THYROID SWELLING

Thyroid Examination

Inspection of hand
- Sweaty or dry palms
- Palmar erythema
- Fine tremors
- Thenar/Hypothenar Muscle
- Thyroid Acropachy
- Pulse
- Proximal Myopathy

Inspection of Eye
- Exophthalmos (front, lateral and above)
- Eye Movement
- Lid Lag
- Lid Retraction (from lateral view)
- Loss of outer 1/3rd of eyebrows

Thyroid
- Inspect and Describe lump (movement on deglutition and protrusion of tongue, site,
number, size, shape, overlying skin, scars)
- Palpate from behind, find thyroid cartilage, then cricoid cartilage, then locate the
isthmus
- Palpate each lobe and describe (size, site, shape, movement with swallowing,
tenderness, temperature, consistency, edge, surface, lower border palpable,
mobility)
- Fixation to Sternocleidomastoid and skin
- Tracheal Deviation
- Percuss retrosternal
- Auscultate for thyroid bruits, carotid bruit
- Cervical lymphadenopathy, supraclavicular

Inspect Leg
- Pretibial Myxoedema
- Proximal Myopathy
- Deep Tendon Reflex

If there is thyroidectomy scar, check for signs of hypothyroidism

- Chvostek’s sign
- Trousseau’s sign
- Hoarseness of voice
Differentials
- Simple Nodular Goitre
o Follicular Adenoma
o Thyroid Cyst
o Thyroiditis
- Multi Nodular Goitre
- Thyroid CA
o Follicular
o Medullary
o Papillary
o Anaplastic
o Hurthle Cell Type
o Lymphoma
- Lymphadenopathy
- Thyroglossal cyst
- Sebaceous cyst
- Lipoma

Investigation
- TFT – TSH level, T4 and T3
- FBC – haemoglobin, haematocrit,
- Blood Grouping – GSH, GXM
- Pre-operative assessment (LFT, ECG, CXR, RP, FBS, FPL, etc)
- Ultrasound of neck – thyroid origin, site, number, consistency, lymph nodes (*cyst –
drain and palpate for residual lump)
- CXR – look for tracheal deviation
- CT Scan – staging, retrosternal extension
- FNAC – cytological findings, confirm tissue type. (follicular, papillary, anaplastic,
medullary, lymphoma)

Management
- Follicular if one sided, Hemithyroidectomy, then send for HPE, if got capsular or
vascular invasion, do completion total thyroidectomy, lymph node dissection
- If MNG, papillary, medullary straight total thyroidectomy, lymph node dissection
- Post-Operative Complication
o Haemorrhage with Hematoma
o Recurrent laryngeal nerve injury – Stridor and hoarseness
o Hyperthyroidism
o Tracheomalacia
o Infection
o Hypoparathyroidism – perioral numbness, chovstek’s sign, trousseou’s sign
o Hypothyroidism
o Permanent hypoparathyroidism
o Hypertrophic Scar and Keloid
 - Cancer follow up –whole body scan for micro metastasis – TSH Suppression dose,
Radio iodine ablation. starts on thyroxine replacement therapy
- Thyroglobulin marker for recurrence
-

MEN 2A
- Medullary Thyroid
- Pheochromocytoma
- Hyperparathyroidism

MEN 2B
- Medullary Thyroid
- Pheochromocytoma
- Neurocutaneous Neoplasm

Thyroid Anatomy
- Pretracheal fascia (attached to larynx) and Paratracheal fascia
- Superior and inferior, thyroidea ima artery
- Right and left lobe, pyramidal lobe
- Superior laryngeal nerve – high pitch voice
- Recurrent laryngeal nerve – hoarseness of voice, stridor

Thyroid Pharmacology

Anti Thyroid – Methimazole, Carbimazole, Propylthiouracil

Thyroid Replacement – Levothyroxine
ADR anti-thyroid – agranulocytosis

Grave’s Disease – RAI, Total Thyroidectomy (contraindicated in pregnancy, reproductive

age)

Haematoma post thyroidectomy – compress the veins, leads to laryngeal oedema,

respiratory distress.. manage by off suture completely , superficial skin and fascial closure.