Thyroid Examination - General Surgery

Thyroid Examination in Surgery

1. Thyroid Examination Sana Rasheed Akhtar Saeed Medical and Dental College

2. ANATOMY The thyroid gland is located in the  anterior neck , spanning between the C5 and T1 vertebrae . It is an  endocrine  gland, divided into two lobes which are connected by an   isthmus . It is said to have a butterfly shape. It lies behind the sternohyoid and sternothyroid muscles ,  wrapping  around the cricoid cartilage and superior tracheal rings. It is inferior to the thyroid cartilage of the  larynx .  The gland is in the  visceral compartment  of the neck, along with the trachea,  oesophagus  and  pharynx . The compartment is bound by  pretracheal fascia .

3. Greetings Always do the following steps before proceeding towards the examination . 1. Greetings 2. Introduce yourself and also ask the name of patient 3. Consent 4. Privacy – ask for female attendant or chaperon 5. Exposure of patient ( Dupatta off ) Proceed towards General Examination and Relevant History.

4. General Appearance:

5. May be caused by Thyroid neoplasms Relevant questions to be asked? About anti thyroid medication 1 2 3 ( Gargarahat ) Awaz ka beth jana 4

6. 5 Hyperthyroidism

7. 1 st Step : Inspection Examination of thyroid should be done in 3 positions. i . Front ii. Back iii. Front EXAMINATION FROM FRONT Make the patient sit comfortably on a stool and inspect the thyroid with neck slightly hyperextended and inspect the thyroid from the front.

8. For Short neck patients, PIZILLO Method : Ask the patient to clasp the hands over the occiput and push the head backwards against the resistance of the clasped hands. This makes the thyroid more prominent.

9. First, notice shape of the swelling, and it’s situation.   Shape Oval/globular/spherical pear or irregular – diffuse or localised Location Whether it is on one side of the midline, IN the midline, or it extends on both the sides.

10. One side of Midline In the midline Extends on both sides of midline

11. Now notice the EXTENT of the swelling . Particularly the lateral border in relation to sternomastoid . And the lower border in relation to the suprasternal notch of the sternum A thyroid swelling always lies deep to the sternomastoid muscles. Demonstrated by contracting the sternomastoids . Then note whether the lower border ends above the suprasternal notch or it extends behind the suprasternal notch. Both the borders are to be appreciated.

12. Next, inspect the surface of the swelling A simple goiter and a single nodule have a smooth surface. A multinodular goiter has a nodular or bosselated surface.

13. Then, Inspect the Skin over the swelling . Redness and edema : suggestive of inflammation Scars of previous surgery Sinuses Dilated veins Pigmentation/ulceration A scar from previous thyroid surgery tells us this is a recurrent thyroid swelling A sinus in middle of the neck may discharge mucus like fluid is thyroglossal fistula

14. Pulsatility : watch the swelling for a few seconds quietly for pulsatility . Pulsatility shows presence of an artery.

15. Deglutition test Ask the patient to do DEGLUTTION TEST Give him/her a glass of water. Ask them to take a sip and put away the glass. Then swallow the water. Notice the movement of swelling . Thyroid swelling moves up with deglutition.

16. Other Swellings that move up on degluttition A swelling that is not attached to the pretracheal fascia like LIPOMA will not move upwards during deglutition Thyroid cartilage may move upward but not the swelling

17. Tongue protrusion test If the swelling is in the midline , tongue protrusion test is done to rule out thyroglossal cyst. Ask the patient to extend the neck and open the mouth wide. Now keeping the mouth ask the patient to move the tongue out and in. If swelling moves upwards – thyroglossal cyst This sign is diagnostic of thyroglossal cyst which is connected to the foramen cecum of the tongue. A thyroglossal fistula also moves upwards with the tongue as it is also connected to foramen cecum.

18. Pemberton sign : to diagnose retrosternal goiter compression: •• Raise both arm over head, until they touch the ears •• Maintain the position for a while •• Congestion of face and distress occurs due to obstruction of great veins of thorax Facial flushing seen PAMBERTON’S SIGN for retrosternal goiter. Retrosternal goiter Multinodular goiter can become so much enlarged resulting in the extension of the enlarged gland into the thoracic region and can cause Superior Vena Cava compression Dilatation of subcutaneous veins over anterior part of upper thorax.

19. PALPATION Let the patient sit in comfortable position seating with neck extended. Ask for consent.

20. Warm both hands gently Always ask about tenderness (check patient’s facial expressions) and compare temperature of swelling with surrounding normal skin with dorsal surface of hand. Then stand behind the patient. Place the hands around the neck with the thumbs over the occiput and tips of the other fingers over the front of the neck. This is the standard method for palpation of the thyroid gland. The flexion of the neck can be adjusted by the grip between thumb over the occiput and index fingers under the chin. Now keep the neck slightly flexed to relax the deep cervical fascia and ask the patient to make a swallowing movement as you are palpating. As thyroid moves up and down, lower border can be appreciated and nodules if present can be felt more easily. Palpate the anterior surfaces of the lobes , one by one by reclining the head to the side (same side as the lobe being palpated)

21. Check:

22. PALPATE TRACHEA AND CAROTID PALPATIONS To palpate the trachea, first note position of the larynx then palpate the trachea downwards. May be easy to appreciate its displacement to opp. Side in unilateral goiter. In bilateral goiter, trachea may not be palpable. So first note the position of the larynx, and the position of the trachea over the suprasternal notch.

23. Palpate tracheal rings in the suprasternal notch. If they are not present, retrosternal extension is suspected. LAHEY’S METHOD for deep surface of the gland Now stand in front of the patient. Extend the neck slightly To palpate right lobe push the right lobe with your right hand to right side and palpate with left hand. Repeat on left side.

24. Crile’s method for palpation of small nodules Place the thumb on the thyroid while the patient swallows; this method is used to diagnose doubtful nodules

25. Fixity to skin Pinch the skin over the swelling to look for fixity to skin and (fixity suggests malignant infiltration) Test the mobility of the skin in vertical and horizontal direction.

26. Kocher’s test (for scabbered trachea) To rule out tracheal narrowing. Ask the patient to extend neck and take deep breaths. Compress swelling from both sides. Stridor on compression of lateral lobes indicates narrowing of the trachea. It may also be seen in a malignant thyroid infiltrating the trachea.

27. PALPATE CAROTID ARTERY PULSATIONS (Berry’s Sign) Palpate carotid artery pulsations on transverse process of 6 th cervical vertebra. In unilateral goiter, compare affected side with normal side. If goiter is large: POSITIVE >>>>

28. Percussion

29. Auscultate for carotid and thyroid bruit Bruit – increased vascularity

30. SIGNS OF THYROTOXICOSIS Features of Primary Thyrotoxicosis 1. Eye signs 2. Tachycardia 3. Tremors 4. Moist skin 5. Thyroid bruit

31. EYE SIGNS Lid retraction – Stellwag’s sign - upper lid raised & lower lid normal --Starring look with infrequent blinking and wide palpebral fissures.

32. von Graefe’s sign - Lid lag sign. Tested by asking the patient to look up and down many times fixing the EYE SIGNS

33. Exophthalmos Bulging of the eyeball Strip of white sclera is visible between the iris and lower eyelid. Naffziger’s test: Go behind the patient, extend the neck, see through the supraciliary ridge, you can diagnose exophthalmos EYE SIGNS

34. Joffroy’s sign - Absence of wrinkling of forehead. The patient looks the roof of the room without forehead wrinkling. MÖbius sign - Inability to converge the eyeball. Jellinek’s sign - Increased pigmentation of eyelids. Check for pretibial myxedema - hypothyroidism EYE SIGNS

35. Ophthalmoplegia (malignant exophthalmos) – Weakness of ocular muscles due to edema and cellular infiltration of these muscles. – Paralysis of superior rectus, inferior oblique and lateral rectus. – On paralysis of these muscles, patient is unable to look upwards and outwards . EYE SIGNS

36. Chemosis – Due to obstruction of venous and lymphatic drainage of conjunctiva by increased retro-orbital pressure. EYE SIGNS

37. Perform ankle reflex Auscultate the heart Auscultate the chest Palpate the Spine for tenderness Say thanks to patient and cover the patient.

38. References Dr Muhammad Shahid Mehmood – Akhtar Saeed Medical and Dental College. https://teachmeanatomy.info / Dr Ghanshyam Vaidya - Youtube Long Cases in GENERAL SURGERY - R Rajamahendran