History taking for Thyroid nodule?
- Features of hyperthyroidism
- Local symptoms including dysphagia, subjective dyspnea, positional dyspnea, pressure or choking sensation, pain, globus sensation, Pemberton sign.
- Exposure to radiation.
- Personal and family history for specific endocrine disorders, including familial medullary carcinoma, MEN2, PTC, or a history of polyposis, including Gardner syndrome or Cowdens yndrome.
What is Kocher's test?
The swelling is pressed slightly on either side of trachea. If trachea is already compressed, or if there is tracheomalacia, patient will have stridor.
- »» Kocher’s test negative (no stridor)
- »» Kocher’s test positive (stridor on compression of both lobes)
Lahey’s method of palpation?
To palpate the left lobe, push the right lobe to the left with the left hand so that the left lobe becomes prominent. The left lobe is then palpated with the right hand. The anterolateral surface and the posterior surface of the left lobe are then palpated.
Pizzillo’s method of palpation?
For obese patients - Patient keeps both his hands on the occiput and extends the neck. The slightly enlarged gland may be seen and palpated either from the front or back
Crile’s method for palpation?
- For small swelling - Palpate the swelling with
- the pulp of the thumb. Place pulp of the thumb over the swelling and ask the patient to swallow as the swelling moves up and down. Palpate the surface of the swelling with the pulp of the thumb.
What other swelling apart from thyroid moves up and down with deglutition?
- Subhyoid bursitis
- Prelaryngeal or pretracheal lymph node
- Any swelling arising from larynx or trachea
- Thyroglossal cyst
Ask the patient to raise both arms over the head touching the ears and maintain this position of the arms above the head for 2-3 minutes. If there is retrosternal prolongation of goiter then there will be congestion of face, engorgement of vein in the neck and patient may have respiratory distress.
Naffziger method is for demonstration of exophthalmos. Stand behind the patient. Look from behind with the neck of the patient slightly extended and look along superior orbital margin. Exophthalmos is present when the eyeball is seen beyond the superior orbital margin.
Von Graeffe sign?
Steady the patient’s head with one hand and ask the patient to look at your finger held in front of the eye. Ask the patient to look up and down following your finger moving in front of the eye up and down quickly for 5–6 times. Normally, the movement of upper lid follows the movement of eyeball. In case of thyrotoxicosis, the lid may lag while the eyeball move downward and the upper sclera become visible.
loss of wrinkling of forehead
Patient is asked to look at a distant object and then asked to look at the finger of the clinician brought suddenly in front of the eye from the side. In thyrotoxicosis, there is failure of medial convergence of the eyeball.
- Normal carotid artery is palpated at the level of upper border of thyroid cartilage along the anterior border of sternocleidomastoid.
- When carotid pulse is impalpable due to infiltration of carotid sheath by a malignant thyroid swelling then it is called positive Berry’s sign.
Where do you auscultate for bruit/thrill over the thyroid gland?
The bruit/thrill is audible at the upper pole of the thyroid gland.
Causes of respiratory distress in a patient with thyroid swelling?
- Retrosternal goiter may cause tracheal compression and respiratory distress
- Long standing multinodular goiter may cause tracheomalacia and respiratory distress. This may be more pronounced in postoperative period
- In patients with thyrotoxicosis congestive cardiac failure may cause respiratory distress.
- Carcinoma thyroid causing bilateral recurrent nerve palsy or mechanical compression of trachea may cause respiratory distress.
Lymph node levels of neck?
- The level I node compartment includes the submental and submandibular nodes, above the hyoid bone and anterior to the posterior edge of the submandibular gland.
- Level II, III, and IV nodes are arrayed along the jugular veins on each side, bordered anteromedially by level VI and laterally by the posterior border of the sternocleidomastoid muscle.
- Level III nodes are bounded superiorly by the level of the hyoid bone and inferiorly by theinferior aspect of the cricoid cartilage; levels II and IV are above and below level III, respectively.
- Level V nodes are in the posterior triangle, lateral to the lateral edge of the sternocleidomastoid muscle.
- Level VI contains the thyroid gland and the adjacent nodes bordered superiorly by the hyoid bone, inferiorly by the innominate (brachiocephalic) artery, and laterally on each side by the carotid sheaths.
- Levels I, II, and V can be further subdivided as noted in the figure. The inferior extent of level VI is defined as the suprasternal notch. Many authors also include the pretracheal and paratracheal superior mediastinal lymph nodes above the level of the innominate artery (sometimes referred to as level VII) in central neck dissection.