Thyrotoxicosis: symptoms and signs. Eye symptoms

Eye symptoms with thyrotoxicosis

Among the eye symptoms of thyrotoxicosis are:
protrusion of eyeballs ( exophthalmos ).
wide opening of the eyes (called "Delrymple's sign").
Stellwag's symptom - means rare blinking.
sparkle of eyes.
Graefe's symptom. It consists in the fact that the upper eyelid lags behind when lowering the eye. This is explained by an increase in the tone of the muscle that regulates the raising and lowering of the upper eyelid. At the same time it becomes noticeable stripe sclera is white.
Moebius sign. It means convergence disorder, that is, the loss of the ability to fix different objects at close range due to the predominance of the tone of the oblique muscles over the tone of the internal rectus muscles.
Kocher's sign.
Jellinek's sign.
These signs, especially exophthalmos, i.e. protrusion of the eyes, and opening of the palpebral fissures, give the patient’s face a characteristic expression of frozen fear or fright.
However, the presence of ocular symptoms is not necessary: ​​some patients with very severe thyrotoxicosis do not have them at all. Therefore, it is a mistake to assess the severity of thyrotoxicosis based on the severity of eye symptoms.

The interpretation of individual eye symptoms encounters some difficulties. For example, it is not easy to explain bulging eyes (exophthalmos). It has now been proven that it is caused by contracture of m. orbitalis (müllerian muscle). Previously, it was explained by the proliferation of retrobulbar fatty tissue, dilation of retrobulbar veins, arterial vessels orbits, etc. These assumptions are contradicted by the absence of pronounced changes in the vessels of the fundus, and mainly by the fact that bulging eyes can appear suddenly, sometimes within a few hours. In such cases, it is associated with irritation of the cervical sympathetic nerve. Irritation of the sympathetic nerve can lead to a state of sharp contraction of m. orbitalis, which at the same time covers the back of the eyeball and thus, as it were, pushes the eye out of the orbit.
Since through m. orbitalis veins and lymphatic vessels pass through; with spastic contraction of the muscle, they may be compressed with the development of edema of the eyelids and retrobulbar space.
Exophthalmos in patients with thyrotoxicosis may be completely absent. Usually it is bilateral, less often (in about 10% of patients) unilateral exophthalmos is observed.

Rare blinking (Stellwag's sign), wide opening of the palpebral fissures ( Delrymple's sign), and the special shine of the eyes is explained by the increased tone of m. tarsalis sup. et infer.
Graefe's symptom is not constant. It is characterized by the lag of the eyelid (upper) from the iris when looking down, so that a white strip of sclera becomes visible between the eyelid and the iris. This symptom is also explained by increased tone of m. levatoris palpebrae, as a result of which the voluntary movement upper eyelid. When the eye fixates any moving object, the eyeball moves freely behind it. Graefe's symptom occurs not only with thyrotoxicosis. It is also observed in various cachectic conditions that have nothing to do with.
Mobius's symptom - weakness of convergence - is characterized by the fact that with severe thyrotoxicosis, patients begin to quickly diverge. This symptom sometimes occurs in healthy people. Moreover, it is far from permanent.
In addition to the eye symptoms already listed, patients with thyrotoxicosis experience the so-called Kocher symptom - retraction of the (upper) eyelid with a rapid change of gaze, but this is not constant.
Worthy of attention and lacrimation disorders in patients with thyrotoxicosis. Sometimes it is increased, sometimes decreased. With long-term bulging eyes (exophthalmos), patients develop conjunctivitis, inflammatory changes in the cornea and even panophthalmitis due to non-closure of the eyelids day and night, which, naturally, poses a great danger.
TO eye symptoms in thyrotoxicosis can be attributed to the so-called Jellinek's sign- darkening of the skin on the eyelids. It occurs infrequently and has no diagnostic value. 1

Thyrotoxicosis is a syndrome caused by hyperfunction thyroid gland, which is manifested by an increase in the content of hormones: triiodothyronine (T3), thyroxine (T4), intoxication with thyroid hormones (is " side effect"such diseases of the thyroid gland as Graves' disease, thyroiditis, nodular goiter). Ophthalmopathies are one of the important manifestations of thyrotoxicosis: they are found in 70-80% of cases. The main complaints of patients with endocrine ophthalmopathies are discomfort in the eyeballs, a burning sensation and dryness, lacrimation, visual impairment, protrusion of the eyes. In addition, this disease affects the general condition of patients and significantly affects their quality of life. This article is devoted to identifying features. clinical course thyrotoxicosis and the endocrine ophthalmopathy that occurs with it, as well as methods of diagnosis and treatment of this disease. During a study of patients with thyrotoxicosis on the basis of the First Republican clinical hospital MZ UR" of Izhevsk for 2015 from January to August, statistical data processing was carried out. In total, during this period, 963 patients were treated in the endocrinology department, of which 3% (34 people) were diagnosed with thyrotoxicosis. Almost half had symptoms of ophthalmopathy.

eye symptoms

thyrotoxicosis

endocrine ophthalmopathy

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3. Gerasimov G.A., Dedov I.I., Kotova G.A., Pavlova T.L. Diagnosis and treatment of endocrine ophthalmopathy/ Problems of endocrinology, 2000.

4. Zarivchatsky M.F., Styazhkina S.N. Selected pages of surgical thyroidology, 2011. -216 p.

5. Kalinin A.P., Styazhkina S.N. Modern aspects of surgical endocrinology-2010. -376 s.

6. Potemkin V.V. Endocrinology // Medicine Publishing House, Moscow, 1986 .- 432 p.

7. Styazhkina S.N. Labor and non-standard situations in surgery and clinical practice // Collection of scientific and practical articles. – 2014. -№7.

8. Kharkevich D. A. Pharmacology// Publishing group "Geotar - Media", 2010. - 908 p.

Thyrotoxicosis is a syndrome caused by hyperfunction, which is manifested by an increase in the content of hormones: triiodothyronine (T3), thyroxine (T4), i.e. intoxication with thyroid hormones (is a “side effect” of thyroid diseases such as Graves’ disease, thyroiditis, nodular goiter) . The causes of thyrotoxicosis are, firstly, diseases accompanied by excessive production of thyroid hormones, such as diffuse toxic goiter, toxic adenoma and multinodular toxic goiter. Thyrotropinoma is a formation of the pituitary gland that synthesizes thyroid-stimulating hormone in excess, which stimulates the thyroid gland. Secondly, diseases associated with the destruction (destruction) of thyroid tissue and the release of thyroid hormones into the blood. These include destructive thyroiditis ( subacute thyroiditis, thyrotoxicosis with autoimmune thyroiditis, postpartum thyroiditis, painless thyroiditis). Thirdly, iatrogenic thyrotoxicosis - thyrotoxicosis caused by an overdose of thyroid hormone drugs (L-thyroxine, Euthyrox - drugs for the treatment of hypothyroidism)

In 70-80% of cases, ophthalmopathy is detected in patients with thyrotoxicosis. What are ophthalmopathies? This is a progressive disease of the soft tissues of the orbit and eye, which is based on immunomediator inflammation of the extraocular muscles and orbital tissue. Four almost equivalent factors are involved in the development of exophthalmos: 1). an increase in V extraocular muscles as a result of cellular infiltration (neutrophils, plasma cells, mast cells); 2). an increase in V orbital fat against the background of impaired adipogenesis; 3). swelling of the soft tissues of the orbit as a result excess accumulation glycosis; 4). disruption of venous flow in the orbit.

The main complaints of patients upon admission are blurred vision, pain and discomfort in the eyeballs, rapid heartbeat, and weakness. Eye symptoms of ophthalmopathies include exophthalmos (protrusion of the eyeballs), Delrymple's symptom (wide opening of the eyes), Stellwag's symptom (rare blinking), Krauss's symptom (extreme shine of the eyes), Mobius's symptom (convergence disorder, i.e. loss of the ability to fixate different objects at different distances), Kocher's symptom (increased contraction of the upper eyelid, as a result of which a white strip of sclera appears between the upper eyelid and the iris when the vision fixes an object moving upward), Jelinek's symptom (darkening of the skin on the eyelids), Rosenbach's symptom (fine tremor of slightly closed eyelid), Geoffroy's symptom (when looking up, the skin on the forehead wrinkles more slowly than normal), Graefe's symptom (lag of the upper eyelid when looking down), lagophthalmos (the eye does not close completely).

Target

To study the features of the clinic, symptoms, treatment and diagnosis of patients with endocrine ophthalmopathy in thyrotoxicosis on the basis of the First Republican Clinical Hospital of the Ministry of Health of the Urals, Izhevsk for 2015 from January to August. To analyze the echography of the eyes of some patients at the Republican Ophthalmological Clinical Hospital of the Ministry of Health of the Urals.

Materials and research methods

In total, at the clinical base of the BUZ UR “First Republican Clinical Hospital of the Ministry of Health of the Urals” in Izhevsk during this period, 963 patients were in the endocrinology department, of which 3% (34 people) were with thyrotoxicosis. We selected a group of patients with an age range from 20 to 80 years who were on inpatient treatment. So, women accounted for 71% of all studied cases, and men accounted for 29%. The average age of the patients was 50 years. The incidence rate in 2015, by month, was:

January-23, 5%,

February-11.7%,

March - 17.6%,

April-11.7%,

June - 11.7%,

July - 5.8%,

August - 5.8%.

In patients with severe symptoms of endocrine ophthalmopathy, the main complaints upon admission were blurred vision, pain and discomfort of the eyeballs, rapid heartbeat, weight loss, and weakness.

It is known that eye symptoms may or may not be present in thyrotoxicosis. They can also appear both before the clinical manifestations of hyperthyroidism, and 15 and even 20 years after its onset. So, of all the patients in 1 RCH for the specified time with thyrotoxicosis with symptoms of endocrine ophthalmopathies, it turned out:

symp. Shtelvaga - 23.5%;

symp. Moebius - 17.6%;

symp. Gref - 6%.

During the study of echographic images on the basis of the Republican Ophthalmological Clinical Hospital of the Ministry of Health of the Urals, an expansion of the retrobulbar zone was discovered, the total thickness of the rectus muscles of the eye was 22.6 mm and > (in N - 16.8 mm), i.e. increased by an average of 5-6 mm, channel enlargement optic nerve. CT scans with compensated edematous exophthalmos were also examined and thickening of the internal and external rectus muscles of the eye was revealed.

All patients received drug treatment, the purpose of which was, firstly, to normalize the function of the thyroid gland; thiamozol was used as a drug. Secondly, treatment of such symptoms as dry eye with the help of Oftagel, Vidisik; increased intraocular pressure - 0.25% solution of betaxalol, xalatan; swelling of the periorbital tissues, bulbar conjunctiva, retrobulbar tissue, optic nerve head - hypothiazide, furosemide. Thirdly, enzyme therapy using Wobenzym. As well as glucocorticosteroid (prednisolone, dexamethasone), immunocorrective (cyclosporine, immunoglobulins), extracorporeal (plasmapheresis, hemosorption) therapy.

Surgical treatment included tarsorrhaphy (complete or partial suturing of the eyelids), canthorrhaphy (suturing of the eyelids from any corner of the slit), levator tenotomy, decompressive and corrective operations on the extraocular muscles.

Let's look at a few clinical cases:

1). Patient N. was admitted on January 13, 2014 with complaints of mood swings, weight loss of 5 kg over 3 months, heart pain, shortness of breath, and increased blood pressure. Heaviness, pressure in the thyroid gland. Frequent headaches and decreased vision. General anamnesis: general weakness, sweats, fever, pain in knee joints, feeling of dryness in the throat, shortness of breath. Cardiovascular system: heart rate up to 100 beats per minute. Periodic pain in the heart of a piercing and oppressive character. Examination: the thyroid gland is palpable, enlarged to degree 0, painless, homogeneous. Graefe, Mobius, Stellwag, Kocher symptoms are negative. Tests: TSH - 0.021 (normal 0.4-4.0), T4sv - 22.9 (normal 9.3-21.5). Blood-Er 4.40*1012/l, Hb (hemoglobin) 121 g/l, ESR (erythrocyte sedimentation rate) 24 mm/h, Trt (platelets) 191x109/l, segmented neutrophils 50%, eosinophils 3%, Lf ( lymphocytes) 35%, Mts (monocytes) 10%. Ophthalmologist's conclusion: Endocrine ophthalmopathy, stage I OU. Acute-angle glaucoma I-II in OU (both eyes).

Angliosclerosis of the retina OU. Initial cataract OU. Treatment: Plasmapheresis, vinpocetine, panangin, tyrosol, metoprolol.

2). Patient N., 59 years old, was admitted on January 12, 2015.

Complaints: cramps lower limbs, weakness, drowsiness, feeling of a lump in the throat, hoarseness of voice, rapid heartbeat, weight loss of 20 kg over 4 years. The patient has been treating herself since 1989, when she first independently discovered an enlarged thyroid gland. In 1990, resection of the left lobe of the thyroid gland was performed. After this, she did not receive any therapy until 1994, then she took L-thyroxine 50 mcg for 2 years, then stopped. In 2005, 100 mcg was prescribed due to increased weakness and fatigue; she stopped taking it in 2006. Objectively: positive Moebius and Stellwag signs. The thyroid gland is not palpable. The ophthalmologist's conclusion: endocrine ophthalmopathy stage I OU. ECG: paroxysmal atrial fibrillation. Diagnosis: Diffuse multinodular toxic goiter of the 2nd degree, recurrent course. Severe thyrotoxicosis. Endocrine ophthalmopathy stage I. Treatment: Vinpocetine, panangin, tyrosol, veroshpiron, concor. surgical treatment (thyroidectomy).

3). Patient K., 42 years old, was admitted on 02.11.15 to the 1st Republican Clinical Hospital in the endocrinology department

Complaints: increased blood pressure up to 180/100 mm Hg, headache, dry mouth, palpitations, interruptions in heart function, shortness of breath (with physical activity), pain in the eyeballs with increased blood pressure, weakness, insomnia, irritability, increased sweating, swelling in the evenings on the legs and arms, in the morning on the face.

Eye symptoms: exophthalmos => dry eyes, diplopia, periodic redness, discomfort in both eyes; symp. Graefe +; symp. Möbius +; symp. Delrymple +; symp. Jellinek +.

Instrumental methods:

Examination of the thyroid gland: right lobe V- 3.8 cm3; length - 3.6 cm; thickness - 1.5 cm; width-1.5 cm.

Left lobe V-2.4 cm3; length - 3.0 cm; thickness - 1.3 cm; width - 1.3 cm.

The isthmus is 0.4 cm. The echostructure is heterogeneous, the contours are uneven.

Ultrasound of the eye and adnexa from November 27, 2014

Retrobulbar tissue has moderately increased echogenicity.

Ophthalmologist's conclusion: endocrine ophthalmopathy stage II. Retinal angiopathy OU. Initial cataract OD.

Conclusions:

1. Endocrine ophthalmopathies occupy an important place among patients with thyrotoxicosis and are found in 70-80% of cases. The main complaints upon admission were blurred vision, pain and discomfort of the eyeballs, rapid heartbeat, weight loss, and weakness.
2. It was revealed that endocrine ophthalmopathy is a disease more common among women (71%) than among men (21%). The average age of the patients during this time was calculated to be 50 ± 4 years. We studied the appealability of patients in different months of the year and found that the peak of appealability occurs in the month of January - 23.5%.
3. When analyzing the echography of the eye in a number of patients on the basis of the BUZ UR "Republican Ophthalmological Clinical Hospital of the Ministry of Health of the UR" and found an expansion of the retrobulbar zone, the total thickness of the rectus ocular muscles was 22.6 mm and > (in N - 16.8 mm), i.e. . increased by an average of 5-6 mm, an increase in the optic nerve canal. We also examined computed tomograms of patients with compensated edematous exophthalmos and revealed thickening of the internal and external rectus muscles of the eye.
4. When treating patients, symptomatic, glucocorticosteroid immunocorrective, extracorporeal therapy, as well as enzyme therapy and radioactive iodine treatment were performed, which in most cases had a beneficial effect.
5. We examined several clinical cases and made conclusions: 1 case - endocrine ophthalmopathy stage I OU. Acute-angle glaucoma I-II in OU (both eyes); Case 2 - endocrine ophthalmopathy stage I OU; Case 3 - endocrine ophthalmopathy stage II. Retinal angiopathy OU. Initial cataract OD.

Bibliographic link

Styazhkina S.N., Chernyshova T.E., Poryvaeva E.L., Khafizova C.R., Ignatieva K.D. OPHTHALMOPATHS IN THYROTOXICOSIS // Contemporary issues science and education. – 2016. – No. 1.;
URL: http://site/ru/article/view?id=24052 (access date: 03/20/2019).

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Delrymple's sign is a wide opening of the palpebral fissure in patients with thyrotoxicosis.

Graefe's symptom (A.Graefe) is a lag of the upper eyelid and the appearance of a white strip of sclera above the iris when the eyeball moves downward in patients with thyrotoxicosis.

Kocher's symptom (E.Th.Kocher) is a lag in the movement of the eyeball from the movement of the upper eyelid and the appearance of a white strip of sclera above the iris when the eyeball moves upward in patients with thyrotoxicosis.

Stellwag's symptom (C. Stellwag) is a rare and incomplete blinking in patients with thyrotoxicosis.

Reprev-Melikhov symptom – an angry look in patients with thyrotoxicosis.

Moebius sign (P.J.Moebius) – weakness of convergence in patients with thyrotoxicosis.

Jellinek's symptom (S. Jellinek) is skin pigmentation on the eyelids in patients with thyrotoxicosis.

Rosenbach's symptom (O. Rosenbach) is a small rapid trembling of drooping eyelids in patients with thyrotoxicosis.

Stasinski's symptom (T. Stasinski) - injection of the sclera with a cruciform arrangement of dilated vessels in patients with thyrotoxicosis.

Symptoms of gastrointestinal pathology

Courvoisier-Terrier symptom – an enlarged (congestive) gallbladder is palpated below the edge of the liver, oval in shape, elastic in consistency, displaceable, painless. Described with compression of the common bile duct due to cancer of the head of the pancreas, as well as with primary damage to the major duodenal papilla: papillitis, stenosis, cancer.

Mussi-Georgievsky's symptom – pain on palpation between the legs of the m. sternoclaidomastoideus on the right. A sign of damage to the gallbladder, most often in acute cholecystitis.

Murphy's sign (J.B.Murphy) - palpation during inspiration at the site of the gallbladder projection (the patient is on the left side, sitting or standing, with either 4 fingers or 1 finger immersed). A symptom is considered positive if during take a deep breath the patient suddenly interrupts it due to the appearance of pain when the fingertips touch the sharply sensitive gallbladder, as evidenced by the patient’s reaction in the form of a cry of pain and a facial expression.

Kehr's symptom (H.Kehr) is the appearance of pain in the area where the gallbladder is located during deep palpation in the right hypochondrium.

Gausmann's symptom is a sensation of pain in the area of ​​the gallbladder with a short blow with the edge of the palm below the right costal arch at the height of inspiration.

Lepene-Vasilenko symptom – the appearance of pain in the area where the gallbladder is located when delivering jerky blows with the fingertips while inhaling below the right costal arch.

Ortner-Grekov symptom (N.Ortner, I.I.Grekov) – pain appears when the inflamed gallbladder is shaken when the edge of the palm is struck on the edge of the right costal arch.

Eisenberg's symptom - the patient rises on his toes while standing, and then quickly falls on his heels. A positive symptom is the occurrence of pain in the right hypochondrium as a result of shaking of the inflamed gallbladder.

Pekarsky's symptom is pain when pressing on the xiphoid process. The symptom is often observed with recurrent chronic cholecystitis.

Mendel's sign (F.Mendel) - tapping the fingers on the front of the hand abdominal wall. Positive when pain appears, usually coinciding with the projection site of a fairly deep ulcerative defect in the stomach or duodenum.

Grotta's symptom (J.W.Grotta) – atrophy subcutaneous tissue in the area corresponding to the projection of the pancreas onto the abdominal wall.

Choledochopancreatic zone of Chauffard (A.E.Chauffard) - in the epigastrium on the right (in the right upper quadrant of the abdomen) - medially from the bisector dividing the right angle formed by two intersecting lines: the anterior midline of the abdomen and a line drawn perpendicular to it through the navel.

Desjardins' point (A.Desjardins) is a point on the border of the middle and upper third of the distance between the navel and the right costal arch along the line from the navel to the right axilla.

The Gubergrits-Skulsky zone is in the epigastrium on the left, symmetrically to the Shoffard zone.

The Gubergritsa point is 5–6 cm above the navel on the line connecting it to the left armpit.

Mayo-Robson's symptom (A.W. Mayo-Robson) – the appearance of pain on palpation of the left costovertebral angle, which indicates inflammatory process caudal part of the pancreas.

Exophthalmos is bulging eye. With this type of disease, there is a large distance that is observed between the iris of the eye and the upper eyelid.

The eye may lose its mobility or be severely limited in movement.

The phenomenon of exophthalmos can be both eyes are affected at once or only one. The contents of both eye sockets must strictly correspond volume of bone tissue, as well as the size of blood vessels and adipose tissue. In the case of exophthalmos, this balance is disturbed so as to lead to the phenomenon of protrusion.

Varieties

Highlight 4 varieties exophthalmos:

1. Constant, in which neoplasms appear after an injury to the hand, eyes or brain herniation.
2. Throbbing, after injury to the eyes and skull.
3. Intermittent, manifests itself after tilting the head.
4. Progressive malignant, occurs due to dysfunction of the thyroid system.

Also, there may be one - or double-sided, pronounced or inconspicuous.

Edema exophthalmos

Exophthalmos in itself is not a disease, it is only symptom. Therefore, to successfully treat the disease, it is worth understanding better true reasons, which led to the appearance of this deviation from the norm.

Attention! Edema exophthalmos is one of its most dangerous forms, in which eyeballs, literally dislocate from eye sockets, which leads to disability patient.

Complex shapes protrusions occur extremely rare. More often than not, everything is quite limited severe swelling and phenomena of protrusion of the eyeballs.

Edema exophthalmos develops in patients, whose age exceeds forty years. It can occur equally in both men and women. Patients often complain of increased intraocular pressure.

Edema exophthalmos can be like: one-sided, so bilateral.

Diagnostics

To diagnose this type of disease, they are used the latest devices, which are available in modern eye clinics.

With the help of this kind of equipment, it becomes possible to determine intraocular pressure with exophthalmos, as well as the degree vascular damage, which, without fail, occurs during protrusion phenomena.

Great value has an external medical examination, which can and should be performed by a professional doctor.

Symptoms

If we talk about the symptoms of this disease, we can highlight the following types of them:

Treatment

Unfortunately, medicine does not have adequate methods treatment of exophthalmos. This disease poses a significant danger to its carrier. Therapy should be carried out by an experienced ophthalmologist, as well as an endocrinologist. Most often, drugs are prescribed that stabilize the patient’s hormonal levels. Here we are talking about prednisolone, which is prescribed in dosages reaching 1200 mg.

Also of great importance is the prescription of drugs that contain the active substance "thyroidin". If we talk about prednisolone, then this medication is necessary to relieve the inflammatory process, which always manifests itself with exophthalmos. Thyroidin can normalize thyroid function, which is also of great importance for the successful fight against disease symptoms.

It is worth noting the importance local treatment, which consists in the purpose various kinds eye drops, as well as topical drops. Here, most often, we are talking about prescribing a series of hormonal drops, such as "Dexamethosone", which help relieve inflammatory processes.

Photo 1. Eye drops Dexamethasone 0.1%, 10 ml, manufacturer “Pharma”.

Also very popular is the use of ointments that contain an antibiotic. Let's say tetracycline ointment.

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Thyrotoxic exophthalmos

Thyrotoxic exophthalmos is a consequence of a disease called thyrotoxicosis. It is important to note that this type of disease most often develops in women, whose age exceeds fifty years. The phenomena of protrusion are often accompanied by redness of the lower eyelid, as well as inflammatory processes that occur in the eye orbit.

A huge number of visual and computer techniques are used for diagnosis. In particular, the patient is sent to undergo e ultrasound, computed tomography, and also magnetic resonance imaging. All these methods can provide true information about the condition of the patient's fundus, as well as the condition of the orbital and periorbital areas of the eyes.

Signs

Symptoms that can provoke this disease:

• Increased fatigue and irritability. These symptoms should be classified as general, which are a consequence serious illness.
• Tremor hands

• Swelling of the lower eyelid.
• Redness of the lower eyelid.
• Major changes in the fundus, which lead to increased intraocular pressure.
• Increased sleepiness.
• Serious pain syndrome, which consists in unbearable dull or throbbing pain, which may be characteristic of this disease.

How to treat thyrotoxicosis

Treatment of thyrotoxic exophthalmos can be carried out using a wide range of different methods. No method does not allow you to completely eliminate from this kind of disease. The first and most common method is that the doctor prescribes to the patient conservative treatment , which can and should include a wide range of medications.

Medicines

An endocrinologist may advise using a common and completely inexpensive drug, which is called "L-thyroxine." This drug used to treat endocrine diseases and is successfully used in patients who have certain thyroid diseases. As a result of the influence of this drug, the thyroid hormone background, and the phenomena of exophthalmos may decrease.

In addition, an ophthalmologist can prescribe medications that can reduce swelling and inflammation. Here we are talking about local therapy. As such therapy, it is prescribed "Dexamethasone" which successfully fights inflammation.

It is also very important to prescribe eye drops that can reduce elevated intraocular pressure . These drugs include "Betoptik." These are unique drops that have no analogues. As a result of their unique pharmaceutical mechanism of action, they are able to influence the phenomenon high blood pressure in order to reduce it or bring it back to normal.

Photo 2. Emoxipin, eye drops, 5 ml, solution 10 mg/ml, manufacturer RUE "Belmedpreparaty".

In cases of thyrotoxic exophthalmos, it often suffers retina of the eye. Therefore, it is simply necessary to prescribe drops that can support the retina. Such drops include "Emoxipin", which is able to combat the manifestations of hemorrhages in the ocular environment, and can also strengthen the retina.

In addition, quite often the therapist resorts to prescribing prednisolone in tablet form, which can be purchased at any city pharmacy at small price. Prednisolone is able to reduce inflammation and restore hormonal levels, which is of great importance in the thyrotoxic type of disease.

Radioiodine therapy

Very often, with thyrotoxic exophthalmos, it is prescribed radioiodine therapy, which is able to equalize the hormonal levels in the thyroid gland. The meaning of this type of procedure is that the human thyroid gland is capable of attracting huge amounts of iodine.

Therefore, when this substance is introduced into the body chemical element, this gland begins its active work to absorb in a matter of hours required quantity element of the periodic table.

This procedure is most directly related to the treatment of thyrotoxic exophthalmos, because after normalization of hormonal levels, we can observe a decrease in the intensity of the symptoms of eye protrusion.

Operation

In some cases, for the successful treatment of exophthalmos, surgical methods. In modern surgical rooms, widespread received the so-called thyroidectomy, which consists in partial removal thyroid gland. After this type of operation, we can talk about a significant regression of exophthalmos, but not about its cure.

It is also worth noting that, despite the great popularity of this operation, it has a number of significant contraindications. Such contraindications include the fact that, often, after surgery, thyrotoxic exophthalmos turns into its edematous form, which is the worst prognosis for this disease.

Therefore, before carrying out this type of surgical intervention, you should always think about oh that's enough sad consequences . It is possible that in some cases it is worth limiting ourselves to only conservative methods of treating an insidious disease.

Endocrine exophthalmos

Endocrine exophthalmos is associated with a kind of imbalance in the functioning of the endocrine glands. As a result of increased production thyroid-stimulating hormone, you can often encounter the phenomena of protrusion of the eyeballs.

Endocrine glands can increase or decrease the production of various hormones. In case of increased activity, this can lead to serious deviations in human life.

If we talk about the symptoms of this disease, they manifest great similarity to those symptoms which have been described in case of thyrotoxic exophthalmos. Methods for diagnosing this disease are also similar to those described above.

If we talk about treatment methods, then in cases of endocrine exophthalmos, it is prescribed course of corticosteroid therapy. It also happens X-ray therapy, which involves administering high doses of radiation. In addition, surgical treatment methods are used. These include excision ocular orbit , as well as her decompression.

Pulsating exophthalmos

With pulsating exophthalmos, a significant disturbance occurs in the vascular bed. This type of violation manifests itself by being upset vascular tone in the cavernous sinus. Very often this kind of disease can be observed in children who have a disease called cerebral hernia. If we talk about diagnostics, the following types are used:

• Ultrasound.
• Computed tomography.
• Magnetic resonance imaging.

The same methods are used as for the types of exophthalmos mentioned above.

If we talk about main symptoms of this disease, then they have similarity to symptoms of thyrotoxic exophthalmos, however, with a pulsating protrusion, the patient’s vision does not disappear.

It is disrupted so that the patient has enormous visual discomfort. Often with this disease, we can talk about nystagmus of the eyeballs.

Therapy

The disease is being treated X-ray therapy. It is important to use enough large doses of radiation in order to achieve a significant effect. Small doses of radiation are not able to have a significant effect on this disease.

By radical method in the treatment of pulsatile exophthalmos, is a method in which the so-called dressing carotid artery . As a result of this type of fixation, the pressure on the eyeballs is reduced, which means the symptoms of bulging are reduced.

However, with this surgical method exposure, serious side effects may occur in the form of increased intraocular pressure. Therefore, the surgeon is obliged to weigh all the pros and cons before performing this type of operation in order to avoid serious complications in the form of complete or partial loss of vision.

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6. Ectodermal disorders: brittle nails, hair loss.

7. Digestive system: stomach ache, unstable chair with a tendency to diarrhea, thyrotoxic hepatosis.

8. Endocrine glands : ovarian dysfunction up to amenorrhea, fibrocystic mastopathy, gynecomastia, impaired carbohydrate tolerance, relative thyrogenic, that is, with normal or increased levels of cortisol secretion, adrenal insufficiency (moderate melasma, hypotension).

Conservative pharmacological treatment

The main means of conservative treatment are the drugs Mercazolil and methylthiouracil (or propylthiouracil). The daily dose of Mercazolil is 30-40 mg, sometimes with very large goiters and severe course thyrotoxicosis it can reach 60-80 mg. The maintenance daily dose of Mercazolil is usually 10-15 mg. The drug is taken continuously for 1/2-2 years. Reducing the dose of Mercazolil is strictly individual, it is carried out based on the signs of elimination of thyrotoxicosis: stabilization of the pulse (70-80 beats per minute), increase in body weight, disappearance of tremor and sweating, normalization of pulse pressure.

Radioiodine therapy (RIT) is one of the modern methods treatment of diffuse toxic goiter and other diseases of the thyroid gland. During treatment, radioactive iodine (isotope I-131) is introduced into the body in the form gelatin capsules orally (in in rare cases liquid solution I-131 is used). Radioactive iodine, which accumulates in the cells of the thyroid gland, exposes the entire gland to beta and gamma radiation. This destroys the gland cells and tumor cells, spreading beyond its borders. Radioiodine therapy requires mandatory hospitalization in a specialized department.

Absolute indications For surgical treatment allergic reactions or a persistent decrease in leukocytes noted during conservative treatment, large goiters (enlargement of the thyroid gland above grade III), heart rhythm disturbances of the type atrial fibrillation with symptoms of cardiovascular failure, pronounced goitrogenic effect of Mercazolil.

The operation is performed only when a state of drug compensation has been achieved, since otherwise a thyrotoxic crisis may develop in the early postoperative period.

Nodular toxic goiter is hyperthyroidism due to an autonomously functioning adenoma of the thyroid gland (thyroid gland) in the form of one or more nodules. The function of the remaining parts of the gland is suppressed by low levels of TSH due to high levels of thyroid hormones. These areas are identified by their ability to accumulate radioactive iodine after TSH injection. Nodules and cysts in the thyroid gland are often incidental findings detected by ultrasound. In patients with a single nodular formation in the thyroid tissue, identified clinically or using ultrasound, the possibility of cancer should be considered.

SURGICAL TREATMENT. All malignant and some benign thyroid formations are subject to surgical treatment.

Indications for surgical treatment

· History of irradiation of the neck area (suspicion of a malignant process)

Large size of the node (more than 4 cm) or due to it compression symptoms

Progressive growth of the node

Dense consistency of the knot

· Young age of the patient.

The scope of the operation for a solid benign nodular formation is removal of a lobe with or without the isthmus of the gland; for highly differentiated cancer (papillary or follicular) - extremely subtotal thyroidectomy.

Indications for surgical intervention: diffuse toxic goiter of moderate and severe form, nodular toxic goiter (thyrotoxic adenoma), large goiter,

compressing the organs of the neck, regardless of the severity of thyrotoxicosis. Before surgery, it is imperative to bring the functions of the thyroid gland to a euthyroid state.

Contraindications to surgical intervention: mild forms of thyrotoxicosis, in old, malnourished patients due to the high operational risk, in patients with irreversible changes liver, kidneys, cardiovascular and mental diseases.

3. Goiter and thyrotoxicosis. Complications during and after surgery. Clinic of complications, their treatment and prevention.

Intraoperative complications: bleeding, air embolism, damage to the recurrent nerve, removal or damage to the parathyroid glands with subsequent development of hypoparathyroidism. If both recurrent nerves are damaged, the patient experiences acute asphyxia and only immediate tracheal intubation or tracheostomy can save the patient. In patients with thyrotoxicosis in the postoperative period, the most dangerous complication-- development thyrotoxic crisis. The first sign of thyrotoxic crisis is a rapid increase in body temperature to 40°C, accompanied by increasing tachycardia. Blood pressure first increases and then decreases, and neuropsychic disorders are observed.

In the development of the crisis, the main role is played by insufficiency of the adrenal cortex function, caused by operational stress. Treatment of a crisis should be aimed at combating adrenal insufficiency, cardiovascular disorders, hyperthermia and oxygen deficiency.

Tracheomalacia. With long-standing goiter, especially with retrosternal, retrotracheal and retroesophageal goiter, due to its constant pressure on the trachea, degenerative changes in tracheal rings and their thinning - Tracheomalacia. After removal of the goiter, immediately after extubation of the trachea or in the immediate postoperative period, it may bend in the area of ​​softening or bring the walls closer together and narrow the lumen. Acute asphyxia occurs, which can lead to the death of the patient if urgent tracheostomy is not performed (see " Inflammatory diseases trachea").

Postoperative hypothyroidism - insufficiency of thyroid function, caused by its complete or almost complete removal during surgery, develops in 9-10% of operated patients. Hypothyroidism is characterized general weakness, a constant feeling of fatigue, apathy, drowsiness, and general lethargy of patients. The skin becomes dry, wrinkled, and swollen. Hair begins to fall out, pain appears in the limbs, sexual function weakens.

Treatment: thyroidin and other thyroid medications are prescribed. With the development of microsurgical technology and advances in immunology, allotransplantation of the thyroid gland began to be performed using a graft on a vascular pedicle. Free implantation of pieces of gland tissue under the skin, into the muscle is also used, however, these operations usually give a temporary effect, so in practice they mainly use replacement therapy.

4. Thyroiditis and strumitis. Definition. Concepts. Clinic. Diagnostics. Differential diagnosis. Conservative and surgical treatment. Hashimoto's and Fidel's thyroiditis.

The inflammatory process that develops in the previously unchanged thyroid gland is called thyroiditis, and that developing against the background of goiter is called strumitis. The cause of the development of thyroiditis and strumitis is acute or chronic infection.

Acute thyroiditis or strumitis begins with fever, headache and severe pain in the thyroid gland. The pain radiates to the occipital region and ear. A swelling appears on the front surface of the neck, which is displaced when swallowing. Severe complication thyroiditis is the development of purulent mediastinitis. Sometimes sepsis develops. That is why hospitalization for the purpose of active treatment is indicated for all patients.

Treatment: antibiotics are prescribed; When an abscess forms, its opening is indicated to avoid the spread of the purulent process to the neck and mediastinum.

Hashimoto's chronic lymphomatous thyroiditis. The disease is classified as an autoimmune organ-specific pathological process, in which antibodies formed in the body are specific to the components of one organ. With Hashimoto's thyroiditis, under the influence of unknown causes, the thyroid gland begins to produce altered hormonally inactive iodine proteins that differ from thyroglobulin. Penetrating into the blood, they become antigens and form antibodies against acinar cells of the thyroid gland and thyroglobulin. The latter inactivate thyroglobulin. This leads to disruption of the synthesis of normal thyroid hormones, which causes increased secretion of TSH from the pituitary gland and hyperplasia of the thyroid gland. In the later stages of the disease, the thyroid function of the gland is reduced, and the accumulation of iodine in it decreases.

Clinical presentation and diagnosis: Hashimoto's thyroiditis most often occurs in women over 50 years of age. The disease develops slowly (1-4 years). The only symptom for a long time is an enlarged thyroid gland. It is dense to the touch, but is not fused with the surrounding tissues and is mobile during palpation. Subsequently, discomfort and signs of hypothyroidism appear. Regional lymph nodes are not enlarged.

The detection of antithyroid autoantibodies in the patient's serum is of great importance in diagnosis. The final answer is obtained by puncture biopsy.

Treatment: conservative, includes the administration of thyroid and glucocorticoid hormones. The dose of thyroid hormones is selected individually, the average daily dose of thyroidine is 0.1--0.3 g. The daily dose of prednisolone is 20--40 mg for 1 1/2 - 2 months with a gradual dose reduction. .

If malignant degeneration is suspected, or if the organs of the neck are compressed by a large goiter, surgery is indicated. Subtotal resection of the thyroid gland is performed. After surgery, treatment with thyroidin is necessary due to inevitably developing hypothyroidism.

Chronic fibrous thyroiditis of Riedel. The disease is characterized by growth in the thyroid gland connective tissue, replacing its parenchyma, involving surrounding tissues in the process. The etiology of the disease has not been established.

Clinic and diagnostics. The thyroid gland is diffusely enlarged, stony in density, fused with the surrounding tissues. There are moderate signs of hypothyroidism. Pressure on the esophagus, trachea, blood vessels and nerves causes the corresponding symptoms.

Treatment: before surgery it is almost impossible to exclude a malignant tumor of the thyroid gland, therefore, for Riedel's thyroiditis it is indicated surgery. The maximum possible excision of fibrosing thyroid tissue is performed, followed by replacement therapy.

5. Thyroid cancer. Classification. Clinic. Diagnostics. Differential diagnosis. Types of operations. Combined treatment.

Clinical and morphological classification of thyroid tumors

1. Benign tumors

a) epithelial embryonic, colloidal, papillary,

b) non-epithelial fibroma, angioma, lymphoma, neurinoma, chemodectoma

2. Malignant tumors

a) epithelial papillary adenocarcinoma, follicular adenocaria noma, Langhans tumor, solid cancer, squamous cell and undifferentiated cancer,

b) non-epithelial tumors - sarcoma, neurosarcoma, lymphoreticulosarcoma

Thyroid cancer accounts for 0.4-1% of all malignant neoplasms. Develops in nodular goiter with normal or reduced function and very rarely in diffuse toxic goiter In 15-20% of patients, histological examination nodular goiter cancer is detected. Cancer is 3-4 times more common in women than in men. Factors contributing to the development of thyroid cancer include trauma, chronic inflammatory processes, x-ray irradiation thyroid area, long-term treatment I133 or thyreostatic drugs. Benign tumors of the thyroid gland are rare.

There is an International Classification of Thyroid Cancer according to TNM system, however, in practice, classification by stages is more often used.

Clinical stages thyroid cancer

Stage I - a single tumor in the thyroid gland without its deformation, growth into the capsule and limited displacement

II A stage single or multiple tumors of the thyroid gland, causing its deformation, but without growing into the capsule of the gland and limiting its displacement

Regional and distant metastases none

Stage II B - single or multiple tumors of the thyroid gland without growing into the capsule and without limited displacement, but in the presence of displaceable metastases in the lymph nodes on the affected side of the neck

Stage III is a tumor that spreads beyond the capsule of the thyroid gland and is associated with surrounding tissues or compresses neighboring organs. Tumor displaceability is limited, there are metastases to displaceable lymph nodes

Stage IV, the tumor grows into surrounding structures and organs with complete non-displacement of the thyroid gland, non-displaceable lymph nodes Metastases to the lymph nodes of the neck and mediastinum, distant metastases Regional lymphogenous metastasis occurs in the deep cervical, preglottic, pre- and paratracheal lymph nodes. Hematogenous metastasis is observed in distant organs, most often the lungs and bones are affected.

Clinic and diagnosis: early clinical symptoms-- a rapid increase in the size of the goiter or normal thyroid gland, an increase in its density, and a change in contours. The gland becomes tuberous, inactive, and the cervical regional lymph nodes are palpated. The immobility and compaction of the tumor create a mechanical obstacle to breathing and swallowing. When the recurrent nerve is compressed, the voice changes and hoarseness develops associated with paresis of the vocal cords. At a later stage, symptoms due to tumor metastasis are observed. Patients often complain of pain in the ear and back of the head

For the differential diagnosis of thyroid tumors, the data of cytological and histological examination of tumor punctate are of primary importance, which make it possible not only to establish a diagnosis of the disease, but also to determine the morphological type of the tumor. False-negative results during puncture of a malignant thyroid tumor are obtained in approximately 30% of patients

Treatment: The main treatment for thyroid cancer is surgery. For papillary and follicular forms of thyroid cancer (stages I-II), extracapsular subtotal thyroidectomy with revision of the lymph nodes and their removal when metastases are detected. At stage III of the disease, combination therapy: preoperative gamma therapy, then subtotal or total thyroidectomy with fascial-sheath excision of tissue on both sides. At cancer III--IV stages, if preoperative radiation therapy has not been performed, it is advisable to carry out postoperative radiation. To influence distant metastases in differentiated forms of cancer, I133 is prescribed. The prognosis is favorable for follicular and papillary forms of thyroid cancer. In solid and undifferentiated forms of cancer, the prognosis is poor even with relatively early surgical intervention.

6. Acute mastitis. Classification. Clinic of various forms. Diagnostics. Conservative treatment. Indications for surgery, methods of surgery. Prevention of mastitis in pregnant and postpartum women.

Mastitis (mastitis; Greek mastos breast + -itis; synonym breast) is inflammation of the parenchyma and interstitial tissue of the mammary gland.

There are acute and chronic mastitis. Depending on functional state mammary gland (presence or absence of lactation) there are lactation (postpartum) and non-lactation M. Lactational M. accounts for 95% of cases of M. In this case, most often (up to 85%) lactation M. occurs in primiparous women. In 95% of patients, the causative agent of M. is pathogenic staphylococcus, often (up to 80%) insensitive to widely used antibiotics.

Acute mastitis. The inflammatory process in the mammary gland can be limited to inflammation of the milk ducts (galactophoritis), which is accompanied by the release of milk mixed with pus, or inflammation of the glands of the areola (areolitis, calf). As the disease progresses, serous infiltration is replaced by diffuse purulent infiltration of the mammary gland parenchyma with small foci purulent melting, which subsequently merge, forming abscesses. Depending on the location of the purulent focus, there are

· subareolar,

· subcutaneous

· intramammary

retromammary

Taking into account the course of the inflammatory process acute mastitis divided into

serous (initial),

· infiltrative,

· infiltrative-purulent (apostematous - like a “honeycomb”),

abscess,

· phlegmonous,

· gangrenous.

Signs of serous M. are engorgement and swelling of the mammary gland, accompanied by an increase in body temperature. Sweating, weakness, fatigue, sharp pains in the mammary gland. The gland is enlarged in size, swollen, painful on palpation, with the help of which an infiltrate without clear contours is determined. Expressing milk is painful and does not bring relief. The number of leukocytes in the blood increases to 10-1210 9 /l, ESR increases to 20-30 mm per 1 hour. ineffective treatment after 2-3 days, serous M. can turn into infiltrative, which is characterized by greater severity of clinical signs of inflammation and a deterioration in the general condition of the patient. Hyperemia of the skin of the gland appears; upon palpation it is more clearly defined inflammatory infiltrate. The transition to infiltrative purulent and abscess M. is accompanied by an increase in general and local symptoms inflammation, more pronounced signs intoxication. Body temperature is constantly high or takes on a hectic character. Hyperemia of the skin of the affected gland intensifies, the infiltrate increases in size, and a fluctuation appears in one of its areas.

Phlegmonous M. is characterized by extensive purulent lesions of the mammary gland without clear boundaries with healthy tissue. An increase in body temperature up to 40° and chills are noted. The mammary gland is sharply enlarged, covered with swollen, shiny, hyperemic skin with a bluish tint. Regional lymphadenitis occurs early. In rare cases, due to the involvement of blood vessels in the inflammatory process and their thrombosis, gangrenous M develops. An important role is also played by the body's autosensitization to organ-specific antigens: milk, breast tissue. The process is characterized by rapid purulent melting of the tissue, spreading to the cellular spaces chest, accompanied by skin necrosis and severe intoxication. The condition of the patients is extremely serious: the body temperature is increased to 40-41°, the pulse is increased to 120-130 per minute. Leukocytosis up to 3010 9 /l is observed with a shift of the leukocyte formula to the left, protein is detected in the urine.

Mastitis can be complicated by lymphangitis, lymphadenitis and rarely sepsis. After opening (especially spontaneous) an abscess, milk fistulas are formed, which can close on their own, but over a long period of time.

The diagnosis is based on medical history and clinical examination results. A bacteriological examination of pus, milk (from the affected and healthy gland) is carried out, and in case of high body temperature and chills - a bacteriological examination of the blood. Electrothermometry of the skin and thermal imaging examination of the mammary glands can reveal a higher temperature over the lesion (by 1-2°C) than in unaffected areas. Ultrasound also plays an important role. Treatment should begin when the first signs of the disease appear, which allows in a significant number of cases to prevent the development of a purulent process. Conservative therapy start by carefully expressing milk. Before expressing, a retromammary novocaine blockade is performed with a 0.25% solution of novocaine (70-80 ml), to which antibiotics (oxacillin or methicillin) are added in half the daily dose, 2 ml of no-shpa is administered intramuscularly (20 minutes before expressing) and 0. 5-1 ml of oxytocin (in 1-2 minutes), desensitizing therapy is carried out. With lactostasis, after pumping, pain in the mammary gland stops, small, painless lobules with clear contours are palpated, and body temperature normalizes. For serous and infiltrative M., these measures are carried out repeatedly, but no more than 3 times a day. Antibiotics are prescribed (semi-synthetic penicillins, in more severe cases - lincomycin, gentamicin). In the absence of positive dynamics within 2 days. (normalization of body temperature, reduction in the size of the infiltrate and its pain on palpation), surgical intervention is indicated, in doubtful cases - puncture of the infiltrate with a thick needle. To improve efficiency complex treatment suppress or temporarily inhibit lactation with drugs that inhibit the secretion of prolactin by the anterior pituitary gland (parlodel).

Surgical intervention consists of a wide opening of the abscess and its pockets, examination of its cavity, separation of the bridges, careful removal of necrotic tissue, drainage purulent cavity. In case of infiltrative-purulent M., the entire zone of infiltrates is excised within the healthy tissue. If there are several abscesses, each of them is opened with a separate incision. Intramammary abscesses are opened with radial incisions; retromammary abscesses are opened with a lower semi-oval incision, which avoids crossing the intralobular milk ducts and ensures good conditions for the outflow of pus and the discharge of necrotic tissue. Treatment of wounds after opening the abscess is carried out taking into account the phase of the wound process. In the postoperative period, milk continues to be expressed in order to prevent lactostasis. In localized forms of acute M., a purulent focus is excised within healthy tissue, the wound cavity is drained through counter-apertures with one double-lumen or several single-lumen silicone drains, and a primary suture is applied. In the postoperative period, flow-wash drainage of the wound with antiseptic solutions is carried out, which makes it possible to achieve wound healing in a more rapid manner. early dates and with better cosmetic and functional results. Adequate antibiotic therapy, detoxification and restorative therapy, the prescription of vitamins and drugs that increase the immunological reactivity of the patient's body, local UV irradiation, ultrasound and UHF therapy are indicated. The prognosis for timely treatment is favorable. Prevention of M. begins during pregnancy. In the antenatal clinic, along with recommendations regarding rational nutrition pregnant women, physical exercise, breast care, teaching women the rules and techniques breastfeeding, significant attention is paid to identifying pregnant women high risk development postpartum mastitis. IN obstetric department One of the decisive factors in preventing M. is compliance with sanitary and hygienic and anti-epidemic measures, prevention and timely treatment of cracked nipples and lactostasis (engorgement) of the mammary glands.

7. Dishormonal diseases of the breast. Classification. Clinic. Diagnostics. Differential diagnosis. Treatment is conservative and surgical.

Dishormonal mastopathy is currently understood as a group of benign diseases of the mammary gland, characterized by the appearance of nodular compactions, pain in the mammary glands, and sometimes pathological secretion. This group includes about 30 independent diseases associated with various dysfunctions of the ovaries, adrenal glands, pituitary gland and accompanied by relative hyperestrogenemia, imbalance of progesterone and androgens, disruption of the cyclic production of pituitary hormones and increased concentrations of plasma prolactin. The terms fibroadenosis and fibroadenomatosis are also used as synonyms for mastopathy. fibrocystic mastopathy and a number of others.

Mastopathy is usually found in patients aged 25 to 50 years. Various forms of the disease occur during routine examinations in 20-60% of patients of this type. age group, and according to autopsies - in more than 50% of women. After menopause, all signs of the disease, as a rule, disappear, which, of course, indicates the role of hormonal imbalances in the origin of mastopathy.

Benign changes in the mammary glands X-ray signs are divided into diffuse benign dysplasia (adenosis, fibroadenosis, diffuse fibrocystic mastopathy) and local forms(cysts, fibroadenomas, ductectasia, nodular proliferations).

According to the WHO histological classification (1984), mastopathy is defined as fibrocystic disease and is characterized wide range proliferative and regressive processes in mammary gland tissue with an abnormal ratio of epithelial and connective tissue components. For clinical practice, a classification is used in which mastopathy is divided into diffuse and nodular.

Forms of diffuse fibrocystic mastopathy:

• adenosis with a predominance of the glandular component;
• fibrous mastopathy with a predominance of the fibrous component;
• cystic mastopathy with a predominance of the cystic component;
• mixed form of diffuse fibrocystic mastopathy;
• sclerosing adenosis.

Forms of nodular (localized) fibrocystic mastopathy:

• nodular mastopathy;
• breast cyst;
• intraductal papilloma;
• fibroadenoma.

Diffuse fibrocystic mastopathy most often occurs in women 25-40 years old, affects both mammary glands, and is often localized in the outer upper quadrants. Pain in the mammary glands, as a rule, appears a few days before menstruation and gradually increases during the second phase of the cycle. In some cases, the pain radiates to the shoulder, armpit, or scapula. With a long course of the disease, the intensity of pain may weaken. Of nipples with some form diffuse mastopathy discharge appears (colostrum, transparent or greenish in color).

In mastopathy with a predominance of the glandular component, dense formations are detected by touch in the mammary gland tissue, passing into the surrounding tissue. X-rays show multiple shadows irregular shape with fuzzy contours. In mastopathy with a predominance of the fibrous component, the gland has a soft-elastic consistency with areas of diffuse compaction with coarse fibrous heaviness. There is no discharge from the nipples. In mastopathy with a predominance of the cystic component, the presence of multiple cystic formations, well limited from the surrounding gland tissue. A characteristic clinical sign is pain that worsens before menstruation. The mixed form of mastopathy is characterized by an increase in glandular lobules and sclerosis of intralobular connective tissue. To the touch, either diffuse fine granularity or disc-shaped doughiness is determined.

Nodular fibrocystic mastopathy is characterized by slightly different clinical manifestations. Thus, the nodular form occurs in patients 30-50 years old; it is a flat area of ​​compaction with a granular surface. The lump does not disappear between periods and may increase before menstruation. These formations can be single or multiple and are detected in one or both glands and are determined against the background of diffuse mastopathy. A breast cyst is a mobile, often single formation of a round shape, elastic consistency with a smooth surface. The formation is not associated with fiber, skin and underlying fascia. Cysts can be single or multiple. Intraductal papilloma is located directly under the nipple or areola. It can be determined in the form of a round, soft-elastic formation or an oblong cord. In the presence of intraductal papilloma, spotting from the nipple. Fibroadenoama is a benign tumor of the breast. It is a painless round formation of elastic consistency with a smooth surface. It is relatively rare. Malignancy of fibroadenoma occurs in 1-1.5% of cases. Treatment is surgical in the amount of sectoral resection of the mammary gland with urgent histological examination. In general, the most characteristic for mastopathy clinical manifestations is: soreness of the mammary glands, a feeling of increase in their volume, engorgement (mastodynia) and swelling of the glands. Pain can radiate to the armpits, shoulder and shoulder blade.

When diagnosing diseases of the mammary glands, hereditary predisposition to this pathology is assessed. The patient's complaints about pain, engorgement, swelling of the mammary glands, the time of their appearance, and their connection with the menstrual cycle or its disorders are clarified. The presence of discharge from the nipples is determined, the time and reason for their appearance, consistency, color, and quantity are specified. An objective examination reveals the symmetry of the mammary glands, the presence of tumor-like formations, asymmetrical retraction of the nipples, the presence of cicatricial changes, skin retractions, papillomas, birthmarks on the skin of the mammary gland, the degree of development of the mammary glands is assessed.

Palpation of the mammary glands is also important diagnostic value. In this case, the consistency of the mammary glands, its symmetry, the presence of seals and their nature are determined. Particular attention should be paid to the presence of nodules. Their size, density, uniformity, quantity, mobility, connection with the underlying tissues and skin are assessed. As instrumental methods use ultrasound and mammography. In this case, it is more advisable to perform ultrasound on young women, once every 6 months. Mammography is recommended for women under 40 years of age if focal pathology of the mammary glands is suspected according to ultrasound, and for women over 40 years of age for preventive purposes once a year.

Treatment. Patients with diffuse forms Mastopathy is subject to conservative treatment, which is mainly symptomatic. Many treatment regimens and drugs have been proposed, however therapeutic tactics should be developed specifically for each patient. In the treatment of such patients, the participation of an endocrinologist and gynecologist is mandatory. All patients with nodal forms diseases should be sent to a surgical hospital for surgical treatment. After examination, such patients undergo sectoral resection of the affected part of the mammary gland with an urgent intraoperative histological examination of the specimen, based on the results of which the final volume of surgical intervention is determined. Any nodule detected in the mammary gland must be regarded as precancer. In such cases, neither watchful waiting nor conservative treatment is acceptable.

8. Benign breast tumors. Clinic. Diagnostics. Differential diagnosis. Treatment.

The mammary gland contains various tissues of the human body, each of which can give rise to tumor growth. The most common types of tumors are epithelial and non-epithelial tumors. Among benign epithelial tumors, fibroadenomas and adenomas are the most common. The most common non-epithelial benign tumors found in the mammary gland are fibromas, lipomas, and lymphangiomas. They have morphological structure and characteristic clinical signs regardless of the organ in which they develop.

The most recognized is histological classification benign breast tumors, proposed by WHO experts in 1978-1981 gg.

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