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Examination of Neck
https://t.me/med1917
Features
Smooth, soft, cystic, fluctuant, non-transilluminant
swelling which moves upwards with deglutition but
not while protruding the tongue out. It should be
differentiated from thyroglossal cyst and pretracheal
lymph nodes. It contains turbid fluid which often may
get infected to make swelling tender or to form an
abscess (Fig. 13.39).
Fig. 13.39: Sagittal and front view showing location
and relation of subhyoid bursa.
Anatomy of Lymphatics of the Head and Neck
Waldeyer’s lymphatic ring (Inner) (Fig. 13.40): It
consists of adenoids above, lingual tonsils below and
two palatine tonsils laterally one on each side.
Outer circular chain of nodes (outer Waldeyer
ring): Occipital, post-auricular, preauricular, parotid,
facial, submandibular, submental, superficial cervical
and anterior cervical.
Facial nodes: Superficial—Upper-infraorbital;
Middle-buccinator; Lower-supramandibular; Deep
groups-in relation to pterygoids;
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Fig. 13.40: Waldeyer ring
Submandibular lymph nodes drain: The side of the
nose; cheek; angle of the mouth; entire upper lip; outer
part of the lower lip; the gums; side of the tongue.
Submental lymph nodes drain: From the central part
of the lower lip, floor of the mouth and apex of the
tongue.
Superficial cervical nodes: They lie on outer surface
of the sternomastoid around the external jugular vein.
They drain the parotid region and lower part of the
ear.
Deep cervical lymph nodes: Upper deep cervical
lymph nodes—jugulodigastric nodes; Lower deep
cervical lymph nodes—jugulo-omohyoid nodes;
middle deep nodes. They drain from that half of head
and neck and finally form a jugular lymph trunk from
lower deep cervical to join thoracic duct on the left
side and junction of right subclavian and right jugular
vein on right side.
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SRB’s Clinical Surgery
Examination of
14
History taking begins with:
1. Name: It is first and basic requirement.
2. Address: Knowing the residential place may be
important in certain types of goitres. – endemic goitre
due to iodine deficiency is common in interior regions,
mountainous areas like V indhyas, Himalayas. Goitre
is more common in south India than north India. It
is also common in Middle East and European countries,
North America, Bulgaria near river Struma which
eventually reaches Aegean Sea. Follicular and
anaplastic carcinoma may be more common in iodine
deficiency areas but papillary carcinoma is not related
to iodine deficiency. Chalk or limestone producing
areas like Southern Ireland and Derbyshire are
goitrogenic areas as calcium is goitrogenic (Fig. 14.1).
3. Occupation: Not much related to thyroid diseases.
4. Age: Simple goitre is often seen in girls during
puberty . Goitre due to dyshormonogenesis occurs in
younger age group. Physiological goitre occurs when
there is increased metabolic demand of the hormone
like in puberty, pregnancy. Solitary nodule, colloid
goitre, papillary carcinoma and primary thyrotoxicosis
are seen between 20-40 years. Multinodular goitre,
follicular carcinoma and Hashimoto’s thyroiditis are
seen in middle aged women.
Fig. 14.1: Goitre may occur in many family members.
Two siblings presented with goitre.
Thyroid
5. Sex: Most of the thyroid diseases like hyperthyroidism (8:1), hypothyroidism, goitres, neoplasms
(3:1) are commonly seen in females.
Chief Complaints
Swelling in front of the neck and its duration; Pain
in the swelling and its duration; Hoarseness of voice
due to recurrent laryngeal nerve palsy; Difficulty in
swallowing or breathing; Tremor in the hands; Generalised weakness; Palpitation; Loss of significant weight.
History
History of Present Illness
Swelling
Its duration, mode of onset whether sudden or insidious
in nature should be asked. Origin of the swelling, its
progress whether gradual (benign) or rapidly progressive (malignancy) or recent rapid increase in a preexisting swelling (benign turning into malignancy) or
sudden rapid increase may be seen in haemorrhage.
Haemorrhage or malignant transformation (follicular
carcinoma) can occur in a preexisting multinodular
goitre. Thyroglossal cyst may be present since
childhood. Swelling may be single/multiple or
occupying one lobe, or both lobes or isthmus. Most
of the goitres, solitary nodule, multinodular goitre are
slow growing swellings. Anaplastic carcinoma,
follicular carcinoma, medullary carcinoma are rapidly
growing tumours. Papillary carcinoma which is the
commonest thyroid malignancy , even though malignant
is a slow growing tumour often for few years.
Note: Any thyroid of any size or any duration or any
consistency or in any age group can be malignant
unless proved otherwise.
Examination of Thyroid
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Pain
Its duration, character like dull aching/pricking, site
of pain, radiation, factors which alters the pain should
be asked for. Usually goitres are painless. Thyroiditis
may be painful. Malignancy is initially painless but
later becomes painful. Infiltration into surrounding
structures (nerves)/necrosis/haemorrhage makes it
painful and tender. Anaplastic carcinoma commonly
infiltrates into nerves to cause pain.
Pressure Symptoms
Dysphagia (oesophageal compression), dyspnoea
(tracheal compression), stridor (infiltration into
trachea), hoarseness of voice (recurrent laryngeal nerve
compression) and Horner’s syndrome (infiltration of
cervical sympathetic chain – ptosis, loss of sweating,
in face same side, miosis and enophthalmos). Their
duration, onset and progression should be asked.
Features of Toxicity
Increased appetite/loss of weight/diarrhoea/chest pain
aggravated by exercise/palpitation/amenorrhoea/
irritability/nervousness/sleeplessness (insomnia)/hand
tremors/increased sweating/cold preference/heat intolerance/proximal muscle weakness in the thigh or arm
like fatigue on getting down steps or lifting weight
using arms (myopathy)—due to difficulty in isometric
contraction and increased muscle metabolism/wasting
of muscles/visual disturbances with bulging of the eyes
(exophthalmos). Usually in primary thyrotoxicosis,
symptoms appear first which are more severe than
secondary type; later diffuse thyroid swelling appears
in the neck. Here often swelling in the neck may not
be present or may not be obvious. In secondary
thyrotoxicosis obvious swelling appears first which
is nodular later symptoms of thyrotoxicosis appear
which are less severe initially compared to primary
thyrotoxicosis; but symptoms gradually become more
severe. Neurological and eye signs are more common
in primary thyrotoxicosis.
Features of hypothyroidism/myxoedema: Muscle
weakness/lethargy/weight gain/poor appetite/facial
swelling/cold intolerance/menorrhagia/constipation/
superciliary madarosis in lateral half of the eyebrows/
loss of hairs in scalp/change in voice due to vocal
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cord oedema/dry skin/muscle fatigue/lethargy/less
memory/sleepiness. Myxoedema crisis may develop
with acute exacerbation of features.
Past History
History of irradiation should be asked for carcinoma
thyroid. Irradiation to head and neck region may have
been given for benign lesions like adenoids, tonsillitis,
thymus, acne vulgaris or haemangiomas or malignancy
in younger age groups like for lymphomas. Chernobyl
nuclear disaster in Ukraine in 1986 caused increased
incidence of papillary carcinoma of thyroid in children
in that area. Previous history of having thyroglossal
cyst must be noted which might have been infected
causing fistula either due to spontaneous burst or after
surgical drainage of the infected cyst. Previous surgery
for thyroid in recurrent thyroid swelling or earlier
surgery for thyroglossal cyst in case of thyroglossal
fistula should be asked for.
Personal History
History of smoking, alcohol intake or any drugs which
may cause alteration in thyroid function should be
asked. History of any drug intake like patient may
be on thyroxine or on antithyroid drugs or beta blockers
or other drugs like lithium, PAS or sulphonylureas
which may alter the thyroid should be noted. Dietary
habits should be asked. Vegetables belonging to
Brassica family like cabbage, kale and rape are
goitrogens. Type of salt used in the family iodized/
home rock salt is also important.
Family History
Dyshormonogenesis, medullary carcinoma of thyroid
can be familial (MEN syndrome). Endemic goitre and
Grave’s disease can occur in families. Altered thyroid
function may be the cause for infertility.
Menstrual History
History of menarche/menopause; duration of menstruation, history suggestive of menorrhagia, amenorrhoea, oligomenorrhoea, etc. should be asked for.
Hyperthyroidism can cause amenorrhoea; hypothyroidism may cause menorrhagia.
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Treatment History
SRB’s Clinical Surgery
History of undergoing investigations or treatment
relevant to thyroid disease should be asked for . Patient
may be taking L thyroxine (as once a day – small tablet)
or may be taking antithyroid drugs like carbimazole
or propylthiouracil usually three times a day for
hyperthyroidism. History should be detailed whether
patient is becoming better after therapy or not (drug
response). Often patient may be taking drugs like P AS
or sulphonylureas which are goitrogenic. History of
intake of drugs for other diseases should be mentioned.
General Examination
Like any other long case. Thyrotoxic patient is anxious/
thin and undernourished. Obesity is seen in myxoedema. Patient may be cachexic in thyroid carcinoma
which is advanced/metastatic. Exophthalmos should
be looked for in toxic patient. Irritable/agitated tensed
face with eye signs is seen in toxic thyroid. Myxoedema
face is typical. It is expression less, mask-like puffy
face. Patient will be dull with low intelligence (every-
thing is slow – walking, talking, moving, thinking,
reflex). Hasty – rapid gait is seen in hyperthyroid and
slow-lethargic gait in hypothyroidism. Pulse—Its
character, whether tachycardia, collapsing/Corrigan’ s
or pulsus paradoxus type or ectopic or fibrillation has
to be looked for. Pulse rate may be slow in hypothyroidism. Sleeping pulse rate is checked at late night
or early morning for three consecutive nights and
average is taken. Sedating with diazepam or phenobarbitone to check sleeping pulse rate prior to sleep
is a controversial (better to avoid). Sleeping pulse rate
is graded as per Crile’s grading. Blood pressure may
be high in toxic thyroid (Figs 14.2 and 14.3).
Fig. 14.2: Palpation of radial pulse for its count, volume,
variations should be done in thyroid diseases.
Fig. 14.3: Thyrotoxicosis with exophthalmos.
ankle region in front should be inspected for pretibial
myxoedema. It is a feature of primary thyrotoxicosis.
It is due to deposition of myxomatous tissue
(Fig. 14.4).
Crile’s grading Sleeping pulse rate/minute
I Up to 90
II 90-110
III > 110
In toxic thyroid, patient will be thin and underweight
in spite of patients’ good appetite. In hypothyroidism,
patient will be obese and overweight. Skin is wet and
warm in hyperthyroidism (moist palm while shaking
hands). Ankle (Achilles tendon) reflex is prolonged
with delayed relaxation in hypothyroidism and it is
shortened and brisk in hyperthyroidism. Both legs and
Tremor of the Hands and Tongue
Hand tremors are observed in outstretched hands and
fingers. Often small object like pen may be kept to
watch the tremor better. Fine tremors are observed
in toxic thyroid (Figs 14.5A to C). It is due to diffuse
irritation of the grey matter. T ongue twitching can be
observed by opening the mouth and carefully observing
the tongue. Tongue should be within oral cavity to
check the tremor. Protruded tongue causes fasciculation of intrinsic muscles of tongue which mimic
tongue tremor.
Examination of Thyroid
https://t.me/med1917
A
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Fig. 14.4: Pretibial myxoedema is seen
in primary thyrotoxicosis.
Assessment of voice change:
• Pitch of the voice—whether raised/lowered or pitch locked
• Breath support during speaking whether adequate or not
• Ability to alter the rapidity of speech – slow / fast / medium
• Altered laryngeal and neck muscle tension
Indirect laryngoscopy—with tongue pulled out using gauze,
warmed ILS is passed into the oral cavity to see vocal
cords. Patient is asked to say ‘e’ to see the vocal cord
movements
Local Examination
Inspection
Thyroid is the only endocrine gland which is properly
clinically accessible; only gland can be involved in
all age groups; only gland where malignant tumours
are mostly nonfunctioning.
Inspectory findings of the swelling should include (Figs
14.6A and B): Its location/size (both vertical and
B
C
Figs 14.5A to C: Tremor of the outstretched hands and
tongue (within) should be checked properly in toxic thyroid.
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A
B
Figs 14.6A and B: Simple goitre. Inspection
of goitre is very important.
SRB’s Clinical Surgery
horizontal dimensions of each lobe and isthmus or
if it presents as a single mass dimension of the single
swelling)/shape (butterfly shape if both lobes are
involved)/extent (from posterior border of sternomastoid laterally to midline in single lobe enlargement
of gland or from one side to opposite sternomastoid
if both lobes are enlarged)/ upper extent is usually
up to thyroid cartilage/lower margin may or may not
be clearly visible or may be visible during deglutition/
upwards movement with deglutition (thyroid moves
upwards during deglutition due to attachment of the
condensed vascular pretracheal fascia (Berry’s
ligament) above (Fig. 14.7), medially and behind to
cricoid cartilage and this pretracheal fascia is also
attached to larynx, thyrocricoid cartilage → thyrohyoid
membrane → hyoid with inferior constrictor muscle
which moves upwards during deglutition)/scar or
Fig. 14.7: Thyroid moves upwards with deglutition. Often
it is better to give a glass of water to the patient to drink.
dilated veins (in toxic goitre, carcinoma thyroid, venous
compression, retrosternal goitre) or pigmentation on
the skin over the swelling/pulsation over the swelling
(toxicity, malignancy)/surface on inspection (smooth
or nodular). Pizzillo’s method of inspection is done
in obese short necked individuals by pushing the head
backwards against clasped hands placed over the
occiput.
Surface is smooth in physiological goitre, primary
toxic goitre and Hashimoto’s thyroiditis. It is nodular
in multinodular goitre. In malignancy it can be smooth
or nodular. Thyroglossal cyst, subhyoid bursa,
prelaryngeal or pretracheal lymph nodes also move
with deglutition (Figs 14.8 to 14.10A).
Swellings which move upwards with deglutition
Thyroid swelling
Subhyoid bursa
Thyroglossal cyst
Pretracheal / prelaryngeal lymph nodes
Swelling from larynx / trachea
In some occasions whether swelling moves while
protruding the tongue or not should be looked for.
Thyroglossal cyst moves upwards with protrusion of
tongue. Patient is asked to open the mouth and then
swelling/cyst is held firmly. Now patient is asked to
protrude the tongue out to feel an upward movement
of the swelling with a typical ‘tug’ like feeling in
the swelling on inspection. Thyroglossal fistula
presents as a withdrawn opening in the midline below
Examination of Thyroid
https://t.me/med1917
Fig. 14.8: Diffuse toxic goitre. Surface of thyroid here
is smooth. Exophthalmos is also present.
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Fig. 14.10A: Recurrent nodule thyroid. Patient has undergone thyroidectomy once earlier. Note the scar in the neck.
Fig. 14.9: Large carcinoma of thyroid which is
vascular. Note the dilated veins.
the hyoid bone having a crescentic fold of skin (Fig.
14.10B).
Occasions wherein thyroid swelling may not move
upwards with deglutition-
Anaplastic carcinoma thyroid – often
Carcinoma thyroid with extensive local infiltration into soft
tissues, trachea / larynx and posterior muscles
Intrathoracic retrosternal extension with infiltration /
impaction
Riedel’s thyroiditis with encasement of trachea
Massive thyroid wherein upward movement is difficult
to observe and appreciate
Fig. 14.10B: Thyroglossal cyst.
Any other swelling in the neck should be looked
for like lymph nodes. Lymph nodes are commonly
involved in papillary carcinoma of thyroid and
occasionally in follicular carcinoma of thyroid.
Palpation
Palpation of thyroid is done from behind with the
patient sitting on a stool comfortably and flexing the
neck. Both thumbs of the examiner are placed over
the back of the neck and fingers of each hand are placed
on the respective lateral lobes for palpation (Figs
14.11A to C). Isthmus should also be palpated like
this. For detailed palpation of one side lateral lobe
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A
B
C
Figs 14.11A to C: Palpation of thyroid from behind with
patient sitting in a stool comfortably and neck flexed. Careful
palpation for nodules should be made.
SRB’s Clinical Surgery
patient is made to flex the neck towards that side to
relax the sternomastoid muscle. But many specific
tests are done with examiner standing in front.
Palpatory findings of the swelling includes: Temperature over swelling (swelling may be warm in toxic
thyroid, malignancy , thyroiditis)/tenderness (haemorrhage, thyroiditis, tumour necrosis can cause tenderness)/ extent/position/shape/size (should be measured
in centimeter both vertically and horizontally)/movement of the swelling upwards with deglutition/surface
(smooth or nodular)/consistency (soft or firm or hard
or variable and if so different locations of different
consistencies should be mentioned)/margin (well defined or diffuse, lower margin which is most important
should be specially mentioned))/independent mobility
of the swelling/plane of the swelling (it is checked by
contracting the sternomastoid muscles by placing
examiner’s hand under the chin of patient and patient
has to flex the neck against resisting hand) (relation of
the single side gland to sternomastoid muscle is
checked by contracting the muscle by turning the chin
against resistance of the examiner’s hand which is
placed on the opposite side) /whether skin is free or not.
Pizzillo’ s method also can be used for palpation in short
neck and obese patients to make nodules more
prominent (Figs 14.12A to 14.14).
Thyroid swelling moves upwards with deglutition;
but does not show independent upward mobility; it
shows horizontal mobility along with trachea. A small
encapsulated swelling occasionally may show independent free mobility.
Surface is smooth in primary toxic goitre, Hashimoto’s thyroiditis; nodular in multinodular goitre.
Consistency in thyroid swelling is variable in malignancy; it can be soft/firm/hard. It is hard in Riedel’s
thyroiditis and calcified cyst. It is firm or hard in
multinodular goitre. It is soft in colloid goitre, physiological goitre and primary toxic goitre. T ensely cystic
swelling can be felt hard; neoplastic solid swelling can
be softer—thyroid paradox.
Lower margin of the gland/swelling should be
checked during deglutition by placing the examiner’s
index finger horizontally just above the sternum.
Thrill is checked in the upper pole of the gland
as superior thyroid artery is superficial and enters the
upper pole of gland in front. Thrill signifies toxicity
or increased vascularity (Figs 14.15A and B).
Examination of Thyroid
https://t.me/med1917
A
Fig. 14.13: Lower border should be assessed in case of
thyroid enlargement to rule out possible retrosternal
extension.
329
A
Figs 14.12A and B: Contraction of sternomastoid one side/
both sides to confirm that thyroid is deep to deep fascia.
Method of Palpation of Thyroid Gland
Thyroid gland is palpated from behind with patient
sitting on a stool with neck partially flexed. Both thumbs
of the examiner are kept over the cervical spine and
fingers placed in front to feel the gland—both lateral
lobes and isthmus for all features.
Crile’s Method of Palpation of Gland
It is the palpation of the nodule/swelling in front using
the pulp of the thumb when patient is swallowing (Fig.
14.16).
Pizzillo’s Method
It is the method of inspecting and often palpating
the thyroid gland in short necked and obese
Fig. 14.14: Skin should be pinched to confirm that
swelling is not adherent to skin.
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SRB’s Clinical Surgery
A
Fig. 14.16: Crile’s method of palpation
using thumb for any nodules.
B
Figs 14.15A and B: Superior pole of thyroid should be
palpated for thrill which signifies vascularity.
individuals. Patient is asked to keep her/his clasped
hands over the occiput and head is pushed against
the hands; gland which becomes prominent will be
inspected or palpated from front or behind (Fig.
14.17).
Lahey’s Method of Examination
It is the method used to palpate any nodules in the
posterior part of the gland. It is mainly useful in solitary
nodule of thyroid. Examiner should stand in front of
the patient. If right lobe is needed to be palpated, left
lateral lobe is pushed towards right to make posterior
aspect of the right lobe more prominent as gland gets
pushed and rotated towards right side. Posterior
becomes posterolateral (by rotation of trachea) or
Fig. 14.17: Pizzillo’s method of examination.
lateral which is felt for any nodules. Posterior aspect
of left lobe is palpated by pushing the right lobe towards
left side (Fig. 14.18).
Kocher’s Test
It is the test to check for tracheal compression. Patient
is asked to see straight. W ith fingers and thumb both
lateral lobes of the thyroid gland are gently compressed
directing posteromedially. If patient develops stridor—
Kocher’s test is positive. If patient develops no stridor,
it means test is negative (Fig. 14.19). In a long
standing goitre and large goitre, weakening of tracheal
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