Neck and Thyroid
asked to examine the neck, do the section entitled "Neck." If you
a goitre, ask to examine the rest of thyroid status. If asked to assess
the thyroid status then do the section marked "Thyroid status" and then
examine the neck. The differential for a neck lump is wide but by far
the most common station will be a goitre.
Survey quickly: exophthalmos (eye protrusion), myxoedematous facies (round, red), ankle oedema)
Neck from front: masses, scars (can be subtle)
Glass of water present (for patient to swallow)
If mass present see if it moves up on swallowing (water):
"take a sip of water and hold it in your mouth... now swallow"
Stick out tongue (thyroglossal cysts move up)
In mouth for lingual thyroid
Say "tell me if it is tender"
Trachea central? (can be pushed to site by throid swellings)
Lymph nodes systematically: supraclavcular, submandibular, submental,
pre-auricular, post-auricular, suboccipital, pos triangle, occipital.
Matted/fixed/hard (neoplastic), If find enlarged lymph nodes but no goitre examine
axillae, groins (Hodgkin's)
Both hands feel lumps. Solitary, multiple or diffuse
enlargement of whole gland. Dimensions (eg. large), edge (behind
sternum), surface (Graves = smooth, or nodular), consistency
(soft = Graves, firm = multinodular, hard = cancer)
Move up on swallowing (water)?
Travel up sternum & on clavicles for dullness (may
indicate retrosternal extension
Bruit (in thyrotoxic patients if very vascular thyroid). Ask patient
to take deep breath in then out, and then hold it (otherwise they quickly run out of breath)
"I Would Like to"
Examine the sensation and neck movements
Assess thyroid status
Inspect: Composure: restlessness vs. immobile
Ask them to stand up from sitting with their arms crossed across their
chest: proximal myopathy (proximal muscle weakness)
Hands: thyroid acropachy (looks like clubbing), warm/sweaty
Stretch out arms for tremor, and place a piece of paper on
downturned hands to demonstrate this (it will jiggle around on their
Pulse: fast, slow, AF
(note movements will not correspond to a CN palsy as lesions in the
Exophthalmos (look from above)
Lid retraction (white sclerae visible above eye), lid lag
on the examiner's finger. Move finger slowly upwards and downwards.
+ve if lids move more slowly than the eye)
Pretibial myxoedema (diffuse, non-pitting edema and thickening of the skin usually on the anterior aspect of the lower legs found in Graves disease)
Ankle reflexes (slow relaxing in hypothyroidism): this is
demonstrated by getting the patient to stand facing a chair, then kneel
one leg on the seat of the chair. Tap on their heel (which should be
facing up) with a tendon hammer.
Say "I would like to examine this patient's neck"
Eye thyroid signs
Signs found in Graves only:
Lid retraction, lid lag
Graves (hypErthyroid), HashimOtO's (HypOthyrOid), low iodine/puberty/pregnancy, multinodular colloid goitre with nodules too small to feel
Multinodular colloid goitre (commonest thyroid swelling in finals), cysts, adenoma
Solitary nodule (ominous):
thyroglossal cyst (small, smooth, midline, moves up with tongue extrusion), tumour, dominant nodule in multinodular goitre
Thyroid anatomy. (Public domain from http://seer.cancer.gov).