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Clinical examination of the thyroid. Hugo R K Lisbôa, MD, Ph.D. Medical College University of Passo Fundo - RS BRAZIL. Objectives of this lecture.

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clinical examination of the thyroid

Clinical examination of the thyroid

Hugo R K Lisbôa, MD, Ph.D.

Medical College

University of Passo Fundo - RS

BRAZIL

objectives of this lecture
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
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
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
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
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
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
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
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

slide10

Classical Clinical Examination

  • The following information could be obtained
  • volume
  • consistency
  • mobility of the thyroid gland
  • surface
  • temperature
  • fremit
  • sensibility
palpation
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
slide12

ANATOMIC BONDARIES OF THYROID

Four anatomic points must be identified

before palpation of thyroid gland is

performed

  • Cricoid cartilage
  • Supraesternal notch
  • Carotid arteries
classical goiter classification
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
Simplified Goiter Classification
  • Degree 0 No goiter
  • Degree 1 Goiter palpable but not visible
  • Degree 2 Goiter palpable and visible
clinical examination of the thyroid17
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
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
Ultrasonography of thyroid intra and inter observer variation

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)

Two experts examined 152 thyroid lobes measuring

solid nodules and they agreed in 45 %

Inter observer variation - kappa = 0,55 e 0,6 (2)

relationship to other physical characteristics in children
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)

slide21

Relationship to other physical

characteristics in children

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.

slide22

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%.

slide23

Accuracy of clinical examination in the diagnosis of goiter

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

which characteristics should the thyroid be related
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
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
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
What a hard thyroid means?
  • If painful - Subacute thyroiditis
  • If not painful- Hashimoto’s thyroidites, cancer or Riedel’s thyroidites (rare)

Thyroid gland is considered to be hard if it had

a consistency similar to the thyroid cartilage.

slide29

What a painful thyroid means?

  • Subacute thyroiditis
  • Hemorrhage into a nodule
  • Cancer (rare)
summary
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
slide31

Usefulness of clinical examination of the thyroid

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

useful links
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
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