Examination of the Thyroid.
Introduction:
Explain the procedure and take consent.
Physical Examination: General appearance: - thyroid swelling, prominent eyes - primary toxic
goitre. Wasting, sweating, nervousness, trembling, hot and moist palms and elevated sleeping
pulse rate are the features of primary thyrotoxicosis.
Local examination: Inspection: thyroid gland can only be seen if it is swollen.
Pizzillo's method: patients hands are placed behind the head and the head pushed backward against the clasped hands. Movement on swallowing: - thyroid swelling moves upward on deglutition. Thyroglossal cyst moves upwards on deglutition and protrusion of the tongue. Retrosternal goitre: the lower border of the swelling also moves up on deglutition. This is not possible in case of retrosternal goitre. Congestion of the face and distress may be seen in case of retrosternal goitre due to obstruction of the great veins at the thoracic inlet.
Palpation: the thyroid gland should always be palpated with the patient's neck slightly flexed. The gland may be palpated from behind and from the front with the four fingers of each hand placed on each lobe. Careful assessment of the margins, particularly the lower, is important.
Lahey's method: palpation of each lobe is best carried out from the front.
Whether the whole thyroid gland is enlarged? Surface: smooth or bosselated, consistency: firm, soft or hard, uniform or variable.
Swelling: position, size, shape, and extent.
Mobility: in horizontal and vertical planes. Fixity means malignant tumour or thyroiditis.
To get below the thyroid: an important test to discard the possibility of retrosternal extension. The patient is asked to swallow and the lower border is palpated for any extension downwards.
Pressure effects: on the trachea, larynx (stridor and dyspnoea), the oesophagus (dyspnoea), the recurrent laryngeal nerve (hoarseness), the carotid sheath (pulsation of the artery cannot be felt), and the sympathetic trunk (Horner's syndrome). Position of larynx and trachea should be noted.
Toxic manifestation: primary toxic thyroid is generally not enlarged whereas an enlarged thyroid or nodular thyroid with toxic manifestation is generally a case of secondary thyrotoxicosis. CVS in secondary and CNS in primary thyrotoxicosis are mainly affected.
Evidence of myxoedema or not. Swelling malignant or benign.
Pulsation or thrill in the thyroid.
Percussion: over the manubrium sterni to exclude the presence of retrosternal goitre.
Auscultation: in primary toxic goitre a systolic bruit may be heard over the goitre due to increased vascularity.
Measurement: circumference of the neck may be taken at frequent intervals.
General Examination: primary toxic manifestation (Graves' disease): exophthalmos, Von Graefe's (lid lag) sign, tachycardia, tremor of the hand, moist skin, intolerance of hot weather and thyroid bruit. Secondary thyrotoxicosis: AF is quite common. CVS is mainly effected. Cardiomegaly and signs of cardiac failure: ankle oedema, orthopnoea and dyspnoea. Exophthalmos and tremor absent. Metastasis: lymph nodes, bones and lungs.