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Thyroid and Neck Examination DR AMY ROSS (FY2) OSCE PREP – HISTORY TAKING OSCE PREP – EXAMINATION OF THE THYROID GLAND/NECK/PERIPHERAL THYROID STATUS THYROID ANATOMY TRIANGLES OF THE NECK THYROGLOSSAL CYST GOITRE SALIVARY GLANDS LIPOMA SEBACEOUS CYSTS CYSTIC HYGROMA BRANCHIAL CYSTOSCE examination hints and tips Possible OSCE scenarios: - could ask you to take thyroid history and then ask questions about hypo/hyperthyroidism (e.g show TSH T3/4 and ask about primary and secondary hyperthyroidism for example) - could ask to complete examination of neck or may ask for peripheral thyroid status examination, patient may have findings. Questions on findings for example investigations and management etc What does the thyroid gland do??Thyroid history HYPERTHYROIDISM HYPOTHYROIDISM Weight & appetite Weight LOSS and appetite Weight GAIN and appetite Energy levels Decreased INCREASED Temperature Heat intolerance Cold intolerance Irritable/anxious Depression Mental state Diarrhoea Constipation Bowel habit Menstruation Can have reduced flow or irregularMenorrhagia Palpitations/insomnia Skin/hair – outer thinning eyebrows OtherOther important parts of history Past Medical Hx – ? Previous thyroid or other endocrine conditions ? Any previous thyroid surgery Drug Hx – Any medications, ?any thyroid medications FHx – ?any family history of thyroid disorders/cancer etc SHx – ICE, impacting work or activities ?smoker ?alcohol intake if female ? Are they pregnantThyroid anatomy The thyroid gland § located in the anterior neck § Spans the C5-T1 vertebrae. § Consists of two lobes (left and right), which are connected by a central isthmus anteriorly § butterfly-shape appearance. § Lobes of the thyroid gland are wrapped around the cricoid cartilage and superior rings of the trachea. § Gland located within the visceral compartment of the neck (along with the trachea, oesophagus and pharynx. Bound by the pretracheal fascia. §The thyroid gland secretes hormones directly into the circulation and is highly vascularised.Arterial Supply The arterial supply to the thyroid gland is viatwo main arteries: Superior thyroid artery – arises as the first branch of the external carotid artery. It lies in close proximity to the external branch of the superior laryngeal nerve (innervates the larynx). Inferior thyroid artery – arises from the thyrocervical trunk (a branch of the subclavian artery). It lies in close proximity to the recurrent laryngeal nerve (innervates the larynx). In a small proportion of people (around 10%) there is an additional artery present– the thyroid ima artery. It arises from the brachiocephalic trunk and supplies theanterior surface and isthmusof the thyroid gland. Venous Drainage Venous drainage is carried by tsuperior, middle, and inferior thyroid veins, which form a venous plexusaround the thyroid gland. The superior and middle veins drain into the internal jugular vein and the inferior empties into the brachiocephalic vein. Innervation The thyroid gland is innervated by branches derived from thesympathetic trunk . These nerves do not control the secretory function of the gland– the release of thyroid hormones is regulated by the pituitary gland. LymphaticDrainage The lymphatic drainage of the thyroid is to theparatracheal and deep cervical nodes. Examination of thyroid status: General Inspection § Initially comment on: Does patient appear irritable or anxious/slow sluggish Body habitus ?increased or decreased weather etc? appropriately dressed ? Wearing shorts in cold Skin and Hair - ?thinning of the hair ?any signs of pretibial myoxoedema ? “Peaches and cream” complexion – thickened and yellow skin discolouration ?peri-orbital oedemaInspection & palpation of the handsMuscle power and reflexes Test for proximal myopatr yisted shoulder abduction. Then ask patient to stand up from chair with arms crossed. What muscle group does this test? Test reflexes Brisk ? Slow relaxingInspection of the face Thinning of lateral 1/3 eyebrows– hypo or hyper..?? EYES – examine from above and behind 1. Exophthalmos 2. Proptosis 3. Lid retraction 4. Periorbital oedema Examination of Thyroid gland § Introduction and consent § Seated position, glass of water § Wash hands and clean stethoscope § Tendon hammer and piece of paper § Useful to ensure all equipment is present prior to starting examination Inspection § Adequately expose neck and sternum §From the front and from the side ?scars ? swellings §then swallowient to sip water, hold it and § Goitre and thyroglossal cyst moves up on swallowing § Stick out tongue – thyroglossal cyst moves up (linked to foramen caecum– back of the tongue) § Thyroid gland masses and lymph nodes will not move during tongue protrusion §proceeding with examination **n before Palpation of thyroid gland (tips) § Stand behind the patient and palpate the thyroid gland (stabilise one lobe while palpate other side). (Warn them that going to stand behind them) § Ask them to tilt their chin slightly downwards to relax the muscles of the neck to aid palpation of the thyroid gland. 3S’s, 3C’s, 3T’s… ?? diffusely enlarged or single nodule ?? Smooth or nodular ?? Soft firm or hard gland due to hyperthyroidism (suggestive of Graves’ disease).aused by increased vascularity of the thyroid § Palpate the thyroid isthmus using the pads of your fingers. § Palpateeach lobe of the thyroid in turn by moving your fingers out laterally from the isthmus. §glandate thyroid gland whilst patient swallows mouthful of wat–observe direction of movement of § Consider examination of lymph nodes for cervical lymphadenopathyPercussion § Can percuss to see if evidence of a retrosternal goitre by moving downwards from the sternal notch to assess forretrosternaldullness. § Retrosternal dullness may indicate a large thyroid massextending posterio-inferiorly to the manubrium. §?Any signs of tracheal deviation as seen with a large goitre §Does anyone know what Pemberton’s sign is?Pemberton’s test and sign - Test for retrosternal goitre - get the patient to raise their arms (ensure no difficulties or pain prior to attempting) and hold above their head - elevates the clavicles and raises thoracic inlet Sign – pink face due to temporary SVC obstruction – risk of stridorAuscultation Auscultate each lobe of the thyroid gland for a bruit using the bell of the stethoscope. A bruit indicates increased vascularity, which typically occurs in Graves’ disease.Pretibial myxoedema Pretibial myxoedemais a form of diffuse mucinosis. - an accumulation of excess glycosaminoglycans in the dermis and subcutis of the skin. - usually presents itself as a waxy, discoloured (usually pink or brown) induration of the skin on the anterior aspect of the lower legs (pre-tibial region). - rare complication of Graves’ disease.Further assessments and investigations Thyroid function tests: these include TSH, T3 and T4. ECG:should be performed if an irregular pulse was noted to rule out atrial fibrillation. Further imaging:an ultrasound scan of the neck to further assess any thyroid lumps.Neck lumpsLumps in the neck– differentials Midline Goitre Thyroglossal cyst Lateral Lymph node/ Salivary glands Solitary thyroid nodule Vascular: aneurysm or carotid body tumour Sebaceous cyst/lipoma Cystic hygroma/branchial cyst NeurofibromaAnterior triangle of neck •Superiorly – inferior border of the mandible (jawbone) . Contents •Laterally – anterior border of the sternocleidomast.id •Medially – sagittal line down the midline of the neck. § Common carotid arterybifurcates within the triangle into the external and internal carotid branches • Internal Jugular vein • facial[VII], glossopharyngeal [IX], vagus[X], accessory [XI], and hypoglossal [XII]Posterior triangle of neck • Anatomical area located in lateral aspect of neckGoitre Types ofgoitre There are several different subtypes of goitrewhich include: Diffuse goitre: the whole thyroid gland is enlarged due to hyperplasia of the thyroid tissue. active (toxic) autonomously producing thyroid hormones (causingh may be hyperthyroidism) or inactive. Multinodular goitre: the presence of multiple thyroid nodules which may be active or inactive (euthyroid). Active multinodular goitres are often referred to as a toxic multinodular oitre. Need USS to confirm if simple or multi-nodular.Thyroglossal cyst In the embryo, the thyroid gland starts to develop near base of the tongue – in area known as foramen cecum. - descends during development and reaches its destination in the anterior neck by week 7. The descent of the developing thyroid gland forms the thyroglossalduct – tract that connects the gland to its origin at the foramen cecum. - usually regresses by the 10th week of gestation, but can persist in some individuals. If it fails to regress, cysts can result from build up of secretions. - can become infection or form fistulae - Mnx – complete excisionLymph node examinationCauses of Cervical lymph node enlargement LOCAL GENERALISED ACUTE INFECTION (E.G.TONSILLITIS, ACUTE INFECTION (E.G. ACUTE OTTITIS EXTERNA) MONONUCLEOSIS) NEOPLASTIC – LOCAL SPREAD FROM CHRONIC INFECTION ( E.G. TB/ SYPHILLIS/ HEAD AND NECK HIV) NEOPLASTIC – DISTANT SPREAD FROM NEOPLASMS – PRIMARY OR SECONDARY LUNG/BREAST/ ABDOMEN HODGKIN or NON-HODGKIN LYMPHOMASalivary glands - Parotid, submandibular and sublingual glands - Parotid (Stenson’s) duct by upper 2 molar - Submandibuar duct under tongue on either side of frenulum Causes for enlarged salivary gland: - Acute viral infection - Acute bacterial infection - Calculi and infection - Sjogren’s syndrome - Tumours e.g. Parotid tumour Solitary thyroid nodule - Thyroid Cancer usually presents as solitary nodule, 95% benign and 5% malignant - Diagnosis by radioiodine scan, USS and FNA. - Most common type of thyroid cancer is Papillary which has 98% 5 year survival. Vascular: aneurysm or carotid body tumour Corotid aneurysm - Localised, pulsating, laterally expansile Corotid body tumour – not laterally expansile, hard solid, high in neck, slowly enlarging mass, often where carotid bifurication arisesLipoma - Subcutaneous - Soft - Mobile, not attached to skin - Fluccuant “Squidgy” - Anywhere but palms, soles or scalp - due to overgrowth of fat cellsSebaceous cyst - commonly found on scalp, face, ears, trunk, back, or groin - firm, smooth, round - attached to skin at punctum - Commonly term used for: Epidermoid cyst/Pilar cyst – contains keratin not sebum (rare) - Epidermoid cysts originate in the epidermis and pilar cysts originate from hair follicles.Cystic hygroma - solitary or multiple cystic growth - most commonly found in posterior triangle - usually visible about a year after the birth of the child - due to blockage of vessels present in the lymphatic system - benign condition but associated with chromosomal abdnormalities e.g. Turner’s, Noonan’sBranchial cyst - usually develops in teenagers or young adults - fluid rich in cholesterol crystals - develops from remnants of 2 branchial cleft - usually lateral , appears from upper border of sternocleidomastoid - usually distinct and smooth - on USS appears snow like with speckles (popular MCQ q)