Download Context of neck examination

Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
The PBL case is Peggy Marland, a 67 year old woman who has thyrotoxicosis due to a “hot” nodule. The case
introduces the anatomy, histology and imaging of the thyroid gland, thyroid hormones and the differential
diagnosis of a neck lump physiology.
The focus is on:
 Surface anatomy of the neck. The diagram of anterior neck structures appears is too low on the neck
photograph - please point this out to the students.
 General examination of the neck including the lymph glands. They have had a session on palpating the
neck lymph glands so this should be relatively straight forward
 Thyroid status and gland examination.
Time
(Session 1)
13.30 – 13.35
(5 mins)
Activity
Setting the stage
 Clinical relevance - Importance of adapting neck examination to the
presenting complaint.
 Explain objectives for session
 Stimulate prior recall – triangles of neck and palpation of cervical lymph
glands from recent ENT clinical skills session.
Time
(Session 2)
15.30 – 15.35
(5 mins)
13.35- 13.45
(10 mins)
13.45 – 15.00
(15 mins)
Exercise - Surface anatomy of neck.
13.45 – 15.00
(60 mins)
Core learning activity - Thyroid status examination.
 4 stage teaching
 In 4th stage use different students for part tasks
Practice with feedback
 Split the group into threes to practice and provide feedback to one another
 Monitor and provide constructive feedback
15.45 -17.00
(60 mins)
15.00
Encourage ongoing practice and transfer
 Reminder about ongoing practice
 Self directed learning - Essential learning for GEP year 1
17.00
Core learning activity - General neck and thyroid gland examination
 They covered cervical lymph gland examination a few weeks ago.
 Demonstrate of a general neck exam explaining what you are doing and
then follow this with a quick practice in pairs.
15.35- 15.45
(10 mins)
15.45 -17.00
(15 mins)
Learning outcomes
By the end of this session students should be able to:
 Identify the gross surface anatomy of the neck on a colleague
 Perform a general neck examination on a colleague
 Perform a thyroid status and gland examination on a colleague
Clinical relevance
The neck area is a very important area in clinical examination due to the large number and variety of
structures located there.
 There are a large number of lymph nodes in the cervical area. These could be a vital source of clues as
to the type and extent of pathology other body parts.
 The thyroid gland is a common source of pathology.
In this session you will be learning how to do a general examination of the neck. We will then learn how to
examine the thyroid gland and how to assess the multi-systemic effects of an over or underactive thyroid
gland.
Links with other learning


You have learnt how to assess lumps and examine the neck lymph nodes
Later this year you will be learning wrist full neurological examinations
Page 1 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Related Basic Science
Please prepare for this session by understanding the relevant physiology and embryology of the thyroid
gland. We will cover the relevant neck surface anatomy during the session.
Embryology of thyroid gland
The thyroid gland develops from an outgrowth of the pharyngeal endoderm. As the embryo grows the thyroid
gland descends into the neck, and for a short time the gland is connected to the developing tongue by a
narrow tube, the thyroglossal duct. At around seven weeks, the gland reaches its final destination in the neck
and the thyroglossal duct has normally disappeared, although the site of its origin remains as a pit on the
tongue, the foramun cecum. Remnants at the base of the duct can from a pyramidal lobe in the isthmus of
the thyroid. If a segment or the thyroglossal duct remains, it develops into a thyroglossal cyst which may
appear in childhood or adolescence anywhere in the midline of the neck at any point along the thyroglossal
tract. The cyst will remain “attached” to the tongue by the remnants of the duct and can be seen to move
upwards when the tongue is protruded, and also to the thyroid gland so it will also elevate when the gland
rises on swallowing.
Surface anatomy of the neck
Exercise – Palpate or identify the following on a colleague:
Trapezius muscle
 Upper attachment is to the occiput, lower attachments are to the transverse processes of the cervical
and thoracic vertebrae and to the clavicle.
 Push down firmly on hips, identify the anterior border.
Sternocleidomastoid muscle (SCM)
 There are two heads – sternal and clavicular. The body of the muscle attaches to the mastoid.
 It is easy to identify the sternal head and body of the muscle by turning the head away from the side
of the muscle.
Posterior triangle of the neck
The boundaries of the posterior triangle are as follows:
 Posterior border of the sternocleidomastoid muscle
 Clavicle
 Anterior border of trapezius
Anterior triangle of the neck
The boundaries are as follows:
 Midline of the neck
 Inferior border of the mandible
 Anterior border of the sternocleidomastoid muscle.
Page 2 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Vertebra prominens This is the vertebra in the cervico-thoracic region which has the most prominent
spinous process palpable from the skin surface (usually C7- although in a minority of people could be C6 or
T1).
To identify the vertebra prominens, flex the head and feel for the most prominent spinous process. It is
usually quite an obvious bony area that protrudes from the back of the neck.
Hyoid bone – This is a “u-shaped” bone, the two horns can be gripped between the finger and thumb and
moved side to side. It is palpable in the upper midline posterior to the chin.
It can feel quite uncomfortable when palpated – palpate your own in this exercise.
Thyroid cartilage - The thyroid cartilage is the midline prominence of the neck also known as “Adam’s
apple”. Its notched upper border is just below the hyoid bone.
Carotid artery pulse – Lateral to the upper aspect of the thyroid cartilage, medial to the sternocleidomastoid
muscle.
Cricoid cartilage. - This is the lower border of the larynx, it lies inferior to the thyroid cartilage and is the only
complete ring of cartilage in the respiratory tract.
This is an important landmark in the neck. It lies at C6 and marks the junction of the larynx with the
trachea and the junction of the pharynx with the oesophagus. It is palpable inferior to the thyroid
cartilage
Cricothyroid ligament – This lies between the thyroid and cricoid cartilage.
Palpate it between the two cartilages. It is an important landmark for emergency intubations.
Trachea -This starts at the level of C6 below the cricoid.
Thyroid gland - usual position
Identify the usual position of the thyroid gland (a normal healthy thyroid is neither visible nor palpable)
The gland is “H” shaped with a right and left lobe joined by a narrow isthmus.
 The thyroid isthmus usually lies below the cricoid cartilage
 The lobes lie lateral to the trachea extending upwards to the lower half of the lateral margins of the
thyroid cartilage.
 There is some normal variation as incomplete embryological descent can result in it being found at any
point between the base of the tongue and the tracheaThe usual position is anterior to the 2nd and 3rd
tracheal ring
Page 3 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Context of neck examination
This obviously depends on the history and clinical contex, but some examples include:
 In patients who have suffered a traumatic neck injury, the management and examination is focussed on
finding out if the patient has sustained a spinal cord injury.
 In patients with possible musculoskeletal pain, the examination would be focussed around the neck and
the surrounding muscles.
 In patients with a lump or swelling a general examination of the neck and thyroid gland is required
 If the swelling had appeared in the anterior triangle or if the patient had symptoms which raised the
possibility of a thyroid disorder, a specific examination which includes both a systematic examination
of thyroid function/status and an examination of the gland is needed
Today we will be focussing on the latter two scenarios, and the following examinations:
 Thyroid status examination.
 Neck and thyroid gland examination
Page 4 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Clinical features of thyroid disease
Thyroid disorders can be difficult to diagnose because patients with thyroid problems may have multisystemic effects such as the following:
 Physical/pressure related symptoms from the actual swelling/goitre
- Swelling in the neck
- Stridor due to tracheal compression
- Upper body oedema and distended veins due to retrosternal goitre compressing the SVC
 Metabolic signs or symptoms
- Eg weight loss and tachycardia due to excessive levels
- Eg weight gain and bradycardia due to diminished levels
 A deterioration in a pre-existing condition
- Deterioration of angina due to excessive thyroid hormones (demand > supply)
 A new condition
- Cardiac failure may be “high output failure” due to excessive hormones or due to myxodematous
infiltration of the heart with low hormone levels.
 An incidental finding
- Ascites in an abdomen patient may be due to hypo or hyper states
 A combination of any of the above
In clinical practice we refer to:


Thyroid status assessment: Thyroxine is responsible for regulating the rate of metabolism, and hence
could affect several other systems if the level is abnormal.
It is important to define the thyroid status which means whether a patient is clinically:
-

Euthyroid (normal)
Hyperthyroid –excess thyroxine levels. Thyroxine potentiates the effects of adrenaline, and many of
the features of hyperthyroidism represent increased activity of the sympathetic nervous system.
Hypothyroid – thyroxine deficiency
Hence a systematic examination is required to assess thyroid status.
Thyroid gland examination - the examination of the gland
Important points
 The thyroid gland is not usually visible unless enlarged.
 The term “goitre” refers to an enlargement of the thyroid gland
 The thyroid cartilage moves upwards on swallowing which means that the thyroid gland may be
seen or palpated on swallowing.
 A goitre can extend down into the superior mediastinum (retrosternal extension/retrosternal goitre)
 A thyroglossal cyst moves upwards on swallowing AND when the tongue is protruded.
Graves’ disease
This is the commonest cause of hyperthyroidism. It is an autoimmune disorder which could result in an
increase in size of intraorbital contents with characteristic eye features. However patients with Graves
disease aren’t always hyperthyroid- they may be euthyroid or hypothyroid.
Usually examinations of the status and gland are performed together when assessing a patient
suspected of having a thyroid disorder
Page 5 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
GENERAL EXAMINATION OF THE NECK AND THYROID GLAND
INTRODUCTION AND PREPARATION
 Introduce yourself to the patient and check the patient’s name.
 Explain the examination. After you have inspected the neck you will need to examine it standing behind
the patient. The patient will need to expose their neck and “collar bones”.
 Obtain consent.
 Clean your hands
 Position the patient sitting on a chair and expose the whole of the neck including the clavicles. The neck
needs to be slightly extended (chin slightly elevated to show any swellings)
INSPECTION
 Look from the front and back, and comment on any abnormalities anatomically (anterior triangle,
posterior triangle, midline etc)
 Goitre (front only) – look in the midline below the level of the cricoid cartilage
 Swellings
 Obvious lymphadenopathy
 Scars (a necklace scar at the base of the neck is often difficult to see)
 Pulsation
 SWALLOW: Ask the patient to take a sip of water and hold it in their mouth- then ask them to swallow
whilst observing to help distinguish between:
 a goitre or a thyroglossal cyst which will elevate
 other midline swellings such as lymph nodes, lipomas, dermoid cysts, which will remain still.
 TONGUE: Ask the patient to stick out their tongue to help distinguish between:
 a thyroglossal cyst which will elevate
 a goitre which will not move
PALPATION – MUST BE DONE GENTLY


TRACHEAL DEVIATION
From the front, check for tracheal deviation
 a goitre can push trachea to one side


THYROID GLAND/GOITRE
Now stand behind, and do the following:
 Palpate the two lobes and isthmus of the thyroid using the tips of your index and middle fingers
 To keep the thyroid gland in a fixed position to enable you to assess the surface texture, firmly press
and fix one side using your first and second and use the tips of the first two fingers of the other hand
to examine the texture of the opposite lobe. Do this on both sides Swap hands and examine the other
lobe
 Repeat the swallowing test (with a sip of water) whilst palpating over the thyroid.
If you find a goitre - define it in terms of:
 Site (Anterior or posterior triangle, unilateral or bilateral)
 Size.
 Consistency (hard = possible malignancy) / soft = likely benign)
 Shape and surface (
 Mobility
 Tenderness
 Borders (well circumscribed or irregular)



CERVICAL LYMPH NODES PALPATION
Work systematically through the entire neck region, palpating all the neck lymph node areas, and
covering the triangles to identify any lymph nodes of any other swellings or abnormalities.
 Start on the mastoid process on the right and the left
 Palpate down the anterior border of the trapezius muscle on each side
 Then gently palpate the posterior triangles with the flat of your fingers
Page 6 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
 Palpate up the posterior border of the sternocleidomastoid on each side back up to the mastoid
process
 Then palpate down the anterior border of the sternocleidomastoid on each side, your fingers should
meet in the midline at the sternal notch
 Then continue palpating upwards in the midline towards the chin.
 Palpating the carotid pulse is not part of this examination- if you do palpate it you must
never palpate both carotid pulses at the same time as this could cause cerebral ischaemia.
 Continue anteriorly in the midline and palpate the submental lymph nodes
 Then follow along the inferior border of the horizontal ramus of the mandible and palpate the
submandibular group of nodes.
 Then move to the pre-auricular, post-auricular and finally the occipital group of lymph nodes
 Your hands should then meet in the midline at the patient’s occiput
Describe any swellings found
Site
Size
Shape
Surface
Skin (overlying)
Contour
Consistency
Tenderness
Temperature
Tethered (mobility)
Pulsation
Fluctuancy
Border
exact position eg anterior/posterior triangle, anatomical relations
cm or describe as pea/walnut sized etc
eg spherical, ovoid, irregular
smooth, irregular etc.
normal, red, abnormal pigmentation, puckering, dimpling etc.
does the outline look regular or irregular?
soft, firm, rubbery, hard (associated with malignancy),
tender (inflammatory lesion/abscess) or non tender
assess overlying skin
mobile or fixed (associated with malignancy)
absent or present
absent or present
well circumscribed or ill defined (inflammatory or malignancy)
PERCUSSION
 Percuss for retrosternal extension or a retrosternal goitre, beginning just below the sternal notch
(normally resonant, but dull if goitre present).
AUSCULTATE
 If a goitre is found, auscultate over both sides for a bruit. Ask your patient to take a deep breath in and
hold it, whilst you listen with the diaphragm.
 The thyroid arteries profusely anastomose with one another over the surface of the gland. An
overactive gland demands more blood supply and a bruit suggests the increased flow typically seen
in Grave’s disease.
 There is no need to auscultate if there is no goitre.
CLOSURE




Thank the patient.
Leave the patient comfortable, help with dressing if necessary.
Clean your hands
Record / report your findings
IF YOU ARE ASKED TO DO A GENERAL NECK EXAMINATION, WITHOUT A THYROID
GLAND EXAMINATION, DO THE ABOVE BUT OMIT THE FOLLOWING:
 Palpation of the thyroid gland
 Percussion
 Auscultation
HOWEVER IF YOU ARE ASKED TO A GENERAL NECK EXAMINATION ONLY, AND YOU
INCIDENTALLY FIND AN ENLARGED THYROID GLAND, YOU SHOULD GO ON TO DO A
FULL THYROID GLAND EXAMINATION AS ABOVE
Page 7 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
THYROID FUNCTION/STATUS EXAMINATION
Introduction and preparation







Introduce yourself to the patient and check the patient’s name.
Explain that you would like to ask a few questions and then perform a general examination including
hands, face, neck, chest and legs, which will require exposure of these areas of the body. Their chest
can be kept covered until it is examined.
Obtain consent.
Ask the patient if they have any pain
Clean your hands
Position the patient initially sitting down, ensuring there is enough room for you to position yourself
behind the patient later in the examination
Gather equipment – stethoscope, pen torch
Ask a few relevant questions


Before starting the examination it may be necessary to ask the patient some questionsin order to elicit
symptoms to help diagnose the thyroid status
Watch the patient as you are talking and listen to the quality of the voice and speed of their speech as
you may pick up clinical signs whilst doing this.
Ask about changes in:
Weight
Appetite
Bowel habit
Periods
Temperature tolerance (to
heat or cold)
Skin, hair
Clues for hyperthyroidism
Weight loss
Increased appetite
Diarrhoea
Change/irregular
Heat intolerance - too hot
when other people are cold
Increased sweating
Mood
Exercise tolerance and
palpiations
Family history
Anxiety
Shortness of breath or
palpitations
Graves’ disease
Page 8 of 15
Clues for hypothyroidism
Weight gain
Reduced appetite
Constipation
Change/irregular
Cold intolerance - too cold
when other people are hot
Dry skin, hair / eyebrows
thinning.
Depressed mood
Shortness of breath
Underactive thyroid
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Then move on to the examination to assess thyroid status
Examination
General appearance,
clothing and behaviour
Voice/speech
Hands and wristsincluding pulse (rate and
rhythm) examine hands
and nails and then ask to
hold out arms horizontally
to look for a tremor – if
uncertain, balance a piece
of paper on the hands.
Check pulse rate and
rhythm
(If history is suggestive,
you could also examine for
signs consistent with carpal
tunnel syndrome, although
this is not a core/essential
part of thyroid status
examination)
Upper limbs – for
proximal myopathy- ask
the patient to abduct their
shoulders to 90 degrees,
and to resist when you
push downwards.
Face
Colour
Eyebrows
Hair
Eyes
Ask the patient to look
forwards:
Hyperthyroidism
Anxious, agitated, dressed
inappropriately for warmer
climate
Talks quickly
Hypothyroidism
Sleepy, slow movements,
dressed inappropriately for
cooler climate
Hoarse voice, slow speech
Palmar erythema
Warm, sweaty palms
Tremor
Acropachy – similar to clubbing,
a feature of Graves’ disease
Onycholysis – nail lifts off bed
Tachycardia, atrial fibrillation,
bounding pulse
Dry coarse palm/skin
Bradycardia, atrial fibrillation
Signs consistent with carpal
tunnel syndrome:
Weakness present.
Weakness present
Red and sweaty
Coarsened facial features
Loss/thinning of lateral third
eyebrows
Dry and thin
There are no eye changes
in hypothyroidism
Lid retraction is similar to the
wide eyed stare of fear due to
circulating catecholamines– the
sclera can be seen between the
iris and upper eyelid.
Exopthalmos – the sclera can
be seen between the iris and
lower eyelid
Chemosis – corneal oedema
Peri-orbital oedema/redness
Look from above the
patients head standing
behind the patient:
Proptosis – the eyeball
protudes beyond the
supraorbital ridge.
Hold a pen (or finger)
horizontally above patient’s
head about 0.5m in front of
their face. Ask them to
follow it, moving it quite
quickly downwards in
vertical plane.
Lid lag – movement of the
eyelids is delayed, lagging
behind the upper margin of the
iris as the eye moves
downwards (normally the eyelid
and globe move in unison)
Page 9 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Ask the patient to keep
their head still and follow
your upright finger. Ask to
report any double vision or
discomfort. Draw a H
pattern and watch the
eye movements. Move
your finger slowly and no
more than 1m span.
Ophthalmoplegia – look to see
if the eyes move in unison. If
there is any weakness of the
extraoccular muscles the patient
will see double (diplopia). Any
discomfort is due to the pressure
effect of infiltration.
(Simple diplopia = diplopia
which occurs when looking in
one direction only  usually
neurogenic origin
Complex diplopia = diplopia
when looking in several different
directions  usually myogenic
origin)
Malignant exopthalmos is an
emergency. Increased
intraocular pressure can cause
blindness due to pressure on the
optic nerve.
PLEASE NOTE: All of the eye
signs mentioned above
usually due to of Graves
disease APART FROM lid-lag
and lid-retraction, which are
due to excessive sympathetic
activity.
Chest
Signs of heart failure
Signs of a pleural effusion
Percuss and auscultate
bases only
Abdomen
None
Ascites- check for shifting
dullness
CHEST AND ABDOMEN ARE NOT AN ESSENTIAL CORE PART OF THE EXAMINATION,
AND SHOULD ONLY BE DONE IF YOU HAVE A SPECIFIC SUSPICION THAT IT MAY BE
PRESENT BASED ON YOUR HISTORY.
Lower limbs
Power- fold arms and
Weakness present
Weakness present
stand from sitting position
without using their hands
Check knee reflexes
Brisk
Look at the skin of the
lower limbs and particularly
overlying the shins
Pre-tibial myxoedema is a
course, plaque-like thickening of
the skin (purple ,orange or
brown) caused by
mucopolysacharide deposition.
It is an uncommon feature of
Graves’ disease.
Closure




Thank the patient.
Leave the patient comfortable, help with dressing if necessary.
Clean your hands
Record / report your findings
Page 10 of 15
Slow relaxation phase
Generalised myxoedema
can be seen due to a
mucopolysacharide
deposition under the skin.
It is non-pitting.
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
SUMMARY OF NECK AND THYROID EXAMINATION
INTRODUCTION
 Introduce yourself (full name)
 Consent
 Explain what examination entails
 Ask if in any pain
 Clean your hands
 Ensure adequate exposure (all of neck including clavicles)
 Position sitting on a chair with neck slightly extended
 Gather equipment (stethoscope, pen torch)
INSPECTION
 Scars
 Swellings
 Goitre
 Pulsation
 Lymphadenopathy


Swallow
o Sip of water see if any midline structures move
Protrude tongue
o Check if any swellings elevate or remain still
PALPATION
 Front
o Tracheal deviation
 Behind
o THYROID GLAND  lobes and isthmus/any goitre/nodules
 Fix gland with one hand so you can examine its surface on the other side
 Repeat swallowing test whilst palpating thyroid
o Lymphadenopathy
 Stand behind the patient
 Start at the mastoid process
 Go down ANTERIOR BORDER of TRAPEZIUS
 Then palpate POSTERIOR TRIANGLE
 Go up the POSTERIOR BORDER OF THE SCM upto the MASTOID
 Go down the ANTERIOR BORDER OF THE SCM to the STERNAL NOTCH
 Palpate the anterior triangle (between the anterior border of the SCM and the midline)
 Go up the MIDLINE (bilaterally) upto the chin
 Palpate following areas:
 SUBMENTAL
 SUBMANDIBULAR (inferior border of horizontal ramus of mandible)
 PRE AURICULAR
 POST AURICULAR
 OCCIPITAL
 (you have already done ANTERIOR+POSTERIOR TRIANGLES as above)
PERCUSSION
 Retrosternal extension of goitre
AUSCULTATION
 Bruits
CLOSURE
 Thank patient
 Ensure comfort and dignity
 Clean your hands and stethoscope
 Record findings
Page 11 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
IF YOU ARE ASKED TO DO A GENERAL NECK EXAMINATION, WITHOUT A THYROID
GLAND EXAMINATION, DO THE ABOVE BUT OMIT THE FOLLOWING:
 Palpation of the thyroid gland
 Percussion
 Auscultation
HOWEVER IF YOU ARE ASKED TO A GENERAL NECK EXAMINATION ONLY, AND YOU
INCIDENTALLY FIND AN ENLARGED THYROID GLAND, YOU SHOULD GO ON TO DO A
FULL THYROID GLAND EXAMINATION AS ABOVE
Page 12 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
SUMMARY OF THYROID STATUS EXAMINATION
GENERAL INSPECTION
 Clothes
 Body habitus (high/low BMI)
VOICE/SPEECH
 Deep
 Hoarseness
 Fast/slow
HANDS
 Warm/cool
 Sweaty
 Palmar erythema
 Acropachy
 Onycholysis
 Tremor
 Pulse rate/rhythm
UPPER LIMBS
 Reduced power
FACE
 Dry thin hair
 Loss of outer third eyebrows
 Red/sweaty
EYES







Proptosis
Exophthalmos (look from on top of patients head)
Lid retraction
Lid lag
Chemosis
Opthalmoplegia
Periorbital oedema
LOWER LIMBS
 Power
 Knee reflex
 Pretibial myxoedema
CLOSURE
 Thank patient
 Ensure comfort and dignity
 Clean your hands and stethoscope
 Record findings
Page 13 of 15
Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
Self Directed Learning
Clinical reasoning – Graves’ disease (primary hyperthyroidism)
Graves’ disease is an autoimmune disorder and is the commonest cause of hyperthyroidism (although
patients with Graves disease can be hypothyroid or euthyroid as well), women are five times more
likely to be affected than men. Autoantibodies bind to and stimulate the TSH receptor, bringing about the
signs and symptoms observed. The autoimmune mediated pathology in Graves’ is particularly targeted at
the soft tissues in the eye leading to mucopolysaccharide deposition, retro-orbital inflammation, swelling of
the extra-occular muscles and periorbital oedema.
Ophthalmopathy may precede any other symptoms and signs
The specific eye signs are:
 Exopthalmos
 Chemosis
 Proptosis
 Opthalmoplegia
 Malignant exopthalmos
None specific eye signs:
 Lid retraction and lid retraction
Other signs specific to Grave’s disease are
 Thyroid acropachy
 Pre-tibial myxoedema
The goitre seen in Grave’s disease is
 Usually diffuse, smooth and non tender.
 It may be highly vascular and demonstrate a bruit.
Systemic signs
 Patients with Graves’ disease may also exhibit any other signs associated with hyperthyroidism.
Once you start clinical attachments in T year you will come across a variety of thyroid disorders. The
diagnosis and management of thyroid disorders is complicated and very specialised. However, you will find it
helpful to familiarise yourself with the following disorders.
Secondary hyperthyroidism
This is overactivity in an already diseased and hyperplastic gland, typically occurring in middle aged patients
with a pre-existing euthyroid goitre.
Symptoms tend to relate to the effects on the cardiovascular system – cardiac failure and atrial fibrillation are
common. Nervousness, irritability and tremor may also be present but there is no ophthalmopathy (ie not
Graves’ disease).
The goitre is usually nodular.
Thyroid carcinoma
There are several types of primary malignant tumours of the thyroid gland. They may present like other
goitres, as a lump in the neck, often more rapidly growing.
Although dysphagia is uncommon, swallowing is often uncomfortable.
Hoarseness is suggestive of infiltration of the recurrent laryngeal nerve.
Deep cervical lymph nodes may be palpably enlarged.
Patients are usually euthyroid.
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Neck and thyroid examination (including thyroid gland and status)
Lead Lecturer: Dr Hamed Khan 2016-17
References and Further Reading
Textbooks:
 Khan, H et al. (2013) OSCE’s For Medical Finals, Blackwell, Oxford
 Hansen J, Lambert D (2005) Netter’s Clinical Anatomy, Icon Learning Systems, New Jersey
 Moore K L, Dalley A F (2006) Clinically Oriented Anatomy 5th Edition, Lippincott, London
 Bickley L S, Hoekelman R A (1999) Bates’ Guide to Physical Examination 7th Edition, Lippincott, London
 Cox N L T, Roper T A (ed) (2006) Clinical Skills, Oxford University Press, Oxford
 Welsby P D (2002) Clinical History Taking and Examination 2nd Edition, Churchil Livingstone, London
 Epstein O, Perkin D G, De Bono D P, Cookson J (1997) Pocket Guide to Clinical Examination 2nd Edition,
London
 Kumar P, Clark M (2002) Clinical Medicine 5th Edition, London
 Ellis H, Calne R, Watson C (2006) Lecture Notes General Surgery 11th Edition, Blackwell, Oxford.
 General Practice Notebook online http://www.gpnotebook.co.uk/homepage.cfm (accessed 19/4/10)
 Akunjee M, Akunjee N, Mann Z, Ally M (2012) Clinical Skills Explained, Scion Publishing Ltd Banbury
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