Examination of a Thyroid Lump
Examination of a Thyroid Lump. Demonstrated by Dr. D. J.
Anthony, Senior Lecturer, Department of Anatomy, Faculty of Medicine, University of Colombo. The thyroid gland is located in the anterior triangle of the neck, with its two lobes on either sides of the trachea connected by the isthmus. Before starting any clinical examination one should introduce himself to the patient and obtain the appropriate consent. The privacy of the patient should be ensured. The examination room should be well lit. The patient should be positioned appropriately. Adequate exposure of the patient is essential and there should be a chaperone.
"Hi, I am doctor D. J. Anthony." "In this video clip we are going to demonstrate" "the neck examination of a patient with a goiter." "You can see the patient comfortably seated on a chair" "and the accompanying chaperon nearby." "The other essential part is to obtain the consent." (Sinhalese) "Mama Dr. D. J. Anthony.
Poddak gediya pariksha karala balanawa." Basic steps of Thyroid Lump Examination Inspection Palpation Percussion Auscultation Relevent general examination The relevent general examination can be done at the beginning or at the end of the thyroid lump examination. "We will follow" "the order of inspection," "palpation, percussion" "and auscultation." "First of all the inspection of the neck." "It's always better for the examiner's eyes to be" "in level with the patient's neck." "On inspection there is a lump occupying the anterior triangle of the neck." "The lump" "appears asymmetrical more" "on the right side than the left side" "and on the right side there is a well demarcated small nodule sitting on" "the enlarged lump." "There are no scars visible in the neck." "There are no visible pulsations" "and the skin overlying the lump" "is normal." "There are no obvious dilated veins" "in the neck." "We will get the patient to raise the hands to see whether the" "veins get distended," "when she raises her hands. (Sinhalese) Ath deka udata ussanna." (Sinhalese) "Tikak wela thiyan inna." "still we can't see any dilated veins" "which means the Pemberton" "sign is negative, which means there is no evidence of retrosternal" "extension on inspection." (Sinhalese) "pallehata danna." "Now we will see whether this" "lump is arising from the thyroid gland." "For that I will give the patient a sip of water" "and ask her to swallow while inspecting the neck" "for upward movements of the lump." (Sinhalese) "Me wathura tika aragena kate thiyaganna" (Sinhalese) "gillinna epa mama kiyana kal." (Sinhalese) "dan gilinna" "You could see very well the upward movement of the lump" "with swallowing" "which suggest that the lump is arising from the thyroid gland." Note whether the lump is located more towards the mid line or laterally situated.
A mid line lump is more suggestive of a thyroglossal cyst. A thyroglossal cyst will move upwards with protrusion of the tongue. If it doesn't, it is more likely to be a thyroid lump. Smooth surface lump Multinodular lump Solitary nodule In inspection we look for overlying skin changes, surface of the goiter, symmetry or asymmetry of the swelling, pulsations and movement with swallowing. "Now we will proceed with the palpation." "And the palpation is done" "best from behind." "It is important" "for the patient" "to flex the neck a little bit, not much," "in order to relax the strap muscles," "so that we can feel the goiter" "easily; and" "make sure your thumbs are" "against the nape of the neck" "and your fingers" "coming forwards" " over the lump." "I will palpate" "one side at a time." "The lump appears to be;" "It is a multinodular goiter" "and with" "more nodules" "onto the right side" "than the left side." "It's a non tender lump with" "well defined margins" "and I can't feel any pulsations" "The next step is to see whether I can get below the lump while she is" "swallowing." "That is again to to see whether there is retrosternal extension." (Sinhalese) "Me wathura tika kate thiyaganna. Mama kiyanakota gillinna." (Sinhalese) "gilinna" "I can feel the lower borders very distinctly" "while she is swallowing." "Therefore," "there is no evidence of" "retrosternal extension" "on palpation." "Now I will look for" "carotid pulses." "Right side is not displaced." "Left side is not displaced either." "Then I will look for" "tracheal deviation" "for which I will come from front." "You can see" "the both heads of the sternocleidomastoid." "And I will insert my finger" "into the suprasternal space" "and try to go between the trachea and the sternocleidomastoid head." "And I can easily insert my finger on the right side" "and on the left side it's difficult" "which means there is evidence" "that the trachea is shifted to the" "left." "Sometimes," "when the thyroid gland is much enlarged towards the isthmus, it's very" "difficult to do this maneuver." "In that case" "the alternative maneuver is" "to first" "feel for the" "laryngeal prominence" "which can be easily felt" "and then" "bring your finger down" "along the larynx and the trachea to see which way the trachea is going and "here you can see" "my finger is going towards; I can feel it," "almost to the left side;" "more towards the left side than the right side" "which means the trachea is displaced" "to the left side." In palpation We feel for the surface Borders Consistency and thrills over the goiter Then we feel displacement of carotid pulses and trachea. "The next step of the examination is percussion." "That is to see wether there is any evidence of retrosternal extension." "It is important to percuss from" "resonant" "to dull." "Therefore," "I will percuss like this." "Resonant" "Resonant right throughout." "It is resonant right throughout" "which means there is no evidence of" "retrosternal extension on percussion" "The final step of the examination is" "auscultation" "to look for a bruit." "And I can't" "hear any bruits." "Now I will palpate for enlarged lymph nodes." "We will start with submental, which are not enlarged." "Then the submandibular." "Then we proceed to upper deep cervical." "Then the lower deep cervical." "Supraclavicular" "Occipital lymph nodes" "And the posterior auricular lymph nodes." "None of the lymph nodes are enlarged." "Thank you very much" "So to summarize the examination findings;" "this is a multinodular goiter with" "more nodules on the right side" "than the left side" "and the nodules are soft to firm in consistency and non-tender." "There is no evidence of" "retrosternal extension" "and the trachea is shifted to left" "and there is no evidence of" "carotid pulse displacement" "or there is no evidence of" "lymph node enlargements." In the relevant general examination, we look for peripheral signs of thyroid status for thyrotoxicosis or hypothyroidism Then we look for peripheral signs of metastatic malignancy. Following eye signs should be noted if present which suggest thyrotoxicosis.
Lid lag and retraction Exopthalmos Proptosis and Opthalmoplegia Ask the patient to outstretch the hands and observe for fine tremors which may be seen in thyrotoxicosis. Check for the radial pulses of the patient. Tachycardia and bounding pulses are seen in thyrotoxicosis Examine the palms for moisture and warmth which is also suggestive of thyrotoxicosis. If the patient has signs of myxedema, dry and cold palms or delayed relaxation of deep tendon reflexes hypothyroidism should be suspect. If carcinoma is suspected look for signs of metastatic malignancy Note any enlarged lymph nodes with hard consistency as noted before in the goiter examination.
Palpate the entire skull for hard bony nodules which is associated with follicular carcinoma. Look for any bony deformity or tenderness over long bones. Palpate the liver for any firm nodules and percuss the abdomen for free fluid. Percuss and auscultate over the lungs for signs of effusion and consolidation. If any of these are present metastatic malignancy is highly suggested. Horner syndrome can be caused by either pressure exerted by a retrosternally extended goiter or by malignant infiltration of a thyroid carcinoma.
The features of Horner syndrome are Ptosis Enopthalmos Miosis and Anhydrosis ~Audio Visual Unit~ ~Faculty of Medicine~ ~University of Colombo~ ~Sri Lanka~.
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