Thyroid_Gland_Examination.pptx presented by Munguci

The slide is about how one can examine the thyroid gland thoroughly

1. EXAMINATION OF THE THYROID PRESENTER: MUNGUCI JAMES LECTURER : DR. SANDRA NABUKALU DATE : 16 TH OCTOBER 2024

2. OUTLINE Anatomy Embryology Physiology Steps of thyroid examination ( Preparation Inspection, Palpation, Percussion, Auscultation) Assessment and investigation Common thyroid conditions

3. Anatomy of the thyroid gland The thyroid gland is a butterfly shaped endocrine gland, located in the anterior part of the lower neck, anterior to the larynx. Has 2 lobes connected by the Isthmus. The right lobe is slightly larger than the left lobe Each lobe extends from the middle of the thyroid cartilage to the 4 th or 5 th tracheal ring. The Isthmus is btn 2 nd and 4 th tracheal ring.

4. Embryology The thyroid arises from 1 st and 2 nd pharyngeal pouches composed of endoderm. It originates near the base of the tongue. It begins as a diverticular growth from the primitive pharynx. On day 20-24, endodermal cells of the primitive pharynx proliferate and create the thyroid diverticulum. The diverticulum descends in the 5 th week, to reach its destination in the neck. During descent, the thyroid is connected to the tongue by the thyroglossal duct. In the 5 th week it is divided into the right and left lobes Ultimobrancial bodies from the 4 th and 5 th pharyngeal pouches ( Parafolicular C-cells) which secrete calcitonin.

5. Physiology It is an endocrine gland. It screets hormones belonging to the amine group, i.e. Thyroxine( T4) and Tri-iodothyronine( T3) Secretions from the Thyroid hormone are influenced by the thyroid stimulating hormone from the pituitary gland.

6. Thyroid Examination has the following steps Preparation Inspection Palpation Percussion Auscultation

7. Preparation Before examination, take a detailed and proper history. Wash your hands before the patient Introduce your self to the patient. Confirm patient details including the name, date of birth, etc Explain the examination briefly to the patient using patient-friendly language. Gain consent to proceed with the procedure Position the patient. Adequately expose the patient’s neck and the upper sternum

8. Inspection Focus during inspection: Behaviour Hands Pulse Face Eyes Thyroid

9. 1. Behaviour Hyperactivity relates to hyperthyroidism Hypoactivity relates to hypothyroidism.

10. 2. Hands A dry skin indicates hypothyroidism Increased sweat indicates hyperthyroidism Phalangeal bone overgrowth in Graves Disease( Thyroid acropachy) Reddening of the palms( palmar erythema indicates hyperthyroidism) Peripheral tremor( Hyperthyroidism)

11. 3. Pulse Tacchardia in hyperthyroidism. Bradycardia in hypothyroidism. Rhythm irregular in thyrotoxicosis.

12. 4. Face Dry skin in hypothyroidism Sweating in hyperthyroidism Loss of outer third of eyebrows( Queen Anne’s sign/Sign of Hertoghe, shows hypothyroidism. Absent creases on the forehead on upward gaze( Joffroy’s sign).

13. 5. Eyes Anterior displacement of the eye out of the orbit( Exophthalmos). Lid retraction in Graves disease. The sclera is visible). Conjuctivitis in Grave’s disease Bilateral exophthalmos is associated with Graves disease.

14. Eye movement Eye movement can be restricted in Graves disease due abnormal connective tissue deposition in the orbit and extra ocular muscles. Ask patient to keep head still and follow your finger with the eyes. Make a letter H. Observe for restrictions in movement. Ask for pain or double vision.

15. Lid lag. In the presence of lid lag, the upper eyelid lags behind the downward movement( the sclera will be visible above the iris). It occurs due to protrusion of the eye from the orbit( exophthalmos) which is associated with graves disease. Hold your finger high and ask the patient to follow it with their eyes( (head still). Move your finger downwards. Observe the upper eyelid as the as the patient follows your finger downwards.

16. Eye signs in thyroid examination Dalrymple sign. ( Widened palpebral tissue in Graves Disease) Griffith sign. ( Lid lag of the lower eyelid on moving the eye upwards in Graves disease) Jellinek sign. ( Periorbital hyperpigmentation in Graves disease) Joffroy sign. (Lack of wrinkling in the fore head when a patient looks up with the head bent forwards). Mobius sign .(Inability to maintain convergency of the eyes in Graves disease) Rosenbach sign .( Fine tremors of the eyelids when gently closed). Stellwag sign. ( Infrequent or incomplete blinking due to exophthalmos or Graves Disease) Tellas sign. ( Hyperpigmented lower eyelid) Topolansky sign. ( Congestion of the pericorneal region of the cornea in Graves disease).

17. 6. The Thyroid inspection A normal thyroid gland should not be visible. Inspect the neck for a swelling in the region of the thyroid. Observe for changes in the skin, therapeutic marks, erythema, vascular prominence/ or engorgement of neck vessels. Observe for any scars in case of previous surgery. Observe for other masses in the neck, the size and shape.

18. Thyroid inspection continued…. If a mass is present, Ask the patient to swallow some water. Observe for the movement of a mass. Masses in relation to the thyroid gland move with swallowing. Thyroglossal cysts also move with swallowing. Lymph nodes are less mobile because of the inflammatory process.

19. Thyroid inspection continued…. Ask the patient to protrude the tongue. Thyroid glands and lymph nodes do not move with tongue protrusion. Thyroglossal cysts move upwards because of the connection with the base of the tongue.

20. Palpation of the thyroid gland When palpating the thyroid gland, assess the following characteristics; Size: Note if the thyroid gland feels enlarged. Symmetry. One lobe larger than the other(unilateral enlargement maybe caused by thyroid nodule or malignancy) Consistency. Firm, hard, nodular, cystic.( widespread irregular consistency would be suggestive of a multinodular goiter) Masses. Distinct palpable masses Thrill. Increased vascularity in hyperthyroidism (suggestive of Grave’s disease), thyrotoxicosis.

21. How to palpate the thyroid Stand behind the patient and ask them to flex their neck to relax the sternocleidomastoid muscle. Place 3 middle fingers of each hand along the midline of the neck below the chin. Locate the upper edge of the thyroid cartilage( Adams apple). Move inferiorly until you reach the cricoid cartilage/ring The first 2 rings of the trachea are located below the cricoid cartilage and the thyroid isthmus lies over this area. Palpate the thyroid isthmus with your finger pads not the tips. Palpate each lobe including the inferior borders

22. Palpation of the thyroid continued Let the patient swallow so that you feel the symmetrical elevation of the thyroid lobes. (asymmetrical elevation may suggest a unilateral thyroid mass). To report on the masses, mention the position, shape, tenderness, consistency and mobility. i.e Position- The thyroid is located at the midpoint of the thyroid gland, approximately 2cm below the cricoid cartilage, Shape- The nodule is irregularly/round/oval shaped and approximately 2cm in diameter. Tenderness- Non-tender/ mild-tenderness on palpation, Consistency- Firm/ soft/ hard and fixed Mobility -Freely mobile/ fixed to the surrounding tissues/ limited mobility due to adherence to the trachea .

23. Continued….. Ask the patient to protrude the tongue. If it is a thyroglossal cyst, it will move with the movement of the tongue. Examine the regional lymph nodes. Supraclavicular nodes Anterior cervical chain Posterior cervical chain Submental nodes

24. Palpation of the Trachea Palpate the trachea for its position. Note any deviations. These may be caused by thyroid masses/ A large goitre .

25. Percussion Percussion is used to define the lower extent of a swelling that extends below the suprasternal notch by percussing along the clavicles and over the sternum and upper chest wall. This can be done when standing in front of or behind the patient Percuss the sternum moving downward from the sternal notch to assess for retrosternal dullness(indicating enlargement) or resonance (normal) Retrosternal dullness may indicate a large thyroid mass extending posteroinferiorly to the manubrium.

26. Auscultation of the thyroid gland Auscultate each lobe of the thyroid gland for a bruit using the bell of the stethoscope A bruit is present in Graves disease due to increased vascularity.

27. TO COMPLETE THE EXAMINATION….. Explain to the patient that the examination is now finished Thank the patient for their time Dispose of the PPE appropriately and wash your hands Summarise your findings

28. Further assessments and Investigations Thyroid function tests : These include TSH, T3 and T4 Thyroid Antibody tests ( TPOAb , TgAb , ECG : Should be performed if an irregular pulse was noted to rule out atrial fibrillation. Further imaging : An ultra sound scan of the neck to further assess any thyroid lumps. Blood tests ( CBC, Electrolytes, RFTS)

29. Intervention Lifestyle modifications( Diet, exercise, stress management) (hypo and hyper) Antithyroid medications- Carbimazole, propylthiouracil, methimazole.(hyper) Beta blockers- propranolol, atenolol, metoprolol.(hyper) Radioactive iodine therapy,(hyper) Thyroid hormone replacement therapy(THRT)-hypo Monitoring (regular TFTs and clinical assessment)(both) Fine needle aspiration biopsy(FNAB)- thyroid nodule Surgery( Thyroidectomy)

30. Common Thyroid Conditions Goiter (Diffuse, Uninodular , Multinodular) Hypothyroidism Hyperthyroidism Thyroid nodules (Benign and non cancerous, malignant and cancerous, functional- producing thyroid hormones, nonfunctional- not producing thyroid hormones) Thyroiditis ( Hashimoto’s thyroiditis)

31. Thyrotoxicosis Thyrotoxicosis is caused by an excess of circulating thyroid hormone. The gland may be diffusely hyperplastic (Graves’ thyroiditis), nodular or the site of disease such as thyroiditis or an adenoma, but rarely a carcinoma. Symptoms include; Weight loss( Unintentional) Heat intolerance Excess sweating Palpitations Shortness of breath HyperGI motility Tremors, insomnia, nervousness Bony pains Menstrual irregularities( amenorrhea) or Erectile dysfunction( fatigability, low mood, low sexual drive).

32. Symptoms of hypothyroidism Weight gain Cold intolerance Bloating Tiredness all the time, loss of intrest , poor memory Palpitation Shortness of breath Constipation Bony aches Menstrual irregularities or Erectile dysfunction

33. Symptoms of malignancy Fevers especially at night, weight loss and loss of appetite Local metastatic symptoms( Bone aches)

34. Symptoms of thyroid nodules Visible lump or swelling in the neck Pain or discomfort in the neck or throat Dysphagia Hoarseness in the voice Coughing or wheezing Neck stiffness or tightness Fatigue or weakness

35. Goiter A diffuse enlargement of the thyroid gland Most common manifestation of thyroid disease No correlation between size and function. One can be euthyroid, hypothyroid, hyperthyroid. DIFFERENT FORMS OF GOITRES INCLUDE; simple hyperplastic goiters, multinodular goiters, the solitary nodule.

36. Complaints A visible swelling Tightness in the throat Coughing Hoarseness Difficulty in swallowing Difficulty in breathing.

37. REFERENCES Browse’s introduction to the symptoms and signs of surgical disease 5 th edition Herbert L. Fred, MD and Hendrick A. van Dijk . Adapted by Geeky Medics. Thyroid acropathy and pretibial myoxedema .

38. THE END THANK YOU FOR LISTENING