What is the proper procedure for examining a thyroid gland?

Thyroid Physical Examination Technique

The proper thyroid examination involves systematic inspection and palpation from both anterior and posterior approaches, focusing on gland size, nodule characteristics (size, firmness, fixation), cervical lymphadenopathy, and signs of vocal cord dysfunction or tracheal deviation. 1, 2

Patient Positioning and Initial Inspection

• Position the patient seated comfortably with neck slightly extended to optimize thyroid visualization and palpation 2
• Inspect the neck from the front while the patient swallows water, observing for:
  • Visible thyroid enlargement or asymmetry
  • Masses that move with swallowing (confirms thyroid origin)
  • Tracheal deviation suggesting mass effect 1

Palpation Technique: Anterior Approach

• Stand in front of the patient and place your thumbs on either side of the trachea just below the cricoid cartilage 2
• Palpate each thyroid lobe systematically while the patient swallows, assessing:
  • Gland size: Normal thyroid lobes are barely palpable; each lobe should be approximately 4-5 cm in length 1
  • Nodule presence: Note any discrete masses within the gland 2
  • Consistency: Assess whether nodules are soft, firm, or rock-hard 1, 2

Palpation Technique: Posterior Approach

• Stand behind the patient with your fingers placed on either side of the trachea 2
• Use both hands to palpate simultaneously, with the patient's neck slightly flexed to relax the sternocleidomastoid muscles 2
• Have the patient swallow while you palpate to better define thyroid tissue and distinguish it from other neck structures 2

Critical Features to Document

Nodule Characteristics (When Present)

• Size in centimeters: Nodules ≥1 cm warrant further evaluation; nodules ≥2 cm have increased malignancy risk even without suspicious features 3
• Degree of firmness: Very firm or hard nodules increase malignancy likelihood approximately 7-fold 1, 2
• Fixation to adjacent structures: Fixed nodules suggest extrathyroidal extension and significantly increase cancer probability 1, 2
• Presence of multiple nodules versus solitary nodule 2

Regional Lymph Node Assessment

• Systematically palpate cervical lymph node chains (levels I-VI), particularly the central and lateral neck compartments 1, 2
• Enlarged, firm lymph nodes are highly suspicious for metastatic thyroid cancer and dramatically alter management 1, 3

Signs of Local Invasion or Compression

• Assess for vocal cord function by listening to voice quality; hoarseness suggests recurrent laryngeal nerve involvement 1, 2
• Evaluate for dysphagia or dyspnea, which indicate esophageal or tracheal compression from large goiters 1
• Note any rapid growth reported by the patient, as this suggests aggressive pathology 1, 3

Systemic Signs of Thyroid Dysfunction

• Tachycardia and tremor: Suggest hyperthyroidism 2, 4
• Bradycardia and delayed reflexes: Suggest hypothyroidism 4

High-Risk Clinical Features Requiring Immediate Attention

The following findings substantially increase malignancy probability and mandate urgent ultrasound and fine-needle aspiration:

• Age <15 years or male gender with thyroid nodule 3
• History of head and neck irradiation (>20 mGy exposure) 1, 3
• Family history of thyroid cancer, particularly medullary thyroid carcinoma or MEN 2 syndromes 1, 3
• Rapidly growing nodule over weeks to months 1, 3
• Very firm or rock-hard nodule that is fixed to surrounding structures 1, 2
• Vocal cord paralysis detected by hoarseness or voice changes 1, 2
• Palpable cervical lymphadenopathy in conjunction with thyroid nodule 1, 3

Common Pitfalls to Avoid

• Do not rely solely on palpation to exclude thyroid nodules; physical examination detects <5% of nodules compared to ultrasound, which identifies nodules in up to 50% of patients 1
• Do not assume a normal thyroid examination excludes dysfunction; most patients with hypothyroidism or hyperthyroidism have normal-sized glands on palpation 4, 5
• Do not dismiss soft or mobile nodules as benign; while firmness and fixation increase malignancy risk, papillary thyroid carcinoma can present as soft nodules 2
• Do not perform radionuclide scanning as initial evaluation for thyroid nodules in euthyroid patients; it does not reliably distinguish benign from malignant nodules 1, 3

Immediate Next Steps After Examination

• Measure serum TSH as the single best initial laboratory test for thyroid function 6, 4, 5
• Order high-resolution thyroid ultrasound for any palpable nodule or suspected thyroid abnormality to characterize size, composition, and suspicious features 1, 3
• Proceed directly to ultrasound-guided fine-needle aspiration for nodules >1 cm or smaller nodules with high-risk clinical features 3