Neck swellings and Thyroid Clinical Examination
by Dr. Tajuddin FCPS FRCS
Assistant Professor of Surgery
Baqai Medical University Karachi Pakistan
Neck swellings
1. Number: single or multiple.
2. Site: anterior or posterior triangle.
3.Consistency: solid or cystic.
4. Movement:
with swallowing
with protrusion of tongue
no movement with either.
5. Classification
Multiple lumps: lymph nodes
Single lumps in the posterior triangle
not moving
solid: lymph node
cystic
cystic hygroma
pharyngeal pouch
pulsatile: aneurysm
Single lumps in the anterior triangle
not moving
solid
lymph node
carotid body tumour (transmits pulsation)
cystic
branchial cyst
cold abscess
moving with swallowing
solid: thyroid nodule
cystic: thyroid cyst
moving with tongue protrusion
solid: thyroglossal ectopic thyroid tissue
cystic: thryoglossal cyst.
The thyroid Clinical Examination
Inspection
Sit opposite the patient in a good light.
Don't forget to carefully assess the patient's general demeanour,
face and eyes.
For example, is there any sign of:
myxoedema
mental slowness
poorly marked outer eyebrows
dry, scanty and coarse hair
puffiness of the eyelids
a burgundy malar flush
a slow 'worn-out voice?
thyrotoxicosis
nervous tension
fine tremor
exophthalmos
lid lag
signs of weight loss?
A retrostemal thyroid causing thoracic inlet obstruction
respiratory' stridor
dilated veins?
Look for specific features of an enlarged thyroid gland
Is there an obvious goitre? Is it bilateral or unilateral?
Give the patient a glass of water and ask them to swallow
Thyroid swellings (because of the attachment of the thyroid gland to the larynx/trachea by the ligament of Berry and because of its inclusion within the pretrachial fascia) will move upwards on swallowing, unless fixed by malignant infiltration or active inflammation
A thyroglossal cyst will move on protruding the tongue
Look for any pattern of enlargement. Is it:
regular
irregular
bosselated?
Palpation
Do this from behind
Relax the strap muscles by getting the patient to slightly lower their chin
Palpate both lobes of the gland and-the isthmus with the fingers of both hands, while the thumbs rest on the nape of the neck
Define the extents of the gland, requesting the patient to swallow
again
Is the gland uniformly enlarged? If so, is it:
smooth
multinodular
hard
firm?
Does the gland contain any discrete swellings or solitary nodules?
If so, is it:
cystic
solid
a dominant nodule in a multinodular goitre?
Does the swelling extend retrosternally?
Is the trachea deviated ? (This is usually better assessed from in front by placing your finger in the suprasternal notch.)
Is the gland fixed, suggesting malignancy, and are there any lymph nodes palpable?
Is there a thyroid thrill? (Only present in very advanced cases of thyrotoxicosis.)
Percussion
Some surgeons find it helpful to percuss for any retrosternal extension (not a very sensitive physical sign).
Auscultation
Toxic thyroids often exhibit a bruit.
General factors
Do not forget to look for other general signs of hypo- or hyperfunrtion
Myxoedema
bradycardia
subnormal temperature
supraclavicular fat pads
rough dry skin
slow delayed reflexes
Thyrotoxicosis
tachycardia (even atrial fibrillation)
hot sweating hands
fine tremor
pretibial myxoedema.
Eye signs in thyroid disease
Exophthalmos
Assess by standing behind the patient and tilting head backwards. Examine the protrusion of the eyeball in relation to the superciliary ridges.
Mild
widening of palpebral fissure due to lid retraction (Stellwag's sign)
lid lag may also be present
Moderate
. actual bulging due to orbital deposition of fat
absence of wrinkling of forehead when patient looks up (Jeffrey's sign)
. Severe
intraorbital oedema with congestion, raised intraocular pressure and muscle paresis resulting in diplopia (ophthalmoplegia)
Subsequently there may be difficulty in convergence (Moebius's sign)
Progressive
increases in spite of successful treatment of thyroloxicosis. Can result in impaired visual acuity due to chemosis, impaired corneal sensitivity and ophthalmoplegia
Causes of exophthamos
Endocrine
thyrotoxicosis
Cushing's syndrome (rare)
acromegaly (rare)
Non-endocrine
skull deformity (e.g. craniostenosis)
orbital tumours, primary
meningioma
optic nerve glioma
lymphoma
osteoma
haemangioma
orbital tumours, secondary
carcinoma of antrum
neuroblastoma
blood-spread metastases
inflammation (e.g. orbital cellulitis)
vascular lesions
cavernous sinus thrombosis
cavernous sinus A-V fistula
ophthalmic artery aneurysm
eye disease (usually bilateral)
severe glaucoma
severe myopia.
