THYROIDPROF MR ANIL SIVASANKARANUPNM

THYROID GLANDHISTORY Age. Simple Goitre – young girls with iodine

deficiency, goitrogens & dyshormonogenesis. Puberty & Pregnancy. MNG, Solitary & Colloid Goitre’s seen n

young girls. Primary Toxic Goitre’s(PTG) – young patients.

THYROID GLAND Papillary Carcinoma in Young women. Hashimoto’s Disease in Middle Aged

women. Primary Thyrotoxicosis – unbalanced

Psychic condition with Worry & Anxiety.

THYROID GLANDSEX

Majority of Thyroid disorders – Females. Simple Goitres F>M Thyrotoxicosis 8 X F:M Thyroid Carcinomas F>M

THYROID GLANDOCCUPATION. Thyrotoxicosis appears in Stressed

individuals. PTG – Psychic.

RESIDENCE. Endemic Goitre-Geographical Distribution. Iodine deficiency Endemic Simple Goitre. Mountainous(Io) or Lime Stone(Ca)areas.

THYROID GLANDSWELLING. Onset,duration,rate of growth & pain. Primary Thyrotoxicosis c/o CNS S&S Sleepless Nights, Very Worried, Stressed

Out. Palpitations & Ectopic Beats. Secondary Thyrotoxicosis – c/o Cardiac

S&S. CHF/CCF.

THYROID GLAND

Sudden increase in Thyroid swelling with pain indicates Haemorrhage.

Thyroglossal Cyst – present since birth. Goitres are slow growing. Papillary & Follicular Ca are slow

growing. Anaplastic Ca – fast growing.

THYROID GLANDPAIN.

Usually a Painless condition. Inflammatory Conditions – Painful. Malignancy are painless till a late stages. Hashimoto’s Disease-discomfort in the neck. Anaplastic carcinoma-fast growing swelling.

THYROID GLANDPRESSURE EFFECTS.

Enlarged Thyroid: Presses on the

Trachea-Dyspnoea/Stridor. Presses on the Oesophagus-Dysphagia. Presses on the Recurrent Laryngeal

Nerves – Hoarseness of Voice (Anaplastic Ca).

THYROID GLANDSYMPTOMS OF PRIMARY THYROTOXICOSIS. Minimal enlargement of TG. Loss of Weight inspite of Good Appetite. Heat Inolerance/Preference to Cold. Excessive sweating. CNS S & S – Nervous Excitability,

Irritability, Insomnia, Tremor of Hands & Weakness of Muscles.

THYROID GLAND Exopthalmos. Palpitation, Tachycardia & Dyspnoea on

exertion. Staring or Protruding Eyes – difficulty in

closing eyelids. Double Vision – Opthalmoplegia. Oedema of Conjunctiva – Chemosis. Corneal Ulceration – Eye Painful. Amenorrhea.

THYROID GLANDSYMPTOMS OF SECONDARY THYROTOXICOSIS. Long standing Goitre shows features of

Toxicity. Brunt of attack on CVS. Palpitations, Ectopic Beats, Cardiac

Arrythmias, DOE, Chest Pain. CHF/CCF later stages with Ankle Swellings. CNS & Eye S&S – Mild or None.

THYROID GLANDHYPOTHYROIDISM/MYXOEDEMA. Increase Body Weight inspite of Poor Appetite. Fat Accumulate at back of neck & shoulders. Intolerance of Cold Weather. Preference of Warm Climate. Puffiness of Face & Pouting Lips. Dull Expression. Loss of Hair & 2/3rds Eyebrow – Charecteristic. Muscle Fatigue, Lethargy, Failing Memory. Mild Hoarseness due to Oedema of VC. Constipation & Oligomenorrhea.

THYROID GLANDPAST HISTORY.

Any treatment & Results of treatment. In Thyroglossal Cysts – h/o Abscess. Any Drug intake –

PAS/Sulphonilureas/Antithyroid Drugs.These drugs are Goitrogenic.

THYROID GLANDPERSONAL HISTORY.

Dietary Habits. Vegetables of the Brassica Family –

Cabbage, Cauliflower, Broccoli,, Kale & Rape are GOITOGENIC.

Low Iodine Sea Food-may cause Goitre.

THYROID GLANDFAMILY HISTORY. Goitre occurs in more than one member of

the family. Endemic Goitre may affect more members. Enzyme deficiencies within the Thyroid

Gland are Familial. PT seen n more than one member of the

family. Similarly Thyroid Cancers.

THYROID GLANDGENERAL SURVEY.

Build & State Of Nutrition. Facies. Mental State/Intelligence. Skin. Pulse rate.

THYROID GLANDLOCAL EXAMINATION:

INSPECTION: Examination of a Lump in neck. Normally not obvious. Swelling of the thyroid gland-seen. Pizzillo’s method: Hands are placed

behind the head and pt. asked to push back against clapsed hands at occiput.

THYROID GLAND Ask pt. to swallow – thyroid swelling

moves upward on deglutition. This is due to the thyroid gland fixed to

the larynx. Other swellings are – Thyroglossal Cysts,

Subhyoid Bursitis, Pre-laryngeal & Pre-tracheal LN.

These movements reduce on inflammation or malignant infiltration.

THYROID GLAND Retrosternal Goitre-pressure on GV at

Thoracic Inlet gives rise to dilatation of subcutaneous veins over upper anterior part of thorax.

Thyroglossal Cyst-moves upward on swallowing plus moves upward with tongue protrusion(pathognomic feature).

Thyroglossal Fistula – seen in midline below the Hyoid Bone.

THYROID GLAND PALPATION: Palpate the TG with the neck slightly

flexed. The gland can be palpated from front &

back. Seat the pt. and stand behind to

examine. Thumbs placed behind & four fingers

placed on each lobe+isthmus.

THYROID GLAND Each lobe to be examined separately-

additionally do turn the face to one side and examine the same side lobule by relaxing the Sternocleidomastoid.

Extend the neck to palpate the Thyroid Gland-if a nodule is present it becomes more prominent.

THYROID GLAND Palpation of each lobe (Lahey’s method)-

examiner stands in front of the patient. To examine the left lobe properly,the thyroid

gland is pushed to the left from the right side by the left hand of the examiner – left lobe more prominent to palpate by right hand.

Crile’s method-ask the pt. to swallow while placing the thumb on the gland-slight swelling & presence of nodules can be appreciated.

THYROID GLANDWhether whole thyroid gland is enlarged? Surface Smooth – P.Tcosis/Colloid Goitre. Bosselated – MNG. Consistency-Uniform or Variable. Firm – Ptoxicosis/Hashimotos Thyroiditis. Slightly Softer – Colloid Goitre. Hard in Reidel’s Thyroiditis/Carcinoma. Consistency will be variable.

THYROID GLANDWhen a swelling is localized. Note position, size, shape, extent &

consistency. Cystic swelling within the TG – feels firm

due to great tension within the cyst. Calcified Cyst-feels hard.Mobility – horizontal & vertical planes Fixity means Malignant Tumour or

Chronic Thyroiditis.

THYROID GLANDTo get below the thyroid gland.

Discard Possibility of Retrosternal Extension.

Clinicians Index Finger is placed on the Lower Border of Thyroid Gland, pt. asked to swallow thus lower border will be palpable as it comes up.

THYROID GLANDPressure Effect of Thyroid Swelling. On Trachea or Larynx-leads to STRIDOR

Inspiratory Noise of Inrushing air through narrowed Trachea).Later Dyspnoea.

Pressure on Recurrent LN – Hoarseness of Voice.

Carotid Sheath pressure. Kocher’s Test-If pressure on Trachea is

suspected,slight push on lateral lobes will produce stridor. Indicates obstructed Trachea.

THYROID GLAND Kochers test + - MNG & Ca Thyroid

infiltrating the Trachea. Tracheal position by palpation or placing

a Stethoscope. Xray’s will show exact position of

Trachea. MNG can push the Carotid Sheath

backwards & Malignant Thyroid may engulf the CS and no pulsations felt.

THYROID GLANDSympathetic Trunk infilttration by TG

HORNER’S SYNDROME: Enopthalmos-sinking of Eye Ball. Pseudoptosis-drooping of Upper

Eye Lid. Miosis-Constriction of Pupil. Anhidrosis-Absence of Sweating on

affected side of Face.

THYROID GLANDObstruction of Major Veins of Thorax.

Pemberton’s Sign: Engorgement of Neck Veins on asking

pt. to raise the hands above the head and arms to touch the ears.

THYROID GLANDTOXIC MANIFESTATION. Primary Toxic Thyroid – generally the

gland is not enlarged. Brunt of attack is on the CNS.

Enlarged or Nodular Thyroid with Toxicity is generally Secondary Thyrotoxicosis.Brunt of the attack is on the CVS.

THYROID GLANDWhether there is any: Evidence of Myxoedema. Evidence of Malignant or Benign

swelling. Pulsation or fluid thrill or bruit. Palpation of Cervical LN –Papillary Ca

where the TG is not enlarged but LNs’ palpable.

THYROID GLANDPERCUSSION: Over the Manubrium Sternii- to rule out

Retrosternal Goitre.

AUSCULTATION: Primary Toxic Goitre-Systolic Bruit heard

due to increased vascularity.

THYROID GLANDMEASUREMENTS:

Neck Circumference at most prominent part of swelling to be taken.

This is to determine whether swelling is increasing or decreasing.

THYROID GLANDGENERAL EXAMINATION.

Look for Primary Toxic Manifestations in Young Goitre pts’.

Look for Secondary Toxic Manifestations in Nodular Goitre.

Look for Metastsis in Malignant Thyroid Disease.

THYROID GLANDPRIMARY TOXIC GOITRE.EYE SIGNS: UNI OR BILATERAL.LID RETRACTION (LR): Overactivity of the Involuntary smooth

muscles of Levator Palpebrae Superioris muscle.

Upper Eye Lid is higher than normal & lower Eye Lid in Normal position-LR.

THYROID GLAND Lid Lag – Upper Eye Lid cannot keep face with

the eyeball when it looks down following examiner’s finger moving downwards from above.

EXOPTHALMOS: When Eyeball is pushed forward due to increase

in fat or oedema or cellular infiltration in the retro-orbital space ,the eyelids are retracted,sclera become visible below the lower edge of iris folowed by upper edge of iris.

THYROID GLANDVon Graefe’s Sign: The Upper Eye Lid lags behind the

eyeball as the pt.is asked to look downwards.

Joffroy’s Sign: Absencs of wrinkling on the forehead

when the pt. looks upwards with face inclined downwards.

THYROID GLANDStellwag’s Sign: Staring look and infrequent blinking of

eyes with widening of palpebral fissure. This is due to toxic contraction of striated fibres of Levator Palpebrae Superioris.

Moebiu’s Sign: Inability or Failure to Converge the

Eyeballs.

THYROID GLANDDalrympte’s Sign: Upper Sclera is visible due to retraction of

upper eyelid.OPTHALMOPLEGIA. Weakness of Ocular muscles due to Oedema

& Cellular Infiltration of muscles. Most often superior,lateral rectus & inferior

oblique muscles are affected. Paralysis of these muscles – pt unable to look

upwards & outwards.

THYROID GLANDCHEMOSIS. Oedema of the Conjunctiva. Conjunctiva is Oedematous, thickened &

crinkled. Chemosis is caused by obstruction of

the Venous & Lymphatic drainage of the conjunctiva by the increased retro-orbital pressure.

THYROID GLAND TACHYCARDIA

Increased Pulse Rate without rise in Temperature –Toxic Goitre.

Sleeping Pulse Rate. Rapid Irregular Puls e-??? – AF.

THYROID GLAND TREMOR: PT Goitre – Fine Tremor. Fine tremors are better seen in an

outstretched arms with fingers spread out.

Put out the tongue straight for ½ mt – Fibrillary Twitching noted.

Trembling of Tongue & Fingers noted in Severe cases.

THYROID GLAND MOIST SKIN:

PTG – hands & Feet are Moist. The Palms are hot & moist. Heal Intolerance with Cold Tolerance.THYROID BRUIT: PTG charecteristic feature. Increased Vascularity of the Gland. Relatively Late Sign-heard on Lateral Lobes

of TG.

THYROID GLANDSECONDARY THYROTOXICOSIS: MNG or Thyroid Adenoma Elderly Aged

Pts’. CVS mainly affected. AF common. Heart enlarged. Signs of Cardiac Failure – Oedema of

Ankles, Orthopnea, Dyspnoea while climbing staircases.

THYROID GLANDMETASTASIS – Search: Stony Hard, Irregular , Immobile TG. LN spread. Bony Spread – Follicular Ca. Examine the Long Bones, Skull, Spine &

Ends of Long Bones. Mets to Lungs.

THYROID GLAND SPECIAL INVESTIGATIONS:

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