• Thyroid notch
• Feel membrane between cricoid cartilage and thyroid cartilage (can puncture in asphyxia - different from tracheotomy)
• R and L lobes joined by isthmus (few mm wide)
• Pyramidal lobe (aka thyroglossal tract): not present in all people, residual thyroid tissue signifying normal descend from foramen caecum (if cyst formation: thyroglossal cyst)

• Skin subcut tissue, platysma (facial expression; cervical br of facial n)
• Approach from front: outer sternohyoid, inner sternothyroid (these directly attached to thyroid anteriorly)
• Approach from side: SCM (bulkier - therefore harder to examine thyroid from lateral aspect cf. anterior)
• Internal jugular vein (lateral), common carotid (artery), vagus n inside carotid sheath (so in between artery and vein) [usually VAN, from lateral to medial]
• Recurrent laryngeal n: control all vocal cord m's unless cricopharyngeal (ext br of superior laryngeal n)

Exposure neck and anterior chest

Address Pt - ask his name - hoarseness? (Recurrent laryngeal pt)

Stand front of Pt - visible (from side)

Get down to same level as Pt

Enlargement of the thyroid, in the midline of the neck - in about the lower 1/3 of a line joining the notch of the laryngeal cartilage to the suprasternal notch

Dilated vein or surgical scar?

Any skin changes?

Thyroid enlargement is symmetrical or asymmetrical (indicates diffuse or nodular enlargement)

Pt to swallow - thyroid moves up (must swallow even if no abnormalities seen) - must give water for proper swallowing)

Pt to protrude tongue

• Thyroglossal tract cyst: position from base of tongue to isthmus

Ptosis: protrusion of eyeball due to autoimmune thyrotoxicosis (Graves), see sclera between iris and upper and lower eyelid

Exophthalmos: protrusion of eyeball

• View from side
• Assoc. conditions: swelling, oedema, cannot close eyelids properly (dryness, irritation)

Lid retraction: view sclera between upper lid and iris (due to sympathetic overactivity; levator palpebrae superioris); if milder, may show lid lag (Pt to follow your finger upwards, then move finger down, lid movt lags behind iris movt

Abnormal eye movt: diplopia

Dermapathy: tibial myxoedema (pretibial area)

Pulse, sweatiness (elderly: atrial fibrillation)

Stand behind Pt (warn Pt first!) and palpate gland (thin necks: feel normal thyroid gland; soft; feel tracheal rings through the gland)

If enlarged - diffuse or nodular?

• Diffuse: usually soft

If palpable nodule - characteristics? Size, shape, consistency, surface, mobility, etc.

Palpate trachea - central or deviated

1. Cannot feel lower border
2. Percuss anterior chest wall (resonant at lung, dullness at retrosternal expansion of goitre - not reliable, need big mass before dullness detected)

Retrosternal/ Substernal/ Mediastinal goitre (anterior mediastinum)

• Usually multinodular goitre (esp. obese, old, short neck -> usu. elderly Pt with long-standing goitre) - every inspiration is a -ve pressure that sucks thyroid swelling downwards
• No barrier between neck and thorax (cf. diaphragm between thorax and abdomen)
• Therefore, when palpating thyroid, try to find lower border
• Suspect retrosternal extension: Pemberton's sign (Pt raise both UL), Valsalva (strain; increase intraab pressure, 'like going to the toilet') -> venous obstruction? (this increases VR)
• If present, likely to be retrosternal extension

Thrill in toxic goitre

• Graves: upper poles have most thrill/ bruit (nr superior thyroid artery)
• Not present in tumours (hypodynamic vascularity)

Enlarged regional LN

• Thyroid nodule may be quite small, but LN grossly enlarged

Not relevant in thyroid examination

Only if Graves (thyrotoxic) - bruit

• Not important in routine examination