1. Thyroid history and examination HOLLY WILSON & MICHAEL AHN

2. Plan  Common disorders of the thyroid  How to take a thyroid history  Thyroid examination  A brief overview of neck lumps  Case studies

3. Function of the thyroid gland  Hypothalamus  TrH  TrH  pituitary gland  TSH  TSH stimulates:  Proliferation of thyroid tissue  Stimulates release of T 3 /T 4  Promotes iodine uptake/oxidation/etc.  T 3 /T 4 acts on peripheral tissues to:  Raise BMR  Increase # of beta-adrenoceptors  Fetus = responsible for maturation of the brain, bones, lungs

4. Common disorders of the thyroid Congenital Ectopic thyroid (90% lingual) Thyroglossal cyst Acquired Goitres Neoplasms

5. Goitres Simple Simple hyperplastic (iodine def) Multinodular (most common, dyspnoea/dysphagia/cosmesis) Toxic Grave’s (IgG to TSH R) Toxic multinodular Inflammatory Bacterial – staph/strep Viral – De Quervain’s – Cocksackie Autoimmune – Hashimoto’s (thryoglobulin + thyroid peroxidase antibodies)

6. Thyroid neoplasms  Benign  Follicular adenoma (common)  Malignant  Papillary (70%) iodine rich areas  Follicular (15%) iodine poor areas  Medullary (5-10%) – C cells, secretes calcitonin, assoc. MEN2 (phaeo)  Anaplastic (5%) 

7. History – systemic Sx  SYSTEMIC  Weight & appetite  Sweating & heat intolerance  Palpitations  Tremor  Menstrual irregularities  Irritability/anxiety/lethargy (not improved by sleep)/depression  Diarrhoea/constipation  Hair loss

8. History – local Sx  Neck lump – rapid (cyst) or slow onset?  Change in voice  Ca until proven otherwise!!  Recurrent laryngeal = vocal cord palsy = hoarse, stridor  External (superior) laryngeal = cricothyroid = cords open, monotone, aspiration

9. History – risk factors for thyroid disease  RISK FACTORS  Diet – iodine deficient?  Radiation exposure?  FHx  Autoimmune  IDDM  Addison’s  Pernicious anaemia

10. History – warm & fuzzy  “What is worrying you most about this?” = ideas + concerns  Some patients are terrified they have thyroid Ca, others have no idea why they were there (inappropriate TWWR)!  “Was there anything particular you were hoping we could do for you?” = expectations

11. Thyroid Examination

12. Thyroid exam  “Examine the neck” or “examine the thyroid”  If obvious signs of hyperthyroidism, “I would like to begin by assessing the peripheral thyroid status…”  Then examine the neck

13. Introduce “Hello, my name is ____ and I have been asked to do a thyroid examination. This involves me having a look and feel of your thyroid gland and checking the rest of the body. Is that okay?”

14. General Inspection Appearance  Have patient sitting down on a chair, facing you  Note:  Well/unwell/acutely unwell?  Agitation?  Fidgety?  Visible tremor?  Weight loss?  Muscle wasting?  Etc.

15. Inspection – Hands  Dryness/softness of skin  Sweat?  Palms - temperature + colour  Erythematous along thenar/hypothenar eminences? (sign of hyperthyroidism)  Thyroid acropachy  Swelling of phalangeal soft tissue  Due to Anti-TSH-r Abs binding to TSH-r in soft tissue  proliferation

16. Inspection – Wrist Radial Pulse  Rate  Bradycardia (<60bpm – sign of hypothyroid)  Tachycardia ( >100bpm – sign of hyperthyroid)  Rhythm  Irregular – sign of thyrotoxicosis

17. Inspection – Face + Eyes

18. Inspection – Face Skin  Dryness/softness of skin  Dry = hypothyroid  Wet = hyperthyroid (excessive sweating)  Noticeable weight loss?

19. Inspection – Eyes  Eyelid  Lid retraction (sclera visible above iris)  Globe position  Look at the eye facing the patient, beside the patient, and behind (thus above) the patient  Look for anterior displacement of the globe – exophthalmos  Conjunctiva  Injection? (Graves’)

20. Examination – Eyes Movements  The “H” test – ask patient if any discomfort/double vision, observe any restriction of movement  Lid lag test – head still  follow vertical movement of finger  observe any lag in upper eyelid

21. Inspection – Thyroid Where is the thyroid gland? What’s its normal size?

22. Thyroid Anatomy  2 shield -like, lobulated glands  Joined across the midline by an isthmus  Between 2 nd – 4 th tracheal rings  Anterior to lower part of larynx + upper trachea  Extends posteriorly to lie lateral to pharynx + oesophagus  Covered anteriorly by infrahyoid (strap) muscles

23. Inspection – Thyroid Expose the patient Inspect the anterior + lateral views of neck Skin  Any changes?  Erythema?  Scars – ask  Previous surgery? Visible lumps  IT MIGHT NOT BE THYROID GLAND  Assess/comment on size + shape + location  Normal gland should NOT be visible

24. Inspection – Thyroid  If mass is observed  Ask patient to swallow water  Note any changes in movement of mass  Immobile = lymph nodes  Mobile = thyroid masses, thyroglossal cyst  Ask patient to protrude tongue  Immobile = thyroid masses/lymph nodes  Mobile = thyroglossal cyst

25. Palpation – Thyroid Explain to patient  Stand behind him/her and feel the thyroid gland  Ask to do series of tasks Thyroid gland  Feel around the midline and locate the isthmus  Palpate each lobes and note for:  Size  Symmetry  Consistency  Mass  Palpable thrill  Ask to swallow water + protrude tongue

26. Palpation – Thyroid Lymph Nodes  Palpate for lymphadenopathies  Note size, shape, consistency, location of mass Trachea  Warn patient!  Comment on any deviation

27. Percussion – Thyroid Sternum  Percuss downwards from the sternal notch (Angle of Louise)  Dullness = expanding thyroid mass into retrosternal region (possibly retrosternal goitre)

28. Auscultation – Thyroid  Auscultate for possible bruit

29. Special Tests Limbs  Inspect for pretibial myxoedema  Inspect for proximal myopathy  Ask patients to stand with arms crossed  Check reflexes  Hyporeflexia = hypothyroidism  Hyper-reflexia = hyperthyroidism

30. To Finish…  Thank patient  Wash hands  Summarise findings  To conclude my examination…:  TFT  ECG  Further imaging if required (USS  CT/MRI)