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🏥 Thyroid Swelling — Complete Case Presentation Guide (ENT)

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📋 PART 1: FULL CASE HISTORY

Biodata

• Name, Age, Sex, Occupation, Address, Religion
• Key pointers: Female > Male (4:1), any age, but common 30–50 years

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Presenting Complaint

"Swelling in front of the neck for ___ months/years"

• Duration — sudden vs. gradual
• Progression — increasing, static, decreasing

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History of Presenting Complaint (HOPI)

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Associated Symptoms — Compressive

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Associated Symptoms — Thyroid Status (MUST ask)

• Weight loss despite good appetite
• Palpitations / fast heartbeat
• Heat intolerance, excessive sweating
• Tremor of hands
• Diarrhea, frequent bowel motions
• Irritability, anxiety, emotional lability
• Oligomenorrhea / amenorrhea
• Eye symptoms: protrusion, double vision, grittiness (suggests Graves' disease)

• Weight gain
• Cold intolerance
• Constipation
• Dry skin, coarse hair, hair loss
• Bradycardia, lethargy
• Menorrhagia
• Hoarseness of voice

• Rapid increase in size
• Hard, fixed swelling
• Hoarseness (RLN invasion)
• Dysphagia
• Cervical lymph node enlargement
• Previous head and neck irradiation

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Past History

• Previous thyroid disease or surgery
• History of radiation to neck/head in childhood
• Iodine-deficient area (endemic goitre)

Family History

• Goitre, thyroid cancer
• MEN syndrome (MEN 2A/2B — associated with medullary thyroid carcinoma)
• Autoimmune thyroid disease

Drug History

• Lithium (causes goitre/hypothyroidism)
• Amiodarone (iodine-rich, affects thyroid)
• Antithyroid drugs (prior use)
• Oral contraceptive pill

Dietary / Social History

• Iodine intake, cruciferous vegetable excess
• Smoking (mildly protective against autoimmune thyroiditis but risk for thyroid cancer)
• Residence in endemic goitre area

Menstrual History (in females)

• Changes in cycle — suggests thyroid dysfunction

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🔍 PART 2: CLINICAL EXAMINATION

General Appearance

• Eyes: Exophthalmos, lid lag, lid retraction, chemosis, ophthalmoplegia → Graves' disease
• Hands: Fine tremor, warm moist palms, thyroid acropachy, onycholysis (hyperthyroidism); dry, cold, bradycardia (hypothyroidism)
• Pulse: Tachycardia / atrial fibrillation (hyperthyroidism)
• Pretibial myxedema (Graves' disease — bilateral shin deposits)

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Examination of the Neck Swelling

Inspection

1. Position of swelling — midline, anterior, submandibular
2. Shape and size
3. Skin over swelling — normal, inflamed, dilated veins, scars
4. Movement with swallowing → HALLMARK of thyroid swelling — moves upward on swallowing (attached to pretracheal fascia)
5. Movement with tongue protrusion → moves on tongue protrusion = thyroglossal duct cyst (NOT thyroid gland)
6. Visible pulsations
7. Pemberton's sign — patient raises both arms above head: facial congestion and stridor = substernal goitre

Palpation (stand behind patient, offer water to swallow)

• Confirm movement with swallowing
• Surface: Smooth (diffuse goitre, Graves') vs. nodular (multinodular goitre, adenoma, malignancy)
• Consistency: Soft (colloid), firm (Hashimoto's, follicular), hard/stony (malignancy, calcification, Riedel's)
• Tenderness: Suggests De Quervain's thyroiditis, acute thyroiditis
• Extent: Below sternum? (bimanual, feel at jugular notch)
• Trachea — central or deviated?
• Regional lymph nodes — cervical chain, level I–VI
• Berry's sign — loss of pulsation of carotid artery behind goitre = malignant invasion

Percussion

• Dullness below sternum → substernal extension

Auscultation

• Bruit over thyroid → Graves' disease (hypervascular, continuous bruit)

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🩺 PART 3: DIFFERENTIAL DIAGNOSIS OF MIDLINE NECK SWELLING

Why Thyroid Swelling Moves with Swallowing

Why Thyroglossal Cyst Also Moves with Swallowing AND Tongue Protrusion

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⚗️ PART 4: INVESTIGATIONS

Baseline

Imaging

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💊 PART 5: MANAGEMENT

Medical Management

• Iodine supplementation (iodine-deficient areas)
• Monitor with TFTs and USS
• Levothyroxine (TSH suppression) — rarely used now due to risk of thyrotoxicosis

• Antithyroid drugs (ATDs): Carbimazole (first-line) or Propylthiouracil (PTU — pregnancy first trimester)
  • Mechanism: Inhibit thyroid peroxidase → block hormone synthesis; PTU also inhibits peripheral T4→T3 conversion
• Beta-blockers (Propranolol): Symptom control (palpitations, tremor) while awaiting ATD effect
• Radioactive Iodine (RAI / I-131): Definitive; ablates thyroid tissue; contraindicated in pregnancy, active ophthalmopathy
• Surgery (total/subtotal thyroidectomy): Large goitre causing compression, failed medical, patient preference

• RAI preferred in elderly
• Surgery for large compressive MNG

• Levothyroxine replacement (T4)

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Surgical Management

Indications for Surgery

1. Compressive symptoms (dysphagia, dyspnea, stridor)
2. Cosmesis
3. Malignancy (proven or suspected — FNAC Bethesda IV/V/VI)
4. Failed medical therapy
5. Toxic goitre — contraindication to RAI (e.g., pregnancy, active eye disease)
6. Substernal goitre

Types of Thyroid Surgery

Post-operative Complications

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Management of Thyroid Carcinoma

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🎓 PART 6: PROBABLE VIVA QUESTIONS & ANSWERS

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A: Movement with swallowing. The thyroid gland is invested by the pretracheal fascia attached to the trachea and larynx, so it ascends with laryngeal elevation during swallowing.

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A: Both move with swallowing (below hyoid), but a thyroglossal cyst also moves with tongue protrusion — because it is tethered to the hyoid bone via the residual thyroglossal tract, and tongue protrusion elevates the hyoid via the geniohyoid muscle.

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A: Surgical excision of a thyroglossal duct cyst, involving: (1) removal of the cyst and its entire tract, (2) resection of the central/middle third of the hyoid bone, and (3) a cuff of tongue base musculature up to the foramen cecum. The hyoid is removed because the duct branches extensively around it (especially above), and failure to remove it leads to high recurrence. (K.J. Lee's Essential Otolaryngology)

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A: The thyroglossal duct has extensive branching around and above the hyoid bone. Leaving hyoid remnants leads to recurrence of the cyst. Resecting the middle third of the hyoid ensures complete clearance of the tract.

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A: When the patient raises both arms above the head, facial congestion, neck vein engorgement, and stridor develop due to thoracic inlet obstruction by a substernal goitre compressing the superior vena cava or thoracic inlet.

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A: Loss of carotid pulsation palpable behind a goitre, indicating malignant encasement and invasion of the carotid artery.

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A: Serum TSH is the most sensitive single test. Suppressed TSH = hyperthyroidism; elevated TSH = hypothyroidism. Free T3 and T4 are then measured to assess the degree of dysfunction.

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A: On radionuclide scanning, a cold nodule shows absent/reduced isotope uptake relative to normal thyroid tissue. It carries a 5–15% risk of malignancy, significantly higher than hot nodules (which are rarely malignant). Cold nodules require FNAC for cytological evaluation. (Swanson's Family Medicine Review)

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A: A 6-tier cytological classification system for FNAC of thyroid nodules:

• I: Non-diagnostic
• II: Benign
• III: Atypia of undetermined significance (AUS)
• IV: Follicular neoplasm
• V: Suspicious for malignancy
• VI: Malignant

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A: The Recurrent Laryngeal Nerve (RLN). It lies in the tracheoesophageal groove and must be identified and preserved. Unilateral damage causes hoarseness; bilateral damage causes bilateral vocal cord palsy, presenting as stridor and potentially requiring emergency tracheostomy. The external branch of the superior laryngeal nerve is also at risk, causing loss of high-pitched voice projection.

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A:

• RLN injury → hoarseness / stridor
• Hypoparathyroidism → hypocalcaemia → tetany → Chvostek's/Trousseau's signs
• Haemorrhage / haematoma → can cause acute airway compression
• Hypothyroidism → lifelong LT4 required
• Thyroid storm (if unprepared hyperthyroid patient)
• Wound infection, keloid scar

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A: Graves' disease is an autoimmune condition where TSH receptor antibodies (TRAb/TSI) stimulate the TSH receptor → diffuse goitre with hyperthyroidism. Classic triad: diffuse toxic goitre + exophthalmos + pretibial myxedema (not all need be present). Confirmed by suppressed TSH, elevated fT3/fT4, positive TRAb, and homogeneous goitre on USS with increased vascularity (thyroid "inferno" on Doppler).

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A: Subacute granulomatous thyroiditis, probably viral (post-URI). Presents with painful, tender thyroid, low-grade fever, raised ESR. TFTs show initial hyperthyroidism (release of preformed hormones) → hypothyroid phase → recovery. Treated with NSAIDs (mild) or corticosteroids (severe).

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A:

• Physiological: puberty, pregnancy (increased iodine demand)
• Endemic: iodine deficiency (>5% population)
• Sporadic: non-endemic, unknown cause
• Toxic diffuse: Graves' disease
• Toxic nodular: toxic adenoma, Plummer's disease (toxic MNG)
• Non-toxic MNG: most common type overall
• Autoimmune: Hashimoto's (hypothyroid), Graves' (hyperthyroid)
• Neoplastic: adenoma, carcinoma

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A:

• Grade 0: No palpable/visible goitre
• Grade 1: Palpable but not visible with neck in normal position
• Grade 2: Visible with neck in normal position; not visible when head extended
• Grade 3 (old classification): Visible at a distance

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A: Any thyroid nodule >1 cm on USS, or smaller nodules with suspicious sonographic features (hypoechoic, irregular margins, microcalcifications, taller-than-wide shape, abnormal vascularity, extrathyroidal extension, suspicious LN). ACR TI-RADS guides size thresholds for biopsy. (Harrison's 22e)

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A: The ACR Thyroid Imaging Reporting and Data System — a 5-tiered scoring system (TI-RADS 1–5) categorizing sonographic features of thyroid nodules by composition, echogenicity, shape, margins, and echogenic foci. Higher TI-RADS = higher malignancy risk → lower size threshold for FNAC. (Harrison's 22e)

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A: Iodine deficiency → reduced efficiency of thyroid hormone synthesis → compensatory rise in TSH → TSH stimulates thyroid cell proliferation and growth → goitre. TSH is sometimes only mildly elevated, suggesting increased tissue sensitivity to TSH and activation of alternate local growth pathways (endothelins, nitric oxide). (Harrison's 22e)

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A: Autoimmune thyroiditis with lymphocytic infiltration and destruction of thyroid tissue. Anti-TPO and anti-Tg antibodies are positive. Initially may cause transient thyrotoxicosis (Hashitoxicosis), but usually leads to hypothyroidism. Goitre may or may not be present. Associated with other autoimmune diseases (DM Type 1, Addison's, vitiligo).

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A:

1. History and clinical exam — assess for hyper/hypothyroidism, malignancy risk factors
2. Serum TSH — if suppressed → radionuclide scan (hot nodule = autonomous adenoma, rarely malignant)
3. Ultrasound — characterize nodule (TI-RADS scoring)
4. FNAC — for nodules meeting size/sonographic criteria (Bethesda classification)
5. Additional: CT if substernal, calcitonin if medullary suspected

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📸 Clinical Images

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🗂️ QUICK SUMMARY CARD FOR PRESENTATION

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