Thyroid Examination

 

Thyroid Examination

General examination for thyroid status
Hands
  1. Increased sweating
  2. Palmer erythema
  3. Pulse and water hummer pulse (Tachycardia, AF, Any arrhythmia except HB and Sleeping pulse >90 bpm)
  4. Fine tremors (by a sheet of paper on out stretched hands with palms facing downwards)
  5. Thyroid acropachy
  6. Onycholysis
  7. Areas of vitilligo
Eyes

(stabilize the head)

  1. Lid retraction (front – Dalrymple’s sign)
  2. Lack of forehead wrinkling on looking upwards without moving the head (front – Joffroy’s sign)
  3. Lid lag (front – Von Graefe’s sign)
  4. Defective convergence (front – Moebius’s sign)
  5. Ophthalmoplegia (front)
  6. Exophthalmos (back)
  7. Loss of hair of outer third of eyebrows
Other systemic manifestations
  1. Pretibial myxoedema
  2. Proximal myopathy
  3. Signs of heart failure
  4. Gynecomastia

Thyroid Examination

Local examination

Inspection

Palpation

Position Patient: Neck extended

Doctor: In front of the patient

Patient: Slightly flexed

Doctor: Front then behind

Exposure All head till clavicle All head till clavicle
Comment on

Description

  • lump (as any swelling)
  • Scar of previous operation (Healing or Complication)

Relation to surrounding

Sternomastoid Muscle contraction
  • Tilt the patient’s head to the same side
  • Pinch the muscle
  • Ask him to swallow
Skin Ask patient to swallow Ask patient to swallow
Carotid artery
  • Normal site
  • Equal volume
  • Displacement
  • Weak pulse
  • ‘Berry’s sign’
Trachea Move up and down

While standing the patient put fingers on gland and ask him to swallow will feel the gland and the larynx go up

Put fingers to stop descent of the gland while the larynx goes down

Manubrium Is lower edge seen? Is lower edge felt?
Neck L.N.s
Neuro-Vascular Bundle
Percussion Resonant or dull?
Auscultation Upper pole of the gland

To hear systolic bruit if gland is highly vascular as in toxic goiter

Thyroid investigations

Essential

  • Serum: TSH (T3 and T4 if abnormal); thyroid autoantibodies
  • FNAC of palpable discrete swellings; ultrasound guidance may reduce the ‘Thy1’ rate

Optional

  • Corrected serum calcium
  • Serum calcitonin (CEA may used as an alternative screening test for medullary cancer)
  • Imaging: Chest radiograph, Ultrasound, CT and MRI (for known cancer, some reoperation and some retrosternal goitres)
  • Isotope scan (if discrete swelling and toxicity coexist)
Thyroid operations

Indications for operation in thyroid swelling

  • Neoplasia: FNAC positive + Clinical suspicion, including: Age, Male sex, Hard texture, Fixity, Recurrent laryngeal nerve palsy and Lymphadenopathy
  • Recurrent cyst, Toxic adenoma, Pressure symptoms, Cosmesis and Patient wishes
Choice of therapy of thyrotoxicosis
Diffuse toxic goiter
  • >45 years: radioiodine
  • <45 years: surgery for large goiter and anti-thyroid drugs or radioiodine for small goiter
Toxic nodular goiter
  • Surgery
Toxic nodule
  • >45 years: radioiodine
  • <45 years: surgery
Recurrent thyrotoxicosis after surgery
  • Radioiodine
  • Anti-thyroid drugs for women intending to have children
  • Surgery has a little place
Failure of previous treatment with anti-thyroid drugs or radioiodine
  • Surgery
  • Thyroid ablation with I123

TAKING HISTORY FROM A PATIENT WITH thyroid PROBLEM

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Neck symptoms

  • Swelling and cosmetic problem
Site
Onset Accidentally: When washing or member of family or friend point it out
Course Grow slowly or Grows rapidly if malignant
Duration
Other swellings
Relation to other symptoms like pain
  • Painless
  • May be painful
  • Acute thyroiditis, Subacute thyroiditis, Hashimoto’s disease and Anaplastic carcinoma
  • Pain
  • Pressure symptoms: Dyspnea or Dysphagia
  • Dysfunction

Toxic symptoms

Symptoms of hypothyroidism
Metabolic (4w’s)
  • Weight: Loss of weight
  • Weather: Intolerance to hot weather
  • Wet: Excessive seating
  • Warm: Hands are warm and wet
  • Weight: Weight gain but Poor appetite
  • Weather: Likes hot weather and dislike cold weather
  • Weakness: Tiredness
  • Warm (not): Feels cold
Neurological
  • Nervousness and Irritability
  • Insomnia
  • Difficult to think
  • Difficult to speak quickly and clearly
  • Myxedema madness
  • Hallucinations
  • Dementia
  • Myxedema coma
Cardiovascular
  • Palpitation
  • Shortness of breath
  • Tiredness
  • Breathlessness
  • Ankle swelling
Gastrointestinal
  • Change in appetite
  • Diarrhea
  • Constipation
  • Progressive and obdurate
Genital Reduction in quantity of menses Menorrhagia
Cause
  • Sex: Puberty or Pregnancy
  • Sepsis
  • Psyche
  • Middle and old age
  • More in women than men
Others
  • Muscular Weakness
  • Skin Pigmentation
  • Symptoms of malignancy
    • Symptoms suggesting spread
      • Local: Multiple lumps in the neck and Pain in the ear
      • Distant: Bone (Pain, Swelling or Pathological fractures), Lung (Breathlessness or Chest pain), Brain (Mental changes or Fits) and Liver (Jaundice)
    • General symptoms associated with cancer
      • Malaise, Weight loss or Cachexia

Differential diagnosis of different thyroid gland presentations

Correlation between clinical state of thyroid gland, endocrine function and diagnosis

Hypothyroid

Euthyriod

Hyperthyroid

Diffuse enlargement

Thyrioditis
  • Iodine deficiency
  • Enzyme defect
  • Goitrogens
  • Thyrioditis
  • Amyloid
  • Physiological
  • Pregnancy
  • Puberty
  • Primary hyperthyroidism
  • ‘Graves’ disease’

Multinodular enlargement

  • Multinodular goitre with gross degeneration
  • Multinodular goitre
  • Lymphoma
  • Anaplastic carcinoma
  • Medullary carcinoma
  • Secondary hyperthyroidism
  • ‘Plummer’s disease’

Solitary nodule

  • Coincidental nodule with myxedema
  • Cyst
  • Dominant nodule
  • Adenoma
  • Follicular carcinoma
  • Papillary carcinoma
  • Autonomous toxic nodule

No palpable goitre

  • Thyroiditis
  • Primary myxedema
  • Post-thyroidectomy
  • Post-radioactive iodine
Clinical differences between the 2 main types of thyrotoxicosis

Grave’s disease

Toxic nodular goiter

Age Young Elderly
Onset Abrupt Gradual
Course Exacerbations and remissions Steady
Nervous symptoms +++ +
Metabolic manifestations +++ +
CVS manifestations + +++
Eye signs +++ exophthalmos Usually no exophthalmos
thyroid
  • Diffuse enlagmant
  • Soft
  • Vascular
Multiple or solitary nodules
Differences between the commonest three types of thyroid carcinoma

Papillary carcinoma

Follicular carcinoma

Anaplastic carcinoma

Incidence & Aetiology
  • 60%
  • Neck irradiation
  • With Grave’s disease
  • 17%
  • Endemic goitrous area
  • 13%
Age May occur in children and young adults Middle age Elderly
Sex F:M 3.5:1 2:1 1:1.3
Microscopic picture
  • Papillary projections

formed of Connective tissue

Covered by Single layer of epithelial cells with pale empty nuclei ‘orphan Annie eyes’

  • Laminated calcified bodies ‘Psammoma bodies
  • Hurthle’s cells
Thyroid follicles

  • With variable degree of differentiation
  • Solid sheets may be present
  • Diagnosis depend on finding capsular or vascular invasion or on detecting metastasis
May take the form of spindle cell or large cell type
Multiplicity
  • Up to 80%
  • May be due
  • Multicentricity
  • Intrathyroid lymphatic spread
Rare
Spread
  • Mainly lymphatic
  • Blood spread may occur with tumors that extend outside the thyroid
Mainly blood spread Mainly direct invasion

Lymphatic or blood spread

10-year survival more than 90%
  • Encapsulated 97%
  • Invasive 70%
Most patients dies within 1-2 years
Hormone dependent May be functioning
Remember

The Ps of the Papillary thyroid cancer

The Fs of Follicular cancer

Papillary cancer

Popular (most common)

Psammoma bodies

Palpable lymph nodes (in 1/3 of patients)

Positive (excellent) prognosis

Follicular cancer

Far-away metastasis(blood spread, commonly bone)

Female (2:1 ratio)

FNAC not useful

Favorable prognosis

With Medullary carcinoma MEN II

Multi-centric