CHAP 27

EXAMINATION OF THYROID GLAND

MOCS SD – PG 374
 HISTORY
• AGE
• SEX
• RESIDENCE
• OCCUPATION
• C/C
• SWELLING
• PAIN
• PRESSURE EFFECTS
• SYMPTOMS OF PRIMARY THYROTOXICOSIS
• SYMPTOMS OF SECONDARY THYROTOXICOSIS
• SYMPTOMS OF MYXOEDEMA (HYPOTHYROIDISM)
• PAST HISTORY
• PERSONAL HISTORY
• FAMILY HISTORY
 AGE
• Girls approaching puberty, Teen-aged girls
• Cond of need (i.e. Puberty, Preg) – Hormone prod norm, Hormone requirement augmented
• = SIMPLE GOITRE
• ETIO
• Deficient iodide in endemic areas
• Goitrogens
• Dyshormonogenesis

• Women of 20s & 30s = COLLOID , MULTINODULAR, SOLITARY NODULAR GOITRES

• Young = 1° TOXIC GOITRE
• Middle-aged women = HASHIMOTO’S DISEASE

• CA THYROID NOT necessarily disease of old age

• Young girls = PAPILLARY CA
• Middle aged women = FOLLICULAR CA
• Old age = ANAPLASTIC CA
 SEX
• Females

RESIDENCE
• IODINE DEF ENDEMIC SIMPLE GOITER =
• Areas
• Near rocky mountains (e.g. Himalayas, Satpudas, Vindyas)
• Producing chalk/limestone (e.g. Derbyshire, Southern Ireland)
• As calcium is goitrogenic
• Low land where
• Soil lacks iodides
• Water supply comes from far away mountain ranges (e.g. Great Lakes of North America)

• Southern India > Northern India

OCCUPATION
• Individuals working under stress & strain
 SWELLING
• Onset, Duration, Rate of growth
• Same size for sometime or Very slow = SIMPLE GOITRE
• Extremely slow = COLLOID, MULTINODULAR, SOLITARY GOITRE
• Slow = PAPILLARY, FOLLICULAR CA
• Exist as lump in neck for many years before metastasising
• Fast = ANAPLASTIC CA

• Association w pain
• Worried, Stressed, Strained
• FEATURES OF THYROTOXICOSIS
• Sudden ↑ size + Pain in goiter = HAEMORRHAGE inside

• Sleep
• Sleepless night = 1° THYROTOXICOSIS
• Palpitations, Ectopic beats, Congestive cardiac failure = 2° THROTOXICOSIS
 PAIN
• Painless = GOITRE
• Painful =
• INFLAMMATORY COND OF THYROID GLAND
• ANAPLASTIC CA
• Infiltrate surrounding structures & nerves
• Painless 1st , Painful in later stages = MALIGNANT DISEASES OF THYROID GLAND

• Discomfort in neck = HASHIMOTO’S DISEASE

PRESSURE EFFECTS
• Enlarged thyroid  Press on
• Trachea  Compress on trachea/Deviate trachea to one side DYSPNEA
• Symptom worse when neck flexed forwards/laterally
• As air rushes through narrowed trachea  Whistling sound  STRIDOR
• Oesophagus  DYSPHAGIA – BUT NOT true dysphagia
• As oesophagus muscular tube – Pushed aside/Stretched easily - ∴ Rarely obstructed by thyroid gland
• Rather in 1st stage of deglutition thyroid gland moves up - ∴ Enlarged thyroid makes swallowing uncomfortable
• Recurrent laryngeal n  HOARSENESS OF VOICE

• Carotid sheath  PULSATION NOT FELT

• Maj veins in thorax  ENGORGEMENT OF NECK VEINS
• Sympathetic trunk  HORNER’S SYNDROME
• ANHIDROSIS – Absence of sweating of affected side of face
• ENOPTHALMOS – slight sinking of eyeballinto orbit
• MIOSIS – Contraction of pupil
• PSEUDOPTOSIS – Slight drooping of upper eyelid
 NOTE
• 1° THYROTOXICOSIS
• Brunt of attack more on nervous system
• 2° THYROTOXICOSIS
• Brunt of attack more on cardiovascular system

SYMPTOMS OF 1° THROTOXICOSIS
• ENLARGEMENT OF THYROID GLAND NOT MUCH
• ∴ ONLY SYMPTOMS INDICATE PRESENCE OF DISEASE
• SLEEP
• Sleepless night
• WEIGHT
• LOSS OF WEIGHT
• Inspite of GOOD APPETITE
• TEMP
• Excessive sweating
• Heat intolerance
• Preference for cold
• CNS
• Excitability, Irritability, Tremor of hands, Weakness of muscles
• EYE
• Exopthalmos
• C/C – Starring/Protruding eyes, Difficulty in closing eye lids
• Diplopia/Double vision
• ETIO : Muscle weakness (i.e. ophthalmoplegia)
• Oedema/Swelling of conjunctiva (i.e. chemosis)
• Corneal ulceration  Pain
• ETIO : Exposure keratitis
 SYMPTOMS OF 2° THROTOXICOSIS
• LONG-STANDING MNG, SN  MANIFESTATIONS  K.A. 2° THROTOXICOSIS
• CVS
• Palpitations, Ectopic beats, Congestive cardiac failure

• SYMPTOMS OF MYXOEDEMA (HYPOTHYROIDISM)

• PAST HISTORY
PERSONAL HISTORY
• DIET
• Vegetables of brassica family – Cabbage, Kale – Goitrogens
• FAMILY HISTORY
 LOCAL EXAMINATION
• SIMILAR TO EXAMINATION OF SWELLING
• INSPECTION
• Number, Situation

• Shape, Size
• Colour, Edges, Surf

• Impulse on coughing
• Movement w
• Respiration
• Deglutition
• Protrusion of tongue
• Peristalsis, Pressure effects, Pulsation
• Skin over swelling
• PALPATION
• Shape, Size
• Consistency, Edges, Extent, Surf, Temp, Tenderness
• Compressibility, Fluctuation, Fluid thrill, Mobility, Pulsatility, Reducibility, Translucency

• Impulse on coughing
• Fixity to overlying skin
• PERCUSSION
• AUSCULTATION
• MEASUREMENT
• STATE OF REGIONAL LN
• EXAMINATIONS PECULIAR TO THYROID GLAND DESCRIBED BELOW
 INSPECTION
• METHOD
• Inspection in normal position
• Pizzillo’s method
• INDICATION : Obese, Short-necked
• PROC
• Place hands behind head
• Ask pt to push head backwards against clasped hands
• IMP : Improves inspection of goitre
• THYROID GLAND
• NOT obvious on inspection normally
• Seen ONLY when swollen
• RESULT
• Uniform thyroid swelling involving whole thyroid gland
• = COLLOID GOITRE, HASHIMOTO’S DISEASE, PHYSIOLOGICAL GOITRE
• Isolated nodules of different sizes in thyroid region
• = NODULAR GOITRE
 D/D ON INSPECTION
• RETROSTERNAL GOITRE
• P on great veins at thoracic inlet  DIL OF SUBCUTANEOUS V OVER UPPER ANT PART OF THORAX
• NOT POSSIBLE TO DETERMINE LOWER BORDER OF SWELLING ON DEGLUTITION
• Ask pt to raise both arms over head until they touch ears
• Maintain position for awhile
• CONGESTION OF FACE + DISTRESS
• Due to obstruction of great veins at thoracic inlet

• THYROGLOSSAL CYST
• MOVES UPWARDS ON DEGLUTITION
• MOVES UPWARDS W PROTRUSION OF TONGUE$

• THYROGLOSSAL FISTULA
• NEAR MIDLINE LITTLE BELOW HYOID BONE
 METHODS OF PALPATION
METHOD 1 LAHEY’S METHOD
• PT • PURPOSE : Palpation of each lobe
• Sit on stool • CLINICIAN
• Slightly flex neck • Stand in front pt
• CLINICIAN • PALPATION OF LT LOBE
• Stand behind pt • Push thyroid gland to left
• PALPATION • From rt side
• Thumbs of both hands behind neck • By lt hand of clinician
• Other 4 fingers of each hand on each lobe & isthmus • Palpate w rt hand

METHOD 2 CRILE’S METHOD

• PURPOSE : Additional info abt 1 lobe • PURPOSE : To appreciate
• PT • Presence of nodules
• Flex & Rotate face to side to be examined • Slight enlargement of thyroid gland
• As relaxes sternomastoid muscle of tht side • PALPATION
• Place thumb on thyroid gland while pt swallow
METHOD 3
• PURPOSE : Additional info abt particular nodule IMP IN PALPATION
• PT • Assessment of lower margin
• Extend neck
• As makes nodule more prominent
 POINTS TO BE NOTED IN PALPATION
• IF SWELLING LOCALIZED
• WHETHER WHOLE THYROID GLAND ENLARGED
• MOBILITY

• TO GET BELOW THYROID GLAND

• PULSATION/THRILL IN THYROID
• PRESSURE EFFECT

• PALPATION OF CERVICAL LN
• IF SWELLING LOCALIZED
• SITUATION
• SHAPE, SIZE, EXTENT

• WHETHER WHOLE THYROID GLAND ENLARGED

• CONSISTENCY
• Uniform/Variable
• Firm = 1° THYROTOXICOSIS, HASHIMOTO’S DISEASE
• Hard = CARCIONOMA – Variable consistency in places, RIEDEL’S THYROIDITIS
• Soft = COLLOID GOITRE
• SURF
• Smooth = 1° THYROTOXICOSIS, COLLOID GOITRE
• Bosselated = MNG

• MOBILITY
• Fixity = CHR THYROIDITIS, MALIGNANT TUMOR
• TO GET BELOW THYROID GLAND
• AIM : To discard possibility of retrosternal extension
• PROC
• Ask pt to swallow  Thyroid swelling moves up
• Clinician place index finger on lower border of thyroid gland
• Palpate for any extension downwards

• PULSATION/THRILL IN THYROID

• PRESSURE EFFECT
• PROC : Palpate trachea
• RESULT : Position of trachea
• KOCHER’S TEST
• PROC : Push slightly on lat lobe
• RESULT
• Stridor = ‘+’ KOCHER’S = OBSTRUCTED TRACHEA = CARCINOMA, MNG
• PROC
• Ask pts to raise hands above head
• Arms touching ears
• RESULT
• Engorgement of neck veins obvious = PEMBERTON’S SIGN = OBSTRUCTION TO MAJ VEINS IN THORAX

• PALPATION OF CERVICAL LN
• IMP IN MALIGNANCY OF THYROID
• Esp Papillary carcinoma of thyroid  Early lymphatic metastasis  Metastatic enlarged LN  K.A. ABERRANT THYROID
 PERCUSSION
• PROC
• Percuss over manubrium sterni
• AIM
• To exclude presence of retrosternal goiter

• THEORETICAL IMP ONLY

 AUSCULTATION
• PRESSURE EFFECT
• PROC : Place sthethoscope on suspected zone
• RESULT : Passage of air indicate Position of trachea
• OTHER FINDINGS
• Systolic bruit = 1° TOXIC GOITRE
 MEASUREMENT
• PROC
• Circumference of neck
• At most prominent part of swelling
• Taken at intervals
• AIM
• Determine if swelling ↑/↓ in size