Thyroid Examination (OSCE Guide)

1/03/2020

Thyroid Examination (OSCE Guide)

Thyroid examination or the examination of a goiter commonly encountered at Surgical OSCE stations.


THYROID EXAMINATION

Firstly, greet the patient and take consent. Make sure you have enough space behind the patient’s chair before proceeding with the examination.

Examine from front
  1. Inspect – Offer a glass of water and ask to swallow on command & look for the lump moving upwards with deglutition. Observe from the side.
  2. Only if the lump is small and in the midline, ask the patient to put the tongue out while stabilizing the jaw and look for the lump moving upwards.
  3. Look for scars (previous lobectomy scar) and dilated neck veins.
  4. Only if the lump is a large one, elicit Pemberton’s sign.
Then go to back of the patient,
  1. Palpate the thyroid gland from behind. Examine using one hand at a time while stabilizing the gland from the other. Feel for the consistency and nodularity of the gland.
  2. Examine for cervical lymphadenopathy.
After that, come back to front of the patient and look for,
  1. Tracheal deviation – Feel along the trachea downwards.
  2. Retrosternal extension – Check whether you can feel the lower border of the gland while the patient is asked to swallow. If cannot percuss to elicit retrosternal dullness.
  3. Displaced carotid pulsation – Check both carotid pulses, one at a time.
  4. Thyroid bruit – Auscultate over the right upper lobe.
Finally, examine for eye signs and hands to complete the thyroid examination
  1. Eye Signs – Look for Exophthalmos (See from behind), Lid retraction, Lid lag, and Ophthalmoplegia.
  2. Hand signs – Look for sweaty hands, tachycardia (radial pulse), fine tremors.

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THYROID EXAMINATION – PRESENTATION

This patient is having a lump in the anteroinferior aspect of the neck which moves up with deglutition. There are no visible surgical scars in the neck or dilated neck veins and Pemberton’s sign is negative.

The lump is firm in consistency and its surface is nodular with a prominent nodule in the right upper lobe. There is no cervical lymphadenopathy. Its lower border can be felt, trachea is deviated to the left side and the right carotid pulse is deviated posterolaterally. There is no bruit. She is clinically euthyroid and there are no thyroid eye signs.

So, my probable diagnosis is a clinically euthyroid longstanding multinodular goiter (MNG) without retrosternal extension. I would like to investigate her with a thyroid profile, USS neck and FNAC of the prominent nodule to decide on further management



FREQUENTLY ASKED QUESTIONS

1. What are the causes of diffuse thyroid enlargement?

1. Simple colloid goiter.
2. Thyroiditis.
3. Grave’s disease.

2. What are the differential diagnosis for a solitary nodule of the thyroid (SNT)?

1. Prominent nodule of an MNG.
2. Hemorrhage into a colloid cyst.
3. Thyroid adenoma.
4. Thyroid carcinoma.
5. Foci of thyroiditis.

3. What would be the next management option, if the histology of an SNT comes as follicular neoplasm?

Thyroid lobectomy and look for the histology to decide on further management. If the histology is malignant, the other lobe is also removed later.

4. Where would you auscultate for a bruit?

Over the right upper lobe laterally while the patient is holding the breath.

5. What is the significance of a thyroid bruit?

It indicates the increased vascularity of the gland (hyperdynamic circulation) – seen in Grave’s disease.

6. What are the compressive features?

1. Nocturnal dyspnea and cough.
2. Recent onset dysphagia.
3. Deviated trachea.
4. Displaced carotid pulse.

7. What are the features of retrosternal extension?

1. Distended neck veins.
2. Positive Pemberton’s sign.
3. The lower border of the goiter cannot be felt.
4. Retrosternal dullness.

8. What are the malignant features?

1. Recent rapid enlargement.
2. Recent voice change (Hoarseness).
3. Hard in consistency.
4. Cervical lymphadenopathy.
5. Irregular margins.
6. Multiple attachments.

9. What are thyroid eye signs?

1. Lid lag.
2. Lid retraction.
3. Exophthalmos.
4. Proptosis.
5. Ophthalmoplegia.

10. How do you identify a thyroglossal cyst?

It moves upward with deglutition as well as with the protrusion of the tongue when the jaw is fixed. Being in midline differentiates it from goiters.

11. Why do we have to excise thyroglossal cysts?

1. Cosmetically unacceptable.
2. Prone to get infected.
3. May undergo malignant transformation.

12. What is the surgical procedure for a thyroglossal cyst?

Sistrunk procedure (Complete excision of the cyst and its tract together with the middle part of the body of the hyoid bone).

13. What are the indications for thyroidectomy for a multinodular goiter (MNG)?

1. Cosmetically unacceptable (Patient’s wish).
2. Compressive symptoms.
3. Secondary thyrotoxicosis.
4. Suspected or proven malignancy.

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