Thyroid Examination

Plethoric Facies

Horner’s syndrome

Neck – front and sides

• localised vs generalised swelling
• scars
• dilated veins (Pizzilo’s)
• ask patient to swallow: look for mobility and inferior border

Palpate entire gland – standing behind the patient

• tenderness?
• inferior border (ideally have the patient swallow some water)
• anterior surface
  • gland consistency
  • thrill
  • lateral displacement
  • mobility
  • size
  • shape
• carotids (trachea)
• cervical nodes

Percuss – to determine any retrosternal extension

• clavicles
• manubrium

Auscultate

• thyroid bruit
• Pemberton’s sign

Then shift your attention to the patient’s:

• Palms – e.g. palmar erythema
• Pulse – e.g. tachycardia
• Eyes – eye signs

Hint: push thyroid and larynx across with the contralateral hand affording the ipsilateral hand to better discriminate a solitary nodule from that of a multinodular goitre.

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Pursuing the examination of a goitre

Is the thyroid generally enlarged or is its enlargement localised to a particular lobe or pole or, indeed, the isthmus?

Are there any obstructive symptoms or signs suggestive of carcinoma, a Reidel thyroiditis or a long-standing multinodular goitre (MNG)?

• stridor – dyspnoea, cyanosis, restlessness, Kocher’s test
• dysphagia – difficulty swallowing
• plethora or dilated veins

Toxic signs – especially seen in Grave’s Disease

• eye signs
• hyperdynamic circulation, hot and moist skin, pulsatile goitre, tachycardia, thyroid bruit, thyroid thrill
• weight loss
• tremor
• cardiovascular disease – atrial fibrillation, heart failure (toxic adenoma, MNG)

Hypothyroid signs

• cold extremities
• loss/thinning lateral eyebrow
• waxy, yellow and burgundy skin (glycosaminoglycans deposition)
• bloated face with puffy eyes
• hair loss and dry skin
• bradycardia
• pretibial myxoedema

Signs of malignancy in a goitre

• rapidly enlarging solitary swelling
• fixity or hardness
• Berry’s sign – impalpable carotid pulsation
• Horner’s syndrome, hoarseness of voice
• lymphadenopathy
  • carotid sheath
  • pretracheal nodes
  • cervical nodes
• change in long-standing goitre
• other
  • direct oesophageal or tracheal infiltration or obstruction
  • distant metastases
  • cystic vs solid (transillumination)
  • male > female (dominant nodule)
  • pain – secondary haemorrhage in adenomatous cyst, thyroiditis (not necessarily malignant)

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Exophthalmos

Mild:

• widening of palpebral fissures (retraction of upper eyelids)
• Naffziger’s method negative
• von Graefe’s (lid-lag) sign positive

Moderate:

• bulging due mostly to increased deposition of fat
• Naffziger’s method positive
• Joffroy’s sign positive – absence forehead wrinkling on upward gaze, head bent forward

Severe:

Intra-orbital oedema with increased deposition orbital fat ± cellular infiltration

1. intra-orbital congestion
2. increased intra-ocular pressure
3. muscular paresis (ophthalmoplegia)
   1. reduced range of movement
   2. double vision
   3. Moebius’ sign: difficulty in convergence
   4. only in 50% of those with Grave’s disease
   5. immune mediated
   6. both eyes not necessarily affected
   7. unequally affected in significant proportion
   8. pretibial myxoedema (occasionally seen in those with exophthalmos)

Differential Diagnosis of exophthalmos

• proptosis – intra-orbital mass (Gifford’s sign)
  • upper eyelid easily everted

Progressive exophthalmos (rare)

Continuing increase in exophthalmos despite treatment and visual acuity becomes impaired by:

• chemosis – oedema of conjunctiva (“folds” seen)
• reduced corneal sensitivity – herald of corneal ulceration
• exophthalmic ophthalmoplegia (usually asymmetric) – elevators first, then adductors, of globe

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Hyperthyroidism and Pregnancy – management

Anti-thyroid treatment offers less risk to the patient and their pregnancy than surgery. Pharmacotherapy crosses the placenta to prevent both foetal and maternal hyperthyroidism.

Propylthiouracil (PTU) is used:

• Avoid β-blockers
• Radioiodine is contraindicated

But there is the risk of hypothyroidism in the foetus (T4/T3 → placental foetus slowly), therefore use lowest possible dose (≤ 200 mg / day PTU) aiming for FT4 within normal limits, remembering that total T4 levels are increased in pregnancy.

If needing ≥ 300 mg / day PTU in first trimester, best to plan for a subtotal thyroidectomy in the second trimester.

Management of Ophthalmopathy

• mild
  • elevate head at night ± diuretics
  • tinted glass
  • 1% solution methylcellulose eye drops
• severe
  • prednisone 120-140 mg / day (reducing quickly to lowest effective dose)
  • orbital radiation
  • orbital decompression

The mode of treatment of hyperthyroidism does not seem to influence the course of the ocular disease.

Hypothyroidism is to be avoided

Manage any associated dermopathy with topical steroids