THYROID EXAMINATION
History:
Age -
simple goitre is commonly seen in girl approaching puberty.
both multinodular and solitary nodular goitres as well as colloid goitres are found in women of 20s and 30s.
papillary carcinoma - young girls
follicular carcinoma - middle aged women ; anaplastic - old age
primary toxic goitre- young
Hashimoto's disease- middle aged women
Sex-
majority- females
Thyrotoxicosis is eight times commoner in females than in males.
Occupation-
Thyrotoxicosis may appear in individuals working under stress and strain.
the patients with primary toxic goitre may be psychic.
Residence-
Himalayas, the Vindyas, the Satpuda ranges which form the goitre belts in India.
Swelling-
Onset, duration, rate of growth, whether associated with pain
Primary thyrotoxicosis- nervous system
Secondary thyrotoxicosis- Cardiovascular system
Pain-
Pressure effect-
dyspnoea
dysphagia
hoarseness of voice
stridor
Symptoms of primary thyrotoxicosis-
loss of weight inspite of good appetite.
Preference of cold, intolerance to heat, excessive sweating
Nervous excitability, irritability, insomnia, tremor of hands, weakness of muscles {symptoms of involvement of nervous system}
Exophthalmos
Staring or protruding eyes and difficulty in closing her eyelids
amenorrhoea
Symptoms of secondary thyrotoxicosis-
when a longstanding solitary nodular or multinodular goitre or colloid goitre shows manifestations of thyrotoxicosis the condition is called secondary thyrotoxicosis.
Palpitation, ectopic beats, cardiac arrhythmias, dyspnoea on exertion and chest pain {C V S}
Symptoms of myxoedema (Hypothyroidism)-
increase of weight
fat accumulates
intolerance of cold weather
skin dry
puffiness of the face with pouting lips and dull expression
loss of hair
muscle fatigue and lethargy
Past history-
course of treatment
drug- PAS, Sulphonilurea, Antithyroid drugs
Personal history-
Dietary habit -Vegetables {brassica family- cabbage, kale & rape}
Family history-
Primary thyrotoxicosis has been seen in more than one member of the same family.
PHYSICAL EXAMINATION
Build and State of nutrition-
Thyrotoxicosis- thin & underweight
Hypothyroidism- obese & overweight
Facies-
Thyrotoxicosis- facial expression of excitement, tension, nervousness or agitation with or without variable degree of exophthalmos
Hypothyroidism- puffy face without any expression
Mental state & intelligence-
Hypothyroid patients are naturally dull with low intelligence.
SPR-
Sleeping pulse rate-
Skin-
Thyrotoxicosis- moist
Hypothyroidism- dry & inelastic
LOCAL EXAMINATION
INSPECTION-
Pizzilo's method- to render inspection easier one can follow Pizzilo's method in which the hands are placed behind the head and the patient is asked to push her head backwards against her clasped hands on the occiput.
ask the patient to swallow and watch for the most important physical sign- a thyroid swelling moves upwards on deglutition.
other swelling which moves on deglutition are-
Thyroglossal cysts
Thyroid swelling
Subhyoid bursitis
Prelaryngeal lymph nodes
Pretracheal lymph nodes
Retrosternal goitre- The patient should be asked to raise both the arms over his head until they touch the ears.
congestion of face and distress become evident in case of retrosternal goitre due to obstruction of the great veins at the thoracic inlet.
Thyroglossal cyst- Pathognomonic feature is that it moves upwards with protrusion of tongue since the thyroglossal duct extends downwards from the foramen caecum of the tongue to the isthmus of thyroid gland.
Thyroglossal fistula- is seen near the midline a little below the hyoid bone. The opening of the fistula is indrawn and overlaid by a crescentic fold of skin.
PALPATION
The thyroid gland should always be palpated with the patients's neck slightly flexed. The gland may be palpated from behind and from the front. The patient should be sitted on a chair and the clinician stands behind the patient. The patient is asked to flex the neck slightly. The thumbs of both the hands are placed behind the neck and the other four fingers of each hand are placed on each lobe and the isthmus.
Additional information about a particular nodule of the thyroid gland one may ask the patient to extend the neck.
To get more information about a particular nodule of the thyroid gland one may ask the patient to extend the neck. This only makes the nodule more prominent for better palpation.
Palpation of each lobe is best carried out by Lahey's method. In this case the examiner stands in front of the patient. To palpate the left lobe properly, the thyroid gland is pushed to the left from the right side by the left hand of the examiner. During palpation the patient should be asked to swallow in order to settle the diagnosis of the thyroid swelling.
Slight enlargement of the thyroid gland or presence of nodules in its substance can be appreciated by simply placing the thumb on the thyroid gland while the patient swallows. (Crile's method)
During palpation the following point should be noted:-
Whether the whole thyroid gland is enlargerd? If so, note its surface-whether it is smooth(primary thyrotoxicosis or colloid goitre) or bosselated (multinodular goitre) and its consistency whether uniform or variable. It may be firm in case of primary thyrotoxicosis, Hashimoto's disease, etc. It is slightly softer in colloid goitre and hard in Riedel's thyroiditis or carcinoma in which the consistency may be variable in places.
When a swelling is localised, note its position, size, shape, extent and its consistency.
the mobility should be noted in both horizontal and vertical planes. Fixity means malignant tumour or chronic thyroiditis.
to get below the thyroid gland is an important test to discard the possibility of retrosternal extension. Clinician's index finger is placed on the lower border of the thyroid gland. The patient is asked to swallow, the thyroid gland will move up and the lower border is palpated carefully for any extension downwards.
Pressure effect from the thyroid swelling should be carefully looked for. If pressure on trachea is suspected, slight push on the lateral lobes will produce stridor (Kocher's test). Narrowing of the trachea, ie. "Scabbard trachea" becomes quite obvious in X-ray. Sympathetic trunk may also be affected by thyroid swelling. This will lead to Horner's syndrome (enophthalmos, pseudotosis, miosis, anhidrosis).
whether there is any toxic manifestation or not. Primary toxic thyroid is generally not enlarged whereas an enlarged thyroid or nodular thyroid with toxic manifestation is generally a case of secondary thyrotoxicosis.
Whether there is any evidence of myxoedema or not?
Whether the swelling is a malignant one or a benign one.
Is there any pulsation or thrill in the thyroid?
Palpation of cervical lymph nodes- Papillary carcinoma of thyroid is notorious for early lymphatic metastasis when the primary tumour remains quite small.
PERCUSSION-
This is employed over the manubrium sterni to exclude the presence of a retrosternal goitre.
AUSCULTATION-
In primary toxic goitre a systolic bruit may be heard over the goitre due to increased vascularity.
GENERAL EXAMINATION-
In general examination one should look for:-
Primary toxic manifestations in case of goitres affecting the young
Secondary toxic manifestations in nodular goitre
Metastasis in case of malignant thyroid disease
Primary toxic manifestations-
Eye Signs- There are four important changes that may occur in the eyes in thyrotoxicosis. Each one may be unilateral or bilateral-
Lid Retraction- This sign is caused by over-activity of the involuntary (smooth muscle) part of levator palpebrae superioris muscle. When the upper eyelid is higher than normal and the lower eyelid is in its normal position this condition is called lid retraction. Lid Lag is a different term. This means the upper eyelid cannot keep pace with the eyeball when it looks down following an examiner's finger moving downwards from above. Both lid retraction and lid lag are not exophthalmos.
Exophthalmos- When eyeball is pushed forwards due to increase in fat or oedema or cellular infiltration in the retro-orbital space the eyelids are retracted and sclera becomes visible below the lower edge of the iris first followed by above the upper edge of the iris. Now the following tests or signs-
Von Graefe's sign- The upper eyelid lags behind the eyeball as the patient is asked to look downwards.
Joffroy's sign- Absence of wrinkling on the forehead when the patient looks upwards with the face inclined downwards.
Stellwag's sign- This is staring look and infrequent blinking of eyes with widening of palpebral fissure. This is due to toxic contraction of striated fibres of levator palpebrae superioris.
Moebius' sign- This means inability or failure to converge the eyeballs.
Dalrymple's sign- This means the upper sclera is visible due to retraction of upper eyelid.
Ophthalmoplegia- There may be weakness of the ocular muscles due to oedema and cellular infiltration of these muscles. Most often the superior and lateral rectus and inferior oblique muscles are affected. Paralysis of these muscles prevents the patient looking upwards and outwards.
Chemosis- This is oedema of the conjunctiva.
Tachycardia- or increased pulse rate without rise of temperature is constantly present in primary toxic goitre. Sleeping pulse rate is more confirmatory in thyrotoxicosis.
Tremor of the hands (Fine tremor) is almost always present in a primary thyrotoxic case. Ask the patient to straight out the arms in front and spread the fingers. Fine tremor will be exhibited at the fingers. The patient is also asked to put out the tongue straight and to keep it in this position for at least 1/2 a minute. Fibrillary twitching will be observed. In severe cases the tongue and fingers may tremble.
Moist skin
Thyroid bruit- This is due to increased vascularity of gland. But this sign is a relatively late sign and mostly heard on the lateral lobes near their superior poles.
Secondary Thyrotoxicosis- the CVS is mainly affected. Signs of cardiac failure such as oedema of the ankles, orthopnoea, dyspnoea while walking up the stairs may be observed.
Search for metastasis- When the thyroid swelling appears to be stony hard, irregular and fixed loosing its mobility even during deglutition a careful search should be made to know about the spread of the disease.
Special Investigations for Thyroid disease
Differential diagnosis of Thyroid swelling