---

History and Examination of Thyroid Swelling

---

HISTORY

1. Age

• Puberty (teen girls): Simple/physiological goitre - most common age group
• 20s-30s: Colloid goitre, multinodular goitre, solitary nodular goitre, follicular carcinoma
• Young adults: Primary toxic goitre (Graves' disease), papillary carcinoma
• Middle-aged women: Hashimoto's thyroiditis
• Old age: Anaplastic carcinoma (most aggressive)

2. Sex

• Thyroid disorders are predominantly female conditions
• Thyrotoxicosis is 8x commoner in females
• Thyroid carcinomas: female-to-male ratio 3:1
• All types of simple goitre are far more common in females

3. Occupation

• Thyrotoxicosis may appear in individuals under stress and strain
• Primary toxic goitre patients may have a psychic/anxious personality

4. Residence

• Endemic goitre belts: Mountain and hilly areas with low iodine content in water (Himalayas, Vindhyas, Satpura ranges in India; Derbyshire, Yorkshire in UK; Great Lakes region, North America)
• Calcium-rich chalky areas are also goitrogenic (southern Ireland, Derbyshire)

5. History of the Swelling

• Onset and duration - sudden vs. gradual
• Rate of growth - slow growing (benign) vs. rapid growth (suspect malignancy or haemorrhage into a nodule)
• Pain - painless swelling is usual; sudden painful enlargement suggests haemorrhage into a nodule
• Sleep pattern - "Does she spend sleepless nights?" Sleeplessness is a feature of primary thyrotoxicosis
• Position - does the swelling enlarge during puberty, pregnancy, or menstruation (physiological demand states)?

6. Pressure Symptoms (ask directly)

• Dysphagia - oesophageal compression
• Dyspnoea / stridor - tracheal compression
• Hoarseness of voice - recurrent laryngeal nerve compression
• Venous engorgement - superior vena cava compression (retrosternal goitre)

7. Symptoms of Thyroid Dysfunction

8. Family History

• Simple goitre runs in families
• Enzyme deficiencies in thyroid hormone synthesis are familial
• Primary thyrotoxicosis has familial occurrence
• Thyroid cancers can affect more than one family member

9. Drug History

• Goitrogenic drugs: Antithyroid drugs, para-aminosalicylates
• Dietary goitrogens: Turnips, cabbage, kale, soya bean (brassica family)
• Previous thyroid treatment (radioiodine, surgery, antithyroid drugs)

---

PHYSICAL EXAMINATION

A. General Survey

---

B. Local Examination of the Thyroid

INSPECTION

• Normal thyroid is not visible on inspection; only visible when enlarged
• In obese or short-necked individuals, use Pizzillo's method: patient clasps hands behind the occiput and pushes head backwards - this extends the neck and makes the goitre more prominent
• Note:
  • Uniform enlargement (whole gland): Physiological goitre, colloid goitre, Hashimoto's disease
  • Isolated nodules: Multinodular or solitary nodular goitre
• Key sign on inspection: Ask patient to swallow - a thyroid swelling moves upward on deglutition (because the gland is attached to the larynx by the pretracheal fascia)
• Thyroglossal cyst also moves up on swallowing AND also on tongue protrusion (pathognomonic)
• Retrosternal goitre: Dilated subcutaneous veins over upper anterior thorax; lower border cannot be seen to emerge on swallowing; Pemberton's sign - raising both arms over the head until they touch the ears causes facial congestion and respiratory distress due to obstruction of great veins at thoracic inlet

PALPATION

1. Site and extent - confined to thyroid region, one or both lobes, isthmus
2. Size - measure in centimetres
3. Shape - uniform, nodular
4. Surface - smooth (colloid/physiological goitre), irregular/nodular (multinodular goitre), bosselated (carcinoma)
5. Consistency:
   • Soft/elastic: Colloid goitre
   • Firm: Simple goitre, Hashimoto's thyroiditis
   • Hard/stony: Carcinoma, Riedel's thyroiditis
   • Fluctuant: Thyroid cyst
6. Tenderness - tender in thyroiditis; usually non-tender in benign/malignant goitre
7. Mobility - moves with deglutition (normal thyroid and benign lesions); restricted or fixed mobility = inflammation or malignant infiltration
8. Retrosternal extension - after patient swallows and swelling moves up, place fingers at lower border to detect any downward extension; inability to get below the swelling = retrosternal prolongation
9. Pressure effects:
   • Tracheal displacement: visible or palpable deviation
   • Kocher's test: Lateral compression of the lobes produces stridor - indicates obstructed/softened trachea (tracheomalacia) - positive test = indication for surgery
10. Lymph nodes - palpate all cervical groups for lymphadenopathy (suggests malignancy)
11. Carotid pulsation - compression may obliterate it (large lateral lobe lesion)
12. Thrill - place fingers over the gland; a thrill = vascularity, seen in primary toxic goitre (Graves')

PERCUSSION

• Percuss the sternum and upper chest to detect retrosternal dullness in retrosternal goitre

AUSCULTATION

• Place stethoscope over the gland: a bruit (vascular murmur) is heard in primary toxic goitre due to greatly increased blood flow - confirms toxic goitre

---

C. Examination of Eyes (Critical in Thyroid)

1. Exophthalmos
2. Thyroid swelling (with or without thrill)
3. Tachycardia
4. Tremor of outstretched fingers/tongue

---

SPECIAL INVESTIGATIONS

A. In-Vitro (Biochemical) Tests

B. In-Vivo (Isotope) Tests

1. Radioactive Iodine Uptake (RAIU - 131I or 99mTc):
   • Measures iodine trapping by the thyroid
   • Elevated uptake: hyperthyroidism, iodine deficiency goitre
   • Reduced uptake: hypothyroidism, thyroiditis
   • Contraindicated in: children, pregnancy
2. T3 Suppression Test (Werner's test):
   • Differentiates thyrotoxicosis from other causes of raised uptake
   • In normal persons: exogenous T3 suppresses uptake by 50-80%
   • In thyrotoxicosis: only slight suppression (10-20%) due to autonomous gland
   • Dangerous in elderly and patients with heart failure
3. TRH Stimulation Test:
   • Has replaced T3 suppression test in most centres
   • Absent TSH response to TRH = thyrotoxicosis or autonomous nodule
4. Thyroid Scan (Scintigraphy - 131I or 99mTc):
   • Maps functioning thyroid tissue
   • Hot nodule (increased uptake): autonomous/toxic nodule - rarely malignant
   • Cold nodule (absent uptake): 20% are malignant - requires FNAC/surgery
   • Indications: solitary palpable nodule, suspected retrosternal goitre, ectopic thyroid
   • 131I scan at 24 hours; 99mTc scan at ~30 minutes

C. Imaging

D. Cytology / Histology

• FNAC (Fine Needle Aspiration Cytology): Most important investigation for a thyroid nodule; distinguishes benign from malignant with high accuracy; mandatory for cold nodules
• Trucut/core needle biopsy: When FNAC is inconclusive
• Histopathology (gold standard): Post-surgical specimen; only way to definitively diagnose follicular carcinoma (capsular/vascular invasion needed)

E. Miscellaneous

---

SUMMARY TABLE: Key Clinical Pointers

---