Approach

• General approach to examination of the neck

[Thyroid physiology/goitre]

• Goitre - non-specific term describing any swelling of the thyroid gland (no pathology implied)
• Goitres become visible when they are 3 times the normal size (weighing more than 50g)
• Goitres graded according to WHO grading scheme:

1. Grade 0: Not palpable or visible
2. Grade 1: Palpable goitre
   • 1A: Detectable only on palpation
   • 1B: Palpable and visible with neck extended
3. Grade 2: Goitre visible with neck in normal position
4. Grade 3: Large goitre visible from a distance

Thyroid examination

1. Thyroid itself
   • Inspection, protrusion of the tongue, swallowing, palpation
   • Inspection: obvious midline lump, scars in horizontal crease from surgery, raised JVP from venous obstruction
   • Palpation: stick tongue out (thyroglossal cyst), repeat swallowing test, describe features of lump - feel for size, tenderness, mobility, consistency.  Work out if thyroid is diffusely enlarged or nodular
   • Confirm findings by palpating from the front
     

     Diffuse enlargement	Nodular enlargement
     Toxic (hyperthyroid) = grave's disease Non-toxic = simple colloid goitre, thyroiditis	Solitary nodule Multinodular goitre + draining cervical lymph nodes

   • Percussion
   • Auscultation:
2. Structures around the thyroid
   • Palpate trachea for deviation (ask about dysphagia)
   • Percuss over sternum from notch downwards - retrosternal extension / Pemberton's sign = signs of compression when raising arms (leading to suffocation, giddiness, syncope)
   • Repeat a sentence - assess quality of voice
   • Test for proximal myopathy: assess strenght oif muscles, get them to stand up from sitting position (seen in Grave's disease)
   • Test reflexes: Supinator jerk
3. Thyroid status
   • Hands:
     1. Increased sweating (hyperthyroidism)
     2. Palmar erythema (hyperthyroidism)
     3. Thyroid acropachy (pseudoclubbing - Grave's disease)
     4. Onycholysis (Plummer's nails)
     5. Vitiligo (autoimmune disorders)
     6. Tremor
     7. Pulse: tachycardia / atrial fibrillation in hyper / bradycardia in hypothyroidism
   • Eyes
     1. Loss of hair on outer 1/3 or eyebrows (hypothyroidism)
     2. Lid retraction = raised upper eyelid but sclera not visible around the iris = Dalrymple's sign
     3. Lid lag
     4. Proptosis: eye protruding forward, visible beyond the level of the supraorbital ridge when looking over the head of the patient
     5. Exophthalmos: both eyelids move away from the centre of the iris so that the whiteness of the sclera is visible below or all around the iris
     6. Chemosis - venous / lymphatic drainage disturbed by protrusion of the eye and appearance is oedematous and wrinkled
     7. Ophthalmoplegia
     8. Stellwag's sign: infrequent blinking in hyperthyroidism

Completion

1. Ask how the thyroid mass is affecting life