Bader Al-Mukhtar RCSI-MUB SC (2)

Thyroid gland

The thyroid gland is a butterfly-shaped gland.

It consists of 2 lateral symmetrical lobes joined together by a central isthmus
that normally covers the second and third tracheal rings.
The normal thyroid may be just visible in a thin young person below the
cricoid cartilage.
The thyroid gland is ensheathed by the pretracheal fascia and moves on
swallowing.
GOITRE is enlargement of the thyroid gland.

History
Presenting Complaint/History of presenting complaint
Questions to ask:
Lump or goiter
Compression symptoms:
o SOB
o Dysphagia
o Prominent veins
Metabolic change in:
o Activity
o Sleep
o Appetite and weight
o Bowel habit
o Menstrual cycle
o Heat intolerance
Prefer cold weather
Sweat more than others
o Cold intolerance
Prefer warm weather
Use more blankets than others
Cardiac:
o Palpitation
o SOB
o Edema (peri-orbital, ankle)

1
Bader Al-Mukhtar RCSI-MUB SC (2)

o Sweating

CNS change in:

o Behavior (Nervousness, irritability and anxiety)
o Cognition and concentration
o Mood
Skin, hair, voice:
o Skin:
dry/moist
cold/warm
o Hair loss
o Change in voice: hoarseness, slow to talk

Past Medical and Surgical History

Medications
Some drugs can cause hypothyroidism:
Carbimazole and Propylthiouracil: used to treat hyperthyroidism.
Lithium - bipolar mood disorder.
Amiodarone arrhythmias.
Social History
Occupational exposure to x-rays or radiation.
Home situation in event of thyroid emergency or increased forgetfulness.
How well the patient copes with various problems and the conditions at home
and work will have an important effect on the success of treatment.
Family History
Family history of thyroid disease, autoimmune disease or systemic connective
tissue disease.
It is important to enquire about a family history of ischemic heart disease as
hypothyroidism is associated with hypercholesterolaemia.
Review of Systems
A full system enquiry should be performed due to the multi system nature of the
symptoms of thyroid disease.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

1) Hyperthyroidism

The commonest cause in young people is graves disease, an autoimmune disorder

where circulating immunoglobulins stimulate TSH receptors on the surface of thyroid
follicular cells.

History

Table 1: Signs and Symptoms of Hyperthyroidism

Metabolic Increased appetite with weight loss,
Heat Intolerance [preference for
cooler surrounds]
Bowel habit: Diarrhoea,
Oligomenorrhea (light menstrual
bleeding or Amenorrhoea (absence of
menstruation)

Cardiovascular Palpitations (atrial fibrillation)

Tachycardia

Neuropsychiatric Increased sweating,

Nervousness, irritability and anxiety
Tremor
Insomnia (inability to sleep)
Hyperkinesis, proximal myopathy

Ocular Exophthalmos or Proptosis (abnormal

protrusion of the eyeball)
Lid retraction - thyroid stare
Lid lag ((eyelid lags behind eye's
descent as patient watches your finger
descend slowly)

Skin and hair changes Pretibial myxoedema (oedematous

swellings above lateral malleoli)
Hair loss
Warm, moist skin

1
Bader Al-Mukhtar RCSI-MUB SC (2)

2) Hypothyroidism

Primary disease of the thyroid or secondary due to pituitary/hypothalamic failure

Myxoedema implies a more severe form of hypothyroidism;
mucopolysaccsaccharides accumulate in the ground substance of tissues including the
skin.

Table 2: Signs and Symptoms of Hypothyroidism

Metabolic Tiredness (fatigue)
Lethargy, physical and mental
slowing
Cold intolerance: preference for
warmer weather
Bowel habit: Constipation
Weight gain
Menorrhagia/amenorrhoea

Cardiovascular Bradycardia or
CCF, non-pitting oedema (eg
eyelids, hands, feet)
Symptoms of anaemia: chest pain,
shortness of breath

Neuropsychiatric Poor cognition/dementia,

Myalgia
Carpal tunnel syndrome
Slowly relaxing reflexes
Peripheral neuropathy

Ocular Puffy face swelling of eyelids

[oedema]

Skin and hair changes Dry pale skin with thinning hair
Lump in neck

Others Hoarsness of voice

1
Bader Al-Mukhtar RCSI-MUB SC (2)

Examination of the Thyroid Gland

Inspection.
Palpation.
Percussion.
Auscultation.
Pembertons sign.

Inspection (SSSRP)
Symmetry. The gland is usually symmetrical.
Swelling/ Goitre and its movement with swallowing
o The presence of a goitre is best observed with the neck slightly
extended. Therefore, tip the patient's head back a bit.
o Look at the front and sides of the neck and decide whether there is
localized or general swelling of the gland.
o Movement with swallowing: Take a sip of water and hold it in your
mouth. Look at the neck. Now swallow.
Swallowing allows the shape of the gland to be seen better.
Only a goitre or a thyroglossal cyst because of attachment to
the larynx, will rise during swallowing.
Check whether the base of the gland can be seen as it rises
[implying the absence of retrosternal extension].
o Remember that 80% of people with a goitre are biochemically
euthyroid, 10% are hypothyroid and 10% are hyperthyroid.
Scars. A thyroidectomy scar forms a ring around the base of the neck in the
position of a high necklace
Redness. Rarely, redness of the skin over the gland occurs in cases of
suppurative thyroiditis.
Prominent veins. Dilated veins over the upper part of the chest wall, often
accompanied by filling of the external jugular vein. This suggests retrosternal
extension of the goitre [thoracic inlet obstruction].

Palpation
Ask the patients permission to feel the neck and then approach patient from
behind.
Slightly flex the head to relax the sternomastoids.
Place the fingers of both hands gently on the patient's neck.
With the pulps of right index and middle fingers feel for the cricoid cartilage.
Below this palpate the isthmus of the thyroid gland which lies over the
trachea.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

Then palpate, symmetrically, the 2 lobes of the thyroid gland which extend
laterally behind the sternomastoid muscle using the pulps of the fingers over
the gland

Consider the following (tenderness, size and shape, consistency, mobility):

1. Tenderness. A feature of:
Usually: thyroiditis (subacute or rarely suppurative).
Less often: bleed into a cyst or carcinoma
2. Size.
Feel particularly carefully for a lower border, because its
absence suggests retrosternal extension.
3. Shape.
Note whether the gland is uniformly enlarged or irregular and
whether the isthmus is affected.
If a nodule that feels distinct from the remaining thyroid tissue
is palpable, determine its location, size, consistency, tenderness
and mobility.
Also decide whether the whole gland feels nodular
(multinodular goitre).
4. Consistency.
Soft: normal.
Firm: simple goitre.
Rubbery hard: Hashimoto's thyroiditis.
Stony hard: carcinoma, calcification in a cyst, fibrosis, or
Riedel's thyroiditis.
5. Mobility. Carcinoma may tether the gland.
Repeat the assessment while the patient swallows. Ask the
patient to swallow again while you palpate the thyroid; ensure
the neck is slightly flexed to ease palpation.

Decide if a thrill is palpable over the gland, as occurs when the gland is
unusually metabolically active as in thyrotoxicosis.

Palpate the lymph nodes.

o Using the pads of your index and middle fingers, move the skin over
the underlying tissue in each area.
o Most importantly palpate for: submental (in the midline, behind the
mandible), submandibular (midway between the angle and the tip of
the mandible), tonsillar (at the angle of the mandible), preauricular
(in front of the ear), posterior auricular (behind the ear, superficial to
the mastoid process), occipital/suboocipital (at the base of the skull
posteriorly), superior/superficial cervical (superficial to the
sternocleidomastoid), posterior cervical (along the anterior edge of

1
Bader Al-Mukhtar RCSI-MUB SC (2)

the trapezius), deep cervical chain (deep to the sternocleidomastoid,

hard to find), supraclavicular (deep in the angle formed by the
clavicle and the sternocleidomastoid).
o Describe lymph node findings [Enlarged lymph nodes near goitre will
suggest the possibility of carcinoma of the gland particularly if they
are firm or hard].

Feel each carotid artery absence of its pulsation may very occasionally
indicate malignant infiltration by thyroid carcinoma.
Feel the trachea is it deviated? may be displaced by a retrosternal gland

Percussion
The upper part of the manubrium can be percussed from one side to the other.
A change from resonant to dull indicates a possible retrosternal goitre, but this
is not a very reliable sign.

Auscultation
Listen over each lobe for a bruit. This is a sign of increased blood supply
which may be caused by:
o Hyperthyroidism.
o Occasionally, the use of antithyroid drugs.
o A carotid bruit (louder over the carotid itself).
o A venous hum (obliterated by gentle pressure over the base of the
neck).

If there is a goitre, apply mild compression to the lateral lobes and listen again
for stridor.

Pemberton's Sign

1
Bader Al-Mukhtar RCSI-MUB SC (2)

This is a test for thoracic inlet obstruction due to a retrosternal goitre or any
retrosternal mass.
Get the patient to lift both arms as high as possible. OR simply ask the patient
to raise both arms over their head.
Wait for a few moments, then look for:
1. Facial congestion (plethora).
2. Facial cyanosis.
3. Respiratory distress.
4. Inspiratory stridor.
5. Dilated veins over the upper chest and filling of the external jugular
vein (venous congestion).

Ask the patient to take a deep breath in through the mouth and listen for
stridor.

Peripheral signs

First: Hyperthyroidism/Thyrotoxicosis
I. GENERAL INSPECTION
Weight loss.
Anxiety.
The frightened facies of thyrotoxicosis.
Agitation and irritability.

II. VITAL SIGNS

Pulse.
o Sinus tachycardia (sympathetic overdrive).
o Atrial fibrillation (due to a shortened refractory period of atrial cells
related to sympathetic drive and hormone-induced changes).
Blood pressure. Hypertension (systolic increased pulse pressure).

III. HANDS AND NAILS:

Look at the nails for:
Onycholysis (Plummer's nail). Separation of the distal nail from the nail bed.
It is said to occur particularly on the ring finger, but can occur on all the
fingernails, and is apparently due to sympathetic overactivity. It is rarely seen
in association with Graves' disease.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

Thyroid acropathy (acropathy is another term for clubbing). Specific to and

rarely seen in Graves' disease. Not seen in other causes of thyrotoxicosis.

In the palms:
Inspect for Palmar erythema (also in RA, liver disease, pregnancy, OCP).

Feel for Warmth and Sweatiness (sympathetic overactivity).

Ask the patient to put out the arms and look for:
Fine resting tremor (due to sympathetic overactivity). Ask the patient to stick
their hands out palms down and place a sheet of paper on the back of the
hands/over the fingers. This will make even the slightest tremor very obvious.

IV. ARMS
Proximal myopathy (proximal muscle weakness). Ask the patient to raise
arms over head.
Reflexes. Look for abnormal briskness (hyperreflexia), especially in the
relaxation phase.

V. EYES
Exopthalmos. Protrusion of the eyeball from the orbit. It occurs only in
Graves' disease. It is usually bilateral, but can also be unilateral (in this case
exclude tumour of the orbit, and cavernous sinus thrombosis). It is
characterized by an inflammatory infiltrate of the orbital contents, but not of
the globe itself.
o This may be very obvious, but if not, look carefully at the sclerae,
which in exophthalmos are not covered by the lower eyelid.
o Next look from behind over the patient's forehead (i.e. from above)
for exophthalmos, where the eye will be visible anterior to the superior
orbital margin.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

o Now examine for the complications of proptosis, which include:

1. Chemosis (oedema of the conjunctiva and injection of the
sclera, particularly over the insertion of the lateral rectus).
2. Ophthalmoplegia (paralysis of eye muscles, the inferior rectus
muscle power tends to be lost first, and later convergence is
weakened).
3. Conjunctivitis.
4. Corneal ulceration (due to inability to close the eyelids).
5. Optic atrophy (rare and possibly due to optic nerve
stretching).
Thyroid opthalmopathy. Related to sympathetic overactivity and are not
specific for Graves' disease.
1. Look for the thyroid stare (a frightened expression).
2. Look for lid retraction (where there is sclera visible above the iris).
3. Test for lid lag (von Graefe's sign) by asking the patient to follow your
finger as it descends at a moderate rate from the upper to the lower part
of the visual field. Descent of the upper lid lags behind descent of the
eyeball.

Thyroid stare, Lid retraction and Exopthalmos.

VI. NECK
Examination of the thyroid gland. Examine for thyroid enlargement/goitre, which
is usually detectable (60-90% of patients).
In Graves' disease the gland is classically diffusely enlarged and is smooth and
firm. An associated thrill may be present. Absence of thyroid enlargement
makes Graves' disease unlikely, but does not exclude it.
Possible thyroid abnormalities in patients who are thyrotoxic but do not have
Graves' disease include a toxic multinodular goitre, a solitary nodule (toxic
adenoma), or subacute thyroiditis (de Quervain's thyroiditis). In de Quervain's
thyroiditis there is typically a moderately enlarged firm and tender gland.

VII. CHEST
Gynaecomastia occurs occasionally.
Examine the heart for systolic flow murmurs (due to increased cardiac
output).
Examine for signs of congestive cardiac failure, which may be precipitated
by thyrotoxicosis in older people.

VIII. LEGS
Pretibial myxoedema. Despite the name, this occurs only in Graves' disease
(Graves' disease dermopathy) and not in hypothyroidism.
o This takes the form of bilateral firm, elevated dermal nodules and
plaques, which can be pink, brown or skin-coloured.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

o They are caused by mucopolysaccharide accumulation.

Proximal myopathy. Ask the patient to squat.

Brisk/fast reflexes (hyperreflexia).
Second: Hypothyroidism/Myxoedema
Hypothyroidism (deficiency of thyroid hormone) is due to:
Primary disease of the thyroid.
Less commonly, secondary to pituitary or hypothalamic failure.

I. GENERAL INSPECTION
Obvious mental and physical sluggishness (the patient is out of the spot, falls
asleep).
General CNS slowing is common with stupor or coma in severe cases.
Hypothyroid speech is a feature in about a third of patients. This is
characteristically slow, nasal and deep in pitch.
Weight gain.

II. VITAL SIGNS

Pulse.
o Small volume.
o Slow (bradycardia).
Blood pressure. Hypotension.

III. HANDS
Peripheral cyanosis (due to reduced cardiac output).
Skin. Swollen, and may appear cool and dry.
Yellow discoloration of hypercarotenaemia (there is slowing down of hepatic
metabolism of carotene) may be seen on the palms.
Palmar crease pallor anaemia may be due to:
o Chronic disease.
o Folate deficiency secondary to bacterial overgrowth.
o Vitamin B12 deficiency due to associated pernicious anaemia
(autoimmune disease).
o Iron deficiency due to menorrhagia.
Test for sensory loss, as the carpal tunnel is thickened in myxoedema.
Tinels sign tap over flexor retinaculum, this may cause paraesthesia in the
distribution of the median nerve.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

IV. ARMS
Proximal myopathy (proximal muscle weakness) rare. Ask the patient to
raise arms over head.
Reflexes. Slow to relax 'hung-up', especially the biceps.

V. FACE
Skin and Hair.
o Yellow discoloration of the skin, but not sclera, may be present due to
hypercarotenaemia.
o May be generally thickened.
o Alopecia (hair loss) may be present.
o Vitiligo may be present (an associated autoimmune disease).

o Palpate for coolness and dryness of the skin and hair. There may be
thinning of the scalp hair.
Eyes.
o Periorbital oedema.
o Loss or thinning of the outer third of the eyebrows can occur in
myxoedema (but is also common in healthy persons).
o Xanthelasma (due to associated hypercholesterolaemia).
Mouth.
o Tounge swelling.
o Ask the patient to speak and listen for coarse, croaking, slow speech.
Ears. Bilateral nerve deafness may occur with endemic or congenital
hypothyroidism.

VI. NECK
Look for surgical scars (often concealed by wrinkles).
Examination of the thyroid gland, goitre. A primary decrease in thyroid
hormone results in a compensatory oversecretion of TSH. A goitre will result
if there is viable thyroid tissue. Many cases of hypothyroidism are not
associated with an enlarged gland as there is little thyroid tissue.
Check for an elevated JVP. Right heart failure can be associated with
hypothyroidism specifically in relation to pericardial effusion.

VII. CHEST
Examine:
The heart for a pericardial effusion.

1
Bader Al-Mukhtar RCSI-MUB SC (2)

The lungs for pleural effusions.

VIII. LEGS
Peripheral oedema (non-pitting). Sign of right heart failure.
Reflexes. Ask the patient to kneel on a chair with the ankles exposed. Tap the
Achilles tendon with a reflex hammer. There is normal contraction followed
by delayed relaxation of the foot (the 'hung-up' slow to relax reflex).
Proximal myopathy. Ask the patient to squat.
Peripheral neuropathy.
Cracked heels.