EXAMINATION OF

THYROID
Prepared by:
Syazwani, Rajhmuniran, Picholas
 ANATOMY
 One of the largest of the endocrine
glands (15-20 gm in adults)
 Located inferior to thyroid
cartilage
 Close relations with :
 parathyroid glands
 THYROID
GLAND
Secretes 2 major hormones : Thyroxine (T4)
and Triiodothyronine(T3)
Also secretes calcitonin (parafollicular
cells), for calcium regulation
Hypothalamus secretes
Thyroid-stimulating hormone
releasing hormone - stimulate
the release of TSH
MECHANISM OF ACTION OF
THYROID HORMONES
 ACTIONS OF THYROID HORMONES
1. Effects on fetal development 2. Effects on basal metabolic rate (BMR)
 Increase O₂ consumption of tissues 
 After 11 weeks of gestation, the fetus is
resulting increase BMR & body T
largely dependent on its own thyroid
 Hyperthyroidism - increase BMR to 60-
secretion.
 Essential for normal skeletal and brain
100% of normal
 Hypothyroidism - BMR falls 20-40% below
maturation.
 Hypothyroidism in children:
normal
 In hyperthyroidism, if total caloric intake is
cretinism (mental retardation and
dwarfism) not increased proportionately, protein and
fat stores are catabolised  weight loss.
3. EFFECTS ON CARDIOVASCULAR 4. Sympathetic effects
AND RESPIRATORY
 Increase cardiac output
• increase the number and affinity of β-
and ventilation adrenergic receptors in heart, skeletal
 CO = HR x SV
muscles, adipose tissue and lymphocytes
 T3 stimulates transcription of myosin
due to increase contractility

heavy chain α and inhibits myosin heavy

chain β - improving cardiac muscle
contractility
5. Pulmonary effects 6. Hematopoietic effects

 Thyroid hormones maintain normal  Thyroid hormones increase erythropoiesis

hypoxic and hypercapnic drive in the  In hyperthyroidism, increased cellular
respiratory center.
demand for O2 - increased production of
 In severe hypothyroidism,
erythropoietin (increased
hypoventilation occurs erythropoiesis/increase RBCs production -
polycythemia)
 In hypothyroidism - anemia due to the
lack of development of red blood cells.
Significant anemia can lead to shortness of
breath and fatigue.
7. Gastrointestinal effects 8. Skeletal effects

 Thyroid hormones stimulate secretion of  Thyroid hormones increased bone

digestive juice & gut motility turnover, bone resorption and to a
 In hyperthyroidism - diarrhea, weight lesser degree bone formation
loss
 In hypothyroidism - constipation, weight
gain
9. CNS effects 10. Protein Metabolism
 Thyroid hormones increase responsiveness to  Thyroid hormones stimulate cellular
catecholamines, with consequent increased uptake of amino acids and protein
activation of the reticular activating system
synthesis.
 Hyperthyroidism
Cause excess stimulation of CNS
• Also causes catabolism of protein
•

Hyperthyroidism : causes Thyrotoxic
 Nervousness, irritability, emotional lability myopathy (muscle weakness) - due to
 Fine muscle tremor, rapid tendon reflexes protein catabolism
 Hypothyroidism
• Hypothyroidism : is associated with
 Slow mental activity muscle weakness and discomfort, and
 Reduce muscle tone and delayed reaction time of delayed muscle contraction and
stretch reflexes. relaxation lead to slow movements.
11. Lipid Metabolism 12. Carbohydrate Metabolism

 Increase lipolytic action on fat stores - tends  Increase rate of intestinal glucose
to increase plasma levels of FFA. absorption
 Increase oxidation of the FFA released  Increase uptake of glucose by the cells

 Increase hepatic LDL receptors  Increase hepatic glycogenolysis and

gluconeogenesis
 Hypothyroidism - decrease LDL receptors -
 In hyperthyroidism : worsen underlying
decrease cholesterol excretion - increase DM (increase insulin requirements in
circulating cholesterol diabetics)
 Hyperthyroidism - increase LDL receptors -
increase cholesterol excretion - decrease
circulating cholesterol
13. Vitamin metabolism 14. Endocrine changes

 Thyroid hormones are necessary for  Thyroid hormones increase the metabolic
hepatic conversion of beta carotene - turnover of many hormones
vitamin A (retinol) in the liver  Half-life: increase in hypothyroidism
and decrease in hyperthyroidism
 In hypothyroidism, accumulation of
carotene - yellow discoloration  Thyroid hormones are required for normal
secretion of gonadotropins.
 In hypothyroidism, anovulation and
Beta-carotene is a red-orange pigment found in
plants and fruits, especially carrots and colorful
menstrual disturbances
vegetables.
 15. SKIN CHANGES

Hyperthyroidism Hypothyroidism
• Warm, moist skin • Dry, thick, scaly skin
• Excess thyroid hormones • Accumulation of a variety of
cause extra heat production proteins promotes water
retention
HISTORY TAKING
DEMOGRAPHIC DETAILS
1. Age
 Simple goiter; girls approaching puberty and pregnancy
 multinodular, solitary nodular goiters and colloidal goiters; women in their 20s and 30s;
 Papillary carcinoma; young girls; follicular carcinoma; middle aged women;
 Anaplastic carcinoma; old age; Hashimoto’s disease; middle aged women

2. Sex
 Majority of thyroid disorders are seen in women. Thyrotoxicosis is much commoner in females than
in males;
 Thyroid carcinomas occur three times more often in females

3. Occupation
 Thyrotoxicosis may appear in individuals working under stress & strain

4. Residence
 Endemic goiter due to iodine deficiency. Certain areas known to have low iodine content in the water
and food
5.Medications
Ask about treatment the patient has taken, and its effects on the swelling. Drugs (some may be
goitrogenic)
6.Family history
Some thyroid disorders have a familial predilection.(Hashimoto thyroiditis/Graves dx)
7.Dietary history
Dietary habits are important as vegetables of the brassica family (cabbage, kale, rape) are
goitrogens. If there is insufficient iodine in the diet, an iodine-deficiency goiter may develop.
RELEVANT MEDICAL
HISTORY
 Previous operations on thyroid gland???(cx )
 Medications - antithyroid drugs, thyroxine, iodine-containing
medications ??? (relapse-hyper)
 Radioiodine therapy for previous Grave's disease??(hypo)
 Recent exposure to iodine – contrast material(MNG)
 Fitness for surgery
  Eye symptoms - protruding / staring eyes, difficulty
closing eyelids, double vision (secondary to
ophthalmoplegia) and pain in eye (secondary to corneal
OTHER ulceration
 Adjacent structures: trachea, esophagus, recurrent

ASSOCIATE laryngeal nerves

 Ask about the effect of the swelling on the
D a. trachea, causing breathing difficulty and stridor.

SYMPTOMS b. esophagus, causing dysphagia.

c. recurrent laryngeal nerve, causing hoarseness.
 SYMPTOMS FROM THE
SWELLING
 Duration and change in size - suddenly increased (haemorrhage into necrotic nodule, subacute
thyroiditis, rapidly growing carcinoma)
 onset, duration, rate of growth, and appearance of symptoms such as pain,cause,past medical
history

 A swelling that appears after trauma may be a hematoma, not a thyroid swelling.
 Benign swellings grow slowly; malignant swellings (like an anaplastic cancer of the thyroid) usually
grow faster.
 Note that papillary cancers of the thyroid usually grow slowly.
 Goitres are painless, unless the patient has thyroiditis.
 Anaplastic carcinomas infiltrate surrounding structures and often cause pain.
Duration Onset
How long? A few days? A few months How did it start? After trauma? After an operation? After an insect
or years? bite? On its own?
Recent swellings, a few days old. are Swellings that start after trauma may be hematomas.. Skin
usually inflammatory, such as swellings that occur after insect bites or after minor injuries may be
abscess. Swellings that have been abscesses. [Bhat, 2010].
there for months are typically
neoplastic. Cause
Progression What, in the patient’s opinion, has caused the lump?
Is there a change in rate of growth? Has the mass started Although it is the doctor’s duty to determine the cause of a
growing quickly? Is there a sudden increase in size? swelling, it is a good idea to ask the patient for his or her
A very sudden increase in size suggests a bleed into a mass. opinion. There may have been an injury that occurred before
The size will increase within minutes or hours. A rapid increase the lump [Browse et al, 2005]. It is not a bad idea to confirm is
in size indicates malignancy: the lump has always been present after it was first noticed,
If a swelling is getting smaller, think of an abscess that is or has it ever disappeared. Hernias, inflammatory masses
resolving. [Bhat, 2010]. may recur. [Browse et al, 2005]

Past medical/ surgical history

Similar lump?
Ask the patient if there is an existing similar lump, or a previous similar lump. The
patient may have had a previous swelling that was taken out, only to recur: this
would favor a diagnosis of malignancy.
Diabetes? Past cancer? Past intervention like surgery or radiation?
Infective conditions like abscesses are commoner in persons with diabetes. A past
cancer in one breast predisposes to a cancer in the other. Past surgery or trauma
may be the cause of an epidermal inclusion cyst or a keloid. Past surgery or trauma
in the abdomen may result in an incisional hernia. Past radiation, e.g. radiation to
the neck, increases the risk of some thyroid cancers.
  Hyperthyroidism Hypothyroidism 

General loss of weight inspite of increases appetite Decreased appetite, weight gain,
Tiredness ,sweating lethargy,hyperlipidaemia

Thermogregulatory Preference for cold weather Preference for hot weather

Dermatological Increased sweating Dry skin, "peaches and cream" complexion,

Hair loss, pruritus,palmar erythema

Musculoskeletal Proximal myopathy (autoimmune) with wasting and Muscle fatigue(myalgia)

weakness
Increase linear growth in children

Gastrointestinal Change in bowel habit – diarrhoea ( due to increased Constipation ,Ileus

activity at ganglionic level) frequent defecation

Cardiovascular Tachycardia, atrial fibrillation Bradycardia,pericardial effusion,cardiac

Palpitations, SOB,angina failure,angina
Gynaecological Oligomenorrhoea, amenorrhoea Menorrhagia,infertility,galactorrhea
Delayed puberty
Genitourinary Occasional urinary frequency
Psychiatric Nervousness, easy irritability, emotional lability, Slow thought, speech, action, depression,
insomnia, psychosis dementia
Myxoedema coma
Neurological Fine tremor Symptoms of carpal tunnel syndrome 
(diffuse irritability of grey matter)
CAUSES HYPERTHYROID COMMON HYPOTHYROID

GRAVES’ DISEASE PRIMARY AUTOIMMUNE HYPOTHYROIDISM

1.Primary atrophic hypothyroidism
TOXIC MNG 2. Hashimoto’s thyroiditis
OTHERS- Chief Cause (Iodine deficiency)
 Post thyroidectomy /radioiodine tx
TOXIC ADENOMA  Drug induced-antithyroid /amiodarone/lithium
 Subacute thyroiditis (temporary hypo after hyper)
EXOGENOUS
(IODINE EXCESS,
FOOD CONTAMINATION,MEDICATION)
Secondary – not enough TSH (hypopituitarism)

ECTOPIC THYROID TISSUE

METASTATIC FOLLICULAR THYROID CANCER Hypothyroidism associations –autoimmune seen with other
autoimmune diseases (Type 1 DM,Addisons)
OTHERS DISEASE
SUBACUTE de Quarvain’s thyroiditis
,drugs(amiodarone),postpartum,TB (RARE) Pregnancy prob- Lead to eclampsia ,anaemia,prem, stillbirth

PRIMARY VERSUS SECONDARY ????

IN SHORT
Hyper vs hypo symptoms
 Primary vs secondary
Onset (slow/fast)
Age
Pain
Morphology
THYROID STATUS
HYPERTHYROIDISM
 Clinical manifestation due to
 Hypermetabolic state (↑BMR)
 Overactivity of sympathetic nervous system

 Skin is soft, warm and flushed (moist)

 Heat intolerance
 Excessive sweating
 Weight loss but increased appetite
 Gastrointestinal hypermotility, increased secretion,
malabsorption, diarrhoea
 Glucose intolerance d/t ↑ glycolysis and lipolysis
 Palpitation and tachycardia
 Congestive cardiac failure may develop in elderly
 Neuromuscular: nervousness, tremor, irritability,
proximal myopathy, insomnia, anxiety
 Alopecia
 Staring gaze, lid lag
 Exophthalmos & pretibial myxedema ONLY in
Graves disease
 General inspection
 weight lose
 anxiety
 Hand
 fine tremor
 onycholysis
 thyroid acropachy
 palmar erythema, warmth,
sweaty
 pulse
 Arms
 proximal myopathy
 abnormal briskness
 Eyes
 exophthalmos
 lid retraction
 lid lag
 ptosis
 Chest
 gynaecomastia
 systolic flow murmurs
 signs of congestive cardiac
failure
 Legs
 proximal myopathy
 hyperreflexia
HYPOTHYROIDISM
Primary: high TSH
Secondary: low TSH
Serum free T4 is low
 Primary if the defect is arised from thyroid gland itself
 Secondary if it is from either pituitary of
hypothalamus
 Clinical manifestation
 Cretinism in infant
 Myxedema in adult
CRETINISM
Clinical features
 Impaired development of skeletal system and central nervous
system
 Mental retardation
 Short stature
 Protruding tongue
 Umbilical hernia
MYXEDEMA
Hypothyroidism developing in older children and adults

Manifestation
 Coarse and thin hair  Cold intolerance
 Cold and dry skin  Slow heart rate
 Mental sluggishness  Heavy period
 Tiredness  Decreased bowel motility,
 Reduced sweating constipation
 Obese
 Proximal myopathy
HYPOTHYROIDISM
 General inspection
 mental and physical sluggishness
 hypothyroid speech (slow and deep pitch)
 Hand
 peripheral cyanosis
 cool and dry
 yellow discolouration of hypercarotenaemia
 palmar crease pallor
 Arms
 proximal myopathy
 Face
 yellow skin
 alopecia
 periorbital oedema
 xanthelasmata
 Chest
 pericardial effusion
 pleural effusion
 Legs
 non pitting oedema
 ankle reflex
 peripheral neuropathy
SPECIFIC EXAMINATION
 INSPECTION
• Surgical scar (thyroidectomy)
• Skin changes, redness (suppurative thyroiditis)
• Masses (site, size, shape, surface, consistency,
tenderness, margin, fixation, mobility, single/multiple)
• Swallow, movement of mass with swallowing
– Rise upon swallowing – goiter, thyroglossal cyst
(attached to larynx)
• Protrude tongue
– No movement – thyroid gland mass, lymph nodes
– Movement – thyroglossal cyst (embryological
remnant of thyroglossal duct)
 PALPATION
• Semi-flexed neck, to relax SCM
• Palpate from behind the pt
• Thyroid ct>cricoid ct
(C6)>Isthmus (2nd ,3rd ,4th tracheal
ring) >Thyroid lobes (thyroid ct
to 4th, 5th tracheal ring)
• Use one hand to steady the gland,
and another to palpate
 PALPATION
If presence of mass, assess:
•
– Site
• Midline : thyroglossal cyts, dermoid cyst,Ludwig’s angina
• Lateral (anterior ∆) : brachial cyst, brachial fistula, chemodectoma, pharyngeal pouch
• Posterior (posterior ∆) : cervical lymphadenopathy, cystuc hygroma, cervical rib, schwannoma
– Size
• Palpate the lower border (absence suggest retrosternal extension)
– Shape
• uniformly enlarged, or irregular
• Involvement of isthmus
• Nodular (MNG)
• Nodules distinct from thyroid (assess location, size, shape, surface, consistency, tenderness, edge,
fixation, mobility)
– Surface
• No nodules (diffuse enlargement) – Grave’s disease, Hashimoto’s thyroiditis, endemic goiter.
• Single node – cyst, benign tumour, may be false positive only one nodule of multinodular goiter detected
 PALPATION
• Cont…
– Consistency
• Soft – Graves’ disease
• Soft (but firmer than fat pad) – normal
• Firm – goiter
• Rubbery hard – Hashimoto thyroiditis
• Stony, hard – carcinoma, calcification of cyst, fibrosis, Riedel’s thyroiditis
– Tenderness
• Commonly present in thyroiditis, and bleeding in cyst or carcinoma
– Margin
• Defined margin – thyroglossal cyst
– Mobility
• Carcinoma may tether the gland
– Thrill
• In unusually metabolically active thyroid (e.g., thyrotoxicosis)
 PALPATION
• Palpate while pt protrude
tongue (thyroglossal cyts)
• Palpate while pt swallowing
(assess symmetry,
asymmetry suggest
unilateral thyroid mass)
• Cervical lymph nodes
(thyroid ca)
• Tracheal deviation (large
goiter)
PERCUSSION
• Percuss on manubrium
– Resonant – normal
– Dull – retrosternal goiter
 AUSCULTATION
• Each lobe, take deep breath, and hold breath
• Bruit (increased in blood supply, e.g.,
hyperthyroidism, Graves’ disease)
• Stridor at lateral lobes (dt upper airway
compression by goiter)
PEMBERTON’S SIGN
 A test for thoracic inlet
obstruction due to retrosternal
goiter, or any retrosternal
mass
 Lifting the arms up pulls the
thoracic inlet upward, so that
the goiter occupies more of
the inflexible bony opening.
 PEMBERTON’S SIGN
 Lift both arms as high as
possible
 Wait for a few moments
 Inspect for
 congestion and cyanosis
 respiratory distress, and
inspiratory stridor
 venous congestion (neck vein
distension
SPECIAL TESTS
1. Pemberton’s sign
- lift both arms as high as possible
- watch the patient's face for signs of congestion, plethora and cyanosis. Respiratory distress and
inspiratory stridor may occur. Venous congestion may be apparent as distension of the neck veins.
- listen for stridor whilst the patient takes in a deep breath. This is a test for thoracic inlet obstruction
due to a retrosternal goitre or any other causes including lung carcinoma, other tumours (lymphomas,
thymomas, dermoid cysts) or an aortic aneurysm.

2. Berry’s sign
- Berry’s Sign is a malignant (bad) thyromegaly with an absence of a carotid pulsation as a direct result
of the tumor encasing the carotid artery and muffling the pulsation.
- Berry’s sign indicates a malignant tumour of the thryoid gland, as opposed to a benign tumour in the
absence of Berry’s Sign.
- originally identified by a thyroid surgeon named James Berry.
THANK YOU