OnExam

The thyroid gland is located in the anterior neck and usually consists of two lobes connected at their lower midregions by a transverse isthmus.

Setting

  1. During the thyroid examination the patient should be sitting comfortably
  2. Use tangential lighting to better inspect the thyroid gland
  3. Give the patient a cup of water to help them swallow during the examination

Inspection

  1. First generally inspect that patient for signs of hyper- or hypothyroidism
  2. Tip the patient's head back slightly
  3. Inspect below the cricoid cartilage for thyroid gland
    • Use tangential lighting as described above
  4. Inspect the thyroid gland
    • A normal thyroid gland is rarely visible because of its relatively small size, partial concealment by the sternocleidomastoids, and soft texture
    • Anteriorly
      Extending the neck can sometimes stretch superficial tissues over the thyroid which can make an abnormality more prominent
    • Laterally
      Look for a prominence protruding from the normally straight contour from the cricoid cartilage and the suprasternal notch
  5. Ask the patient to swallow
    • Give them water to sip if necessary
    • This changes the shadowing of any mass and also allows any low-placed gland to be raised up into view
  6. Note contour and symmetry

Palpation

Although there are many different approaches to palpation of the thyroid gland, the posterior approach will be described here. There is no data which supports one method over another. It is important to use the technique which is the most comfortable and to develop a systematic approach.

Predisposing factors for a false positive assessment of a goiter:
  • Thin individual
  • Gland placed higher than normal
  • Modigliani syndrome (Patient has a normally placed thyroid, however, the neck is long and curvy and this causes a prominence of the gland which is mistakenly attributed to enlargement)
  • Fat pad in the anterior neck
  • Thyroid pushed forward by lesions beneath it
Predisposing factors predisposing to the false negative assessment of goiter:
  • Inadequate physical examination
  • Individuals with short, thick necks
  • Atypical thyroid location: retrosternal, lateral lobes
  1. Seat yourself behind the patient and palpate the lobes of the thyroid with the ipsilateral hands
  2. Ask the patient to flex the neck slightly forward to relax the sternocleidomastoid muscles
  3. Find the isthmus of the thyroid
    • Find the notched thyroid cartilage and the cricoid cartilage beneath
    • The isthmus usually overlies the second, third, and fourth tracheal rings
  4. Ask the patient to swallow water and feel for the isthmus of the thyroid to rise beneath your fingers
  5. Palpate the right and left lobes of the thyroid individually between the trachea and relaxed sternocleidomastoid while asking the patient to swallow
    • Note the size, shape, consistency of the thyroid, and identify any nodules or tenderness
    • A normal thyroid will have a rubbery consistency
    • Soft in Grave’s disease
    • Firm in Hashimoto’s thyroiditis, benign and malignant nodules
    • Tender in thyroiditis
  6. Assessment
    • Small goiter
      • Grade 1 Goiter-enlarged on palpation but no visible enlargementwhen the neck in neutral
      • Grade 2 Goiter-enlarged on palpation and visible with neck in neutral position
    • Large goiter

Auscultation

  • Listen over the lobes for a bruit
  • Classic feature of Graves Disease

Clinical Usefulness

Findings suggestive of hypothyroidism
  • Cool and Dry Skin
      Sensitivity 0.16, Specificity 0.97
  • Cold/Dry palms
      Sensitivity 0.40, Specificity 0.75
  • Hair loss of eyebrows
      Sensitivity 0.29, Specificity 0.85
  • Enlarged thyroid
      Sensitivity 0.46, Specificity 0.84
Findings suggestive of hyperthyroidism
  • Pulse > 90 bpm
      Sensitivity 0.80, Specificity 0.82
  • Skin moist and warm
      Sensitivity 0.34, Specificity 0.95
  • Eyelid retraction
      Sensitivity 0.34, Specificity 0.99
  • Eyelid lag
      Sensitivity 0.19, Specificity 0.99/li>
    • Fine finger tremor
        Sensitivity 0.69, Specificity 0.94

    If goiter is detected by inspection and palpation
    • Sensitivity range 0.43-0.823
    • Specificity range 0.88-1.03
    • Likelihood ratio of goiter being present when clinically detected – 3.8-26.33

  • If goiter is not detected by inspection and palpation
    • Sensitivity range 0.05-0573
    • Specificity range 0.0-0.263
    • Negative likelihood ratio of goiter being absent when not clinically detected – 0.37-0.4
    • (95%CI)

  • Findings suggestive of thyroid carcinoma when goiter is present
    • Vocal cord paralysis
      • Sensitivity 0.242, Specificity 0.992
    • Cervical adenopathy
      • Sensitivity 0.452, Specificity 0.972
    • Fixation to surrounding tissues
      • Sensitivity 0.602, Specificity 0.942
    • Goiter nodular vs. diffuse
      • Sensitivity 0.782, Specificity 0.492

  • Findings suggestive of thyroid carcinoma when nodule is present
    • Vocal cord paralysis
      • Sensitivity 0.142, Specificity 0.992
    • Cervical adenopathy
      • Sensitivity 0.312, Specificity 0.962
    • Fixation to surrounding tissues
      • Sensitivity 0.13-0.372, Specificity 0.95-0.982
    • Diameter > 4 cm
      • Sensitivity 0.662, Specificity 0.662
    • Very firm nodule
      • Sensitivity 0.042, Specificity 0.992

References

  1. Bickley L, Szilagyi P. BATES’ Guide to Physical Examination and History Taking. 9th edition. Lipincott Williams & Wilkins; 2007.
  2. McGee, S. Evidence Based Physical Diagnosis. St. Louis Missouri. Saunders Elsevier. 2007.
  3. Siminoski, K. Does This Patient Have a Goiter? JAMA The Rational Clinical Examination. 1995; Vol 273, No. 10.