What are the typical thyroid palpation exam findings that distinguish hyperthyroidism from hypothyroidism?

Thyroid Palpation Exam Findings: Hyperthyroidism vs Hypothyroidism

On physical examination, hyperthyroidism typically presents with a diffusely enlarged, smooth thyroid gland (especially in Graves disease) or a nodular gland (in toxic multinodular goiter or toxic adenoma), while hypothyroidism generally shows no distinctive palpation findings, as thyroid morphology does not reliably differentiate causes of hypothyroidism. 1

Hyperthyroidism Palpation Findings

Graves Disease (Most Common Cause)

• Diffusely enlarged thyroid gland that is smooth and symmetrical on palpation 2, 3
• The gland may feel firm but not hard 4
• Enlargement is typically uniform across both lobes 2
• Associated findings include tachycardia, tremor, and possible exophthalmos or stare 2, 3

Toxic Multinodular Goiter

• Multiple palpable nodules of varying sizes throughout the gland 3, 5
• The gland is typically enlarged and has an irregular, bumpy texture 3
• May present with compressive symptoms such as dysphagia, orthopnea, or voice changes due to local mass effect 2, 3
• Individual nodules may vary in firmness 5

Toxic Adenoma

• Single palpable nodule that is distinct and well-defined 3, 5
• The nodule may be firm on palpation 5
• The remainder of the gland may feel normal or slightly atrophic 3
• Compressive symptoms may occur if the nodule is large 2

Thyroiditis (Thyrotoxic Phase)

• The gland may be tender and enlarged in subacute thyroiditis 1
• In painless (lymphocytic) thyroiditis, the gland may be normal-sized or slightly enlarged and non-tender 1
• This is a self-limiting condition that typically progresses to hypothyroidism 1

Hypothyroidism Palpation Findings

There are no reliable or distinctive palpation findings that differentiate hypothyroidism from euthyroid states or identify specific causes of hypothyroidism. 1

Key Points About Hypothyroid Palpation

• Thyroid morphology does not help differentiate among causes of hypothyroidism 1
• The gland may be normal-sized, enlarged, or atrophic depending on the underlying etiology 4
• In Hashimoto thyroiditis (most common cause in developed countries), the gland may be slightly enlarged and firm, but this is not diagnostic 1, 4
• Palpation findings are not useful for diagnosis, which relies on laboratory testing (elevated TSH, low free T4) 1, 4

Clinical Algorithm for Evaluation

When Thyroid Abnormality is Palpated:

1. Document specific characteristics: size, symmetry, nodularity, firmness, tenderness, and presence of cervical lymphadenopathy 5
2. Assess for associated signs: tachycardia and tremor suggest hyperthyroidism; bradycardia and delayed reflexes suggest hypothyroidism 2, 3, 4
3. Order thyroid function tests (TSH, free T4) as the initial diagnostic step 3, 4
4. If TSH is low (suggesting hyperthyroidism): proceed with ultrasound to evaluate morphology, followed by radioiodine uptake scan if etiology is unclear 1, 6
5. If TSH is high (suggesting hypothyroidism): imaging is generally not indicated, as it does not change management 1

Common Pitfalls to Avoid

• Do not rely on palpation alone to distinguish hyperthyroidism from hypothyroidism—laboratory confirmation is essential 3, 4
• Do not assume a normal-sized gland excludes thyroid dysfunction—both hyperthyroidism (especially in thyroiditis) and hypothyroidism can occur with normal gland size 1
• Do not skip ultrasound in hyperthyroid patients with palpable nodules, as coexisting malignancy must be excluded even in the setting of hyperthyroidism 6
• Do not order imaging for hypothyroidism workup, as it provides no diagnostic or therapeutic benefit 1
• Recognize that a single palpable nodule in a hyperthyroid patient requires differentiation between toxic adenoma and a non-functioning nodule in Graves disease, which requires radioiodine scanning 3