Các Bệnh Tai - Mũi - Họng

BNH L TUYN GIP Ging vin hng dn: Nguyn Phc Hc Nhm: 6 Sinh vin thc hin: Nguyn Ngc Cm L Nguyn Hong Oanh ng Ngc Thch Tho ng Th Kim Thy Nguyn Mai ng Vy I. GII PHU, SINH L TUYN GIP: 1. Gii phu: Nm trc kh qun, di sn gip, nng 20-25g, gm 2 thy, c eo gia, cao 6cm, rng 3cm, dy 2cm. Cu trc gm nhiu nang gip, trong cha y dch keo, xen ln h thng mch mu rt phong ph, y tng hp v d tr hormon T3, T4. tuyn gip: a. Sinh tng

hp hormone Iod l cht ch yu cho s tng hp hormon gip. Qu trnh tng hp hormon gm 4 giai on : Bt iod Tng hp v d tr hormon gip Oxy ho iod S gn iod vo tyrosin. S di chuyn ca hormon gip: Qu trnh ny din ra ngc li vi s thu nhn iod. S bi tit hormon gip: 93% hormon c phng thch t tuyn gip l thyroxine (100nmol/24gi) v ch hn 7% l T3 (10 nmol/24gi). b. iu ha bi tit: - Tuyn gip c kim sot bi TSH tin yn. - Trong iu kin sinh l, ch cn 55g iod/ngy vo tuyn gip, nu s cung cp gia tng xut hin s gim thu nhn iod hu c, cng nh c ch gii phng hormon. c. Tc dng ca hormone tuyn gip: Tc dng trn s tng trng thi k ang ln ca a tr, cng vi GH lm c th pht trin. Tc dng pht trin b no thai nhi v nhng nm u sau sinh. Tc dng trn chuyn ha - Glucid gy tng glucose mu nhng ch tng nh.

- Lipid: tng thoi ha lipid m m d tr... - Protid: + Liu sinh l: T3,T4 lm tng tng hp protein gip cho s pht trin v tng trng c th. + Liu cao, tc dng d ha ni bt, gy mt protein m, v vy ngi bnh cng gip thng gy Tc dng ln chuyn ha t bo T4, T3 lm tng tiu th O2 hu ht cc m trong c th nn lm tng chuyn ha c s (CHCS),(tr no, tinh hon, t cung, lch, bch huyt, tin yn). Tc dng trn chuyn ha vitamin T3,T4 cn cho s hp thu vitamin B12 rut v chuyn caroten thnh vitamin A. Tc dng trn h thn kinh c - Thc y pht trin tr tu. - Liu cao gy hot bt, bn chn, kch thch; nhc nng tr gy chm pht trin v tr tu. Tc dng ln tim mch

- Trn tim: tng s lng -receptor tim tim nhy cm vi catecholamin nhiu hn, lm nhp tim nhanh. - Trn mch mu: tng chuyn ha v tng cc sn phm chuyn ha m gy dn mch, lm tng lu lng tim Tc dng ln c quan sinh dc - nam gii, thiu hormon gip gy mt dc tnh nhng bi tit nhiu c th gy bt lc. - n gii, thiu hormon gip gy rong kinh, a kinh nhng tha hormon gy t kinh, v kinh hoc gim dc tnh. II. CNG GIP: 1. nh ngha: - L mt tnh trng m trong tuyn gip to ra qu nhiu hoc mn thyroxine. - Cng gip c th tng tc ng k s trao i cht ca c th, lm gim cn t ngt, nhp tim nhanh hoc khng u, ra m hi v cng thng hoc kh chu. 2. Nguyn nhn: - Graves: l mt ri lon t min dch, cc khng th tn cng nhm tuyn gip to qu nhiu T-4, i khi tn cng m ng sau mt (Graves' opxhalmopathy) v da, thng chn - mo xng chy cng chn (Graves

'dermopathy). nguyn nhn ph bin nht. - Tng nng bu tuyn gip: (u tuyn c, bu c a nhn c hi, bnh Plummer). khi mt hoc nhiu u tuyn ca tuyn gip sn xut qu nhiu T-4. - Vim tuyn gip (bn cp): gy ra d tha hormone tuyn gip r r vo mu nguyn nhn gy au tuyn gip Basedow (bnh Graves) - L mt bnh t min c lin quan ti s ri lon ca lympho T c ch (T) - C s hin din ca t khng th khng thyroglobulin, t khng th khng TSH v yu t kch thch lin tc tuyn gip - C s thm nhim cc t bo lympho vo m tuyn gip, c vn nhn v vng trc xung chy. -C th km cc bnh t min khc nh lupus ban d - Bnh c yu t di truyn: gia nh cng b, HLA B8, HLA DR3. - Hay gp n. Bu gip c n nhn hoc a nhn Tuyn gip xut hin mt nhn v vi nhn nm mt thy, nhn ny l nang gip tng cng tng hp cc hormon tuyn gip v c ch cc m lnh xung quanh cng nh c ch tuyn yn gim tit TSH. Vim tuyn gip t

min Hashimoto Tuyn gip vim mn tnh c thm nhim t bo lympho. Hormon tuyn gip tng cao v xut hin cc triu chng cng gip, nht l giai on u. Triu chng cng gip thng t ht. Bnh khng bao gi ti pht Cng gip do iod (bnh Iod Basedow) - Iod khng phi l nguyn nhn gy bnh nhng n thc y vic xut hin triu chng cng gip trn lm sng nhng tuyn gip khng chu nh hng ca hiu ng Wolff Chaikoff. - Qu ti iod c th do dng thuc iu tr c iod (amiodon) thuc cn quang hoc do b xung qu nhiu trong vng dch t thiu iod 3. C ch bnh sinh: 4. Triu chng ca cng gip: (nhim c gip) Lm sng Cn lm sng - Gim cn t ngt, ngay c - Tng nhy cm vi nhit. khi s ngon ming v ch - i cu thng xuyn hn.

n ung bnh thng hoc - Ph i tuyn gip (bu thm ch tng. c). - Nhp tim nhanh (>100 nhp/ - Mt mi, yu c. pht), lon nhp tim hoc - Kh ng nh trng ngc. - Tng s thm n. - Xt nghim min dch: c trong mu khng th chng li tuyn gip: - Cng thng, lo lng v kh Khng chu. th kch thch th th TSH; Khng th khng enzym peroxydase gip (TPO); Khng khng thyroglobulin (Tg), khng c hiu v c th - Run tay v cc th ngn tay. Ra gp m trong hi. bnh Hashimoto; Khng th khng vi tiu th (MIC). -- Xt

nh gi chc nng cng gip: Gia tng nng Thaynghim i kinh nguyt. hormon gip trong huyt tng: T3:(95-190 ng/dl); FT3: (0,2- 0,52 ng/dl); T4:(5-12 g/dl); FT4:(0,9 - 2 ng/dl); T T3 (ng %) /T4 (microgam %): trn 20 (nh gi bnh tin trin); TSH siu nhy (0,5 - 4,5 (U/ ml): gim; tp trung I131 ti tuyn gip sau 24 gi tng cao hn bnh thng. - Xt nghim hnh thi v cu trc tuyn gip: Siu m tuyn gip(ph i, eo tuyn dy, cu trc khng ng nht); Chp nhp nhy tuyn gip (xc nh phn no hnh thi v chc nng tuyn gip vi I123 hoc Tc 99m); Chp ct lp (CT Scanner) v MRI (t s dng); Hnh nh gii phu bnh: (Tuyn gip ln u c hai thy, lan ta, mm v tn sinh nhiu mch mu...); Thm d thng tn mt(o li nhn cu bng thc HERTEL) Tin trin v bin chng - Tim mch: gm nhp tim nhanh, rung nh v suy tim sung huyt. - Gin xng: Qu nhiu hormon tuyn gip cn tr kh nng kt hp canxi vo xng ca c th. - Vn mt: mt phng ln, mt hoc sng, nhy cm vi nh sng v m hoc nhn i. - , sng da: gy mn v sng, thng trn mo xng chy v bn chn.

- Cn cng gip cp: st cao, nhp tim nhanh v thm ch m sng 5. iu tr: a. iu tr ni khoa: - Cc triu chng thng bt u ci thin trong su n 12 tun. - Propylthiouracil gy rt nhiu thit hi cho gan s dng ch khi khng th chu ng c methimazole. - Thng c s dng iu tr tng huyt p. - Khng lm gim mc tuyn gip, nhng n c th lm gim nhp tim nhanh chng v gip ngn nga nh trng ngc. b. iu tr ngoi khoa: Nu khng th chu c thuc khng gip v khng mun dng it phng x tr liu, c th phu thut tuyn gip. Ri ro ca phu thut: thit hi dy thanh m v tuyn cn gip, phi iu tr sut i vi levothyroxine (Levoxyl, Synthroid) cung cp s lng hormone tuyn gip bnh thng. c. iu tr bng ng v phng x I131:Ung it phng x c hp thu bi tuyn gip, n thu nh tuyn v cc triu chng gim dn (3 - 6 thng) d. iu tr bin chng: - Vn v tim: nhp tim nhanh, ri lon nhp tim (rung nh) v suy tim sung huyt. Thng gim vi iu tr thch hp. - Gin xng: Qu nhiu hormon tuyn gip cn tr kh nng kt hp canxi

vo xng ca c th. Nu khng iu tr cng dn n xng yu, d gy (long xng). - Vn mt: mt phng ln, mt hoc sng, nhy cm vi nh sng v m hoc nhn i. - , sng da. - Cn cng gip cp: l s tng t ngt cc triu chng, dn n mt cn st, nhp tim nhanh v thm ch m sng. III. SUY GIP: 1. nh ngha: L mt bnh cnh xut hin do s thiu ht hormone gip, gy nn nhng tn thng m, v nhng ri lon chuyn ha. 2. Nguyn nhn: a. Suy gip tin pht: - Xy ra do tn thng ti chnh tuyn gip - Vim tuyn gip Hashimoto: Tuyn gip c th ln hoc teo, c khi i km vi Addison v cc ri lon ni tit khc. - Tai bin do iu tr: Nht l vi iode phng x, phu thut tuyn gip, vi thuc khng gip tng hp t gp hn. - Cung cp iode khng hp l (tha hoc thiu): Suy gip do thiu iode l vn Vit Nam. - Vim tuyn gip bn cp, vim gip sau sinh: thng xy ra sau giai on nhim c gip trc , suy gip y ch tm thi. - Cc nguyn nhn khc: Lithium: iu tr bnh tm thn.

b. Suy gip th pht : - Suy tuyn yn do u lnh (adenoma), do phu thut tuyn yn, hoc do tuyn yn b hoi t trong bnh Sheehan. - Suy gip tam cp. Do ri lon chc nng hng yn gip ti vng di i. - Suy gip do khng hormone gip ngoi bin (t gp). 3. Triu chng: Lm sng suy gip tin pht Hay gp n, xung quanh la tui 50. Bnh xut hin t t d ln vi cc triu chng ca mn kinh. - Triu chng gim chuyn ha: Mt mi:99%. S rt:89%. Tng cn:59%. - Triu chng tim mch: Nhp tim chm:95%. Hi hp:31%. au vng trc tim:25%. - Triu chng da nim mc: Da kh:97%. Gim tit m hi:89%. Li ln v dy:82%. - Rng lng: 76%. Xanh ti: 67%. Rng tc: 57%. Ph ngoi vi:55%. Ging khn: 52%. ic: 32%. - Triu chng tiu ha: To bn dai dng: 23%. - Triu chng c bp: Chut rt (vp b) > 70% - Triu chng thn kinh: L (Lthargie): 91%. Ni chm: 91%. Gim tr nh: 66%. Ri lon tm thn: 35%. Hn m suy gip

Cn lm sng tr khng y hoc khng c iu tr, vi cc yu t thun li nh: nhim trng, phu thut, chn thng, nhim c... hoc ngng iu tr thyroxine t ngt. T l t vong hn 50%. - Thn nhit h (32-35oC) - Ri lon h hp, vi nhng t ngng th, gim thng kh ph nang. - Tim mch: nhp tim chm, h huyt p, cung lng tim gim, tim ln. - Xt nghim hormone khng nh bnh cnh suy gip - Trong t hn m suy gip ~in gii mu v nc tiu: gim natri mu, km gim clor, gim protid mu, gy nc ni bo d dn ph no, glucose mu c th gim, ADH - nh hng lnn chuyn ha v t chc

ngoi vi: Chuyn ha tng c bn gim <10% so vi bnh thng - nh lng hormone gip lu hnh: Iode ton phn (trong hormone) < 4(g/100ml); T4 < 3g/dl; FT4I gim; T3 < g/dl; FT4I gim; T3 < 80mg/dl; Nu ch T3 gim n c th cha . FT4 < 0,8(g/ dl). - nh lng TSH: Nu suy gip tin pht TSH: >10UI/ml. Nu suy gip do nguyn nhn cao TSH khng tng. - o tp trung iode phng x ti tuyn gip: tp trung iode phng x > 5%, 10% v 20% vo cc thi im 2h, 6h v 24h, c khi thp hn na (bnh thng: 20%, 30%, 40% vo cc thi im trn). X hnh tuyn gip thy hnh nh iode tp trung ri rc, khng ng cht 4. Chn on: - Nhng trng hp c biu hin: tuyn gip ln hoc c Chn on xc nh Chn on phn bit iu tr iode phng x hoc phu thut gip. Cn ngh n

suy gip trc - Nu nghi ng suy gip tin pht: TSH l xt nghim tt nht gip chn on xc nh - Nu nghi ng suy gip th pht: Do gi thng tn tuyn yn, TSH thng gim nhng c khi bnh thng do cn nh lng FT4, khng nn ch da vo nh lng TSH -chn Tui on gi: biu hin th chm chp v tinh thn v th cht... suy gip pht. Cc biu hin trn cng c th c mt phn do gim hot gip. - Suy thn mn: ur, cratinin mu tng... - Hi chng thn h: Ph, thiu mu, cholesterol mu tng... - Bnh Langdon Down: Tr tu, tay chn km pht trin... - Thiu mu, suy dinh dng: Da ti, ph nh, tc lng c th rng - Bo ph: Tng cn, nng n trong vn ng... 5. iu tr: a. Nguyn tc: tt c cc trng hp suy gip cn c iu tr ngoi tr cc th suy gip ch c biu hin cc du sinh hc nh. - Thuc Hormone gip: ch t tuyn gip gia sc.

- Hormone gip tng hp: Levothyroxine(LT4); Liothyronine(LT3); LT4 phi hp vi LT3 (Euthyral) b. iu tr triu chng: - H tr h hp: oxy liu php, t ni kh qun, gip th, ng thi iu tr tnh trnh tru mch. Nhanh chng xc nh TSH, FT4 trc khi cho thyroxine. - Si m t t nhit phng l 22oC. (Si m nhanh lm nng tnh trng try mch v rung tht). B nc in gii, glucose. - Thyroxine:tim 50-100g/dl; FT4I gim; T3 < g/6-8gi/24 gi, sau 75-100g/dl; FT4I gim; T3 < g/ngy cho n khi ung c. iu tr hormone thay th. Cn theo di k v tim mch pht hin tc dng khng mong mun trn tim do thyroxine. IV. BU GIP N THUN: 1.Bu nhc ngha: - Khi nhu cu sinh l ca iode khng s pht sinh hng dch t (bu gip a phng hay bu gip lu hnh) Bu c l t ri rc lot bt thng: tn thng chc nng tuyn gip, khi thiu

iode trm trng gy ra bu c dch t (n n dch t), gim thng minh v tng t sut chu sinh v s sinh ri lon do thiu iode. - T ngi ta nh ngha bu c dch t nh l s ph i ca tuyn gip khu tr hay ton th trong hn 10% L s chng ph i t chc tuyn gip c tnh cht lnh tnh ton qun b hay tng phn khng c triu chng suy hay cng gip, khng do vim, cc yu t gy bnh khng nh hng trong qun th chung. 2. Nguyn nhn: Thiu iode Do cht khng gip Ri lon ph n dy th, c thai, tin mn kinh. Mt iode do tiu chy ko di, hi chng thn h (gim protein ti), thai nghn (tng thi iode nc tiu). - Bp ci trng, thuc khng gip tng hp, cht ngn cn s ti iode nh Thiocyanate, Perchlorate. - Sn c cha Glucoside cyanognique, Linamarin, cht ny khi b thy phn gii phng cyanure, trong c th cyanure b kh c thnh thiocyanate c ch bm iode tuyn gip v tng s

thanh thi iode thn thiu iode c th. Do bt thng tng hp KTT tuyn gip Thiu enzyme, s sai lch bm sinh trong s tng hp thyroxin sn xut ra iodoprotein bt thng. Dng iode liu cao gy c ch tng hp hormon gip do hiu qu Wolff Chaikoff (tc dng thong qua). 3. Bnh sinh: - Gim thyroxintuyn yn tng tit TSH bu gip v tng sn xut hormon gip. y ch l hin tng b tr, phn ng cung cp cho c th thyroxin, do tuyn gip khng b suy hay gim chc nng. - Nng iode trong mu v trong tuyn gip gim, lm tuyn gip ph i b tr cng qua c ch trn. 4. Triu chng: - i vi bu gip n thun: bnh nhn thng c tnh a. Triu Lm sng: chng c nng Triu chng

thc th trng bnh gip. - i vi bu c dch t th nh hng n s pht trin c th nht l tr em, gim thng minh, n n. - i vi bu gip n u: bu ln, c mt khi u gia c, s c ranh gii r, khng dnh vo da, khng au, mm hay chc, di ng theo nhp nut ln xung, khi bu to c th gy chn; khng c ting thi ti nh bu. - i vi bu gip nhiu nhn: gm nhiu khi trn b. Cn lm sng: nh lng FT3, FT4 bnh thng (Bnh thng FT4 = 0,8 - 2,4ng/dl, hoc 8 - 18pg/ml, hoc 10 - 30nmol/L); (FT3 = 0,4ng/dl, hoc 3 - 4pg/ml) Yu t tng protein ti hay tng T4 ton phn: estrogen, thai nghn, vim gan nhim trng, u ty, collagenose. Yu t lm gim T4: suy dng, gim protid mu, x gan, thuc androgene, corticoide liu cao. Yu t ngn cn s kt hp vi protein ti: hydantoin, clofibrate, hparine, phenylbutazone. TSH cc nhy (TSH us) bnh thng (TSH = 0,3 - 4mUI/L). tp trung I131 bnh thng, tr trng hp bu n ho iode. Chp nhp nhy x hnh gip (Sintigraphie): cho bit hnh thi tuyn gip, chc nng tuyn gip nh lng T3, T4 t do bnh thng. Sinh thit: c khi cn thit, cho thy cc bin i lnh tnh nh trong phn gii phu bnh. i vi bu c dch t hay bu c a phng, cn o iode

niu/ngy, hoc t l iode niu/cratinine niu nh gi s trm trng ca thiu ht iode. Th tch ti a tuyn gip (gii hn trn) ngi trng thnh 18 ml c. Tin trin v bin chng: - Xut huyt trong bu: bu to nhanh, au v nng, du chn p cp. - Cng gip: bu nhiu nhn, bu lu nm, Basedow ha phn tuyn bnh thng xen k gia cc nhn, thng do cung cp iode qu nhiu. - Ung th ha. - i vi bu c do thiu iode ngi m mang thai: c th nh hng n s chm pht trin v tinh thn v th cht ca thai nhi. - Ung th gip: tuyn gip to, xut hin mt hoc nhiu nhn cng, b g gh di ng theo nhp nut, khi u to c th chn p gy khn ting, kh th, kh nut. 5. iu tr v d phng: a. Nguyn tc: bnh thng ha nng hormone tuyn gip, m khng i hi tuyn gip phi tng hot v ph i. - Thiu iode cung cp iode. Khng do thiu iode cung cp thm hormonee gip tng hp. - Trong bu gip n do thiu iode: iu tr bng iode hay hormone gip lm tuyn gip nh li. - Trong nhng nguyn nhn khc gy bu gip n lan to khng c, Levothyroxine c th c dng vi mc ch nhm gim kch thc tuyn gip - Hn ti a phu thut,

b. iu tr c th vich bu gip n lan nu toct b d b suy gip. iu tr ngoi khoa iu tr ni khoa - Can thip phu thut trong nhng trng hp sau: + Bu gip qu ln gy chn p (kh nut, kh th, ni khn). + Bu gip lu nm d b ung th ho hoc nghi ng ung th ho. Bu gip do thiu iode hay bu gip a phng: a + Bu nhiu nhn. iode + vo V l. do thm m.. + lm gim th tch tuyn gip. L. Thyroxine vin

c ch nh khi: Lm sng v siu m xc nh bu gip ln + Thyroxin (Levothyroxine, L-Thyroxine, Levothyrox) (T4), vin 50g/dl; FT4I gim; T3 < g, 75g/dl; FT4I gim; T3 < g, 100g/dl; FT4I gim; T3 < g, liu 0.5- 2 vin/ng + Triiodothyronine (Liothyronine) (T3) vin 25 g/dl; FT4I gim; T3 < g, 1- 2 vin/ng + X tr liu ngy cng c ch nh v lm kch thc tuyn nh li, v c th ct b chn lc cc nhn t tr. c. Phng bnh: iode ha mui l phng php c a chung nht trong vic b sung iode qun th thiu ht iode - Mui iode ha (iodat bn vng hn iodure): Nng iode trn vo mui c ngh l 1 phn iode cho 10.000-100.000 phn mui, bng cch da trn s tiu th khong 5g-10g mui/ngy, cung cp chng 50- 500g/dl; FT4I gim; T3 < g iode/ng. S cung cp c nh gi tt khi nng iode trong nc tiu trung bnh t 100-200g/dl; FT4I gim; T3 < g iode/l - Du iode: Lipiodol ng ung: 1ml cha 480mg iode, liu duy nht bng 1ml, d phng 1-2 nm. Tim bp: Tr em 1tui v ngi ln TB tay, liu 1ml. - Nuc pha iode: Iode loi dung dch m c I2, IK hay KIO3 cho vo nc ung t nhu cu 150g/dl; FT4I gim; T3 < g /ngy. - Lugol: 5g I2 + 10g IK trong 100ml (hoc 6mg iode cha trong 1 git Lugol). Thi gian tc dng ngn hn so vi loi du iode, nn cho nhiu ln trong ngy

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