Thyroid swelling-clinical examination.pdf

Thyroid swelling, or goiter, is characterized by enlargement of the thyroid gland, which can be assessed through clinical examination. The examination involves inspection and palpation of the neck while the patient swallows, allowing for observation of the thyroid's contour and any abnormal masses. Key considerations include the symmetry of the gland, presence of nodules, and any signs of obstruction, such as difficulty swallowing or breathing. Further evaluation may involve imaging or fine needle aspiration to determine the nature of the swelling, differentiating between benign and malignant conditions

1. Thyroid Swelling –
Clinical Examination
Presented by:
Dr Shanmugaloga S
PG Scholar
Dept of Shalya Tantra
GAMC,Bengaluru

2. CONTENTS:
➢Thyroid gland-anatomy
➢Thyroid swelling-examination
▪Inspection
▪Palpation
▪Percussion
▪Auscultation
▪Signs of thyrotoxicosis
▪Signs of myxoedema
▪Signs of retrosternal extension
▪Signs of metastasis
➢Thyroid disorders
➢Investigations
➢Management
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3. 3

4. 4SURGICAL ANATOMY

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6. Thyroid – Blood and Nerve supply
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7. Muscles Lymph nodes
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8. A.Inspection
1)Standard method
2)Pizillo’s method
Note for:
➢Size & shape of the swelling
➢Location
➢Borders
➢Surface
➢Skin over the swelling
➢Visible pulsations
➢Upward movement on:
▪Deglutition
▪Tongue protrusion
Standard method
Pizillo’s method
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9. Deglutition:
Moveable thyroid swelling
➢Almost all thyroid swellings
➢Thyroglossal cyst
➢Subhyoid bursitis
➢Pretracheal lymph nodes
➢Extrimisic CA of larynx
Swellings that don’t move
➢Lipoma
➢Retrosternal goitre
➢Giant goitre
➢Swelling d/t Chronic thyroiditis
➢Malignant infiltraion
Tongue protrusion:
Thyroglossal cyst Thyroglossal fistula
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10. B.Palpation:
Methods:
1)Standard method
2)Lahey’s method
3)Crile’s method
Check for:
➢Consistency
➢Surface
➢Borders
➢Tenderness / temperature
Confirm whether affection:
➢Entire gland
▪Size & shape
▪Surface-smooth/ bosselated
▪Consistency- soft/firm/hard
▪Retrosternal extension
➢One lobe/ isthmus
➢Single nodule
▪Size
▪Location-one lobe/isthmus
▪Consistency-soft in adenoma/ firm in cystic swelling (paradox*)
➢Palpable thrill
➢Fixity
➢Trachea (kocher test)
➢Carotid pulsations (Berry’s sign)
➢Lymph nodes
Kocher test
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11. Multinodular goiter
Single nodule with multilobe involvement
Single nodules may be:
➢Adenoma
➢Cyst
➢Calcified nodule
➢Colloid goiter
Diffusely enlarged may be:
➢Diffuse parenchymatous goiter
➢Puberty goiter
➢Diffuse colloid goiter
➢Primary toxic goiter
➢Hashimoto’s thyroiditis
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12. C.Percussion:
•Use heavy percussion stroke over the manubrium sterni
➢Resonant-Normal
➢Dull-retrosternal extension
D.Auscultation:
•Over Upper poles
➢Systolic bruits: primary toxic goiter (increased vascularity)

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13. Look for other signs:
1)Signs of thyrotoxicosis:
➢Eye signs
➢Fine tremors- outstretched hand & protruded tongue
➢Tachycardia- feel radial pulse (also, sleeping pulse rate)
➢Bruit , thrill
➢Warm moist skin
➢Pretibial myxoedema
1)Primary thyrotoxicosis:
➢Eye signs: exophthalmos
➢CNS signs:Tremors
➢Cardiac signs
2) Secondary thyrotoxicosis:
➢Cardiac signs: cardiomegaly, atrial
fibrillations( ccf)
➢CNS signs
➢Eye signs
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14. 1)Thyrotoxicosis:
➢Eye signs
Dalyrimple sign
Jaffroy sign
Moebius sign
Stellwag sign
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15. 2)Signs of myxoedema:
➢Edema of face & legs
➢Dry, coarse skin
➢Hoarseness of voice
➢Lethargy
➢Delayed relaxation of deep reflexes
•Ankle jerk
•knee jerk
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16. 3)Signs of retrosternal extension:
➢Tracheal rings- not palpable
➢Dull note on percussion over manubrium sterni
➢Pemberton sign: (EAST TEST)
▪Dilated veins
▪Congestion of face
▪Puffiness of face
➢Horner’s syndrome
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17. 4)Signs of metastasis:
➢Rapid enlargement of longstanding nodule
➢Hard in consistency
➢Fixity
➢Weak carotid pulsation
➢Tracheal obstruction(kocher test/ xray AP view)
➢Hoarseness of voice
➢Enlarged hard lymph nodes
➢Hard nodules on skull surface
➢Bony deformity / tenderness in long bones
➢P/A – Nodular liver , Ascites
➢Chest examination- effusion/ consolidation
➢Horner’s syndrome
➢h/o recent weight loss
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Platysma sign

18. THYROID DISORDERS:
Functional:
➢Hypothyroidism
➢Hyperthyroidism
➢Euthyroidism
Goiter:
a)Non toxic(simple)
➢Colloid
➢Diffuse parenchymatous
➢Solitary nodular
➢Multinodular
b)toxic:
➢Grave’s disease
➢Multinodular
➢Toxic solitary nodule
c) thyroiditis:
➢Acute bacterial
➢Granulomatous
➢autoimmune{(Hashimoto’s )
➢Riedel’s
➢Chronic from TB or Syphilis
e) rare: amyloid goiter
Thyroid carcinoma:
➢Papillary CA
➢Follicular CA
➢Anaplastic CA
➢Medullary CA
Thyroglossal cyst
Thyroglossal fistula
Hyperparathyroidism (1° / 2° / 3°)
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19. Investigations:
➢Hemogram
➢Blood sugar(FBS/PPBS/HbA1C)
➢TFT (T3, T4, TSH)
➢LFT
➢RFT
➢Xray Chest( AP view & lateral view)
➢USG Thyroid
i.Size, number, position
ii.Solid/ cystic swelling
iii.Cervical lymph nodes
➢Flexible laryngoscopy
➢FNAC
➢I-131 Scan
➢Frozen section biopsy
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Radio-active iodine uptake test

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22. Management:
➢Hypothyroidism:
➢Thyroid hormone supplements (levothyroxine)
➢Hyperthyroidism-
➢Antithyroid medications(methimazole, propylthiouracil)
➢Radio-active iodine therapy
➢Surgery(thyroidectomy)
➢Thyroid nodules and CA:
➢Evaluation with USG & FNAC
➢Thyroidectomy [partial/ subtotal/total (with or without lymph node resection)]
➢Radio-active iodine therapy
➢Monitoring & follow up
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23. References :
1.A manual on clinical surgery . Thirteenth edition. S.Das.
2.Clinical surgical case manual .First edition. Kanchana
Sundaramurthy.
3.Bailey & Love’s Short practice of surgery. 28 th edition. Volume two
4.Examination of Thyroid swelling.Cassette-Clinics. Dr Ghanashyam
Vaidya https://youtu.be/RKgIj-Lczm8?si=bVIhG7SIFSvfKP4q
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