Examination of thyroid

Dr.S.Nithyaraj Prakasam
• Goitre - Any non inflammatory non neoplastic
enlargement of the thyroid is termed as a goiter.
• Location - Front of the neck with both lobes on either
side of the trachea connected by the isthmus.
 Inspection
• Sitting erect on a stool with neck slightly extended.
• Size, Shape, Surface, Skin over the swelling &
movement on swallowing.
• Pizzillo’s method - In Shot and fat neck.
• Extent in relation to the sternomastoids and the
suprasternal notch.
• Moves with deglutition as it is enclosed in the pre
tracheal fascia and attached to the cricoid cartilage
via the Berry’s ligament. while we swallow the
superior constrictor of the larynx is pulled up causing
the movement of the larynx.
• other swellings which move with deglutition-
thyroglossal cyst, pre tracheal lymph node, sub hyoid
bursitis, extrinsic carcinoma of the larynx.
 Palpation
• Standard method, Lahey’s method, Crile’s method
• Size, surface, borders, consistency, fixity to skin,
fixity to deeper structures and thrill at the superior
pole.
 Palpation methods
• Standard method- Stand behind/flex neck slightly to relax deep
cervical fascia and palpate as the patient swallows- appreciate
lateral border, surface and lower border.
• Lahey’method-Stand in front and palpate with slightly extended
neck. Flex the neck on one side to relax the sternomastoid
muscle to appreciate the posteromedial and deep surface.
• Crile’s method- Stand in front and place thumb over the swelling
and access for smaller nodules as the patient swallows
• Thyroid paradox- A cyst might feel firm while and
adenoma might feel soft.
• Kocher’s test- Extend the neck slightly compress the
thyroid look for stridor- scabbard trachea.
• Berry’s sign- Feel carotid pulse between trachea and
the medial border of sternomastoid against the
transverse process of the 6th cervical vertebra.
-In a benign swelling- pushed back and in malignant
swelling there may be obliteration due to tumor
encasement.
• Percussion- Over manubrium sterni for retro sternal
extension.
• Auscultation- At the superior pole of each lobe for a
systolic bruit which indicates thyrotoxicosis.
• Finally look for signs of thyrotoxicosis, signs of
myxedema, signs of retrosternal extension of
goitre(engorged veins over the neck and thorax) and
signs of metastasis(tenderness/swellings over the
bones).
 Clinical case
presentation
A Case of Multi nodular
Goiter
 Case record
Chief complaints

45 year old housewife Mrs.Valli

from Chennai has presented to the
hospital with the c/o a swelling in
the neck for the past 8 yrs.
 History of presenting illness
• Patient was apparently normal 8 years back, when her
family members incidentally noticed a small swelling
over the front of the neck.

• The swelling was initially 2x2 cm in size and since

then it has gradually increased in size to attain the
present size of 10x8 cm.

• There is no history of a sudden increase in size.

• Not associated with pain
• No fever
• No difficulty in swallowing
• No difficulty in breathing
• No change in voice
• No complaints suggestive of hypo or hyperthyroidism
 Past history
• H/o appendectomy 10 yrs back.
• H/o Diabetes mellitus which is under control with OHA
• No H/o HT, CAD, TB or exposure toTB.
• No H/o irradiation to the neck.
• No H/o any drug allergies
• No other major illness in the past.
 Personal history

• She is married
• Takes mixed diet
• Not a smoker or an alcoholic
• Normal sleep wake pattern
 Menstrual history

• Attained menarche at the age of 15 yrs.

• Menopause at the age of 40 years
• Had regular cycles during that time.
• No post menopausal bleeding
 Treatment history

• Takes Glycephage 500mg and Glimipride 5mg twice

a day for diabetes which is under good control now.
 General examination
• Conscious, oriented and cooperative.
• Normal built, well nourished and hydration adequate.
• Eyes and facial features normal.
• No tremors over the outstretched hands.
• No pallor, icterus or pedal edema.
• No cervical or generalized lymphadenopathy.
• Neck reveals a large swelling which shall be described further
 Vitals
• BP: 130/80 mmHg in the Right Brachial in the sitting
posture.
• PR: 80/min, regular in rhythm, normal in volume
taken in the right radial artery.
• RR: 14/min, regular.
• Temperature is normal.
 Inspection
• There is a swelling in the front of
the neck in the region of the
thyroid of size 8x8 cm, more
prominent on the right than the
left.
• The swelling moves up with
deglutition and its lower border is
seen during this process.
• The surface is irregular and bosselated and margins are
well defined.
• The trachea is made out in the midline.
• Skin over the swelling is normal.
• There are no dilated veins seen over the neck or thorax.
• No visible pulsations seen over the swelling or in the
neck.
• There are no surgical scars seen
 Palpation
• There is no local rise in temperature over the swelling.
• Both the lobes including the region of the isthmus are enlarged and
measures 8x8cm.
• Surface is nodular and margins are well defined.
• The swelling is firm in consistency.
• Lower border of the swelling is palpable.
• The lateral margin of the swelling is bounded by the medial border of
the sternomastoid muscle.
• The swelling is mobile in relation to the deeper structures.

• Trachea is felt in the midline.

• Kocher’s test for tracheal compression's negative.

• Carotid pulsations are felt normally on both sides ( Berry’s

sign is negative)

• No pulsations felt over the swelling.

Examination of lymph nodes. Pemberton sign
No cervical nodes felt.

Examination for retrosternal Extension.

Lower margins palpable.

No dilated veins over the neck or chest.

Pemberton’s sign is negative.

Examination for signs of toxicity.

Pulse rate is normal.

No tremors over the outstretched hands.

No eye signs present

 Systemic examination

• Chest: Bilateral air entry is good

• Abdomen:No organomegaly, no free fluid.
• ENT: Normal
• Spine & cranium: Normal.
 Case summary
• 55 yr old diabetic lady presents with a painless, gradually
growing swelling in the region of the thyroid for 8 years. It has
grown from2x2 cm to 8x8 cm over the past 8 years.
• No pressure symptoms, no signs of hypo/hyper thyroidism.
• The swelling has nodular surface and involves both lobes as well
as the isthmus. Margins are well defined and is firm in
consistency.
• There is no evidence of any retrosternal extension and there are
no cervical nodes palpable.
 Impression

• 45 yr old lady with a Euthyroid multi nodular goiter

with no pressure symptoms or retrosternal extension,
most probably benign with T2DM.
 Why do you say so?

• Points from the history.

• Points from the examination.
 What will you do?

• Investigations to make the diagnosis.

• Investigations to support the diagnosis.
• Investigations to stage the disease.
• Investigations to treat the patient.
 Common questions…
• What is trails sign?
• What is TI-RADS?
• Where do you feel for the carotid pulse?
• What is minimum biopsy in a thyroid gland?
• What is Hartley Dunhill procedure.
• Where do you find the Tubercle of Zuckerkandl
Thank you
Dr.S.Nithyaraj Prakasam