thyroid lump examination

Start by patient profile

Position : the patient is sitting & slightly hyper extending his neck
( if the patient were fatty then ask him to push his hands from behind against
his head ; pizillo's method )

Inspection :

1. size &shape of the lump
2. site : according to : 1- sternoclidiomastoid muscle / triangles
2- to midline: on one side both sides or in midline
3- suprasternal notch : if there is extension
3. surface : 1- smooth (nodular) >> multinodular goiter , simple
hyperplasic goiter
2-bosselated >> colloid goiter
4. skin over it : 1- redness , edema , tenderness >> inflammation
2- Scar >> previous thyroid surgery
3- Sinuses >> thyroglossal fistula with mucous discharge
4- Dilated veins >> the mass is obstructing thoracic inlet
5. pulsatility : inspect for seconds to check if its pulsatile & use your
hand at palpation
6. movement with swallowing ( deglutination ) : ask the patient to
swallow , movement indicate that lump is attached to pretracheal
fascia which is attached to thyroid cartilage
swellings that moves while swallowing :
1- thyroid & thyroglossal cyst
2- pretrachal lymph node
3- subhyoid bursa
4- extrinsic ca of larynx
if not moved and in anterior triangle :
1- lipoma
2- carotid body tumor
3- bracial cyst
4- lymph gland

7. movement with tongue protrusion : if +ve its thyroglossal cyst
ask the patient to protrude his tongue and look to the lump ; this
occurs because of cyst attachment to tongue by hyoid bone
palpation :
1. palpate for temperature & tenderness
2. palpate during swallowing & tongue protrusion : put your hand on the
midline then palpate
3. palpate thyroid gland ( normally not palpable )
4. asses borders , edges , consistency , surface
5. composition : 1- soft (cystic) : colloid goiter
2- solid : a- firm : multinodular goiter b- hard: ca thyroid
6. trachea : feel it over jugular notch if not palpable look for thyroid
cartilage deviation if else , look for retrosternal extension by palpation
during swallowing & by percussion later on
7. if the swelling involve the hole gland , one lobe or isthmus only
8. feel for thrill especially at upper lope : if +ve its primary toxic goiter
9. pinch the skin : looking for fixity of it to the swelling
10. carotid artery pulsation : against transverse process of C6 between
posterior border of thyroid and sternoclideomastoid muscle
*if the lump is on one side feel normal side pulsation then affected
side if the lump is benign it will push carotid but it still palpable , but if
its malignant it will be absent or week ( berrys +ve test )
11. lymph nodes : palpate looking for any enlargement
percussion :
over maniburum sterni : to asses lump extension . normally its resonant due
to trachea presence , but with lump extension + tracheal deviation it
becomes dull .
auscultation :
over swelling , especially over horns , for bruits which is diagnostic of primary
toxic goiter , because of increase in gland vascularity










Thyroid diseases
A- in general

By system Hyper thyroidism hypothyroidism
Metabolic -weight loss / thin
hands &face / increase
appetite
- looking hot / sweating
even in cold / likes cold
weather / dislike hot
weather
- Tiredness / weakness
/mental and physical
lethargy
-feels cold / likes hot
weather / dislikes cold
weather
- poor appetite &weight
gain
CVS -Palpitation / SOB with
exercise / extra-systoles
+AF ( irregular
irregularity ) /Tiredness
-bruies & thrills ( on
thyroid gland )
-Breathlessness
-ankle swelling

CNS & PNS -Nervousness
/irritability / insomnia /
depression / excitement
Hyper asthenia
- headaches
vertigo / hand &tounge
tremor
-Difficulty in thinking,
,speaking quickly&
clearly
-Hallucinations /
dementia & myxodema
madness ( myxodema
coma ; in sever cases )

GIT & GUS -Weight loss , incease
appetite / diarrhea
-Ammenoria or
reduction of menses in
females
-Weight gain , decrease
appetite / constipation
-Menorragia ( if
myxodema occurs
before menopause)

B- hands :
1- pulse ( tachycardia / AF / extrasystoles ; thyrotoxicoses , bradycardia
; hypothyroidism )
2- palms ( moist /sweaty; thyrotoxicoses , dry ; hypothyroidism )
3- tremor in hands and tongue ; thyrotoxicoses
4- hands thinar & hypothinar wasting ; thyrotoxicoses
C- eye
a- hypothyroidism : 1- eyes are normal
2- eye lids become swollen and heavy
3- hair of 1/3 out brow full down



b- Hyperthyroidism :
1- Lid retraction & led lag
2- Exophthalmia / difficulty in convergence / abscent forhead
wrinkling ( when looking upward )
3- Opthalmoplagia he cant look outward & upward ( superior rectus
&inferior oblique muscles are mostly involved )
4- chemoses

D- OTHERS :
1- Peritibial myxodema (red blochy raised skin over the shin ) in
hyperthyroidism
2- Wasted muscles & tip finger enlarged hyperthyroidism
3- Delayed deep tendon reflexes & horsiness of voice hypothyroidism
Important notes:
Borders of thyroid lumps : sternoclidiomastoid muscle >> lateral border
supraternal notch >> inferior border
location : according to lobe ( RT , LF , isthmus )
is the rest of the gland is palpaple or not
is it single or multiple
the isthmus is the only part which is normally palpable and it covers the 2
nd
,
3
rd
,4
th
tracheal rings
consistency :
1- cystic , soft ,smooth : ear lobule
2- rubbery : cheeks
3- hard , firm : nose
4- bony hard : frontal bone
old say : solid lumps are cystic __ cystic feels solid >>> in thyroid lumps
about thyroglossal cyst :
1- site : midline chin and 2
nd
tracheal ring either suprahyoid , subhyoid or
pretrachial
2- firm hard & maybe transilluminent .
3- if infected : red , tender and hot / if not : normal overlying skin


thyroid diseases notes :
in 1ry thyrotoxicoses CNS & eye signs are more important than CVS signs
although tachycardia is present .
in 2ry thyrotoxicoses CVS is the more prominent one .



lymph nodes to be examined are ( IF YOU FIND ENLARGMENT COMMENT ON
SITE, SIZE , CONSESTANCY , MOTILITY , TEMPRETURE & TENDERNESS ) :
A - head
1- occipital = base of skull
2- post auricular = over mastoid process
3- pre auricular = front of ear
4- parotid & tonsils = angle of mandible
5- submandibular = half way between angle & tip of mandible
6- submental
B- neck
1- superficial cervical = at SCM muscle
2- posterior cervical = anterior border of trapezius muscle
3- deep cervical = deep to SMC muscle
4- supraclavicular

- in tremor
a- hand : we extend elbow , wrist & separate fingers ; fine &fast tremor appears
by nicked eyes or paper on paitents hand
b- tongue : protrude for 30 seconds
eye signs of thyrotoxicoses " all of them may be unilateral or bilateral " :
1- eye led retraction " stare : by inspection , upper margin of cornea is not covered
by the eye led ( so the white upper sclera is exposed ) upper lid is higher than
normal ; occers due to over activity of the involuntary muscle part of lavetar
palpeprae superioris muscle
2- extra ocular muscle weakness , " opthalmoplagia " : presented as double vision ,
during H of eye muscles
3- lid lag , " von-graefe's sign " : immobility or lagging " dont keep pace with eyeball
movement " of upper eyelid on downward rotation movement of the eye , if
unilateral its called " pseudo-vongraefes"
4- exopthalmous " proptosis " : it is bulging of the eye anteriorly ( bulging out of the
orbit ) , seen by looking at the eyes from above , while being behind of the patient "
naffziger's sign
5- chemosis : edema of the conjunctiva , it appears at redness of the eyes & you may
find ulcers

diagnosis of neck swellings :
A- multiple lumps : lymph nodes



B- single lumps :
1- anterior triangle and moves with swallowing :
# solid :
a- thyroid gland
b- thyroid isthmus lymph node
# cystic :
Thyroglossal cyst " moves with tongue protruding "
2- anterior triangle without swallowing movement
#solid :
a- a lymph gland
b- carotid body tumor
# cystic :
a- cold abscess
b- brachial cyst
3- posterior triangle without swallowing movement :
#solid
A lymph gland
# cystic :
a- cystic hygroma
b- pharyngeal pouch
c- secondary deposit of papillary thyroid carcinoma
# pulsatile :
Subclavian aneurysm



Sings of retrosternal extension :
1- inspect upper chest for dilated veins , it become congested by thoracic inlet
occlusion by a mass
2- palpate trachea & suprasternal notch during swallowing
3- percussion of maniburuim sterni ; if dull its positive for extension

Look for horner's syndrome :
1- ptosis
2- construction pupil
3- exopthalmous
4- abscent alio-spinal reflex
5- anhydrosis " loss of sweeting on the affected side of the body "
Which occurs with : 1- retrosternal goiter
2- malignant goiter affecting " cervical sympathetic nerves "

Sings of metastasis :
1- lymph nodes movement " cervical LN "
2- hard nodule in the skull
3- long bone metastasis
4- nodular liver & ascites
5- chest effusion & consolidation

Investigations :
1- radioactive iodine 131
2- SERUM T3 , T4 , TSH
3- FNA /US / laryngoscope