甲状腺课件本科生实习讲课

甲状腺疾病

（Thediseaseofthethyroid)Thyroid

VIPendocrineglandgland喉结下2～3cm，3.4trachealcartilage前H型，棕红色，20～30g左右两叶+峡部叶宽2cm，高4～5cm；峡宽、高2cm吞咽时↑↓ThyroidThyroid50－150ugI/d腺体I总量：8000ug调节：→自身调节Woffchaikoff效应KI↓T3.T4ThyroidThyroxine：促进人体发育促进protein、carbohydrate、fat分解增强组织氧耗T310%T490%SimplegoiterEtiology:Iodine-defciency相对/绝对Thyroxine合成/分泌障碍Hyperiodine～Endemic～Diffuse～Nodular～SimplegoiterClinicalfeature:BMR→thyroidenlargement+noduledyspnea/dysphagiasecondaryhyperthyroidism/malignanttransformationSimplegoiterDiagnosis:Medicalhistory:PE131I/99mTcBUSFNASimplegoiterTherapy：Iodine-defciency/pregnancy：kelp（土壤缺碘！)Diffuse～（＜20y)：甲状腺素片：30－60mgBid3－6m优甲乐：50－100ugQd±50ug/3－4w3－6mOperation：－SimplegoiterOperation：压迫症状：胸骨后～：substernalgoiter巨大～：SecondaryhyperthyroidismMalignanttransformation?Hyperthyroidism甲亢：Primary～：Graves病85－90%突眼（+)Secondary～：突眼（－)Hyperfunctioningthyroidadenoma：突眼（－)HyperthyroidismPrimary～（exophthalmicgoiter)：20－40y突眼是一种自免疾病球后纤维、脂肪增生，淋巴细胞浸润、亲水性粘多糖透明质酸沉积伴发：Ⅰ型DM，肌无力，RAPrimaryhyperthyroidismEtiology：Autoimmunedisease：HLA-DRSAg（滤泡壁细胞膜TSH－R)：*LATS、TSI、LATS-P、HTS、TR-AbPrimaryhyperthyroidismClinicalfeature:Diffuse～irritable、handtremor、hidrosis、bulimia、emaciation、rapidpulsePrimaryhyperthyroidismDiagnosis1：BMR：（PR+PP)－111N：±10%Mild：20－30%Moderate：30－60%Severe：≥60%PrimaryhyperthyroidismDiagnosis2：thyroidiodineuptake：131I2h：≥25%24h：≥50%+峰值提前和程度无关！PrimaryhyperthyroidismDiagnosis3：Fiveofthethyroidfunction：T3、T4.fT3、fT4.TSHPrimaryhyperthyroidismTherapy：131I：2mm，78%，易甲低Pharmacotherapy：50－60%（P)、33%（S)Operation：curerate95%PrimaryhyperthyroidismOperation:subtotalthyroidectomyIndicationSecondary～、HyperfunctioningthyroidadenomaModerate较大、压迫、胸骨后补救妊娠早、中期PrimaryhyperthyroidismOperation：Preoperotivepreparation：Examination：Neckradiography、laryngoscopy、BMR、[Ca++]Rapidheartrate：心得安10mgTidDrug：Antithyroiddrugs2－4m+Iodine2w（Lugol’ssolution)心得安：P↓不著者，哮喘禁用

PrimaryhyperthyroidismOperation:全麻superiorlaryngealnerverecurrentlaryngealnerveparathyroidglands

PrimaryhyperthyroidismOperation:Post-operativecare:床旁备气切包切口压冰袋voicedrainagePrimaryhyperthyroidismSuricalcomplications：Dyspnea、asphyxia：48hRecurrent/superiorlaryngealnerveinjury：Parathyroidglandsinjury：48hThyroidcrisis：12－36hHypothyroidism：5－50%Recurrence：1－5%tetany

ThyroiditisSubacutethyroiditis（DeQuervain～)：infectionoftheupperrespiratorytract：前驱期有肌痛1－2wv破坏滤泡+巨细胞性肉芽肿甲状腺痛及压痛，向下颌及耳部放散30－40yT↑，ESR↑BMR↑，131I↓激素+甲状腺素ThyroiditisChroniclymphocyticthyoiditis（Hashimoto’s)：Autoimmunedisease+hypothyroidism淋巴cell浸润、滤泡包膜内病变，无粘连、压迫腺体质硬，平滑，椎体叶大BMR↓，131I↓甲状腺素Thyroidadenoma

Pathologicaltype：follicular/papillarycapsule～Clinicalfeature：单发、包膜

Differentialdiagnosis：Therapy（甲亢20%，恶变10%)：单纯（楔形)切除大部切除Thyroidcarcinoma

Pathologicaltype：FNAPapillary～：70%40y（儿童100%)Follicular～：15%50y包膜不完整Anaplastic～：5－10%60y小细胞/巨细胞型Medullary～：C细胞－CT15%家族史Clinicalfeature：Clinicalstages：45y分化型Thyroidcarcinoma

Therapy:甲状腺+颈部淋巴结Low-riskgroup:腺叶+峡部High-riskgroup:患侧全+对侧次全