Examination of thyroid gland... general surgery

About examination of thyroid gland

1. Examination of thyroid gland

2. Thyroid gland Location : Anteriorly in the lower part of neck opposite to C5,C6,C7 and T1 vertebrae. Lies behind sternohyoid and sternothyroid muscles H shaped and brownish red in colour. Consists of vertical right and left lateral lobe and a horizontal isthmus Weight:15-25g 5cm long ,3cm wide and 2cm thick

3. HISTORY Age: Simple goitre is commonly seen in girls approaching puberty. In endemic areas deficient iodide is the cause of simple goitre. As iodine is essential for synthesis of thyroid hormones Goitre and dyshormonogenesis are also cause of simple goitre. Mainly found in teen girls. Also occur where hormone production is below normal level eg :puberty ,pregnancy. Papillary carcinoma is seen in young girls and follicular carcinoma in middle aged women. Anaplastic carcinoma in old age.

4. Sex : Majority disorders are seen in females. Thyrotoxicosis is 8 times commoner in females than in males. Thyroid carcinoma ratio of 3:1. Occupation : Thyrotoxicosis may appear in individuals working under stress and strain. Residence: People leaving near rocky mountains eg:Himalayas, the Vindyas , the Satpuda ranges will have simple goitre due deficient of iodide content in water and food. Calcium is also goitrogenic and areas producing chalk or limestone are also goitrogenic .

5. Swelling : History about onset, duration, rate of growth and whether associated with pain should be noted. In thyrotoxicosis patients often complain of sleepless nights. Sudden increase in size with in goitre indicates haemorrhage inside it. Simple goitre grows very slowly or remain of same size, multinodular or solitary nodular goitre or colloid goitre increases in size extremely slowly for year. Papillary carcinoma and follicular carcinoma has slow growth rate. Anaplastic carcinoma is fast growing swelling.

6. Pain : Goitre is usually painless. Inflammatory condition is painful. In Hashimoto’s disease there is discomfort in neck. A aplastic carcinoma is more known to infiltrate the surrounding structures and nerves to cause pain Pressure effect : Enlarged thyroid may press on trachea to cause dyspnoea or press on oesophagus to cause dysphagia or press on recurrent laryngeal nerve to cause hoarseness of the voice. Makes swallowing uncomfortable. When air rushes through narrowed trachea, a whistling sound is produced which is called stridor.

7. Past history : Enquiry must be made about the course of treatment the patient had and it’s effect on the swelling. In case of fistula there may be previous history of an abscess which was incited or burst spontaneously. Should ask patient if she was taking any drugs eg : PAS or sulphonilurea or any other antithyroid drugs as they are goitrogenic . Personal history: Dietary habit. Person taking sea fish which has low iodide content, my present with goitre. Family history: Enzyme deficiency within thyroid gland which are concerned in synthesis of thyroid hormone also run in families. Primary thyrotoxicosis seen in more than one member in family.

8. A. Physical examination General survey Build and state of nutrition: In thyrotoxicosis the patient is usually thin and underweight. Patient sweats a lot with wasting of muscles and in hypothyroidism patient is obese and overweight. Facies : In thyrotoxicosis one can see the facial expression of excitement, tension, nervousness. In hypothyroidism one can see puffy face without any expression

9. 3. Mental state and intelligence: Hypothyroid patient are naturally dull. 4.Pulse rate is irregular in thyrotoxicosis. Irregularity is more of a feature of secondary thyrotoxicosis. Sleeping pulse rate is very useful index to determine the degree of thyrotoxicosis. In mild thyrotoxicosis it should be below 90, whereas in case of moderate or severe thyrotoxicosis it should be between 90 to 110 or above. Bradycardia in hypothyroidism 5.Skin: Skin is moist particularly the hands in case of primary thyrotoxicosis. Skin is dry and inelastic in myxoedema.

10. B. LOCAL EXAMINATION INSPECTION : Normal thyroid gland can be seen only when thyroid gland is swollen. In case of obese and short- necked individual inspection of thyroid gland is difficult Pizzillo’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

11. Ask the patient to swallow and watch for the most important physical sign- a thyroid swelling moves upwards on deglutition. This is because thyroid gland is fixed to the larynx. Other swelling which may move on deglutition are thyroglossal cysts, subhyoid bursitis and prelaryngeal or pretracheal lymph nodes fixed to larynx or trachea.

12. A thyroglossal cyst also moves upwards on deglutition. But the pathodnomonic feature is that it moves upwards with protrusion of tongue since the thyroglossal duct extends downwards from foramen caecum of tongue to the isthmus of thyroid gland.

13. In retrosternal goitre, pressure on the great veins at the thoracic inlet gives rise to dilatation of the subcutaneous veins over the upper anterior part of the thorax. Congestion of face and distress become evident in case of retrosternal goitre due to obstruction of the great veins at the thoracic inlet.

14. PALPATION : The thyroid gland should be palpated with the patient’s neck slightly flexed. The gland may be palpated from behind and from the front. Patient should be sitted on a stool and 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 other four fingers of each hand are placed on each lobe and the isthmus.

15. Palpation of each lobe is best carried out by Lahey’s method. Here the examiner stands in front of the patient. To palpate the left lobe properly , the thyroid gland is pushed to the left from right side by left hand of examiner. During palpation the patient should be asked to swallow in order to settle the diagnosis of thyroid swelling. Crile’s method

16. During palpation the following points should be noted: 1.Whether the whole thyroid gland is enlarged? Note its surface, is smooth in primary thyrotoxicosis or bosselated in multinodular goitre. 2.When a swelling is localised, note its position, size, shape, extent and its consistency. A calcified cyst may even feel hard. 3.The mobility should be noted in both horizontal and vertical plans. Fixing means malignant tumour or chronic thyroiditis.

17. 4. To get below the thyroid gland is important to discard the possibility of retrosternal extension. Clinician’s index finger is placed on lower border of thyroid gland. The patient is asked to swallow, the thyroid gland will move up and the lower border is palpated. Kochler’s test if it is positive, indicates an obstructed trachea. This is done by gentle compression on lateral lobes may produce stridor due to narrow trachea. Passage of air will indicate the position the position of the trachea.

18. Obstruction to the major veins in the thorax causes engorgement of neck veins are not uncommon. Thus sign becomes obvious when the patients are asked to raise the hands above the head and the arms touch the ears. Known as Pemberton’s sign. 5. Palpation of cervical lymph nodes- important particularly in malignancy of thyroid. Papillary carcinoma of thyroid is notorious for early lymphatic metastasis when primary tumour remains quite small

19. PERCUSSION This is employed over the manubrium sterni to exclude the presence of retrosternal goitre. AUSCALTATION In primary toxic goitre a systolic bruit may be heard over the goitre due ti increases vascularity. Measurement of circumference of neck at most prominent part of swelling may be taken at intervals.

20. GENERAL EXAMINATION One should look for 1.Primary toxic manifestations in case of goitres affecting the young 2.Secondary toxic manifestations in nodular goitre and 3.Metastasis in case of malignant thyroid diseases

21. Primary toxic manifestation- 5 cardinal signs A. Eye signs- 1. Lid retraction 2. Exophthalmos 3. Opthalmoplegia 4. Chemosis B. Tachycardia C. Tremor D. Moist skin E. Thyroid bruit

22. 2. Secondary thyrotoxicosis may complicate multinodular goitre or adenoma of thyroid. Cardiovascular system is mainly affected. Agricultural fibrillation is quite common. Exophthalmos and tremor are usually absent. 3. Search for metastasis – when the thyroid swelling appears to be stony hard, irregular and fixed losing its mobility even during deputation a careful search should be made to know about the spread of diseases.

23. Thank you - Fathima Afra , 35