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How to examine the Thyroid Gland

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Thyroid gland examinations

We have discussed : 1. General examinations, 2. Systemic examinations, 3. Disease specific examinations, 4. Investigations

I. What are the General examination of the Body :

In general examination related with whole body we mainly focus on three things – Primary toxic manifestations, Secondary manifestations and Metastasis.

1. How to check primary toxic manifestations :

Thyroid gland primary toxic manifestations check up

Here we check for – Eye sign, Tachycardia, Tremor, Moist skin, and thyroid bruit.

In eye signs examination we mainly focus on Lid retraction, Exophthalmos, Ophthalmoplegia, and Chemosis.

  • Lid retraction – Overactivity of the involuntary smooth muscular portion of the levator palpebrae superioris muscle causes these symptoms. Lid retraction occurs when the upper eyelid is higher than normal and the lower eyelid is in its normal position.
  • Exophthalmos – When the eyeball is pushed forward in the retro-orbital space due to an increase in fat, oedema, or cellular infiltration, the eyelids retrace and the sclera becomes visible below the lower margin of the iris initially, then above the upper edge of the iris.
  • Ophthalmoplegia – Oedema and cellular infiltration of the ocular muscles may cause ocular muscular paralysis. The superior and lateral rectus muscles, as well as the inferior oblique muscles, are frequently impacted. These muscles are paralysed, preventing the patient from looking upwards or outwards.
  • Chemosis – Oedema of the conjunctiva is what this is. Oedematous, swollen, and crinkled conjunctivae develop. Chemosis is caused by increased retro-orbital pressure obstructing the conjunctiva’s venous and lymphatic outflow.

2. Tests of Tachycardia :

  • In primary toxic goitre, this elevated rate occurs without regard to temperature. In thyrotoxicosis, the sleeping pulse rate is more conclusive.
  • The pulse’s regularity can be disrupted, and a quick irregular pulse can raise suspicions about auricular fibrillation.

3. Examination of tremor :

  • Tremor is an involuntary, rhythmic muscular contraction that causes shaking in one or more body parts.
  • It’s a common movement illness that usually affects the hands, but it can also affect the arms, head, vocal chords, chest, and legs.
  • The patient is advised to spread his fingers and straighten his arms in front of him.
  • The fingers will show signs of fine trembling.
  • The patient is also instructed to pull the tongue straight out and hold it there for at least half a minute.
  • There will be fibrillary twitching. The tongue and fingers may tremor in severe cases.

4. Examination of moist skin :

  • In primary thyrotoxic instances, the hands and feet are most commonly affected.
  • After checking the pulse at the wrist, it’s a good idea to feel the hands as well.
  • The patients’ hands are heated and moist, and they are unable to withstand hot conditions; yet, their tolerance for cold is increased.

2. How to check secondary toxic manifestations :

  • This can make multinodular goitre or a thyroid adenoma more difficult to treat.
  • The cardiovascular system takes the brunt of the damage.
  • Auricular fibrillation is a very prevalent condition.
  • It’s possible that the heart may seems enlarged.
  • While walking up the stairs, signs of heart failure such as oedema of the ankles, orthopnoea, and dyspnoea may be detected. Exaphthalmos and tremor are common asbent symptoms.

3. How to check malignant thyroid diseases :

  • When a thyroid bulge seems to be rock hard, irregular, and immovable, losing mobility even following deglutition, a thorough examination should be performed to determine the extent of the condition.
  • Aside from the cervical lymph nodes, distant metastasis such as bone metastasis, which is common in thyroid cancer, particularly the follicular variety, should be looked for.
  • The skull, spine, ends of long bones, pelvis, and other areas of the body should all be checked for metastases. Finally, lung metastasis, which is common, should be ruled out.

II. What are the Systemic examination of Thyroid gland :

Thyroid systemic examinations

There are mainly five systemic examination of Thyroid gland – Inspection, Palpation, Percussion, Auscultation, and Measurement.

I. How to do the Inspection part :

  • On closer inspection, a normal thyroid gland is not seen. Only when the thyroid gland is enlarged can it be seen.
  • Because this appears to be difficult in obese patients, we mostly use Pizzillo’s approach, in which the patient’s hands are placed behind her head and she is requested to push her head backwards against her clasped hands on the occiput.

Swelling during deglutition :

  • Swelling of the thyroid gland may be homogeneous, affecting the entire gland, or nodules of various sizes may be detected in the thyroid region.
  • A swelling on the lateral side of the neck is occasionally produced by metastases in lymph nodes from a concealed cancer of the thyroid gland, rather than by enlargement of an aberrant thyroid gland.
  • Because the thyroid gland is attached to the larynx, a thyroid enlargement goes higher during deglutition.
  • Thyroglossal cyst, subhyoid bursitis, and prelaryngeal or pretracheal lymph nodes fixed to the trachea or larynx are usually other swellings that shift on deglutition.
  • When the thyroid is fixed by inflammation or malignant infiltration, its movement is severely restricted.

1. Retrosternal goitre :

  1. Dilatation of the subcutaneous veins over the upper anterior section of the thorax is caused by pressure on the great veins at the thoracic inlet.
  2. When these are present, the patient should be asked to swallow so that the bottom border of the swelling can be determined on observation as it travels up on deglutition.
  3. In the event of retrosternal goitre, this is not possible.
  4. Both arms should be raised above the patient’s head until they meet his ears.
  5. For a while, this position is maintained.
  6. Due to occlusion of the great veins at the thoracic inlet, retrosternal goitre causes facial congestion and pain.

2. Thyroglossal cyst :

  • On deglutition, this likewise travels upwards.
  • However, because the thyroglossal duct extends downwards from the foramen caecum of the tongue to the isthmus of the thyroid gland, it travels upwards with tongue protrusion.

3. Thyroglossal fistula :

  • This can be found just below the hyoid bone, along the midline.
  • The fistula’s orifice is incised and covered by a crescentic fold of skin.

II. How to do the Palpation part :

  • With the patient’s neck slightly flexed, the thyroid gland should always be palpated.
  • The gland can be palpated from both the front and the back.
  • The doctor should stand behind the patient and the patient should be seated on a stool.
  • The patient is instructed to bend his or her neck slightly.
  • Both hands’ thumbs are positioned behind the neck, and each hand’s other four fingers are placed on each lobe and the isthmus.
  • Palpation must be completed in its totality.
  • It’s crucial to examine the thyroid gland’s edges carefully, especially the lower one.
  • By stretching and twisting the face to the same side, the examiner can get more information about one lobe by relaxing the sternocleidomastoid muscle on that side.
  • To learn more about a specific thyroid nodule, the patient may be asked to extend his or her neck.
  • This merely serves to highlight the nodule for easier palpation.

Each lobes of thyroid gland is best palpated by Lahey’s method.

1. Lahey’s method :

  • The examiner stays in front of the patient.
  • The thyroid gland is pushed to the left from the right side by the examiner’s left hand to correctly palpate the left lobe.
  • The left lobe becomes more apparent as a result, allowing the examiner to palpate it completely with his or her right hand.

2. Crile’s method :

  • To confirm the diagnosis of thyroid swelling, the patient should be asked to swallow during the examination.
  • Simply placing the thumb on the thyroid gland as the patient swallows can reveal slight enlargement of the gland or the existence of nodules in its substance.

During palpation some points should be noted, and they are –

  1. Is the thyroid gland swollen in its entirety?
  2. When a swelling is localised, take note of its location, size, shape, extent, and consistency.
  3. The gland’s movement should be noticed.
  4. To rule out the possibility of retrosternal extension, it is necessary to go below the thyroid gland.
  5. The effect of thyroid enlargement on pressure should be carefully examined.
  6. Whether or not there is a poisonous manifestation.
  7. Whether or not there is evidence of myxoedema.
  8. Whether or not the swelling is cancerous or benign.
  9. Is there any pulsation or excitement in your thyroid?
  10. The lymph nodes in the neck should be palpated.

III. How to do the Percussion part :

To rule out the presence of a retrosternal goitre, this is used over the manubrium sterni. This is more of a throretical issue than a practical one.

IV. How to do the Auscultation part :

Due to enhanced vascularity, a systolic bruit may be heard above the goitre in primary toxic goitre.

V. How to do the Measurement part :

At intervals, take measurements of the circumference of the neck at the most noticeable portion of the swelling. This will decide whether the swelling is getting bigger or smaller.

III. What are the disease specific examinations

1. How to examine the build and state of nutrition :

In this case, we have mainly two diseases like Thyrotoxicosis and Carcinoma of thyroid.

  • Thyrotoxicosis – The patient is frequently skinny and underweight, and he or she sweats profusely due to muscular wasting.
  • Hypothyroidism – The patient appears to be obese and overweight in this case.
  • Carcinoma of thyroid – Anaemia and cachexia are common symptoms of thyroid cancer.

2. How pulse rate varies and helps to diagnose :

  • Thyrotoxicosis is a condition in which the pulse rate increases yet becomes erratic.
  • Secondary thyrotoxicosis – Here, the pulse rate is more erratic.
  • Mild thyrotoxicosis – The pulse should be less than 90 beats per minute.
  • If the person have moderate or severe thyrotoxicosis, the pulse should be 90 to 100 beats per minute and above 110 beats per minute, respectively.
  • Hypothyroidism causes bradycardia, which is a slowing of the heartbeat.

3. How to examine the skin :

  • Primary thyrotoxicosis – In primary thyrotoxicosis, the skin is moist, especially the hands. When the clinician is checking the pulse, he or she should also touch the patient’s hand. In primary thyrotoxicosis, the palm is hot and moist.
  • Myxoedema – The skin seems dry and inelastic.

4. How to examine the facies :

  • Thyrotoxicosis – The facial expressions of enthusiasm, tension, uneasiness, or agitation can be seen in this situation, with or without varying degrees of exophthalmos.
  • Hypothyroidism – A bloated face with no expression is a sign of hypothyroidism.

5. How to examine the Mental state and intelligence :

  • Patients with hypothyroidism are inherently dull and have a low IQ.
  • In cretins, this is more visible.

There are mainly two types of tests of thyroid glands, and they are – Thyroid function test and Radiograph tests.

1. Thyroid function tests :

This test is performed according to the status of the hormone. There are mainly two types of thyroid function tests and they are : In-vitro test and In-Vivo test.

I. In-Vitro tests :

There are mainly seven In-vitro tests are available. And they are – Serum protein bound Iodine, Serum thyroxine, Total serum Tri-Iodothyronine, T3 Resin Uptake, Free thyroxin index, Serum thyroid stimulating hormone, Test of hypothalamic-Pituitary axis.

II. In-Vivo tests :

There are three types of In-vivo tests are available, and they are – Uptake tests, T3 suppression test or Werner test, Thyroid scan.

2. Radiograph tests :

In radiography we mainly focus on X-ray and Angiography.

3. Other tests :

Bone scan and FNAC tests can be done.

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