Neck and Thyroid

Neck

• Introduce and expose
  

Inspect

• 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

Palpate

• 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)?
  

Percuss

• Travel up sternum & on clavicles for dullness (may indicate retrosternal extension

Auscultate

• 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

Thyroid Status

• Introduce and expose.

Inspect

• Inspect: Composure: restlessness vs. immobile
• Ask them to stand up from sitting with their arms crossed across their chest: proximal myopathy (proximal muscle weakness)

Arms

• Hands: thyroid acropachy (looks like clubbing), warm/sweaty
• Stretch out arms for tremor, and place a piece of paper on their downturned hands to demonstrate this (it will jiggle around on their hands)
• Pulse: fast, slow, AF

Face

• Ophthalmoplegia (note movements will not correspond to a CN palsy as lesions in the muscles)
• Exophthalmos (look from above)
• Lid retraction (white sclerae visible above eye), lid lag (fix on the examiner's finger. Move finger slowly upwards and downwards. +ve if lids move more slowly than the eye)

Other

• 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 best 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

1. Signs found in Graves only: Exophthalmos, ophthalmoplegia
2. Hyperthyroid signs: Lid retraction, lid lag

Common Conditions

• Diffusely swollen: Graves (hypErthyroid), HashimOtO's (HypOthyrOid), low iodine/puberty/pregnancy, multinodular colloid goitre with nodules too small to feel
• Multiple nodules: 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

Anatomy

Thyroid anatomy. (Public domain from http://seer.cancer.gov).