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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
What are some of the complications of Local Mass Effects
* Headaches * Visual field defects * CSF rhinorrhoea * Cranial nerve palsy and temporal lobe epilepsy
26
What does a lack of production of ADH mean
• Diabetes insipidus | - ADH deficiency means decreased water absorption in kidney resulting in polyuria & polydipsia)
27
What are the causes of hypopituitarism
* Pituitary tumours * Radiotherapy * Trauma * Infarction *  Infection (TB, syphilis)
28
What is Acromegaly
* Excessive growth hormone secretion with high IGF-1 levels | * Delayed diagnosis by 7-10 years
29
What are the clinical features of Acromegaly
* Enlargement of supraorbital ridges * Macroglossia * Headaches * Spade-like hands * Joint pain * Hypertension * Impaired glucose tolerance * Impaired glucose tolerance
30
How do we investigate for acromegaly
• Investigate: - IGF-1 levels (GH stimulates liver to produce IGF-1) - dynamic tests - MRI pituitary
31
How do we treat patients with acromegaly
* 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
What are the dental related complications of Acromegaly
* Jaw malocclusion * Teeth mobility * Speech difficulty (macroglossia) * Missing teeth * Teeth separation * Thickening of alveolar processes * Enlarged posterior roots
33
Describe the hypothalamic-pituitary-adrenal axis
* Hypothalamus release corticotropin releasing hormone (CRH) * This acts on the pituitary gland to produce ACTH * ACTH drives the adrenal gland to produce cortisol
34
What is Cushing's syndrome
* 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
What are the clinical features on Cushing's Syndrome
* Weight gain * Moon face * Acne * Bruising * Striae * Osteopenia * Glucose intolerance *  Muscle weakness * Edema * Hirsutism
36
How do we investigate for Cushing's syndrome
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
How do we treat cushing's syndrome
* Surgery * Drugs * Consider radiotherapy for pituitary disease if surgery fails
38
What is primary adrenocortical insufficiency
• Adrenal gland is not producing enough cortisol meaning ACTH levels increase
39
What is secondary adrenocortical insufficiency
• Low ACTH resulting in low cortisol production from the adrenal gland
40
What are the causes of adrenal insufficiency
``` 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
What are the clinical features of adrenal insufficiency
* Weakness * Skin and mucous membrane pigmentation * Loss of weight, emaciation, anorexia, vomiting, diarrhoea * Hypotension * Salt craving * Hypoglycemic episodes
42
How do we investigate for adrenal insufficiency
HORMONAL TESTS: - Dynamic stimulation test (Synacthen test) measuring cortisol - ACTH, adrenal antibodies
43
RADIOLOGICAL (if hormonal tests abnormal)
* MRI pituitary * CT or MRI adrenals * CXR if suspecting TB
44
How do we treat adrenal insufficiency
• Hydrocortisone replacement treatment
45
When is Glucocorticoid cover appropriate for dental procedures
• 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
What are the endocrine causes of hypertension
* Primary aldosteronism * Phaeochromocytoma * Acromegaly * Cushing's syndrome * Hypo/Hyper - thyroidism

Endocrinology & Diabetes (4 decks)

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