulty (macroglossia)
  • Missing teeth
  • Teeth separation
  • Thickening of alveolar processes
  • Enlarged posterior roots
33
Q

Describe the hypothalamic-pituitary-adrenal axis

A
  • Hypothalamus release corticotropin releasing hormone (CRH)
  • This acts on the pituitary gland to produce ACTH
  • ACTH drives the adrenal gland to produce cortisol
34
Q

What is Cushing’s syndrome

A
  • Production of excess cortisol - can be in pituitary or adrenal gland
  • Excess cortisol due to an adrenal tumour means ACTH levels will go down
  • A pituitary tumour means excess ACTH is produced and therefore excess Cortisol
35
Q

What are the clinical features on Cushing’s Syndrome

A
  • Weight gain
  • Moon face
  • Acne
  • Bruising
  • Striae
  • Osteopenia
  • Glucose intolerance
  • Muscle weakness
  • Edema
  • Hirsutism
36
Q

How do we investigate for Cushing’s syndrome

A

HORMONAL TESTS:
- Dynamic Suppression tests (giving steroid means cortisol production is stopped in normal pt. Giving it to someone with cushing’s means cortisol is still produced)

RADIOLOGICAL:

  • MRI pituitary
  • CT adrenals
  • CT chest, abdomen, pelvis (ectopic ACTH tumour)
37
Q

How do we treat cushing’s syndrome

A
  • Surgery
  • Drugs
  • Consider radiotherapy for pituitary disease if surgery fails
38
Q

What is primary adrenocortical insufficiency

A

• Adrenal gland is not producing enough cortisol meaning ACTH levels increase

39
Q

What is secondary adrenocortical insufficiency

A

• Low ACTH resulting in low cortisol production from the adrenal gland

40
Q

What are the causes of adrenal insufficiency

A 
PRIMARY:
• Autoimmune
• TB
•Fungal infections
• Adrenal haemorrhage
• Sarcoidosis
• Amyloidosis
• Metastatic neoplasia

SECONDARY:
• After exogenous glucocorticoids

  • After treatment of cushing’s
  • Hypothalamic or pituitary tumours
41
Q

What are the clinical features of adrenal insufficiency

A
  • Weakness
  • Skin and mucous membrane pigmentation
  • Loss of weight, emaciation, anorexia, vomiting, diarrhoea
  • Hypotension
  • Salt craving
  • Hypoglycemic episodes
42
Q

How do we investigate for adrenal insufficiency

A

HORMONAL TESTS:
- Dynamic stimulation test (Synacthen test) measuring cortisol

  • ACTH, adrenal antibodies
43
Q

RADIOLOGICAL (if hormonal tests abnormal)

A
  • MRI pituitary
  • CT or MRI adrenals
  • CXR if suspecting TB
44
Q

How do we treat adrenal insufficiency

A

• Hydrocortisone replacement treatment

45
Q

When is Glucocorticoid cover appropriate for dental procedures

A

• On treatment therapy e.g.) asthma, rheumatoid arthritis.

  • Prednisolone > 7.5mg
  • Hydrocortisone > 30mg
  • Dexamethasone > 0.75mg

• On replacement therapy:

  • Addison’s
  • ACTH deficiency
    e. g.) Hydrocortisone 20/10mg 10/5/5 mg

For simple procedures:
- Double dose one hour before surgery, double dose oral medication for 24 hours

46
Q

What are the endocrine causes of hypertension

A
  • Primary aldosteronism
  • Phaeochromocytoma
  • Acromegaly
  • Cushing’s syndrome
  • Hypo/Hyper - thyroidism

Endocrinology & Diabetes (4 decks)

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