EXAMINATION OF THE THYROID Gland lecture.pptx

Surgery

1. EXAMINATION OF THE THYROID GROUP 3

2. HISTROY TAKING GENERAL EXAMINATION LOCAL EXAMINATION Inspect Palpate

3. HISTROY TAKING History taking begins with: Name : It is first and basic requirement . Address : Knowing the residential place may be important in certain types of goitres e.g. endemic goiter due to iodine deficiency is common in interior regions, mountainous areas Chalk or limestone producing areas are goitrogenic areas as calcium is goitrogenic Sex: Most of the thyroid diseases like hyperthyroidism (8:1), hypothyroidism, goitres, neoplasms (3:1) are commonly seen in females

4. Age: Simple goitre is often seen in girls during puberty. Goitre due to dyshormonogenesis occurs in younger age group. Physiological goitre occurs when there is increased metabolic demand of the hormone like in puberty, pregnancy. Solitary nodule, colloid goitre, papillary carcinoma and primary thyrotoxicosis are seen between 20-40 years. Multinodular goitre, follicular carcinoma and Hashimoto’s thyroiditis are seen in middle aged women.

5. Chief Complaints Swelling in front of the neck and its duration ; Pain in the swelling and its duration; Hoarseness of voice due to recurrent laryngeal nerve palsy; Difficulty in swallowing or breathing; Tremor in the hands; Generalized weakness; Palpitation; Loss of significant weight

6. History of Present Illness Swelling Its duration, mode of onset whether sudden or insidious in nature should be asked. Origin of the swelling, its progress whether gradual (benign) or rapidly progressive(malignancy ) or recent rapid increase in a preexisting swelling (benign turning into malignancy) or sudden rapid increase may be seen in haemorrhage . Thyroglossal cyst may be present since childhood . Swelling may be single/multiple or occupying one lobe, or both lobes or isthmus . Most of the goitres, solitary nodule, multinodular goitre are slow growing swellings. Anaplastic carcinoma, follicular carcinoma, medullary carcinoma are rapidly growing tumours. Papillary carcinoma which is the commonest thyroid malignancy, even though malignant is a slow growing tumour often for few years

7. Pain Its duration, character like dull aching/pricking, site of pain, radiation, factors which alters the pain should be asked for. Usually goitres are painless . Thyroiditis may be painful. Malignancy is initially painless but later becomes painful due Infiltration into surrounding structure (nerves )/necrosis/ haemorrhage makes its painful and tender. Anaplastic carcinoma commonly infiltrates into nerves to cause pain.

8. Pressure Symptoms Dysphagia (oesophageal compression), dyspnea (tracheal compression), stridor (infiltration into trachea ), hoarseness of voice (recurrent laryngeal nerve compression ) and Horner’s syndrome (infiltration of cervical sympathetic chain – ptosis, loss of sweating, in face same side, miosis and exophthalmos ). Their onset and progression should be asked

9. Features of Toxicity Increased appetite/loss of weight/ diarrhoea /chest pain aggravated by exercise/palpitation/ amenorrhoea /irritability/nervousness/sleeplessness (insomnia)/ hand tremors/increased sweating/cold preference/heat intolerance/ proximal muscle weakness in the thigh or arm like fatigue on getting down steps or lifting weight using arms ( myopathy) which may be due due to difficulty in isometric contraction and increased muscle metabolism/wasting of muscles/visual disturbances with bulging of the eyes (exophthalmos ).

10. Usually in primary thyrotoxicosis, symptoms appear first which are more severe than secondary type; later diffuse thyroid swelling appears in the neck. In secondary thyrotoxicosis obvious swelling appears first which is nodular later symptoms of thyrotoxicosis appear which are less severe initially compared to primary thyrotoxicosis; but symptoms gradually become more severe. Neurological and eye signs are more common in primary thyrotoxicosis

11. Features of hypothyroidism/ myxoedema : Muscle weakness/lethargy/weight gain / poor appetite/facial swelling/cold intolerance/menorrhagia/constipation/ superciliary madarosis in lateral half of the eyebrows/loss of hairs in scalp/change in voice due to vocal cord oedema /dry skin/muscle fatigue/lethargy/less memory/sleepiness . Myxoedema crisis may develop with acute exacerbation of features

12. Past History History of irradiation should be asked for carcinoma thyroid . Irradiation to head and neck region may have been given for benign lesions like adenoids, tonsillitis, thymus , acne vulgaris or haemangiomas or malignancy in younger age groups like for lymphomas Previous history of having thyroglossal cyst must be noted which might have been infected causing fistula either due to spontaneous burst or after surgical drainage of the infected cyst. Previous surgery for thyroid in recurrent thyroid swelling or earlier surgery for thyroglossal cyst in case of thyroglossal fistula should be asked for.

13. Personal History History of smoking, alcohol intake or any drugs which may cause alteration in thyroid function should be asked . History of any drug intake like patient may be on thyroxine or on antithyroid drugs or beta blockers or other drugs like lithium, PAS or sulphonylureas which may alter the thyroid should be noted. Dietary habits should be asked. Vegetables belonging to Brassica family like cabbage, kale and rape are goitrogens . Type of salt used in the family iodized/home rock salt is also important.

14. Family History Dyshormonogenesis, medullary carcinoma of thyroid can be familial (MEN syndrome). Endemic goitre and Grave’s disease can occur in families. Altered thyroid function may be the cause for infertility

15. Menstrual History History of menarche/menopause; duration of menstruation, history suggestive of menorrhagia, amenorrhoea , oligomenorrhoea , etc. should be asked for. Hyperthyroidism can cause amenorrhoea ; Hypothyroidism may cause menorrhagia.

16. Treatment History History of undergoing investigations or treatment relevant to thyroid disease should be asked for Often patient may be taking drugs like PAS or sulphonylureas which are goitrogenic. History of intake of drugs for other diseases should be mentioned

17. General Examination Thyrotoxic patient is anxious/ thin and undernourished. Obesity is seen in myxoedema. Patient may be cachexic in thyroid carcinoma which is advanced/metastatic . Exophthalmos should be looked for in toxic patient. Irritable/agitated tensed face with eye signs is seen in toxic thyroid . Myxoedema face is typical. It is expression less, mask-like puffy face . Patient will be dull with low intelligence ( everything is slow – walking, talking, moving, thinking, reflex). Hasty – rapid gait is seen in hyperthyroid and slow-lethargic gait in hypothyroidism.

18. Pulse Its character , whether tachycardia, collapsing/Corrigan’s or pulsus paradoxus type or ectopic or fibrillation has to be looked for. Pulse rate may be slow in hypothyroidism. Sleeping pulse rate is checked at late night or early morning for three consecutive nights and average is taken . Sleeping pulse rate is graded as per Crile’s grading. Blood pressure may be high in toxic thyroid

19. In toxic thyroid , patient will be thin and underweighting spite of patients’ good appetite. In hypothyroidism , patient will be obese and overweight. Skin is wet and warm in hyperthyroidism ( moist palm while shaking hands ). Ankle (Achilles tendon) reflex is prolonged with delayed relaxation in hypothyroidism and it is shortened and brisk in hyperthyroidism . Both legs and ankle region in front should be inspected for pretibial myxoedema . It is a feature of primary thyrotoxicosis. It is due to deposition of myxomatous tissue

20. Tremor of the Hands and Tongue Hand tremors are observed in outstretched hands and fingers . Often small object like pen may be kept to watch the tremor better. Fine tremors are observed in toxic thyroid . It is due to diffuse irritation of the grey matter. Tongue twitching can be observed by opening the mouth and carefully observing the tongue. Tongue should be within oral cavity to check the tremor. Protruded tongue causes fasciculation of intrinsic muscles of tongue which mimic tongue tremor.

21. LOCAL EXAMINATION The anatomical landmarks relevant to inspection and palpation of the thyroid are shown in

22. Inspection Inspectory findings of the swelling should include Its location/size (both vertical and horizontal dimensions of each lobe and isthmus or if it presents as a single mass dimension of the single swelling )

23. S hape (butterfly shape if both lobes are involved) E xtent (from posterior border of sternomastoid laterally to midline in single lobe enlargement of gland or from one side to opposite sternomastoid if both lobes are enlarged)upper extent is usually up to thyroid cartilage/ lower margin may or may not be clearly visible or may be visible during deglutition

24. With the patient’s neck slightly extended, inspect the area below the cricoid cartilage. Ask him to take a sip of water, extend the neck again and swallow. Watch for the superior movement of the gland, carefully noting its contour and any asymmetry

25. Swellings which move upwards with deglutition Thyroid swelling Sub hyoid bursa Thyroglossal cyst Pretracheal / prelaryngeal lymph nodes Swelling from larynx / trachea

26. scar dilated veins (in toxic goitre, carcinoma thyroid, venous compression , retrosternal goitre) or pigmentation on the skin over the swelling pulsation over the swelling(toxicity , malignancy ) surface on inspection ( smooth or nodular). Surface is smooth in physiological goitre, primary toxic goitre and Hashimoto’s thyroiditis. It is nodular in multinodular goitre. In malignancy it can be smooth or nodular.

27. In some occasions whether swelling moves while protruding the tongue or not should be looked for. Thyroglossal cyst moves upwards with protrusion of tongue . Patient is asked to open the mouth and then swelling/cyst is held firmly. Now patient is asked to protrude the tongue out to feel an upward movement of the swelling with a typical ‘ tug ’ like feeling in the swelling on inspection . Any other swelling in the neck should be looked for like lymph nodes.

28. Palpation Thyroid palpation is best carried out from behind, with the patient’s neck slightly extended Both thumbs of the examiner are placed over the back of the neck and fingers of each hand are placed on the respective lateral lobes for palpation Isthmus should also be palpated like this

29. Palpatory findings of the swelling includes Temperature over swelling, tenderness, extent, position, shape, size (should be measured in centimeter both vertically and horizontally), movement of the swelling upwards with deglutition, surface (smooth or nodular), consistency (soft or firm or hard or variable and if so different locations of different consistencies should be mentioned),margin (well defined or diffuse, lower margin which is most important should be specially mentioned),independent mobility of the swelling ,whether skin is free or not.

30. Crile’s Method of Palpation of Gland It is the palpation of the nodule/swelling in front using the pulp of the thumb when patient is swallowing

31. Pizzillo’s Method It is the method of inspecting and often palpating the thyroid gland in short necked and obese individuals . Patient is asked to keep her/his clasped hands over the occiput and head is pushed against the hands; gland which becomes prominent will be inspected or palpated from front or behind

32. Kocher’s Test It is the test to check for tracheal compression. Patient is asked to see straight. With fingers and thumb both lateral lobes of the thyroid gland are gently compressed directing posteromedially. If patient develops stridor—Kocher’s test is positive. If patient develops no stridor, it means test is negative In a long standing goitre and large goitre, weakening of tracheal rings occurs because of constant pressure which gets narrowed/collapsed during compression

33. Pemberton’s sign : Patient is asked to raise both the arms above the shoulder so as to touch the ears and asked to keep like that for 3 minutes. Patient will develop dilated veins and cyanosis in the neck and upper chest wall, puffiness in face, respiratory distress and rarely dysphagia. It means sign is positive signifying retrosternal extension of goitre

34. Confirmation of Retrosternal Extension Lower margin of the swelling/goitre is not visible—even on deglutition. Lower margin is not palpable on deglutition . Dilated veins over neck or chest wall may be visible. Normal resonant note over the sternum becomes dull on percussion . Retrosternal goitre may be substernal (part of the nodule is palpable in the neck) or plunging goitre ( intrathoracic goitre is forced into the neck occasionally by increased intrathoracic pressure ) or intrathoracic goitre with normal neck. It can be toxic/nontoxic nodules/malignant. Retrosternal goitre is confirmed by CT scan and radioiodine isotope study. It is treated by complete surgical removal usually through neck approach,occasionally through median sternotomy . Radioactive iodine therapy is not used for retrosternal goitre.

35. Position of trachea is checked by palpation using three fingers from below

36. Carotid pulsation should be checked. It is normally felt at the level of the upper border of thyroid cartilage over medial aspect of the sternomastoid muscle on the Chaissagne tubercle (carotid tubercle) on the transverse process of C6 vertebra. It may be deviated posteriorly/laterally in a large goitre. It may be absent in advanced carcinoma thyroid due to infiltration of the carotid sheath by the tumour ( Berry’s sign)

37. Percussion over the manubrium sterni is important. Dullness signifies retrosternal extension. Tenderness may signify secondaries in sternum from follicular carcinoma of thyroid . Auscultation over the upper pole of the gland is done to hear bruit—in patients with toxic thyroid and in very vascular tumours

38. Other systems Cardiovascular system examination is important in thyrotoxicosis—commonly secondary type. Tachycardia, ectopic beats, pulsus paradoxus , extrasystoles atrial fibrillation are the cardiac presentations Respiratory system examination: Secondaries and pleural effusion can occur in follicular carcinoma of thyroid . Abdomen examination: Hepatomegaly is looked for as secondaries in liver are known to occur in follicular carcinoma of thyroid. Hepatosplenomegaly can occur as part of Grave’s disease or Hashimoto’s disease

39. Examination of skull and spine: Localised , warm,vascular , pulsatile secondaries can occur in skull commonly , rib and other bones occasionally as a spread from follicular carcinoma of thyroid In primary thyrotoxicosis exophthalmos and all eye signs are looked for . THANK YOU

40. Hutchison’s clinical methods SRB’s Clinical methods in surgery