23 Mar 2016
This article is titled “History and examination of the thyroid gland”. It has a definite focus towards a patient with a thyromegaly, but it can also be considered a guide to the history and presentation of a patient with a swelling in the neck.
- Adjacent structures: trachea, esophagus, recurrent laryngeal nerves
- Hyperthyroidism and hypothyroidism
- Family history
- Dietary history
- Body habit
- Alertness and motor activity
- Vital signs
- Four special features of neck swellings
- Three special features of neck swellings
- Percuss the swelling for one special feature of a neck swelling
- Auscult the swelling, as any other mass. Look for a bruit. Toxic thyroids may produce bruits. Carotid body tumors of the neck (which are, of course, not related to thyroids) also produce bruits.
- Cervical lymph nodes
- Neurological examination
- Examination of the rest of the body
Simple goiter; girls approaching puberty and pregnancy; multinodular, solitary nodular goiters and colloidal goiters; women in their 20s and 30s; Papillary carcinoma; young girls; follicular carcinoma; middle aged women; Anaplastic carcinoma; old age; Hashimoto’s disease; middle aged women
Majority of thyroid disorders are seen in women. Thyrotoxicosis is much commoner in females than in males; Thyroid carcinomas occur three times more often in females
Thyrotoxicosis may appear in individuals working under stress & strain
Endemic goiter due to iodine deficiency. Certain areas known to have low iodine content in the water and food
How to take a history of swelling is described in the presentation titled “Mass, history and examination”. The same questions should be asked, including onset, duration, rate of growth, and appearance of symptoms such as pain. Does it cause symptoms that relate to pressure effects on nearby structures? A swelling that appears after trauma may be a hematoma, not a thyroid swelling. Benign swellings grow slowly; malignant swellings (like an anaplastic cancer of the thyroid) usually grow faster. Note that papillary cancers of the thyroid usually grow slowly. Goitres are painless, unless the patient has thyroiditis. Anaplastic carcinomas infiltrate surrounding structures and often cause pain.
Special features of neck swellings
Ask about the effect of the swelling on the
a. trachea, causing breathing difficulty and stridor.
b. esophagus, causing dysphagia.
c. recurrent laryngeal nerve, causing hoarseness.
The thyroid may also press on the carotid, but that will be evaluated during examination.
In a patient with a neck swelling that may be the thyroid gland, look for symptoms of hyperthyroidism and hypothyroidism
Hyperthyroidism: Heat intolerance, raised appetite, weight loss, sweating, palpitations, tiredness, agitation/nervousness, dyspnea; also diarrhea, menstrual changes (commonly amenorrhea), insomnia
Hypothyroidism: Weight gain, loss of appetite, constipation, cold intolerance, hoarseness of voice, decreased hearing, hair loss, dry skin, hand pain (carpal tunnel syndrome), angina pectoris, intellectual/ motor slowing (excessive sleeping), muscle cramps, (commonly menorrhagia)
Past, treatment, family, and dietary history
Ask about treatment the patient has taken, and its effects on the swelling. Drugs (some may be goitrogenic)
Some thyroid disorders have a familial predilection.
Dietary habits are important as vegetables of the brassica family (cabbage, kale, rape) are goitrogens. If there is insufficient iodine in the diet, an iodine-deficiency goiter may develop.
General physical examination
Patients with thyrotoxicosis are usually thin and underweight. Patients with hypothyroidism are usually obese and overweight. In case of carcinoma of thyroid; signs of anaemia and cachexia may be present, especially with anaplastic cancers. Patients with early papillary cancer are usually well-preserved.
Patients with thyrotoxicosis may show hyperkinetic movements. Voice changes may occur with hypothyroidism, and with thyroid cancers.
Patients who are hyperthyroid may show features such as fine tremors, onycholysis, palmar erythema, warm and sweaty palms, and clubbing. Xanthomas, cool and dry palms, and cyanosis suggest hypothyroidism.
Pulse and blood pressure: Tachycardia and other arrhythmias occur in hyperthyroidism, while bradycardia and hypotension indicate hypothyroidism.
The eye signs of hyperthyroidism include exophthalmos, chemosis, conjunctival injection, corneal ulceration, opthalmoplegia, lid-lag, lid retraction, and others. The eye signs of hypothyroidism include periorbital edema, loss of outer third of eyebrows, and xanthelasmas near the eyes.
Patients with hypothyroidism may have dry skin and hair, and yellow discoloration of the face and palms due to hypercarotenemia that results from slowing down of hepatic metabolism of carotene.
Inspect the swelling as for a mass. Note the location, size, shape, surface, edges, margins, overlying skin, pulsatility, and adjacent structures (particularly the trachea). Dilated veins may indicate compression of the superior vena cava.
Inspect the swelling for:
a. Look for movement with swallowing. You may need to ask the patient to swallow some water.
b. Thyroglossal cysts (but usually not the thyroid glands) move with protrusion of the tongue.
c. Look at the adjacent structures, especially the trachea.
d. Look for pressure on the thoracic inlet (Pemberton’s test).
Palpate from behind.
Palpate the swelling as for a mass. Note the tenderness, temperature, location, size, shape, surface, margins, edges, fixity, consistency, and thrill. Consider fluctuation and transillumination. Tenderness indicates thyrotoxicosis. A raised temperature indicates inflammation: thyrotoxicosis, or an abscess. Thrills occur in thyrotoxicosis. Be sure to check if you can get below the gland.
The “Lahey’s test” is a palpation of the thyroid from the front. Its objective is to feel the posterior part of the gland.
Inspect the swelling for:
a. Examine the trachea.
b. Perform Kocher’s test.
c. Feel the carotid (Berry’s sign).
Although most swellings do not need percussion, there are some exceptions (e.g. a suspected kidney mass). In neck swellings, one should percuss the upper sternum for a possible retrosternal extension of the goiter.
Always examine the cervical nodes.
Examination for thyroid function
Evaluate the patient for hyperthyroidism. The commonest features of hormonal dysfunction are in the eyes, which have already been examined during general physical examination. Other general features of hyperthyroidism include pretibial myxedema.
Evaluate the patient for hypothyroidism .
Examination of other systems
Patients with hyperthyroidism may have neurological changes such as anxiety, proximal muscle weakness, and increased tendon reflexes. Patients with hypothyroidism may have changes such as mental dullness (even coma), hearing loss, and decreased tendon reflexes.
The other systems: cardiovascular, respiratory, and others should be examined for completeness.
- Talley NJ, O’Connor S. The thyroid. In: Clinical Examintion, a Systematic Guide to Physical Diagnosis. 7th edition, Australia: Elsevier; 2014, p355-61.
- Das S. A Manual on Clinical Surgery. 10 ed. Kolkata: Somen Das; 2013.