Thyroid Examination - Clinical Posting Guide

1. Patient Position and Exposure

• Patient sits upright on a stool or chair, facing the examiner
• Neck fully exposed - remove clothing/scarf from neck and upper chest
• Adequate lighting is essential
• A glass of water must be kept ready (for swallowing test)

2. INSPECTION

From the Front

• Site - midline vs. lateral, anterior triangle vs. posterior triangle
• Size - estimate roughly
• Shape and symmetry - is it diffuse/bilateral or unilateral?
• Skin over swelling - any redness, dilated veins, scars, sinuses
• Visible pulsation
• Distended neck veins (suggesting retrosternal extension)

• The thyroid gland is enclosed within the pretracheal fascia, so it moves upward on swallowing
• A thyroid swelling MOVES UP with swallowing - this is the single most important sign
• A lymph node or sebaceous cyst does NOT move with swallowing (usually)

• A thyroglossal cyst moves upward on tongue protrusion (because it is attached to the thyroglossal tract extending to the foramen cecum)
• The thyroid itself does NOT move on tongue protrusion

• Exophthalmos/proptosis, lid lag, lid retraction (hyperthyroidism)
• Pretibial myxedema (Graves' disease)
• Loss of outer third of eyebrows, dry coarse skin (hypothyroidism)
• Fine hand tremor (ask patient to hold hands outstretched)

3. PALPATION

General approach

• Stand BEHIND the patient
• Ask if there is any pain/tenderness first
• Use both hands/fingers, palpating the gland from behind
• Warm hands before examining

What to palpate and assess:

• Site and extent - which lobe? both lobes? isthmus?
• Size - rough dimensions in cm
• Shape - diffuse / nodular
• Surface - smooth (Graves', simple goitre) vs. nodular (multinodular goitre) vs. irregular (carcinoma)
• Consistency - soft / firm / hard / woody-hard (carcinoma) / fluctuant (cyst)
• Tenderness - present in thyroiditis, haemorrhage into a cyst
• Mobility - ask patient to swallow again while your fingers rest on the swelling; confirm upward movement
• Fixity to skin or deep structures - fixed swelling suggests malignancy
• Lower border - can you "get below it"? If you cannot, suspect retrosternal extension
• Tracheal position - is the trachea central or deviated? (large goitre can push trachea)

• Submental, submandibular
• Anterior and posterior cervical chains
• Jugulodigastric (most important)
• Supraclavicular (Virchow's node on left)

• Place finger in the suprasternal notch; note if trachea is central or shifted

4. PERCUSSION

• Percuss over the manubrium sterni (from the sternal notch downward)
• Normal - resonant over sternum
• Retrosternal goitre - produces dullness on percussion over the upper sternum/manubrium
• This is called Pemberton's manoeuvre test - ask patient to raise both arms above the head; this can cause facial flushing, cyanosis, and raised JVP if there is thoracic inlet obstruction from a retrosternal goitre

5. AUSCULTATION

• Listen over BOTH lobes of the thyroid with the bell of the stethoscope
• Bruit over the thyroid - indicates markedly increased vascularity
  • Continuous bruit ("machinery murmur") = Graves' disease (thyrotoxicosis)
  • Must distinguish from a carotid bruit (which is transmitted, loudest over carotid and softer over thyroid) and cardiac murmur radiation
• A bruit in the context of a diffuse goitre + tachycardia strongly suggests Graves' disease

6. Completing the Examination - Signs of Thyroid Status

Signs of Hyperthyroidism (Thyrotoxicosis)

Signs of Hypothyroidism

7. Special Signs to Know

8. Summary - Presenting a Thyroid Case

"On inspection, there is a midline swelling in the neck, approximately [size], which moves up with swallowing and does not move on tongue protrusion, consistent with a thyroid swelling. There are no dilated veins and no skin changes. On palpation, the swelling is [smooth/nodular], [firm/soft/hard], [tender/non-tender], and [mobile/fixed]. The lower border is [palpable/not palpable]. The trachea is [central/deviated]. No cervical lymphadenopathy. On auscultation, a thyroid bruit [is/is not] present. The patient appears to be [euthyroid/hyperthyroid/hypothyroid] clinically."

9. Relevant Investigations to Mention

• TSH (normal: 0.5-5 μU/mL) - best single screening test; inversely proportional to free T4
• Free T4 (normal: 55-150 nmol/L) and Free T3 (1.5-3.5 nmol/L)
• Thyroid antibodies - TPO antibodies (Hashimoto's), TSH receptor antibodies (Graves'), thyroglobulin antibodies
• Ultrasound neck - distinguishes solid vs. cystic nodule, detects multinodularity and cervical nodes
• FNAC (Fine Needle Aspiration Cytology) - most important investigation for a thyroid nodule; reported using the Bethesda system (or BTA/RCPath UK equivalent)
• Isotope scan (99mTc or 131I) - identifies "hot" (functioning) vs. "cold" (non-functioning, higher malignancy risk) nodules; up to 10% of cold nodules may be carcinomas
• CT/MRI - for retrosternal extension or suspected malignancy with vascular/airway involvement