This document provides details on properly examining a patient presenting with a thyroid swelling. It outlines the important components of history taking including symptoms related to the swelling, pain, pressure symptoms, and features of hyperthyroidism or hypothyroidism. The physical exam section describes in depth how to inspect, palpate, percuss, and auscultate the thyroid gland and surrounding area. It also discusses evaluating lymph nodes, looking for signs of hyperthyroidism, and conducting a full systemic exam. Investigations that may be performed are listed, including fine needle aspiration biopsy, laboratory tests, imaging studies, and managing the case.

1. CLINICAL DIAGNOSIS &
INVESTIGATION IN A CASE OF
THYROID SWELLING
KOUSIK KARMAKAR
8th SEMESTER
MALDA MEDICAL COLLEGE

2. PROPER HISTORY
1. SWELLING:
• DURATION
• ONSET
• SITE
• PROGRESSION
• RAPID GROWTH
2. PAIN:
• DURATION
• SITE
• CHARACTER
• RADIATION
• OTHER FACTORS
3. PRESSURE SYMPTOMS:
• DYSPNEA/ DYSPHAGIA/
HOARSENESS OF VOICE
4. FEATURES OF HYPERTHYROIDISM:
(THYROTOXICOSIS)
• CNS WITN EYE
• CVS
• GIT
• MENSTRUAL
5. FEATURES OF HYPOTHYROIDISM:
1. LETHARGY
2. DEPOSTON OF FAT
3. DEEP, HUSKY VOICE
4. INTOLERANCE TO COLD
6. OTHERS

3. On inspection-
o Number of swellings
o Site, size & shape of the swelling
o Location of the swelling
o Borders of the swelling w.r.t. sternocleidomastoid & suprasternal notch
o Surface of the swelling- smooth/ nodular/ bosselated
o Skin over the swelling- redness & edema/ scars, sinuses & fistula/ dilated veins
o Visible pulsations over the swelling
o Upward movement on deglutition & protrusion of tongue
o Look for lower border of the swelling
o Trial’s sign
o Pizzilo’s method
o Pemberton’s sign

4. PEMBERTON'S SIGN
• PROCEDURE:-
• ASK THE PATIENT TO RAISE BOTH RHE ARMS OVER THE HEAD
TOUCHING THE EARS AND MAINTAIN IT FOR 2-3 MINS.
• INTERPRETATION:-
• POSITIVE
• NEGATIVE

5. • On palpation-
• Temperature
• Tenderness
• Conventional/ standard method- palpation of thyroid from behind
• Thumbs of both hands are kept at the nape of the neck and the other 4 fingers of each hand are placed on each
lobe & the isthmus
• Lower tracheal rings are also palpated- to check for retrosternal extension
• Lahey’s method- palpation of thyroid from front
• Deep/ posteromedial surface is palpated
• To palpate the left lobe properly, thyroid is pushed to the left from right side by the left hand of the examiner and
vice-versa
• Crile’s method- for palpation of small nodules on thyroid gland
• Place the thumb on the affected side over the thyroid & patient is asked to swallow to check for small nodules

6. Whole thyroid not enlarged; only a single nodule:
• Location- lobe/isthmus
• Size
• Consistency- soft/firm
• Is the rest of the thyroid gland palpable???
When total gland is enlarged:
• Surface-
o Smooth- Colloid goiter, Grave’s disease
o Bosselated- MNG
• Consistency-
o Soft- Colloid goiter, Grave’s disease
o Firm- SNG, MNG
o Hard- Ca thyroid, Riedel’s thyroiditis
• Restricted mobility- Malignancy & chronic thyroiditis
• Palpate the lower border to check for retrosternal extension
• Pressure effects:
o Kocher’s test- typically positive in scabbard trachea of large & long-standing MNG
o Carotid sheath is pushed back by benign swelling where carotid pulsations felt
o Check for Horner’s syndrome (enophthalmos/ miosis/ anhidrosis/ pseudoptosis)
• Palpate for thrill
• Berry’s sign

7. • On percussion-
o Direct percussion / heavy strokes on manubrium-
 Resonant= normal
 Dull= retrosternal goiter
• On auscultation-
o Systolic bruit over the goiter in a case of primary toxic goiter due to increased vascularity

8. LYMPH NODES
• EXAMINATION OF THE CERVICAL GROUP OF LYMPH NODES
• NUMBER, SITE, CHARACTER, SURFACE,
MARGIN,CONSISTENCY,MARGIN, ENLARGEMENT

9. TOXIC SIGNS
1.PULSE:
• RATE, RHYTHM, CHARACTER
2.TREMOR:
• HANDS & TOUNGUE
3.THRILL & BRUIT:
4.EYE SIGNS:
1. NAFFZIGGER’S TEST
2. JOFFROY SIGN
3. EXOPHTHALMOS
4. LID LAG (VON-GRAEFE’S SIGN)
5. LID RETRACTION (DARLYMPLE’S SIGN)
6. MOBIUS’ SIGN (CONVERGENCE)
7. STELLWAG’S SIGN (INFREQUENT BLINKING IN OPEN
EYES)
8. ROSENBACH’S SIGN (BLINKING IN CLOSED EYES)
9. GIFFORD’S TEST- TO DIFFERENTIATE BETWEEN
EXOPHTHALMOS & PROPTOSIS

12. GRAVE’S OPHTHALMOPATHY
• CLASS 0- NO SYMPTOMS OR SIGNS
• CLASS I- ONLY SIGNS, NO SYMPTOMS(E.G. LID RETRACTION, STARE, LID LAG)
• CLASS II- SOFT TISSUE INVOLVEMENT
• CLASS III- PROPTOSIS
• CLASS IV-EXTRAOCULAR MUSCLE INVOLVEMENT
• CLASS V- CORNEAL INVOLVEMENT
• CLASS VI-SIGHT LOSS (OPTIC NERVE INVOLVEMENT)
NO
SPECS

13. Clinical Features
Primary Hyperthyroidism
(Grave’s)
Secondary
Hyperthyroidism
(Plumer’s)
Age Young Elderly
Onset Abrupt Gradual
Course Remissions & exacerbations Steady course
Nervous symptoms ++++ +
Metabolic
manifestations
++++ +
Eye signs +++ False
CVS manifestations + +++
Thyroid gland swelling Diffuse Nodular

14. RETRSTERNAL PROLONGATION
•FROM HISTORY
•ON GENERAL SURVEY
1.LOCAL EXAMINATION
2.ENGORGED VEIN
3.MARGIN OF THYROID GLAND
4.PERCUSSION

15. SYSTEMIC EXAMINATION

16. • Assess the cardiac condition :
• Bradycardia and tachycardia
• Assess the pulmonal condition :
• Slow respiration, shortness of breath
• Assess the abdominal condition :
• slowed or rapid peristaltic
• Assess the extremities condition :
• Tremor
• Thyroid dermopathy
• Moist hand, warm
• Dry skin
• Myxedema
• Assess the neuromuscular system
• Slow reflexes
• Hyper reflexes
• Assess the musculoskeletal system
• Muscular weakness

17. FINE NEEDLE ASPIRATION BIOPSY
LABORATORY INVESTIGATION
IMAGING STUDIES
ULTRASONOGRAPHY
RADIO IODINE STUDIES (RADIOACTIVE IODINE UPTAKE SCAN[RAIU])
CT SCANNING AND MRI
X-RAYS

18. FINE NEEDLE ASPIRATION BIOPSY
 MOST IMPORTANT DIAGNOSTIC TOOL. SAFE AND MINIMALLY INVASIVE
 ULTRASONOGRAPHIC GUIDANCE  INCREASES THE ACCURACY OF FNAB
• Indicated if:
• Palpation-guided FNAC non-diagnostic
• Complex (solid/cystic) nodule
• Palpable small nodule (<1.5 cm)
• Impalpable nodule
• Abnormal cervical nodes
• Nodule with suspicious US features
 GHARIB AND GOELLNER (1993) FOUND THAT
 69% OF FNAB RESULTS WERE BENIGN,
 4% WERE MALIGNANT,
 10% WERE INDETERMINATE, AND
 17% WERE NONDIAGNOSTIC.
 SENSITIVITY 83%
 SPECIFICITY 92%
 FALSE-POSITIVE RATE WAS 2.9%, AND THEIR FALSE-NEGATIVE RATE WAS 5.2%.

19. • Malignant (+ve) cytology
• Commonest is PTC(Papillary thyroid carcinoma):
• Characteristics cytological feature- psammoma bodies, orphan annie eye nuclei (cleaved nuclei)
• Others include:
• Medullary thyroid carcinoma(amyloid deposits, intracytoplasmic calcitonin), anaplastic carcinoma(cellular
anaplasia) and high-grade metastatic cancers
• Suspicious cytology in FNAC
• Diagnosis cannot be made
• Includes:
• Follicular neoplasms,
• Atypical PTC, or
• Lymphoma
ORPHAN ANNIE EYE NUCLEI

20. FINE NEEDLE ASPIRATION BIOPSY
COMPLICATIONS
1. MINOR HEMATOMA AND ECCHYMOSIS  MOST COMMON
2. PUNCTURE OF THE TRACHEA, CAROTID ARTERY, OR JUGULAR VEIN MAY
OCCUR
• CAN BE MANAGED BY APPLYING LOCAL PRESSURE

21. FINE NEEDLE ASPIRATION BIOPSY
Limitation
Difficult to differentiate between follicular adenoma and carcinoma on
cytology as it depends upon capsular and angioinvasion
Options in follicular carcinoma
Frozen section biopsy
Unilateral lobectomy
True cut biopsy
Danger of hemorrhage and injury to trachea, recurrent laryngeal
nerve and vessels

22. MANAGEMENT OF A CASE OF STN

23. LABORATORY INVESTIGATIONS
• Serum TSH levels
• Low level suggests
autonomously functioning
nodule (usually benign)
• Doesn’t rule out malignancy
• Serum calcitonin levels
• Highly suggestive of MTC if
increased
• More sensitive marker than
CEA
• PCR assays for germline
mutations in the RET proto-
oncogene
• Diagnostic in Familial
medullary thyroid
carcinoma
• Pentagastrin-stimulated
calcitonin
• Used as tumour markers to
monitor patients who have
been treated for MTC
• Serum thyroglobulin levels
• Cannot differentiate
between benign and
malignant disease
• Used in patients who
underwent total
thyroidectomy * for thyroid
cancer
• Patients undergoing non
operative management of
thyroid nodule
• * increased levels indicate
recurrence
• Urinary VMA, metanephrine
and catecholamine
• To rule out coexisting
Pheochromocytoma in MTC
• Serum levels of CEA
• Increased in MTC but
nonspecific
• Better indicator of
prognosis than Calcitonin
• New patients with MTC should
be screened for RET point
mutations, Pheochromocytoma
and HPT.

24. Range of tests available
TSH - In most situations TSH analysed using a high sensitivity assay is now accepted as the first line test for assessment of
thyroid function. A TSH between 0.4 and 4.0 mIU/L gives 99% exclusion of hypo- or hyperthyroidism,12 while the TSH is
considered more sensitive than FT4 to alterations of thyroid status in patients with primary thyroid disease.
FT4 - This test measures the metabolically active, unbound portion of T4. Measurement of FT4 eliminates the majority of
protein binding errors associated with measurement of the outdated total T4, in particular the effects of oestrogen.
FT3 - FT3 has little specificity or sensitivity for diagnosing hypothyroidism and adds little diagnostic information. The main
value of FT3 is in the evaluation of the 2 to 5% of patients who are clinically hyperthyroid, but have normal FT4. In this
situation, an elevated FT3 would be suggestive of T3 toxicosis, in which the thyroid secretes increased amount of T3 or there
is excessive conversion of T4 to T3.
Thyroglobulin – Levels are increased in all types of thyrotoxicosis, except thyrotoxicosis factita caused by self-administration
of thyroid hormone. The main role for thyroglobulin is in the follow-up of thyroid cancer patients. After total thyroidectomy
and radioablation, thyroglobulin levels should be undetectable; measurable levels (>1 to 2ng/mL) suggest incomplete
ablation or recurrent cancer.

25. Thyroid autoantibodies – The key reason for the measurement of these antibodies is almost entirely for the management
of those with abnormal thyroid function. Autoimmune thyroid disease is detected most easily by measuring
circulating antibodies against thyroid peroxidase and thyroglobulin (Thyroid peroxidase antibodies are also known as
anti-TPO or anti-microsomal antibodies). In subclinical disease, the presence of thyroid antibodies increases the long-
term risk of progression to clinically significant thyroid disease about two-fold. Almost all patients with autoimmune
hypothyroidism and up to 80% of those with Graves’ disease have TPO antibodies, usually at high levels, although
about 5 to 15% of euthyroid women and up to 2% of euthyroid men will also have thyroid antibodies.
Thyroid stimulating antibody - (Previously called long-acting thyroid stimulating antibodies or LATS) has a role in the
diagnosis of Graves disease where other test results are ambiguous. It may also be useful in pregnant women with
Graves disease, to determine the likelihood of fetal thyrotoxicosis.
Range of tests available

26. ULTRASONOGRAPHY
HIGHLY SENSITIVE FOR THYROID NODULES
CAN DEPICT NODULES ONLY A FEW MILLIMETERS IN SIZE
CAN DETECT NON PALPABLE THYROID NODULES
DIFFERENTIATE SOLID FROM CYSTIC NODULES
CAN DETECT ADJACENT LYMPHADENOPATHY
FEATURES SUGGESTIVE OF MALIGNANCY ON USG INCLUDE :
FINE STIPPLED CALCIFICATION
ENLARGED REGIONAL LYMPH NODES
USED TO FOLLOW THE SIZE OF SUSPECTED BENIGN NODULES

27. THYROID NODULE WITH FEW,
EASILY COUNTABLE
MICROCALCIFICATIONS
• SOLID, HYPOECHOIC, AND COARSE CENTRAL
CALCIFICATIONS
• LATER PROVED TO BE MEDULLARY
CARCINOMA
ULTRASONOGRAPHY

28. RADIOIODINE STUDIES
Recommended in patients having Follicular CA on FNAB and suppressed TSH.
Determine functional status of a nodule
• Based on radioisotope studies nodule can be →
Hot
 Autonomous toxic nodule
Warm
 Normally functioning
Cold
 Non functioning nodule (likely to be malignant but not always)
 Limitations of Thyroid scan
• Two dimensional scanning technique
• Inability to measure the size of a nodule accurately
• Missed malignant thyroid nodules

29. Thyroid Scan showing
cold nodule
Thyroid scan showing hot nodule
111 indium octreotide scanning
MTC (70% sensitive)

30. X-RAYS
• CXR and X-ray skull to rule out
metastatic deposits
• Skull metastasis more likely in
Follicular carcinoma
CT SCANNING
& MRI
• Used to evaluate soft-tissue
extension of large or
suspicious thyroid masses
into the neck, trachea, or
oesophagus
• To assess metastases to the
cervical lymph nodes
Images of a large, asymmetric multinodular
goiter. (A) Chest radiography shows marked
tracheal deviation to the right (arrow). (B) Chest
CT confirmed the presence of a large substernal
goiter on the left to the level of tracheal
bifurcation.

31. X-ray of skull showing a couple of painless,
progressively increasing swellings in the
occipitoparietal region of the scalp.