The Medical and Surgical

Management of Thyroid,
Pituitary & Adrenal
Disorders
Dr Miguel Debono
Clinical Lecturer Endocrinology
A. Endocrine
glands are
ductless
glands that
usually
release a
product into
the
bloodstream
for transport
to body
targets



The Endocrine System
B. Hormones
are chemical
signals
produced by
an endocrine
gland that act
at some
distance from
the gland
C. Targets are organs, tissues or cells
capable of responding to the
hormone due to the presence of a
receptor that binds the hormone
The Endocrine System
Thyroid
Physiology
Biochemistry
Hypo/hyperthyroidism
Thyroid nodules

Pituitary
Anatomy
Hormones
Dysfunction tumour
mass effects, hormonal
excess and deficiency

Adrenal
Primary and secondary
failure
Cortisol excess



Largest of all endocrine glands
Produces hormones
thyroxine (T
4
) and tri-iodothyronine (T
3
)
regulate basal metabolic rate
calcitonin which has a role in regulating blood calcium
levels
Unique among human endocrine glands it stores
large amount of inactive hormone within
extracellular follicles
The Thyroid Gland

Clasps anterior and lateral
surface of pharynx, larynx, oesophagus
and trachea like a shield

Parathyroid glands usually lie
between posterior border of thyroid gland
and its sheath (usually 2 on each side of the thyroid)

Internal jugular vein and common carotid artery lie
postero-lateral to thyroid
The Thyroid Gland
Surface anatomy
Free Thyroxine (T4)

Free Triiodothyronine (T3)

Thyroid Stimulating Hormone(TSH)


Hypothyroidism
Cause Hormone concentrations Goitre
Primary failure
of thyroid gland
T
3
and T
4
, TSH Yes

Secondary to
hypothalamic or
pituitary failure
T
3
and T
4,
TSH and/or
TRH
No
Dietary iodine
deficiency
T
3
and T
4
, TSH Yes
Hypothyroidism
Clinical Features of Hypothyroidism
Symptoms Signs
weight gain
lethargy
increased sleep
constipation
cold intolerance
dry skin
hair loss
menorrhagia
deafness
muscle weakness

facial puffiness
periorbital oedema
bradycardia
hoarseness
delayed reflexes




Primary
Dyshormonogenesis
Iodine Deficiency
Autoimmunity
Post Radioactive Iodine
Post Thyroidectomy
Iodine Excess


Secondary & Tertiary
Pituitary Tumours
Pituitary Granulomas
Empty Sella


Isolated TRH deficiency
Hypothalamic disorders
Congenital hypothyroidism
Treatment of hyperthyroidism
Neck Irradiation
Pituitary Surgery or Irradiation
Patients on lithium and amiodarone

Investigations & Management
Thyroid function tests, Thyroid antibodies
Treat with levothyroxine


Delayed eruption
Enamel hypoplasia
Macroglossia
Micrognathia
Thick lips
Dysgeusia
Mouth breathing

Hyperthyroidism
Cause Hormone concentrations Goitre
Abnormal thyroid-
stimulating
immunoglobulin
(eg. Graves
disease)
T
3
and T
4
, TSH Yes

Secondary to excess
hypothalamic or
pituitary secretion
T
3
and T
4,
TSH and/or TRH Yes
Hypersecreting
thyroid tumour
T
3
and T
4
, TSH No
Hyperthyroidism
Common
Autoimmune thyroid
disease
o Graves Disease
o Postpartum thyroiditis

Toxic nodular goitre

Toxic adenoma
Rare
Amiodarone induced

De Quervains thyroiditis

Thyrotroph adenoma

hCG hyperthyroidism
Hydatidiform mole
Choriocarcinoma

Symptoms Signs
Weight loss
Heat intolerance
Anxiety, irritability
Increased sweating
Increased appetite
Palpitations
Loose bowels
Goitre
Tremor
Warm moist skin
Tachycardia
Eye signs
Thyroid bruit
Muscle weakness
Atrial fibrillation


Clinical Features Investigations
Diffuse goitre
Eye signs
Pretibial myxoedema

Vitiligo and features of
other autoimmune
disease

FH of autoimmune
thyroid disease


TSH receptor Abs

TPO Abs

Thyroglobulin Abs

Thyroid Radioisotope
scan


Medical
Drug side effects e.g. nausea, vomiting,
leucopenia leading to agranulocytosis,
aplastic anaemia, drug fever, cholestatic
jaundice

Surgical

Radioactive iodine
Pre - treatment
Post - treatment
Hyperthyroidism
Accelerated dental eruption
Maxillary or mandibular osteoporosis
Increased susceptibility to caries
Periodontal disease
Increased sensitivity to epinephrine which may
result in arrhythmias or palpitations
Surgery, oral infection and stress may
precipitate thyroid crises


New onset
Increase in size
Onset of pain
Associated speech disturbance
Lymphadenopathy
Patient / Doctor concern



Endocrinologist, Endocrine Surgeon

Primary Diagnostic tool FNA US guided

Perform thyroid function tests prior to FNA to
exclude hyperthyroidism

Ultrasound and Radionuclide scans rarely
used




Parathyroid hormone
increases calcium release from bone
increases calcium absorption from kidneys
increases calcium absorption from GI tract through
activation of 1, 25 dihydrocholecalciferol

Primary Hyperparathyroidism
(hypercalcaemia, hypophosphataemia)
Alterations in dental eruption, weak teeth, brown
tumour, loss of bone density, soft tissue
calcifications


Pituitary Disorders
T h e p o s t e r i o r p i t u i t a r y i s n o r m a l , t h e a n t e r i o r p i t u i t a r y i s a b s e n t ; f i n d i n g s i n k e e p i n g w i t h a n e m p t y s e l l a

Empty Sella
Normal Pituitary
Hypothalamic Pituitary Peripheral
Gonadotrophin releasing
hormone (GnRH)
LH
FSH
Oestrogen/
Androgen
Prolactin inhibiting
factor (Dopamine)
PRL
Growth hormone
releasing hormone /
Somatostatin
GH Insulin like
growth factor
Thyrotropin releasing
hormone
TSH T3 and T4
Corticotropin releasing
hormone (CRH)
ACTH Cortisol
Vasopressin (ADH)
Oxytocin
Pituitary
Dysfunction
Tumour
mass
effects
Hormone
excess
Hormone
Deficiency
Investigations
Hormonal tests
If hormonal tests
abnormal or tumour
mass effects perform
MRI pituitary
Local
Mass
effects
Headaches
Cranial Nerve Palsy
and Temporal Lobe
Epilepsy
CSF rhinorrhoea
Visual Field
Defects
GH
Short stature
Abnormal body
composition
Reduced Muscle
Mass
Poor Quality of
Life

Rx: Growth
Hormone

LH/FSH
Hypogonadism
Reduced Sperm
Count
Infertility
Menstruation
Problems

Rx: Testosterone in
males; oestradiol
progesterone in
females

TSH
Hypo
Thyroidism


Rx:
Levothyroxine
ACTH ADH




Adrenal
Failure
Decreased
Pigment

Rx:
Hydro
cortisone



Diabetes
Insipidus
(ADH
deficiency -
Decreased
water
absorption in
kidney
resulting in
polyuria &
polydipsia)

Rx:
DDAVP
Pituitary Hormone Deficiency
Pituitary tumours
Radiotherapy
Trauma
Infarction
Infiltration e.g. sarcoidosis, haemochromatosis
Infection e.g. tuberculosis, syphilis
Sheehans syndrome (post partum pituitary
necrosis)


Acromegaly
Excessive growth hormone secretion with
resultant high IGF-1 levels.

Prevalence of 40-60 cases/million population.

Incidence of 4 cases/million per year.

Equal sex incidence

Delayed diagnosis by 7 to 10 years

Head Related
Coarse facial features
Enlargement of
supraorbital ridges
Separation of teeth
Prognathism
Macroglossia




Other Features
Headaches
Spade-like hands
Joint pains
Excess sweating
Hypertension
Impaired glucose
tolerance


Treatment and its effectiveness
Investigations: IGF1, dynamic tests, MRI pituitary

Surgical resection TSS, TFS

- biochemical control
80% microadenomas
50% macroadenomas

Somatostatin analogues 40% complete responders

Pegvisomant reduces IGF-1 to levels > 90%

Radiotherapy in unsuccessful surgery
Jaw Malocclusion
Difficulty in speech due to macroglossia
Teeth mobility
Missing teeth
Teeth separation
Thickening of alveolar processes
Enlarged posterior roots

In 50% upper airways obstruction caused by
pharyngeal hypertrophy and macroglossia
with obstructive sleep apnoea.

Adrenal Disorders
0
100
200
300
400
500
600
22 23 24 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Clock Time
C
o
r
t
i
s
o
l

(
n
m
o
l
/
L
)
Acrophase: 0832h
(0759h - 0905h)
MESOR: 143.6 nmol/L
(130.1-156.1)
Nadir: 0018h
(2339h 0058h)

Defining Physiological
Cortisol Circadian Rhythm

Excess glucocorticoids due to

Pituitary tumor 70 - 80%

Adrenal tumor 10 - 20%

Ectopic ACTH tumor 10%

Iatrogenic

Glucose intol. 65%

Hyperpig 20%

Muscle weak 60%

K+ meta. alk. 15%

Plethora 60%

Hirsutism 65%

Edema 40%

Weight gain 90%

Menses probs 60%

Moon face 75%

Acne 40%

HTN 75%

Bruising 40%

Striae 65%

Osteopenia 40%


Management of Cushings Syndrome
Investigations
Hormonal tests: Dynamic suppression tests (Dexamethasone
suppression tests) measuring cortisol, ACTH

Radiological (If hormonal tests are abnormal)
MRI pituitary (pituitary tumour)
CT adrenals (adrenal tumour)
CT chest, abdomen, pelvis (ectopic ACTH tumour)

Treatment
Surgery
Drugs
Consider radiotherapy for pituitary disease if surgery fails


History of Glucocorticoid Replacement
Discovery of Addisons disease



From the book On the constitutional and local effects of disease of the supra-
renal capsules. (1855)
- Thomas Addison (1793 1860)
1855
Primary Secondary
Autoimmune
Tuberculosis
Fungal infections
Adrenal hemorrhage
Congenital adrenal
hypoplasia
Sarcoidosis
Amyloidosis
Metastatic neoplasia


After exogenous
glucocorticoids
After treatment of
Cushings
Hypothalamic or
pituitary tumours
Weakness

Skin and mucous membrane pigmentation

Loss of weight, emaciation, anorexia, vomiting,
diarrhea

Hypotension

Salt craving

Hypoglycemic episodes
Management of adrenal insufficiency
Investigations
Hormonal tests: - Dynamic stimulation tests (Synacthen test) measuring
cortisol
- ACTH, adrenal antibodies

Radiological (If hormonal tests are abnormal)
MRI pituitary (pituitary disease)
CT or MRI adrenals (adrenal disease)
CXR if suspecting TB

Treatment
Hydrocortisone replacement treatment

On treatment therapy e.g asthma, rheumatoid arthritis
Prednisolone > 7.5mg
Hydrocortisone > 30mg
Dexamethasone > 0.75mg
On replacement therapy
Addisons e.g. Hydrocortisone 20/10mg
ACTH deficiency 10/5/5mg
Simple Procedures: double dose one hour before surgery,
double dose oral medication for 24 hours

Major Procedures/GA: hydrocortisone 100mg im at
induction and double dose oral medication for 24 hours
http://www.addisons.org.uk/comms/publicat
ions/surgicalguidelines-colour.pdf


Hyperthyroidism render euthyroid

Phaeochromocytoma treat before any
surgery

Cushings avoid infections and pathological
fractures; steroid cover

Refer to endocrinologist


Surgery and other Endocrine disorders

Endocrine Causes of Hypertension
Primary aldosteronism
Phaeochromocytoma
Acromegaly
Cushings syndrome
Hypothyroidism
Hyperthyroidism



Thank you for listening!
Disease Primary Hormone Abnormality Secondary Hormone Abnormality
Autoimmune Hypothyroidism
Pituitary disease with thyroid
hypofunction
Graves Hyperthyroidism
Pituitary tumour with secondary
overactive thyroid
Cushings syndrome from
adrenal tumour
Pituitary tumour with Cushings
disease
Addisons disease
Pituitary tumour with adrenal
hypofunction