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354
11 History andExamination ofThyroid andParathyroid Gland Disease…
Fig. 11.2 Inspection of
thyroid swelling. (a)
Anterior inspection, (b)
Inspection in lateral
view
– Findings on inspection
• Side
• Site
a
Unilateral—Colloid goitre, toxic nodular goitre,
papillary carcinoma, follicular carcinoma.
Bilateral—Multinodular
goitre, papillary carcinoma, follicular carcinoma.
Whole gland—Physiological goitre, Grave’s disease, thyroiditis, anaplastic
carcinoma.
Mid-thyroid and upper
half- medullary thyroid
carcinoma.
Whole gland—primary
hyperthyroidism (Grave’s
disease).
One lobe—solitary thyroid nodule, toxic nodule,
adenoma, thyroid carcinoma.
Both lobes—multinodular
goitre
Isthmus—nodule.
b
• Size
AP—If AP diameter is
more, it is suggestive of
thyroid carcinoma.
Transverse—It is measured from midline to lateral limit of thyroid.
• Numbers
Single—colloid goitre,
nodular goitre, thyroid
adenoma
Multiple—multinodular
goitre
• Surface
Smooth—Grave’s disease,
physiological goitre,
thyroiditis
Lobulated/irregular—
multinodular goitre
• Movement on deglutition—
Thyroid swelling and
thyroglossal cyst move on
deglutition.
• Movement on protrusion of
tongue—Only thyroglossal
cyst moves protrusion of
tongue.
• Swelling—lymph node
enlargement
• Stridor—present or not
• Thoracic outlet obstruction
syndrome—To elicit this,
patient is asked to raise the
11.1 History/Presentation andExamination ofThyroid andParathyroid Disorders
hand above head touching the
ears. Check engorgement of
supercial vein over anterior
chest wall.
• Palpation of thyroid swelling—There
are two methods of palpation of
thyroid.
– Methods of palpation of thyroid
• Anterior approach
patient is examined in the sitting or standing position.
Fig. 11.3 Anterior
approach of palpation of
thyroid
Crico thyroid
membrane
Isthmus
355
First stabilize the head with
left hand then thyroid isthmus is located by palpating
between the cricoid cartilage
and the suprasternal notch.
Move ngers laterally under
sternocleidomastoids to try to
feel for the fullness of the
thyroid, lateral extension.
The sternocleidomastoid
muscle with one hand while
using the other to palpate the
thyroid.
356
11 History andExamination ofThyroid andParathyroid Gland Disease…
Surface of the nodule/swelling should be checked for
symmetry or regularity.
Give patient a glass of water
and ask to swallow a sip of
water, examiner will palpate
for upward movement of the
thyroid gland or hold swelling or nodule between the
thumb and ngers and ask the
patient to swallow to see
either the nodule move with
deglutition
Ask to protrude the tongue to
see the movement with protrusion of tongue.
The passive movement of the
gland or swelling should be
checked in transverse and
vertical directions.
• Posterior approach of palpa-
tion by posterior method is
done in a sitting position and
examiner stands behind the
patient.
patient is examined in the sitting position with slightly
downwards tilted chin. This
is done to relax the muscles
of the neck to help in palpation of the thyroid gland.
Examiner stands behind the
patient places his/her three
middle ngers of each hand
along the midline of the neck
below the chin. First, the
upper edge of the thyroid cartilage (‘Adam’s apple’) to be
identied with ngers then
moves ngers inferiorly until
you reach the cricoid cartilage. The rst two rings of the
trachea are located below the
cricoid cartilage and the thy-
roid isthmus overlies this
area. Thyroid isthmus is
located between cricoid cartilage and suprasternal notch
with pad of ngers.
Now move hands laterally to
feel under the sternocleidomastoid muscles for the fullness of the thyroid.
Patient is asked to swallow
some water to feel the upward
movement of thyroid gland.
– Points to be noted during palpa-
• Tenderness—It is sign of
inammation and indicative of
subacute thyroiditis, acute
infection, acute haemorrhage,
and carcinoma
• Site of thyroid swelling
Mid thyroid and upper
half—medullary thyroid
carcinoma
Whole gland—physiological
goitre, Grave’s disease, simple goitre
One lobe—solitary thyroid
nodule, toxic nodule, follicular carcinoma, papillary
carcinoma
Both lobes—multinodular
goitre, anaplastic carcinoma
Isthmus—solitary thyroid
nodule
• Size (diameter)
Anteroposterior diameter—
Greater AP diameter is indicative of malignancy
Transverse diameter—maximum diameter is noted
• Diameter of more than 4cm is
worse prognostic sign for thyroid carcinoma
• Overlying skin
Fixed/adherent—It is indicative of either inammation or
extrathyroidal spread of
carcinoma
11.1 History/Presentation andExamination ofThyroid andParathyroid Disorders
357
Mobile/not adherent—It is
indicative of benign nodule
• Surface of swelling
Smooth/regular—solitary
thyroid nodule, simple goitre,
physiological goitre, Hashimoto’s thyroiditis
Irregular—multinodular
goitre
• Consistency
Soft—colloid goitre, cystic
nodule
Firm—solitary thyroid nodule, thyroid adenoma
Hard—differentiated thyroid
carcinoma
Stony hard—anaplastic thyroid carcinoma
• Mobility
Mobile—solitary thyroid
nodule, differentiated thyroid
carcinoma
Immobile—anaplastic
carcinoma
Mobility with deglutition—
thyroid swelling, thyroglossal cyst
Mobility with protrusion of
tongue—thyroglossal cyst
• Fixity to underlying
Not xed/free—colloid nodule, nodular goitre
Fixed—extrathyroidal extension of thyroid carcinoma,
anaplastic thyroid carcinoma,
de quervain thyroiditis
A retrosternal thyroid mass,
which is located below the
suprasternal notch, is often
not palpable. The Pemberton
manoeuvre is used to raises
a goitre into the thoracic
inlet when the patient, elevates the arms above head.
This causes shortness of
breath, stridor, or distention
of neck veins.
A thyroid gland or thyroid
mass moves with the larynx
during swallowing (upward
movement, stationary phase,
and descent).
cal sign of hyperthyroidism
due to increase vascularity of
thyroid gland due Graves’ disease and toxic nodular goitre.
This is elicited by placing the
pads of the ngers over the
thyroid swelling, where an
abnormal thrill is palpable.
• Palpate for the other swelling
(enlarge nodes in neck) site—
level VI, than level IV andVII,
followed by level V, III, and II.
• Auscultation of thyroid gland
– Thyroid bruit—It is a continuous
sound that is heard over the thyroid
mass with stethoscope. It is present
in Grave’s disease and due to proliferation of the blood supply when
the thyroid enlarges.
– Carotid bruits—A carotid bruit is
a vascular sound usually heard during systole with a stethoscope over
the carotid artery because of turbulent, non-laminar blood ow
through a stenotic area.
• Clinical signs of hyperthyroidism
(Table11.1)
• Other clinical signs of hyperthyroid-
– Tremor—Ask the patient to stretch
both hands infront of examiner with
ngers apart. A ne involuntary
movement of ngers was noted in
hyperthyroidism. if there is no
movement, then a piece of paper
should be kept over outstretched
ngers. The fan should be switched
off.
– Moist, warm, smooth skin—The
patients with hyperthyroidism usually have moist palms due to excessive sweating. The examiner with
358
Table 11.1 Signs of hyperthyroidism
Sign Description Named after
Facial sign
Joffroy’s sign Absent creases on forehead on
Jellinek’s sign Hyperpigmentation of superior eye
Hertoge’s sign Loss of lateral 1/3 of eyebrow Eugene Louis Chretien Hertoghe
Sainton’s sign Delayed forehead wrinkling on
Stellwag’s sign Infrequent and incomplete blinking
Eye sign
Kocher’s sign Staring looks on visual xation, due
Exophthalmos
Dalrymple’s sign Rim of sclera is seen between
Wilder’s sign Jerking of eye on movement from
Rosenwag’s sign Staring look with infrequent
Payne–Trousseau’s sign Dislocation of globe John Howard Payne, and Armand
Mann sign Eyes seem to be situated at different
Loewi’s sign Quick mydriasis after installation of
Becker’s sign Abnormal intense pulsation of
Upper eyelid sign
Rosenbach’s sign Fine tremors of eyelids when closed Ottomar Ernst Felix Rosenbach
Riesman’s sign Bruits over eyelids David Riesman
Snellen–Riesman’s sign Systolic murmur can be heard over
11 History andExamination ofThyroid andParathyroid Gland Disease…
Alexis Joffroy
superior gaze
Edward Jellineck
fold
upward gaze
causes staring look
Emil Theodor Kocher
to spastic retraction of upper lid
John Dalrymple (1803–1852)
cornea and upper lid (upper eye lid
retraction)
Helenor Campbell Wilder
abduction to adduction
blinking
Trousseau
John Dixon Mann
levels because of tanned skin
Otto Loewi
1:1000 adr
Otto Heinrich Enoch Becker
retinal artery
Herman Snellen (1834–1908),
Von Graefe’s sign Upper eyelid lag on downgaze Friedrich Wilhelm Ernst Albrecht
von Graefe
Dalrymple’s sign Upper lid retraction John Dalrymple
Stellwag’s sign Incomplete and infrequent blink Karl Stellwag
Grove sign Resistance to pulling the retracted
upper lid
Boston’s sign Jerky irregular movement of upper
eyelid on downward gaze
Gifford’s sign Difculty in everting the upper lid Harold Gifford Sr.
Pochin’s sign Reduced amplitude of blinking Sir Edward Eric Pochin
Abadie’s sign Spasm of levator palpebrae
superioris with retraction of upper
lid
Vigouroux’s sign Eyelids fullness/swelling
Lower eyelid sign
Enroth’s sign Oedema of lower/upper lid Emil Emanuel Enroth
Grifth’s sign Lower lid lag on upward gaze Alexander James Hill Grif
Mean sign Increase scleral show on upgaze
Leonard Napoleon Boston
(continued)
11.1 History/Presentation andExamination ofThyroid andParathyroid Disorders
Table 11.1 (continued)
Sign Description Named after
Conjuctival signs
Goldzeiher’s sign Deep bulbar conjunctival injection Wilhelm Goldzieher
EOM movement signs
Moebius sign Unable to converge eyes Paul Julius Möbius
Ballet’s sign Restriction of one or more EOM Louis Gilbert Simeon Ballet
Suker’s sign Poor xation on abduction/lateral
gaze
Jendrassik’s sign Paralysis of all EOM/abduction and
rotation of eyeball limited
Pupillary signs
Knies’ sign Uneven pupillary dilatation in dim
light
Cowen’s sign Jerky contraction of pupil to light/
extensive hippus of consensual
pupillary reex
Other signs
Tremors Involuntary movement of
outstretched ngers
Palmer erythema Palms of both hands become reddish
Moist, warm and smooth palm It is due to hyperhidrosis (excessive
sweating) due to high BMR
Tachycardia Increased pulse rate
Thyroid bruits Sound over thyroid swelling
Hyperhidrosis Increase sweating
Pretibial myxoedema It is an inltrative dermopathy
Diffuse hair thinning
Brisk tendon reex It is a sign of hyperthyroidism
Generalised pruritis
Onycholysis
Palpable thrill It is a sign of graves’ disease
George Francis ‘Franklin’ Suker
Ernő Jendrassik
Max Knies
Jack Posner Cowen
359
his nger palpates the palm of
patient for wet and moist palms.
– Palmer erythema—It is a rare skin
condition in which the palms of
both hands become reddish.
– Tachycardia—Heart rate is more
than normal.
– Thyroid bruit—It is a continuous
sound that is heard over the thyroid
mass in Graves’ disease.
– Hyperhidrosis/excessive sweat-
body metabolism and heat production and also cause activity of the
sympathetic nervous system thus
leading to hyperhidrosis/excessive
sweating.
– Diffuse hair thinning—The hair
loss and thinning are diffused.
– Generalized pruritis—Pruritis
presents in 4–11% of patients of
thyrotoxicosis, particularly who
have long-lasting, untreated
Graves’ disease. The causes are
increased blood ow and skin temperature and decreased itch
threshold.
– Onycholysis—It is characterized
by the painless detachment of the
nail from the nail bed, usually starting at the tip and/or sides. It
involves the ring nger commonly
but can also involve any of the
ngernails.
– Tendon reex—The tendon reex
is over exerted.
– Proximal myopathy—In proximal
myopathy, patient develops wasting
360
11 History andExamination ofThyroid andParathyroid Gland Disease…
of his/her proximal musculature
causing difculties in tasks such as
standing from a sitting position.
This is elicited by asking patient to
stand from sitting position with
cross hands. This is a complication
of multinodular goitre and Graves’
disease.
– Pretibial myxoedema—It is also
known as Graves’ dermopathy, thyroid dermopathy, Jadassohn–
Dösseker disease or Myxoedema
tuberosum. It is an inltrative dermopathy, a rare complication of
Graves’ disease. The pretibial
myxoedema is a form of diffuse
mucinosis in which there is an
accumulation of excess glycosaminoglycans in the dermis and subcutis of the skin. It presents as a waxy,
discoloured induration of the skin
on the anterior aspect of the lower
legs (pretibial region).
• Clinical signs of hypothyroidism
– Weight gain—weight gain despite
decrease appetite. This is due to
decrease BMR.
– Slowed speech and movements
– Dry skin
– Jaundice
– Pallor
– Coarse, brittle, straw-like hair
– Loss of scalp hair, axillary hair,
pubic hair, or a combination
– Dull facial expression
– Coarse facial features
– Periorbital pufness
– Macroglossia
– Hoarseness of voice
– Decreased systolic blood pressure
and increased diastolic blood
pressure
– Bradycardia
– Pericardial effusion
– Abdominal distention, ascites
(uncommon)
– Hypothermia (only in severe hypo-
thyroid states)
– Nonpitting oedema (myxoedema)
– Pitting oedema of lower
extremities
– Hyporeexia with delayed
relaxation
– Ataxia
11.1.1 System-Wise Signs
ofHypothyroidism
andHyperthyroidism
(Table11.2)
Table 11.2 Different signs of hyper- and hypothyroidism
System Hypothyroidism Hyperthyroidism
General appearance and behaviour Slow, lethargic, confused,
overweight
Voice Slow, deep, hoarse Talk quickly
Hand and nail Dry palm Warm, moist, onycholysis, tremor
Pulse Tachycardia Bradycardia
Proximal myopathy Absent Present
Face and hair Loss and thinning of outer 1/3
eyebrow
Tendon reexes Slow Brisk
Eye Eye signs absent Present
Anxious, agitated, underweight
Red and sweaty
11.2 Classication Thyroid Tumours andDiseases
361
11.2 Classication Thyroid
Tumours andDiseases
2. Classication of benign tumour of thyroid
(Table11.4)
3. Classication of thyroid carcinoma depend-
1. Classication of diseases of thyroid
ing on cells of origin (Table11.5)
(Table11.3)
Table 11.3 Classication of thyroid disease
Simple non-toxic goiter Toxic goitre Inammatory
Iodine deciency
Multinodular goitre
Solitary nodule
Physiological
Table 11.4 Classication of benign thyroid tumours
• Primary epithelial tumours
– Adenoma
Follicular cell adenoma
Hurthle’s cell adenoma
Hyalinizing trabecular adenoma
Colloid adenoma
• Primary non-epithelial tumours
– Leiomyoma
– Solitary brous tumour
– Others
Grave’s disease
Toxic nodule
Plummer’s disease
Hashimoto’s thyroiditis
De Quervain’s thyroiditis
Riedel’s thyroiditis
Infective
Table 11.5 Classication of malignant thyroid tumours
1. Follicular epithelial cell
(a) Differentiated thyroid carcinoma
• Papillary and mixed papillary variant
– Classical papillary
– Papillary microcarcinoma
– Encapsulated variant
– Follicular variant
– Aggressive variant
Diffuse sclerotic variant
Tall cell variant
Columnar cell variant
• Follicular carcinoma
– Classical variant (follicular CA)
– Hurthle’s cell variant
(b) Poorly differentiated carcinoma
• Insular carcinoma
(c) Undifferentiated carcinoma
• Anaplastic carcinoma
2. Parafollicular cell
(a) Sporadic medullary carcinoma
(b) Hereditary medullary carcinoma
• Multiple endocrine neoplasia (MEN)-2A
• Multiple endocrine neoplasia (MEN)-2B
• Familial medullary thyroid carcinoma
3. Miscellaneous
(a) Sarcoma
(b) Lymphoma
(c) Squamous cell carcinoma
(d) Mucoepidermoid carcinoma
(e) Clear cell tumour
(f) Plasma cell tumour
(g) Metastatic
• Direct extension
• Kidney
• Colon
• Melanoma
362
11 History andExamination ofThyroid andParathyroid Gland Disease…
11.3 Clinical Atlas ofThyroid
Diseases andTumours
(Fig.11.4)
Fig. 11.4 Clinical
picture of thyroid
disease
(Fig.11.5).
11.4 Presentation/History andExamination ofParathyroid Tumour or Diseases
363
a
Fig. 11.5 Clinical signs of hyperthyroidism, (a) Onycholysis, (b) Exophthalmos (Proptosis, Orbitopathy), (c) Von
Graefe’s sign
11.4 Presentation/History
andExamination
ofParathyroid Tumour or
Diseases
1. History/presentation of parathyroid diseases
and tumours
(a) Chief complaints/symptoms of parathy-
roid disorders—Patient with parathyroid
disorders can be presented with vague
symptoms like
• Symptoms of hypoparathyroidism
– Musculoskeletal system—Tingling
or burning sensation in ngertip,
toe and lips, muscle ache, cramps in
legs, feet, cramps in stomach,
twitching and spasm of perioral,
hands, arm, and throat muscles
– Mood change—Irritability, confu-
sion, mood swings
– Nail, skin and hair—Brittle nger-
nail, dry rough skin
– Other symptoms—abdominal pain,
painful menstruation
• Symptoms of hyperparathyroidism—
Hyperparathyroidism presented with
wide range of symptoms.
– Bone—Approximately 90% of
patients have bony symptoms like
bone pain, increase chance of pathological fracture and other evidence
of bone disease osteoporosis
– Kidney—Patient with hyperpara-
thyroidism can presents with
renal stone, confusion, frequent
urination, loss of appetite, kidney
stone
b
– GIT—Patients with hyperparathy-
roidism may have abdominal symptoms like abdominal pain, nausea,
vomiting, constipation
– Mental health—The patient with
hyperparathyroidism may have
symptoms like depression, memory
loss difculty in concentration
– Other symptoms—muscle weak-
ness, headache, fatigue, etc.
is characterized by subperiosteal resorption of the distal
phalanges, tapering of the
distal clavicles, salt-and-pepper appearance of the skull,
and brown tumours of the
long bones.
• Symptoms of hypercalcemia—hypercalcemia presented with symptoms
like fatigue, weakness, confusion,
constipation renal stones (50–80% of
patients), nausea, vomiting, anorexia,
epigastric pain, anxiety, weakness,
lethargy, sleep disturbance, arthralgia,
dyspnoea, persistence itching, nausea
• Symptoms of hypocalcaemia—
Hypocalcaemia presented with symptoms like cramp-like spasm of the
hand (claw hand), tingling or burning
sensation (pin or needle feeling), seizures, kidney problem, heart arrhythmias, and twitching in face
c