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Exam of thyrod gland
1. CLINICAL DISCUSSION ON
EXAMINATION OF THYROID
GLAND
PRESENTED BY
DR.SHIVAKUMAR B.
FINAL YEAR IN-SERVICE PG SCHOLAR
DEPT OF SHALYA TANTRA
GAMC BENGALORE
UNDER THE GUIDANCE OF
DR.SHRIDHAR RAO S.M.
HOD DEPT OF SHALYA TANTRA
GAMC BENGALORE
2. CONTENTS
• Surgical Anatomy of Thyroid Gland
• Development
• Blood Supply, Nerve supply, Lymphatic drainage
• Physiology
• Gather equipment's
• History taking
• Physical examination
• Local examination
• Investigations
• Treatment
• Ayurvedic aspects
3. Surgical Anatomy of Thyroid Gland
• Endocrine gland ,situated in lower part
of the front and sides on neck. It
weighs about 20gms, highly vascular
organ opposite to the 5th,6th,7th cervical
and 1st thoracic vertebrae
• Consists of right and left lobes, joined
by isthmus.it is ensheathed by pretracheal
layer of deep cervical fascia each lobe is
5*3*1.5cms in size lobe is conical in shape
• Lobule is functional unit, supplied by an
arteriole.
• Each lobule consists of 25-40 follicles,
lined by cuboidal epithelium
4. Development :
•The thyroid gland arises initially as a midline diverticulum in
the floor of the pharynx.
•Endodermal in Origin
•Situation and Extent :
• Each lobe extends from middle of thyroid cartilage to
fourth or fifth tracheal ring.
• Isthmus extends from second to fourth tracheal ring
5. Blood Supply :
Supplied by Superior and Inferior Thyroid Arteries.
Drained by Superior, Middle and Inferior Thyroid Veins.
In some individuals, Fourth thyroid vein (of Kocher) may
emerge between middle and inferior thyroid veins.
6. NERVE SUPPLY
•Derived from sympathetic and parasympathetic
nerve
•Recurent Laryngeal nerve it is branch of Vagus
nerve
•Superior Laryngeal nerve divides into internal
and external laryngeal nerve
7. Lymphatic Drainage :
• Subcapsular Plexus drains
principally to the central
compartment juxtathyroid
'Delphian' and paratracheal nodes,
and also on nodes on superior and
inferior thyroid veins.
• From there it passes to deep
cervical
nodes and mediastinal group of
nodes.
10. History Taking
• Socio-Demographic Details
• Gender
Majority of thyroid disorders are commoner in females.
( Example : Simple Goitres, Thyrotoxicosis and Thyroid carcinomas )
• Thyrotoxicosis is eight times commoner in females than in males
• Every thyroid carcinomas are more often seen in female in the ratio of
3:1
11. AGE
• Pubertal Girls : Simple Goitre
• Young Age : Primary Toxic Goitre , Papillary Carcinoma
• Women in 20s - 30s : Solitary Nodular, Multinodular Goitre and
Colloid Goitre
• Middle aged Women : Follicular Carcinoma , Hashimoto Disease
• Old aged Women : Anaplastic Carcinoma
12. • Occupation : Thyrotoxicosis is common in patients working under
stress and strain
• Residence : Places endemic to goitre due to iodine deficiency.
Eg – Areas near rocky mountains like Himalayas, vindhyas and
satpura ranges. More common in southern India than northern India,
Great Britain-Mendips ,Derbyshire,Yorkshire
13. Swelling
• Onset – Duration – Progression – association with pain
• Simple goitre grows slowly
• Multinodular or solitary nodular colloid goitre increases size though
extremely slowly per year
• Fast growing swelling is seen in anaplastic carcinoma
• Slow growing swelling is associated with papillary and follicular
carcinoma
• History of sleepless nights (primary thyrotoxicosis)
14. PAIN
• Goitre - painless
• Inflammatory conditions – painful
• Malignancies – painless to start , painful in late
stages(infiltration of surrounding structures,nerves to cause
pain )
16. Symptoms of primary thyrotoxicosis
• Loss of weight inspite good appetite
• Preference for cold ,heat intolerance and excessive sweating.
• Nervous excitability ,irritability insomnia, tremor of hands, muscle
weakness
• Staring eyes, protruding eyes, difficulty in closing eyelids, double
vision ,oedema or swelling of conjunctiva(chemosis)
• Palpitation, tachycardia, dyspnoea (Less marked)
17. Symptoms of secondary
thyrotoxicosis
• Palpitations
• Ectopic beats
• Cardiac arrhythmias
• Dyspnoea on exhaustion
• Chest pain
• CCF(late stage with swelling around ankles)
18. Symptoms of Hypothyroidism(myxoedema)
• Increase in weight in spite of poor appetite
• Fat accumulates at the back of the neck and shoulders
• Cold intolerance/preference of warm climate
• Muscle fatigue, lethargy, loss of memory, mild hoarseness of voice,
constipation, oligomenorrhea
19. • Past history :
Drug history for goitrogens:which have low iodine content
(PAS, Thyocyanate, sulphonilurea, antithyroid drugs) Past
response to treatment
• Personal history: Consumption of vegetables of brassica
family i.e cabbage, turnips, cauliflower, sprout (goitrogens)
• Family history :Enzyme deficiencies, primary
thyrotoxicosis,and thyroid cancers
20. Physical Examination
• General survey
• Build and state of nutrition
• Lean and thin – thyrotoxicosis
• Obese – hypothyroidism
• Anaemia and Cachexia - Ca thyroid Facies
• Excitement, tension, nervousness,
exophthalmos (Hyperthyroidism)
Puffy face without expression(mask like face) - hypothyroidism
21. • Mental state and intelligence
• Dull with low intelligence – In hypothyroidism
• Pulse -
Irregular in thyrotoxicosis ,irregularity is more of a feature of secondary
thyrotoxicosis
In hypothyroidism pulse become slow(bradycardia)
• Skin
Moist – primary thyrotoxicosis
Dry and inelastic - hypothyroidism
22. Primary toxic manifestations (To be assessed
during general examination)
• Eye signs
-Lid retraction- by over activity
of involuntary part of the levator
palpebrae superioris muscle
,when the upper eyelid is higher
than normal lower eye lid is in its
normal position
23. - Exophthalmos-when eye ball is pushed forwards
do to increased fat in the retro orbital space
24. Von Graefe’s Sign (lid lag) –the upper eye lid lags
behind the eye ball as the patient is asked to took
downwards
25. Joffroy’s Sign -Absence of wrinkling on forehead
when patient is asked to look up with face inclined
downwards
29. Ophthalmoplegia
Patient can’t look upwards and outwards
Chemosis
Edema of conjunctiva : Venous and lymphatic drainage of
conjunctiva is obstructed due to increased retro orbital pressure
30. • Tachycardia
• Tremor of the hands (fine tremors are observed on outstretched hand
or tongue keep in this position for at least half min)
• Moist skin
• Thyroid bruit
• Search for metastasis
• Bony(skull, spine, pelvis) and lungs.
31. Local examination
Inspection
– Normal gland is not visible
– Pizzillo’s method
• Patient’s hands behind the head, and is asked to push against clasped
hands on the occiput.
• Uniform enlargement of whole gland – physiological goitre, colloid
goitre, Hashimoto’s disease
• Isolated nodules of different sizes – nodular goitre
• Swelling lateral to thyroid – aberrant gland or lymph node from Ca
32. Movement with deglutition :
• Thyroid moves on deglutition (thyroglossal cyst, sub hyoid
bursitis, pretracheal/prelarynngeal lymph nodes) greatly limited
when it is fixed by inflammation and malignant infiltration.
• Look for lower border of the gland,
not possible to see in retrosternal enlargement
– Pemberton’s test
Raising hands above head, with arms touching ears
Facial distress due to thoracic inlet obstruction
• Tongue protrusion test
Differentiate between thyroglossal cyst
and thyroid swelling(in ectopic thyroid gland)
33. Palpation
Position
• Patient is sitting, physician
stands behind/in front of the
patient
• Neck slightly flexed, thumb
behind the neck, other four
fingers on each lobes and the
gland palpated in its entirely.
34. • Lahey’s method
Examiner stands in front of the
patient
Gland is pushed to one side, ideal
for palpating margins
• Crile’s method
Thumb on the gland, patient is
asked to swallow (To look for
nodularity)
35. Points to be assessed during palpation
Whether the whole gland is enlarged ?
– If yes
• Surface – smooth (primary thyrotoxicosis ,colloid goitre and
bosselated (multinodular goitre)
• Consistency –
• Firm - primary thyrotoxicosis or Hashimoto’s disease
• Soft – colloid goitre
• Hard – Riedel’s thyroiditis
• Variable – carcinoma
36. • Is the enlargement localized?
Position, size, shape, extent, consistency
• Is the gland mobile?
To be checked in all directions
Fixed – Carcinomas or Chronic conditions
Can you get below the gland?
Are there any pressure effects?
Kocher’s test – Pushing lateral lobes of gland will cause
stridor(whistling sound), positive in multinodular goitre and carcinoma
thyroid. Position of trachea should be noted. Confirmed by X-ray.
37. • Carotid pulsations for involvement of carotid sheath
• Sympathetic trunk – Horner's syndrome(enophthalmos(posterior
displacement of eye ball), pseudoptosis(musculoskeletaldefect of eye
ball), miosis(contraction of pupil), anhidrosis(decreased sweating)
• Venous obstruction – Pemberton’s sign
• Are there any toxic manifestations?
• Are there any evidence
• Is the swelling benign or malignant?
• Are there any pulsations or thrill?
• Are there cervical lymph nodes palpable?
– Early lymphatic metastasis in papillary carcinoma of thyroid “aberrant
thyroid” of hypothyroidism?
38. Percussion
• Over manubrium sterni to look for retrosternal extension
Auscultation
• Primary toxic goitre – systolic bruit(vascular murmur )over the gland
Measurement of neck circumference to monitor growth of
the swelling
39. DIFFERENTIAL DIAGNOSIS OF THYROID SWELLING
• The word goitre denotes any enlargement of thyroid glands irrespective of
pathology , it is classified into
1. Simple goiter (non-toxic)
a) Diffused hyperplastic goitre- Seen in endemic area affecting children and
adolescent uniform enlargement due to increased TSH stimulation in response
to low level of circulating thyroid hormone.
Symptoms- swelling of the neck, pressure effect trachea and esophagus.
Sign- Diffuse swelling thyroid gland which Moves on deglutition and soft
b) Nodular- usually female late 30s,40s common site in junction of isthmus and one
lateral lobe. same as above signs and symptoms nodule may be palpable.
c) Colloidal-above 25yrs age accumulation of thick colloid material in the gland
after physiological hyperplasia have be subsided same as the above sign and
symptoms.
d) Multi nodular – Cut surface of multi nodular goitre reviles hemorrhagic and
necrotic areas separated by normal tissue which contain normal active
follicles.6:1 female than male.
40. 2. Toxic goitres
a) primary toxic goiter (graves disease)
b) Secondary toxic goitre
3. Neoplastic goiter
a) Benign
b) Malignant
41. 4. Thyroiditis
a) Auto immune (Hashimoto’s thyroiditis)-this is most common form
of thyroiditis four auto antigens has be detected-
thyroglobuline,thyroid cell microsomes , nuclear components and
non thyroglobulin colloid, the thyroid is symmetrically enlarged soft
rubbery and firm in consistency in 80% of cases. More related to
hypothyroid state .
b) Sub acute or granulomatous (De quervain’s) thyroiditis- viral in
origin female around 40yrs of age ,firm and irregular enlargement
,adhesion,fever malaise and pain.
c) Reidels thyroiditis-
• its rare chronic inflammatory process involving one or both lobes
firmly attached to trachea and surrounding tissues.
• difficulty in swallowing, hoarseness of voice
42. 5. Retrosternal goitre – more than 50% is below suprasternal notch
a) Sub sternal –common lower border of gland is behind the sternum
b) Intra thoracic – no thyroid is seen the neck
c) Plunging –patient is asked to cough thyroid plunges out , lower
border is seen in neck
6. Thyroglossal cyst- it appears from cystic degeneration of part of
thyroglossal track it is always on midline below the hyoid bone
7. Thyroglossal fistula-due to infection of thyroglossal cyst from just
above the hyoid bone to isthmus
43. TUMOUR
Benign tumour are rare and it can be either papillary adenoma
or follicular adenoma
Classification of malignant thyroid
tumours as follows
A)Follicular cell origin
a)Differentiated
I. Papillary carcinoma (60%)
II. Follicular carcinoma (15%)
III. Mixed carcinoma
b)Undifferentiated
• Anaplastic carcinoma (13%)
B) Parafollicular cell origin
Medullary carcinoma (6%)
C)Non thyroid cell origin
I. Malignant lymphoma (4%)
II. Sarcoma
III. Metastatic carcinoma
44. Carcinoma is again classified into
a) Papilliferous (young)
b) Follicular (middle aged)
c) Anaplastic (elderly):Rapid growing, surface is irregular,hard
45. Investigations
• Thyroid function test (TSH and T3,T4 )
• Euthyroid (Normal TSH,T3 and T4)
Normal serum value
TSH-0.3 to 5 mIU/ltr, Free T3 – 3.5 to 6 umol/ltr
T3-100 to 160 ng/100ml , Free T4-10 to 30nml/ltr
T4-4.5 to 11 micro gram/100ml
• Thyrotoxic (↓TSH, ↑T3 and T4)
• Myxoedema ( ↑TSH, ↓T3 and T4 )
• Thyroid autoantibodies (Antibodies against Thyroperoxidase and
Thyroglobulin )
• >25 units/mL for TPO(thyroidperoxidase) and titre of greater than
1:100 for antithyroglobulin are considered significant Ca
• Serum Calcitonin / CEA (carcinoembryonic antigen)as screening test
for medullary carcinoma
46. •Thyroid Imaging
• Chest and Thoracic Inlet X-Rays : Retrosternal Goitre, and
clinically significant tracheal deviation and compression.
• Ultrasound Scanning (High frequency)- inexpensive ,easy ,
Important in identification of nodes involved in thyroid cancers.
(May reveal clinically irrelevant swellings )
• CT,MRI and PET: Reserved for assessment of known malignancy,
and status of extent of retrosternal goitre
• Isotope Scanning : Routine isotope scanning not indicated.
Investigation of Choice in toxic patient with nodule or nodularity
of gland.
FNAC :
• Investigation of Choice in Discrete Thyroid Swellings(MNG).
• Detect malignancy ,
47. TREATMENT
Selection of Thyroid Procedure:
• Diagnosis (If known pre-operatively)
• Risk of thyroid failure
• Risk of recurrent laryngeal nerve injury
• Risk of recurrence
• Grave's disease
• Multinodular goitre
• Differentiated thyroid cancer
• Risk of Hypoparathyroidism
48. Treatment for hypothyroidism
1)Non nodular goitre –thyroxin 0.3mg/day for month
Partial thyroidectomy
2)Multi nodular gotre-thyroxin 120 to a 80mg /day(if nodularity
persists)
Post op 0.1 mg of levothyroxine
3)Colloid goitre –partial thyroidectomy(for cosmetic reason)
4)Retrosternal goitre – resection
49. Treatment of Hyper Thyroidism
Aim :
• To restore patient to euthyroid state
• To reduce the functioning thyroid mass
• To minimize complications
Drugs :
• Potassium perchlorate 200mg to 400mg /day
• Propyl thiouracil 200mg TID ( In pregnancy)
• Beta blockers (propranolol 20-40mg)
• Carbimazole(thiourea derivatives) – 10mg 6th hourly ( it blocks oxidation of idodide to
iodine)
• Cortico-steroids (reserve drug in uncontrol hyperthyroidism)
50. Thyroid Operations
• All thyroid operations can be assembled by three basic elements
• Total lobectomy (Removal of one lobe&entire isthamus)
• Isthmectomy
• Subtotal lobectomy
•Total Thyroidectomy = 2*total lobectomy +Isthmectomy, choice today no
chances of recurrence,avoid resurgery
•Sub-Total thyroidectomy = 2*su
btotal lobectomy + Isthmectomy(leaving thyroid tissue as tip of small finger
in both side)
•Near Total Thyroidectomy = Total Lobectomy + Isthmectomy+Subtotal on
other side (Dunhill Procedure)
•Lobectomy = Total lobectomy + Isthmectomy
51. MOST COMMON FOR THYROID GLAND
Most surgical disease of thyroid gland is solitary thyroid nodule
Most common site is at junction of isthamus&lobe
Common drug for thyrotoxicosis is Carbimazole
Common investigation is USG
Common surgery of carcinoma is total thyroidectomy
Common Ca in children is papillary carcinoma
Thyrotoxicosis factitia:over dose of thyroxine at puberty goitre
Jod Basedow thyrotoxicosis:iodine induced thyrotoxicosis in hyperplastic
endemic goitre
Pendred”s syndrome:congenital deafness since infancy in diffuse
hyperplastic goitre
52. गलगण्ड
Nirukti
गलस्य पार्श्वे गलगण्ड एकः ch chi 12/79
Ast hrd utt 21/53
Samprapti
वातः कफर्श्चैव गले [१] प्रवृद्धौ मन्ये तु संसृत्य तथैव मेदः |
कु ववन्न्त गण्डं क्रमशः स्वललङगैः समन्न्वतं तं गलगण्डमाहुः ||२२||
Su Ni 11/22
Dalhana commentary
वातेन कफे न च गलगण्डो भवतत न पपत्तेन, स्वभावेन पपत्तजस्य गलगण्डस्या
भावात्
