Thyroid examination

1. Dr. W. Elkatib

2. Major Steps:
qGeneral exam (Thyroid Status)
qInspection from front
qPalpation from back
qPalpation from front
qPercussion and Auscultation from front
This step can be done at end of exam if the
examiner requested so.
It consists of general examination of:
qHands
qFace
qlegs

3. q Shaking hands with patient may give first
impression (dry and cold in hypoth, and hot
sweaty in hyperth )
q Nails: Plummer’s nails (clubbing, ridging, pitting,
beading, peaked nails and in advanced cases
onycholysis) in hyperth; normal or pale in hypo
q Palm: Palmar erythema in hyperth.
q Muscle wasting: generalized in hyperth, localized
thenar wasting in hypoth (CTS).
q Tremor: in hyperthyroidism

4. q Skin: dry scaly and thick (deposition of muco-
polysaccharides) with sparse hair in hypo. In
regards, it is sweaty, thin with normal hair
distribution in hyper.
q Muscles: (thenar, hypothenar, and interossei) are
wasted in hyper.
q Thyoid acropachy: (Clubbing+wide thickened
fingers and metacarpals due to subperiosteal new
bone formation) in hyperthyroidism.
q Pulse: tachycardia, arrhythmia, and large volume
in hyper; and bradycardia with low volume in
hypo.

5. Isolated M. wasting (usually nerve and muscle
diseases)
CTS in this case

6. PALMAR ERYTHEMA TREMOUR

7. SIGNS:
qTrousseau’s
sign
qChvostek’s sign
qPopliteal sign
q General look:
A. Hyperthyroidism: Staring look with agitation
B. Hypothyroidism: dull appearance, pouting lips,
peri-orbital puffiness and yellow tinge of skin.
q Eyebrows: loss of outer third of eyebrow in both
conditions

9. Late changes in
hypothyroidism
} Nafzingger’s sign in proptosis
} Dalrymple’s sign (lid retraction)
} Von Graeve’s sign (lid lag)
} Moebius’ sign (failure of eye convergence)
} Enroth’s sign (oedema of upper eyelid)

10. } Stellwag’s sign’s (infrequent blinking)
} Joffroy’s sign (absent forehead wrinkles)
} Gifford’s sign (inability to evert upper
eyelid)
} Rosenbach’s sign (tremor of the closed
upper eyelid)
} Reisman’s sign: Bruit over the eyelid

11. Joffroy’s sign
Normal forehead
whrinkles

12. q Both refer to forward protrusion of eyeball
beyond supra-orbital ridge and are used
interchangeably by some physicians
q However, exophthalmos commonly refers to
either:
1. Severe proptosis (>18 mm)
2. Endocrine-induced proptosis

13. q Retro-orbital tumours (NHL, meningioma,…etc)
q Trauma and retro-orbital haemorrhage
q Congenital skull malformations
q Cavernous sinus thrombosis
q AV fistula
q Infection (bacterial and fungal)
q Cushing’s syndrome and acromegaly
q Orbital pseudotumour (sarcoidosis, RA, PAN, SLE,
granulomatous diseases,….etc)

14. Frasier’s sign for proptosis
qPretibial myxedema
(Grave’s disease)
qDelayed relaxation
phase of ankle jerk
(hypothyroidism)

15. q Any Midline swelling (between two sternocleidomastoid
muscles).
q Movement on swallowing (goiter and thyroglossal cyst)
q Movement on tongue protrusion (thyroglossal cyst )
q Overlying skin?
Ø Scar
Ø Erythema
Ø Ulceration
Ø Tracheostomy
Ø Dilated veins
q Confirm movement on swallowing?
q Inferior border? (absent in
substernal extension)
q One lobe, isthmus or all?
q Size (small, moderate, or large)
q Tenderness (tender or not)
q Hotness (normal temp versus hot)
q Surface (diffuse, single nodule,
nodular )
q Consistency (soft, firm, hard)
q Thrill in Graves’ disease

17. q Tracheal position? (central or
deviated)
q Carotid pulsation (absent in
cancer and Reidle’s thyroditis
but displaced posteriorly by big
goiters _the so called Berry’s
sign )
q Auscultation for bruit ( in
Graves’ disease) using the bell
of the stethoscope over the
upper pole of the thyroid
q Substernal extension
q LN basin (crucial in tumours)

18. } Percussion over manubrium (Dull)
} Pemberton’s sign
} Other tests for thoracic outlet
syndrome (as Adson’s, Roos, and
Wright’s tests ). These tests have
modest reliability.

19. Slight compression of
the lateral thyroid
lobes will produce
stridor. This indicates
tracheal weakness and
softening by the
presence of long-
standing goiter.

20. q Throglossal cyst
q LAP (submental level Ia and Delphian level VI)
q Dermoid
q Laryngeal tumour
q Laryngocele (lateral or midline)
q Subhyoid bursitis
q Sternal tumour
q Skin lesions (as epidermoid cyst and lipoma)
q Ludwig angina (midline, lateral, or combined)

21. TG ABSCESS TG SINUS
Level Ia cervical LAP