THYROID GLAND
EXAMINATION
NIRVIGHNAM NOOR
CLINICAL
EXAMINATION
The First Impression
• General Inspection starts when the patient enters the room
• Demeanour: Anxious, restless, fidgety vs. Apathetic, slow
• Habitus: Weight loss vs. Weight gain/obesity
• Clothing: Dressed lightly for the temperature vs. extra layers
• Voice: Hoarse, deep, gravelly voice
GENERAL
ASSESSMENT
Build & Nutritional Status
•Thin, underweight, muscle wasting: Thyrotoxicosis
•Obese, overweight: Hypothyroidism
•Anemia, cachexia : A late sign for Malignancy
Facies
•Excited, tense, agitated, staring look: Thyrotoxicosis
•Puffy, dull, expressionless (mask-like): Hypothyroidism
Mental State & Demeanor
•Anxious, restless, fidgety, rapid speech: Thyrotoxicosis
•Apathetic, slow movement, dull intelligence : Hypothyroidism
Clothing
•Dressed lightly for the temperature: Thyrotoxicosis
•Wearing extra layers: Hypothyroidism
General Physical
Examination
Pulse
•Tachycardia (fast rate > 90 bpm): Sign of Thyrotoxicosis
• Sleeping pulse rate is a very useful index
•Irregular Rhythm (Atrial Fibrillation) : Common
complication of secondary thyrotoxicosis
•Bradycardia : Hypothyroidism
Other features
• Pallor – Not a common sign
• Icterus – Not a common sign
• Cyanosis – Not common , present in Pemberton sign
• Clubbing – Thyroid acropachy(Long standing graves’)
• Lymphadenopathy – Hard nodes can mean malignancy
• Edema – periorbital edema , pretibial myxedema
Skin
•Warm, Moist Palms: Thyrotoxicosis due to increased blood flow and
sweating.
•Cool, Dry, Inelastic Skin: Hypothyroidism (Myxoedema)
Voice
Hoarse, Deep, or Gravelly Voice:
•Suspect Hypothyroidism (due to myxedematous infiltration of
vocal cords)
•Can be a RED FLAG for Malignancy (due to recurrent
laryngeal nerve compression)
Peripheral Stigmata
• Examine the Hands:
• Tremor: Fine tremor of thyrotoxicosis (amplify with paper).
Nails: Onycholysis (Plummer's Thyroid Acropachy: Rare but
nails) seen in hyperthyroidism pathognomonic for Graves'
The Face and
Eyes
Sympathetic Signs (Any
Thyrotoxicosis)
• Dalrymple's Sign
- Upper eyelid is pulled higher than normal,
- Sclera above the iris exposed when patient looks straight ahead
Characteristic "staring" or "frightened" look
Lid Lag (von Graefe's Sign)
• Upper eyelid fails to follow the eyeball smoothly as it looks
downwards
• Ask the patient to follow your finger as you move it slowly from up to
down
• In a positive sign, the lid "lags" behind the globe, revealing a strip of
sclera above the iris.
INFILTRATIVE
SIGNS
Proptosis
• Forward protrusion of the eyeballs
• The sclera is often visible below the
iris
• An increase in the volume of retro-
orbital fat and muscles due to
autoimmune inflammation, cellular
infiltration, and edema
• Best appreciated by inspecting the
patient not just from the front, but
also from the side and from above
Chemosis
• edema of the conjunctiva, making it appear swollen and crinkled
• Obstruction of venous and lymphatic drainage due to the increased
pressure behind the eye
Ophthalmoplegia & Other Eponyms
• Ophthalmoplegia: Weakness of the extraocular muscles,
• leading to restricted eye movements and often causing diplopia.
• Inferior and medial rectus muscles are most affected
• How to Test: Ask the patient to follow your finger in an "H" pattern.
Movement is most often restricted on up gaze and outward gaze
•Joffroy's Sign: Absence of wrinkling on the forehead when the patient
looks up with their head tilted down.
•Gifford's Sign: Difficulty in everting the upper eyelid
•Moebius' Sign: Inability or failure to converge the eyeballs.
Sign / Eponym Description How to Elicit Pathophysiology Associated Condition
Lid Retraction (Dalrymple's Sclera visible above the iris in Observe patient looking straight Sympathetic overstimulation of Any cause of thyrotoxicosis.
Sign) primary gaze, creating a "staring" ahead. Müller's muscle.
look.
Lid Lag (von Graefe's Sign) Upper eyelid lags behind the globe Ask patient to follow your finger from Sympathetic overstimulation of Any cause of thyrotoxicosis.
on downward gaze. an upward to a downward position. Müller's muscle.
Proptosis / Exophthalmos Forward protrusion of one or both Inspect from front, side, and from Infiltrative: Specific to Graves' Disease.
eyeballs. above the patient's forehead. Increased
retro-orbital fat and muscle volume
from GAG deposition.
Ophthalmoplegia Restricted extraocular muscle Ask patient to follow your finger in Infiltrative: Inflammation and fibrosis Specific to Graves' Disease.
movement, especially on upgaze and an "H" pattern; ask about diplopia. of extraocular muscles.
abduction.
Chemosis Oedema and swelling of the Inspection of the conjunctiva. Infiltrative: Obstruction of Specific to Graves' Disease.
conjunctiva. venous/lymphatic drainage due to
increased
retro-orbital pressure.
Stellwag's Sign Infrequent blinking and widened General observation. Sympathetic overstimulation. Any cause of thyrotoxicosis.
palpebral fissure.
Joffroy's Sign Absence of forehead wrinkling on Ask patient to look up while keeping Sympathetic overstimulation. Any cause of thyrotoxicosis.
upward gaze with head tilted down. their head bent forward.
Moebius' Sign Inability to maintain convergence Ask patient to follow your finger as Infiltrative: Weakness of medial Specific to Graves' Disease.
of the eyeballs. you bring it towards their nose. rectus muscles.
Key Peripheral
Signs
Proximal Myopathy:
Test by asking patient
to stand from a chair
with arms crossed.
Pretibial Myxedema: Reflexes (Woltman's
Pathognomonic for Sign): Delayed
Graves'. Non-pitting, relaxation phase of
firm plaques on shins the ankle jerk is a
with "peau d'orange" classic sign of
texture hypothyroidism.
Examination of the
Neck
Inspection of the
Neck
• Look for obvious masses, asymmetry, scars.
• Dynamic Tests:
• Swallowing Water: Confirms thyroid origin of mass (moves up).
• Tongue Protrusion: Pathognomonic for thyroglossal duct cyst
(moves up).
• Enhancing Visibility (Pizzillo's Method): Patient pushes head back
against clasped hands. Useful in short/obese necks.
Deglutition – Important
inspectory tool
• Thyroid gland wrapped in the pretracheal fascia
• Tethered to the larynx (voice box) via the Suspensory Ligament of
Berry.
• Swellings that move with deglutition – goitre , thyroglossal duct cyst,
prelayngeal/pretracheal lymph nodes , subhyoid bursitis
• Swellings that don’t move – other neck swellings, Cervical lymph
nodes, malignant spread , retrosternal goitre
Palpation
• Confirm findings of inspection
• Palpation Technique:
• Patient is seated comfortably and neck slightly flexed.(Extension for tongue
protrusion test)
• Posterior Approach is preferred.
• Landmarks: Find thyroid cartilage,
slide down to the cricoid cartilage(most imp landmark)
the isthmus is just below(2nd to 4th tracheal rings)
• Palpate isthmus, then each lobe (b/w trachea and SCM)
• Have patient swallow while palpating -> Feel the borders
LANDMARKS
•Thyroid Cartilage
•Cricothyroid Membrane: The soft depression located between the thyroid and cricoid cartilage
•Cricoid Cartilage: Most crucial and reliable landmark, inferior border marks the superior edge of the
thyroid isthmus
•Tracheal Rings: The thyroid isthmus overlies the second and third tracheal rings, just below the
cricoid cartilage
•Suprasternal Notch: The depression at the superior aspect of the manubrium, marking the inferior
boundary for routine neck palpation
Describe the gland
• Size: Is the gland enlarged (goiter)?
• Shape: Is the enlargement diffuse or irregular?
• Symmetry: Does it elevate symmetrically with swallowing?
• Surface: Is it smooth, finely nodular ("cobblestone"), or grossly
nodular?
• Consistency: Is it soft (Graves'), firm/rubbery (Hashimoto's), or
hard/"stony" (cancer)?
• Sensation: Is there tenderness (thyroiditis) or a palpable thrill
(Graves')?
• Swallow: Is it mobile or fixed (suspicious for invasive cancer)?
CONTD.
• Specialized Techniques:
• Lahey's Method (Anterior): Palpate left lobe, push the gland left wrt
to patient with the left hand and palpate with right hand
• Crile's Method: Use thumb during swallowing for small nodules.
What to Assess:
Size, Surface , Consistency , Mobility , Lower border, Trachea,
Carotids, Lymph Nodes.
Kocher’s test (Tracheal compression)
• Technique: Gentle lateral pressure on the thyroid lobes.
• Positive: Elicits stridor, indicating a "scabbard trachea."
Auscultation &
Percussion
• Auscultation:
• Use the bell of the stethoscope over the superior poles of the
lateral lobes.
• Listen for a thyroid bruit: a low-pitched, continuous sound specific
to the high blood flow of Graves' disease.
• Percussion:
• Percuss downwards over the manubrium.
• Dullness may indicate a retrosternal goiter
Provoking
Compression
• Pemberton's Sign (Thoracic Inlet Obstruction):
• ○ Technique: Patient elevates both arms until they touch the head for
1 minute
• Positive: Facial congestion, plethora, cyanosis, distended neck veins
• Mechanism: Clavicles compress veins against a large retrosternal
goitre
Post-Operative setting
• Detecting Latent Tetany (Post-Thyroidectomy):
• ○ Chvostek's Sign: Tap facial nerve -> facial muscle twitch. (Low
sensitivity/specificity).
• ○ Trousseau's Sign: Inflate BP cuff -> carpal spasm ("main
d'accoucheur“ – Obstetrician’s hand). (More sensitive & specific).
DIFFERENTIAL
DIAGNOSIS
PROTOCOL
Size & Surface
• Is it a diffuse, smooth enlargement?
•Suggests: Graves' Disease, Colloid Goiter, Hashimoto's Thyroiditis
• Is the surface irregular, nodular, or bosselated?
•Suggests: Multinodular Goiter, Solitary Nodule, Carcinoma
CONSISTENCY
•Soft?
• Graves' Disease (fleshy), Colloid Goiter
•Firm or Rubbery?
• Hashimoto's Thyroiditis , Primary Thyrotoxicosis
•Hard or Stony?
•RED FLAG - Highly suspicious for Malignancy or Riedel's Thyroiditis
• Can also be due to calcification in a long-standing benign goiter
•Tender (Painful on Palpation)?
• Subacute (de Quervain's) Thyroiditis (often exquisitely tender),
Hemorrhage into a cyst, or Acute Suppurative Thyroiditis
Mobility
•Is the gland mobile in both horizontal and vertical planes?
•Normal finding
•Is the gland fixed to surrounding structures and does not move well?
•RED FLAG. Suggests malignant infiltration or chronic fibrosing thyroiditis
(Riedel's)
Assess Surrounding Structures for Local
Effects
• Check the Lower Border (Retrosternal Extension):
•Place your index finger on the lower border of the gland and ask the
patient to swallow.
• Can you feel the entire lower border rise up?
•Yes: Retrosternal extension unlikely
•No (Cannot get below the swelling): Suspect a Retrosternal Goiter
Assess the Trachea
• Gently palpate the tracheal rings
• Is the trachea central:
•Yes: Normal
•No (Deviated to one side): Indicates significant mass effect from
a large goiter or nodule.
•Perform Kocher's Test (if tracheal compression is suspected):
•Does this produce stridor (a high-pitched breathing sound)?
•Yes (Positive Test): scabbard trachea often seen in long-
standing multinodular goiters or infiltrating carcinomas
Assess the Carotid Sheath
•Is the pulse palpable?
•Yes: Normal. A benign swelling may push the artery
posteriorly, but it should still be palpable.
•No (Pulse is absent):
•RED FLAG (Berry's Sign). Suggests the carotid sheath
has been engulfed by an invasive malignant tumor.
• Palpate for Thrill:
• Especially on the superior poles.
•Is a vibration or "thrill" palpable?
Yes: Suggests the high vascularity and turbulent blood flow of
untreated Graves' Disease
Cervical Lymph Nodes
• Palpate all cervical lymph node chains (prelaryngeal, pretracheal,
paratracheal, and deep cervical chains)
•Are any nodes palpable?
•If yes, note their size, consistency and mobility.
•Palpable, hard nodes are highly suspicious for metastatic disease,
a common feature of Papillary and Medullary Carcinoma
COMMON
PRESENTATIONS
• Graves' Disease: Young woman, thyrotoxic, diffuse soft goitre, bruit,
florid eye signs
• Hashimoto's Thyroiditis: Middle-aged woman, hypothyroid, diffuse
firm/rubbery goitre
• Subacute Thyroiditis: Post-viral, severe neck pain, exquisitely tender
gland
• Malignancy: Red flags -> Rapid growth, hard/fixed mass, hoarseness,
cervical lymphadenopathy
