Clinical examination of the

thyroid
Hugo R K Lisba, MD, Ph.D.
Medical College
University of Passo Fundo - RS
BRAZIL
Objectives of this lecture
To evaluate the usefulness and limitations
of the physical examination on the
diagnosis of thyroid diseases according to
concepts of clinical epidemiology
Lesions recognizable through
physical examination
Classification of Nontoxic Goiter
Nontoxic diffuse goiter
Endemic (iodine deficiency, goitrogens).
Sporadic {congenital defects, chemical (lithium)}
Compensatory (following partial thyroidectomy)
Nontoxic nodular goiter
Uni or multinodular
Functional and non functional
Thyroid diseases
50% of people in the community have
microscopic nodules
3.5% have occult papillary carcinoma,
15% have palpable goiters
10% demonstrate an abnormal thyroid-
stimulating hormone level
5% of women have overt hypothyroidism or
hyperthyroidism
Prevalence of the most common
thyroid diseases
Diffuse endemic goiter : Depends on iodine
supply.(The term endemic goiter is used when
thyroid enlargement is found in more than 10%
of the population).
Nodular goiter: Up to 5% everywhere. Increases
with age and iodine deficiency
Thyroid cancer: average annual incidence of all
types of thyroid cancer was 37.0 cases/1,000,000
population
Incidence of Hypo and
Hyperthyroidism (Whickham Cohort)
The mean incidence (with 95%
confidence intervals) of spontaneous
hypothyroidism in women was 3.5/1000
survivors/year (2.8-4.5) and in men was
0.6/1000 survivors/year (0.3-1.2).
The mean incidence of hyperthyroidism in
women was 0.8/1000 survivors/year (0.5-1.4)
and was negligible in men
History
The clinical examination of the thyroid is a
powerful tool for the diagnosis of the most
comum thyroid disease
The thyroid lies immediately under the skin it
is easily reached by inspection and palpation.
Inspection
Tip the patients head back a bit
Use tangential lighting from the tip of the
patients chin
Ask for swallowing
Observe the thyroid cartilage, cricoid
cartilage and the thyroid gland raising
with swallowing
Physical Examination
Do not press to much
the thyroid
You can loose the
sensitivity of your
fingers
Try to not strangle
your patient
Oil on canvas. 1967 Tomie Othake, Brazilian Painter
Classical Clinical Examination
The following information could be obtained
volume
consistency
mobility of the thyroid gland
surface
temperature
fremit
sensibility
Palpation
Palpate the thyroid gland from behind
Localize anatomic boundaries
Thyroid isthmus is often palpable
Thyroid lobes are barely or not palpable
The concistense is rubbery, similar to
that of sternomastoid muscle
ANATOMIC BONDARIES OF THYROID
Cricoid cartilage
Supraesternal notch
Carotid arteries
Four anatomic points must be identified
before palpation of thyroid gland is
performed
ANATOMIC RELATIONSHIPS OF THE
THYROID
ANATOMIC RELATIONSHIPS OF THE
THYROID
Classical Goiter Classification
Ia -thyroid not visible, lateral lobes smaller
than the distal phalanx of the thumb
Ib - thyroid visible with neck in extended
position
II - thyroid visible with the neck in normal
position
III - thyroid visible at distance
Simplified Goiter
Classification
Degree 0 No goiter
Degree 1 Goiter palpable but not
visible
Degree 2 Goiter palpable and
visible
Clinical examination of the
thyroid
Does clinical examination gives
an accurate estimation of the thyroid
gland ?
Accuracy of clinical examination
on diagnosis of goiter in children
Skvor J, showed a discrepancy between palpation and
ultrsonogrphy among 88 individual of 13 years old
Palpation overestimated in 24 occasions
underestimated in 7 occasions
Ultrasonography was suggested as an essential method
for the evaluation of the thyroid in children
Ultrasonography of thyroid intra
and inter observer variation
Two experts examined 152 thyroid lobes measuring
solid nodules and they agreed in 45 %
Inter observer variation - kappa = 0,55 e 0,6 (2)
Two experts and two young physicians
examined twice 53 adults and they agreed
in 30% of the the cases
Intra observer variation kappa= -0,04 and 0,54
Inter observer variation kappa= 0,44 e 1,0 (1)
Relationship to other physical
characteristics in children
Ueda D, examined 300 healthy children and found a
positive correlation among thyroid volume and weight and
height. (1).
Takalo RM et al, found a positive correlation in young
individual of 13 years among thyroid volume measured by
ultrasound and the weight and body surface area(2)
The thyroid volume was found to have a positive
correlation with body surface area, age and
skinfold but in a multiple regression analysis only
body surface area remained associated with
thyroid volume.

The upper limit (95th percentile) of the ratio of
thyroid volume to body surface area (ECOBODY
Index) was 6.2 ml/m2.
Relationship to other physical
characteristics in children
Accuracy of clinical examination in the
diagnosis of goiter
Considering this index as the criterion
standard, the estimated performance of clinical
examination for the detection of goiter in the
1094 schoolchildren was:
sensitivity of 41%,
specificity of 91%,
positive predictive value of 27%
negative predictive value of 95%.
Delange et al, studied 7599 European schoolchildren
recommended that thyroid volume measured by
ultrasound should be considered dependent of age, sex
and body surface area in non iodine deficient areas
in that continent
Accuracy of clinical examination in the
diagnosis of goiter
Thyroid volume in children according to the age
Which characteristics should
the thyroid be related
In areas with malnutrition, such as Bangladesh,
the BSA reference should be preferred to the
reference based on age.
Results from the US children indicated that a
thyroid volume reference based on weight alone
would perform as well as the one based on BSA.
European schoolchildren had larger thyroids
than US children, perhaps due to a residual
effect of iodine deficiency in the recent past in
some areas in Europe.
Thyroid volume relationship to other
characteristics in adults
Riehl J et al, found, among adults in a deficient iodine
intake area, that the thyroid volume was dependent
of the age.
Individuals with less than 21 years 13,3ml
Individuals with more than 70 years 29,9 ml
Accuracy of clinical examination in the
diagnosis of goiter in adults
A good correlation was found between clinical
examination and ultrasonography (r2=0,872) in large
goiters (35,9+-24ml) .
What a hard thyroid means?
If painful - Subacute thyroiditis
If not painful- Hashimotos
thyroidites, cancer or Riedels
thyroidites (rare)
Thyroid gland is considered to be hard if it had
a consistency similar to the thyroid cartilage.
What a painful thyroid means?
Subacute thyroiditis
Hemorrhage into a nodule
Cancer (rare)
Summary
Clinical examination is not accurate in
the diagnosis of small goiters
The thyroid volume is related to age
and body surface area in in children
The upper limit of normal range for
children suggested is 6,2ml/m2
In the diagnosis of goiter in areas of mild to
severe iodine deficiency where the thyroid
glands are bigger

In the identification of normal thyroid due to
its good predictive negative value
Usefulness of clinical examination of the
thyroid
Useful Links
American Thyroid Association
http://www.thyroid.org/
Endocrine Society
http://www.endo-society.org
Asia and Oceania Thyroid Association
http://www-dnm.kuhp.kyoto-u.ac.jp/AOTA/1cir-
e.html
European Thyroid Association
http://www.uwcm.ac.uk/uwcm/md/ETA.html
Latin American Thyroid Society
http://www.lats.org