EVALUATION OF THYROID

GLANDFahad zakwan

MD52014

HISTORY1. AGE:• It is a very important consideration.• Simple goiter is commonly seen in girls approaching

puberty.• In endemic areas deficient iodide is the cause of simple

goiter.• Both multinodular and solitary nodular goiters as well as

colloid goiters are found in women of 20s and 30s.• Papillary carcinoma is seen in young girls and follicular

carcinoma in middle aged women.• Anaplastic carcinoma is mainstay a disease of old age.

2. SEX:•Majority of thyroid disorders are seen in females•All types of simple goiters are far more common in females than in males.•Thyrotoxicosis is 8X more common in females than in males.•Even thyroid carcinomas are more often seen in females in the ratio 3 : 1

3. OCCUPATION:•Though occupation has hardly any relation with thyroid disorders, yet thyrotoxicosis may appear in individuals working under stress and strain.•The patients with primary toxic goiter may be psychic.

4. RESIDENCE:•Expect endemic goiter due to iodine deficiency•No other thyroid goiter has any peculiar geographical distribution•Certain areas are particularly known to have low iodine content in water and food. Residence of these areas often suffer from iodine deficiency endemic goiter. These areas are near rocky mountains.

5. SWELLING:• In case of thyroid swelling history about onset, duration,

rate of growth and whether associated with pain should be noted.• In case of any thyroid swelling it should be asked how

the patient sleep at night.• Does she spend sleepless night??

• In primary thyrotoxicosis patients often complain of sleepless night.• Whether the patient is very worried, stressed or strained are

also feature of thyrotoxicosis.

• Palpitations, ectopic beats and even CCF may be noted in cases of secondary thyrotoxicosis.

• In secondary thyrotoxicosis the brunt of the attack fall more on cardiovascular system, whereas the primary thyrotoxicosis the brunt of the attack fall more on nervous system.• Sudden increase in size with pain in a goiter indicates

haemorrhage inside.• The rate of growth of swelling is quite important.

• While simple goiter grows very slowly or may remain the same size for quite some time, multinodular, solitary nodular or colloid goiters increase in size though extremely slowly for year.

• A special feature of papillary and follicular carcinoma of the thyroid is their slow growth.• They may exist as a lump in the neck for many years before metastasing

• Anaplastic carcinoma however is a fast growing swelling

6. PAIN•Goiter is usually painless condition.• Inflammatory conditions of the thyroid gland are painful.•Malignant diseases of the thyroid gland are painless to start with, but become painful in late stages.• In Hashimoto’s disease there is discomfort in the neck.• Anaplastic carcinoma is more known to infiltrate the surrounding structures and nerves to cause pain.

7. PRESSURE EFFECTS:

•Enlarged thyroid may press on the •trachea to cause dyspnoea•Esophagus to cause dysphagia•Recurrent laryngeal nerve to cause hoarseness of voice

8. SYMPTOMS OF PRIMARY THYROTOXICOSIS• It is very important to understand the symptoms

primary thyrotoxicosis as often on these cases there is not much enlargement of the thyroid gland and only these symptoms will indicate the presence of this disease.• Loss of weight (the most significant symptom)• Preference to cold, intolerance to heat and excessive sweating

are the next symptoms.• Nervous excitability, irritability, insomnia, tremor of hands and

weakness of muscles are the symptoms of involvement of CNS which are the main features of primary thyrotoxicosis.• Cardiovascular symptoms are not so pronounced as seen in

secondary thyrotoxicosis, but even then palpitation, tachycardia and dyspnoea on exertion are symptoms of this disease.

• Exophthalmos is often associated with this condition.• The patient may complain of staring or protruding

eyes and difficulty in closing her eye lids.• Double vision (diplopia) may be caused by muscle

weakness (Ophthalmoplegia)• Edema or swelling of the conjunctiva (chemosis) is

seen in very late cases of exophthalmos.• Ultimately the patient may get pain in the eye if the

cornea ulcerates

• Some women may have change in menstruation, usually amenorrhea.

9.SYMPTOMS OF SECONDARY THYROTOXICOSIS:

• When a long standing solitary nodular, multinodular or colloid goiters shows manifestations of thyrotoxicosis, the condition is called secondary thyrotoxicosis.• As explained above the brunt of the attack falls more on

the cardiovascular system than on the nervous system.• Palpitations, ectopic beats, cardiac arrhythmias,

dyspnoea on exertion and chest pain are the usual symptoms.• Even CCF may appear at late stage with swelling of

ankles.• Nervous symptoms and eye symptoms may be mild or

absent.

10.SYMPTOMS OF MYXOEDEMA (HYPOTHYROIDSM)

• Increase in weight is often complained inspite of poor appetite.• Fat accumulates particularly at the back of the neck and shoulders.• Intolerance of cold weather and preference of warm climate is

noticed.• There is minimal swelling of the thyroid.• The skin may be dry• There may be puffiness of the face with pouting lips and dull

expression.• Loss of hair is a characteristic feature and 2/3rd of he

eyebrows ,may fall off.• Muscle fatigue and lethargy are important symptoms with failing

memory and mild hoarseness due to edema of vocal cords.• Constipation and oligomenorrhea are sometimes complained of.

11.PAST HISORY:•Enquiries must be made about the course of treatment the patient had and its effect on the swelling.•The patient should also be asked if she was taking any drugs e.g. sulphoniuria or any Antithyroid drugs as these are goitrogenic.

12.PERSONAL HISTORY:•Dietary habit is important as vegetables of the brassica family (cabbage, kale and rape) are goitrogens.•Persons who are in the habit of taking a kind of sea fish which has particularly low iodine content, may present with goiter.

13.FAMILY AND SOCIAL HISTORY:• It is often seen that goiters occur in more than one member in a family while endemic goiters may affect more members in the same family.• Similarly enzyme deficiencies within the thyroid gland which are concerned in the synthesis of thyroid hormones are also seen to run in families.• Primary thyrotoxicosis has been seen in more than one member of the same family.• Thyroid cancers are seen to involve more than one member of the same family

PHYSICAL EXAMINATION

GENERAL SURVEY:

1. BUILD AND STATE OF NUTRITION:

• In thyrotoxicosis the patient is usually thin and underweight. The patient sweats a lot with wasting of muscles.• In hypothyroidism the patient is

obese and overweight.• In case of carcinoma of the thyroid,

the patient will have signs on anaemia and cachexia.

2. FACE:• In thyrotoxicosis one can see the facial expression of excitement, tension, nervousness or agitation with or without variable degree of exophthalmos.• In hypothyroidism one can see puffy face without any expression

3.MENTAL STATE AND INTELLIGENCE:•Hypothyroid patients are naturally dull with low intelligence

4. SKIN:•The skin is moist particularly the hands of primary thyrotoxicosis.•Hot and moist palm is a feature of primary thyrotoxicosis.•In myxedema the skin is dry, cool, pale and inelastic.

5.OTHER FINDINGS•Not only the PR becomes rapid, but it becomes irregular in thyrotoxicosis.• Irregularity is more of a feature of secondary

thyrotoxicosis.

• Particularly sleeping pulse rate is a very useful index to determine the degree of thyrotoxicosis.• In case of mild thyrotoxicosis it should be below 90• In case of moderate or severe thyrotoxicosis it should

be 90 – 110 and above 110 respectively.

• In hypothyroidism pulse becomes slow.

GENERAL EXAMINATION• In general examination one should look for:I. Primary toxic manifestations in case of

goiters affecting the young.II. Secondary toxic manifestation in nodular

goiterIII.Metastasis in case of malignant thyroid

disease.

I. Primary toxic manifestations:

•One should look for 5 cardinal signs:

a. Eye signsb. Tachycardia or increase PR

without rise in temperature.c. Tremor of the handsd. Moist skine. Thyroid bruit 4 cardinal signs of primary toxic

goiter shown by numbers: (1) exophthalmos (2) thyroid swelling with/without thrill (3) tachycardia

(4) tremor

a.Eye signs•There are 4 important changes that may occur in the eyes in thyrotoxicosis.•Lid retraction•Exophthalmos•Ophthalmoplegia•Chemosis

•Each one may be unilateral or bilateral

Lid retraction•This is a condition where the upper eye lid is higher than normal and the lower lid is in normal position.•This sign is caused by over activity of the involuntary (smooth muscle) part of levator palpebrae superioris muscle.

Exophthalmos•When eye ball is pushed forward due to increase in fats or edema or cellular infiltration in the retro orbital space, the eyelids are retracted and sclera becomes visible below the lower edge of the iris first, followed by above the upper edge of the iris.• The following are test or signs of exophthalmos.• Von Graefe’s sign• Joffroy’s sign• Stellwag’s sign• Moebius’ sign• Dalrympte’s sign

Von Graefe’s sign• The upper eye lid lags behind the eyeball as the patient is asked to look downwards.

Joffroy’s sign• Absence of wrinkling on the fore head when the patient looks upwards with the face inclined downwards

Stellwag’s sign• This is staring look and infrequent

blinking of the eyes with widening of palpebral fissure• This is due to toxic contraction of

striated fibers of levator palpebrae superiosis.

Moebius’ sign• This means inability or failure to

converge the eye ballsDalrympte’s sign• This means the upper sclera is

visible due to retraction of upper eye lid

Ophthalmoplegia• There may be weakness of the ocular muscles due to oedema and cellular infiltration of these muscles.•Most often the superior and lateral rectus and inferior oblique muscles are affected.• Paralysis of these muscles prevents the patient from looking upwards and outwards.

Chemosis•This is oedema of the conjuctiva.•The conjuctiva becomes oedematous, thickened and crinkled.•Chemosis is caused by obstruction of venous and lymphatic drainage of the conjuctiva by the increased retro-orbital pressure

b.tachycardia•Tachycardia or increase PR without rise in temperature is constantly present in primary toxic goiter.•Sleeping pulse rate is more confirmatory in thyrotoxicosis.•Regularity of the pulse may be disrupted and a rapid irregular pulse should arise suspicion of auricular fibrillation.

c.Tremor • Tremor of the hands (a fine tremor) is almost always present in a primary thyrotoxic case.• Ask the patient to straight out the arms in front and spread the fingers.• Fine tremors will be exhibited at the fingers

• The patient is also asked to put out the tongue straight and to keep it in this position for at least ½ a minute.• Fibrillary twitching will be observed

• In severe cases the tongue and fingers may tremble

d.Moist skin•Moist skin particularly of the hand and feet are quite common in primary thyrotoxic cases.• It should be a routine practice to feel the hands just after feeling the pulse at the wrist.•The palms are hot and moist and the patients can not tolerate hot weather, on the contrary tolerance to cold is increased.

e.Thyroid bruit•Thyroid bruit is quite characteristic in Graves disease (primary thyrotoxic goiter).•This is due to increased vascularity of the gland.•But this sign is relatively late sign and mostly heard over the lateral lobes near their superior poles.

II. Secondary thyrotoxicosis

• May complicate multinodular goiter or adenoma of the thyroid• The cardiovascular system is mainly affected.• Auricular fibrillation is quite common• The heart may be enlarged• Signs of cardiac failure such as oedema of the ankles,

orthopnea, dyspnoea while walking up the stairs may be observed.• Exophthalmos and tremor are usually absent• Patients in this group are generally elderly

iii.Search for metastasis• When the thyroid swelling appears to be stony hard,

irregular and fixed, a careful search should be made to know about the spread of the disease.• Besides examining the cervical lymph nodes, one

should also look for distant metastases which is quite common in thyroid carcinoma particularly the follicular type.• The skull, spine, ends of long bone and pelvis should be

examined for metastatis• Lastly metastatis in the lungs, which is not uncommon

should also be excluded.

LOCAL EXAMINATION

•Examination of the thyroid swelling should begin with the general principles of examination of any swelling.•Here only those peculiar to the thyroid gland will be discussed.

Inspection:• Normal thyroid gland is not obvious on

inspection.• It can be seen only when the gland is

swollen.• In case of obese and short necked

individuals inspection of the thyroid gland becomes difficult.• To render inspection easier one can

follow Pizzilo’s method in which the hands are placed behind the head and the patient is asked to push his/ her head backwards against her clasped hands on the occipitus.

• Ask the patient to swallow and watch for the most important physical sign – a thyroid gland moves up during deglutition.• This is due to the fact that thyroid gland is fixed to the larynx.• Such movement of the thyroid becomes greatly limited when it is fixed by an inflammation or malignant infiltration.

• In retrosternal goiter, 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.• When these are present ask the patient to

swallow and determine, on inspection, the lower border of the swelling as it moves up on deglutition.• This is not possible in case of retrosternal

goiter.• The patient should be asked to raise both

arms over his head until they touch the ears.• This position is maintained for a while.• Congestion of face and distress becomes

evident in the case of retrosternal goiter due to obstruction of the great veins at the thoracic inlet.

Palpation:• The thyroid gland should always be

palpated with the patients neck slightly flexed.• The gland may be palpated from

behind and from the front.• The patient should be seated on a

stool and the clinician stands behind the patient.• The patient is asked to flex the neck

slightly.• The thumbs of both hands are placed

behind the neck and the other four fingers on each hand are placed on each lobe and the isthmus.

• Palpation of each lobe is best carried out by Lahey’s method.• In this case the examiner stands in front of the patient .• To palpate the left lobe properly the thyroid gland is pushed to

the left from the right side by the left hand of the examiner.• This makes the left lobe more prominent so that the examiner

can palpate it thoroughly with his right hand.

•During palpation the patient should be asked to swallow in order to settle the diagnosis of thyroid swelling.• Slight enlargement of the thyroid gland or presence of

nodules in its substance can be appreciated by simply placing the thumb on the thyroid gland while he patient swallows (Crille’s method)

•During palpation the following points should be noted:

i. Whether the whole thyroid gland is enlarged?• if so note its surface - whether it is smooth (primary

thyrotoxicosis or colloid goiter) or bosselated (multinodular goiter) and its consistency whether uniform or variable.• It may be firm in primary thyrotoxicosis , Hashimoto’s

disease etc.• It is slightly softer in colloid goiter• Hard in Riedel’s thyroiditis or carcinoma in which the

consistencies may be variable in places.

ii. When a swelling is localized• Note its position, size, shape and its consistency

iii. The mobility should be noted in both horizontal and vertical planes.• Fixation means malignant tumor or chronic thyroiditis

iv. To get below the thyroid gland is an important test to discard the possibility of retrosternal extension.• Clinicians index finger is placed on the lower border

of the thyroid gland.• The patient is asked to swallow• The thyroid gland will move up and the lower border

is palpated carefully for any extension downwards.

v. Pressure effect from the thyroid swelling should be carefully looked for.• Pressure may be on the trachea or larynx, esophagus and recurrent laryngeal nerve.• If pressure on trachea is suspected slight push on the lateral lobe will produce stridor (Kocher’s test).• Gentle compression on the lateral lobe may

produce stridor• This is due to narrowed trachea• This test is particularly positive in multinodular

goiters and carcinoma infiltrating into trachea narrowing it.

• The position of the larynx and trachea should also be noted.• This may be accessed by placing stethoscope on the suspected

zone• Passage of air will indicate the position of the trachea.• Simple palpation by an experienced hand will also indicate the

position of the trachea.

• A malignant thyroid may engulf the carotid sheath completely and the pulsations of the artery can not be felt.• Sympathetic trunk may also be affected by a thyroid

swelling.• This will lead to Horner’s syndrome

• Slight sinking of the eye balls into the orbit (enophthalmos)• Slight drooping of the upper lid (pseudoptosis)• Contraction of the pupil (miosis)• Absence of sweating on the affected side of the face (anhidrosis)

•Obstruction of the major veins in the thorax causes engorgement of the neck veins.• This sign becomes obvious when the patients are

asked to raise the hands above the head and the arms touch the ears.• This is known as Pemberton’s sign

vi. Whether there is any toxic manifestation or not.• Primary toxic thyroid is generally not enlarged • An enlarged thyroid or nodular thyroid with toxic

manifestation is generally a case of secondary thyrotoxicosis.

vii.Palpation of cervical lymph nodes.• This is extremely important particularly in malignancy

of thyroid.• Occasionally only cervical lymph nodes may be

palpable, while the thyroid gland remains impalpable.• Papillary carcinoma of the thyroid is notorious for

early lymphatic metastasis while the primary tumor remains quite small.

Percussion:•This is employed over the manubrium sterni to exclude the presence of a retrosternal goiter.•This is more of a theoretical importance rather than practical

Auscultation: • In primary toxic goiter a systolic bruit may be heard over the goiter due to increased vascularity.

Thank you!!