Examination of thyroid

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Examination of the Thyroid Gland

The thyroid examination follows a systematic approach: inspection - palpation - percussion (if needed) - auscultation, combined with a thorough history.

1. Positioning and Preparation

Patient seated or standing, neck in a neutral or slightly extended position
Good lighting, expose the lower anterior neck from the cricoid cartilage to the suprasternal notch
Have a glass of water available for swallowing maneuvers

2. Inspection

Inspect the lower anterior neck (between cricoid cartilage and suprasternal notch) for:

Visible goiter - diffuse or nodular enlargement
Asymmetry between right and left lobes
Surface characteristics - smooth vs. irregular
Skin changes over the swelling
Deviation of the trachea (from a large goiter)
Dilated neck veins (suggesting compressive/substernal involvement)
Movement on swallowing - ask the patient to swallow: thyroid tissue (and thyroglossal duct cysts) move upward with swallowing, whereas non-thyroid masses generally do not

Associated general inspection findings to look for:

Feature	Suggests
Exophthalmos / proptosis	Graves' disease (thyroid eye disease)
Pretibial myxedema	Graves' disease
Periorbital puffiness, dry skin, coarse hair	Hypothyroidism
Fine tremor, warm moist skin	Hyperthyroidism
Onycholysis	Hyperthyroidism (Graves')

3. Palpation

Technique

The thyroid is palpated using the fingertips, with the examiner positioned either in front of or behind the patient.

Anterior approach:

Use all four fingers of the right hand to palpate the right thyroid lobe
Use fingers of the left hand to palpate the left lobe
Gently displace the trachea laterally toward the lobe being examined while palpating

Posterior approach (common in clinical practice):

Stand behind the patient
Place both thumbs on the nape of the neck
Use both index and middle fingers to palpate the gland on either side of the trachea below the cricoid

During palpation, ask the patient to swallow - this confirms that the structure being felt is the thyroid gland (moves upward with the larynx).

What to assess

Parameter	Normal	Abnormal
Size	10-20 g; each lobe ~4 cm tall × 2 cm wide	Goiter if enlarged
Symmetry	Symmetric right and left lobes	Asymmetric = dominant lobe or nodule
Texture	Soft	Rubbery/firm = Hashimoto's; hard/stony = malignancy
Tenderness	Non-tender	Tender = thyroiditis (subacute), hemorrhage into cyst
Mobility	Moves freely with swallowing	Fixed = invasive carcinoma
Surface	Smooth	Nodular = MNG or adenoma
Nodules	None	Size, number, consistency, tenderness, mobility

Substernal Extension - Pemberton's Maneuver

Ask the patient to raise both arms with forearms pressed against the sides of the face
A positive Pemberton's sign = rapid development of facial plethora and distension of neck veins, indicating narrowing of the thoracic inlet from substernal goiter shifting upward
Also: palpate the sternal notch - inability to feel the inferior thyroid border suggests substernal extension

4. Auscultation

Place the bell of the stethoscope over the thyroid gland
A thyroid bruit (systolic or continuous) indicates markedly increased vascularity - classic in Graves' disease
A loud venous hum may also be heard in the supraclavicular space in Graves'
A bruit distinguishes Graves' disease from other causes of hyperthyroidism (e.g., toxic MNG, where no bruit is present)

5. Regional Lymph Node Assessment

Carefully palpate all cervical lymph node groups (levels I-VII). Lymphadenopathy adjacent to the thyroid raises suspicion for malignancy. Key levels to check:

Level VI (central compartment: pretracheal, paratracheal nodes) - most commonly involved in thyroid cancer
Level III and IV (jugular chain)
Level V (posterior triangle)

Palpable cervical nodes may also occur in Hashimoto's thyroiditis and Graves' disease (benign).

6. Assessment of Vocal Cord Function

Listen to the patient's voice quality - hoarseness suggests recurrent laryngeal nerve (RLN) involvement (malignancy, large goiter)
Note: unilateral RLN palsy can be present without obvious voice change - formal laryngoscopy may be needed

7. Tracheal Examination

Assess for tracheal deviation by palpating the trachea in the suprasternal notch
Large goiters or substernal extension can cause deviation or compression

8. Key Clinical Signs by Diagnosis

Condition	Key Examination Findings
Graves' disease	Diffuse, soft, symmetric goiter; bruit; exophthalmos; pretibial myxedema; thyroid acropachy; tremor; tachycardia
Hashimoto's thyroiditis	Firm, rubbery, non-tender gland; sometimes tender in early phase; may be small or large
Toxic multinodular goiter	Irregular, nodular gland; no bruit; no eye signs
Simple/Colloid goiter	Soft, diffusely enlarged, non-tender, euthyroid
Thyroid carcinoma	Hard, irregular, fixed nodule; palpable lymph nodes; hoarseness
Subacute (de Quervain's) thyroiditis	Tender, firm gland; may follow a viral illness
Substernal goiter	Positive Pemberton's sign; goiter extending below clavicle

9. Associated Systemic Signs to Complete the Examination

Pulse rate and rhythm (tachycardia/AF in hyperthyroidism; bradycardia in hypothyroidism)
Blood pressure (wide pulse pressure in hyperthyroidism)
Reflexes (brisk = hyperthyroidism; slow, delayed relaxation = hypothyroidism)
Skin and hair (warm moist = hyper; dry coarse = hypo)
Eyes: lid lag, lid retraction, chemosis, proptosis measurement (Hertel's exophthalmometer)
Hands: tremor, acropachy, onycholysis

Sources:

Goldman-Cecil Medicine, Physical Examination (Block 36)
Schwartz's Principles of Surgery, 11th Ed. - Thyroid Chapter (Block 18)
Cummings Otolaryngology Head and Neck Surgery - Clinical Assessment (Block 27)
Current Surgical Therapy 14e - Physical Examination (Block 10)

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