Physical Examination Findings of an Enlarged Thyroid
On physical examination, an enlarged thyroid gland (goiter) presents as a visible or palpable swelling in the anterior neck that moves upward with swallowing, and the clinician should palpate the neck and thyroid gland systematically to assess size, texture, tenderness, and nodularity. 1
Inspection Findings
- Visible neck swelling: A goiter may be visible as anterior neck fullness or asymmetry, particularly when the patient extends their neck or swallows 2
- Movement with swallowing: The thyroid gland characteristically moves upward during swallowing, which distinguishes it from other neck masses 1
- Grading system: Goiters are commonly graded as:
- Grade I: Palpable but not visible
- Grade II: Visible with neck in normal position and palpable 3
Palpation Technique and Findings
- Systematic palpation: The clinician should palpate the neck and thyroid gland from behind the patient or facing the patient, using both hands to assess each lobe and the isthmus 1
- Size assessment: Normal thyroid volume is approximately 7-8 mL in adults, with males having larger volumes (8.3 ± 3.3 mL) than females (6.1 ± 2.6 mL) 4
- Texture variations:
- Diffusely enlarged and smooth: Typical of Graves' disease, Hashimoto's thyroiditis, or iodine deficiency 3, 5
- Nodular: Suggests toxic multinodular goiter or presence of discrete nodules requiring further evaluation 1, 2
- Firm texture: May indicate malignancy risk, particularly if the mass is >1.5 cm and has reduced mobility 1
Tenderness Assessment
- Non-tender goiter: More common in chronic conditions like Graves' disease, Hashimoto's thyroiditis, and multinodular goiter 1, 2
- Tender/painful goiter: Suggests subacute thyroiditis or, rarely, acute inflammatory processes in Graves' disease with elevated inflammatory markers 6
- Important distinction: A nontender neck mass is generally more suspicious for malignancy than a tender mass 1
Associated Physical Findings by Etiology
Hyperthyroidism (Graves' Disease)
- Diffusely enlarged thyroid gland with smooth, symmetric enlargement 5
- Stare or exophthalmos (eye findings specific to Graves' disease) 5
- Systemic signs: Tachycardia, tremor, warm moist skin, hyperreflexia 5
Toxic Nodular Goiter
- Palpable nodules within an enlarged gland 1
- Compressive symptoms: Dysphagia, orthopnea, dyspnea, or voice changes from local compression 5
Hypothyroidism with Goiter
- Diffusely enlarged gland that may be smooth or have a "bosselated" texture in Hashimoto's thyroiditis 3
- Grade I or II goiter depending on severity 3
Critical Examination Caveats
- Palpation limitations: Physical examination may miss thyroid abnormalities in up to 18.5% of cases where ultrasound detects lesions, particularly in older patients 4
- Substernal extension: A goiter extending behind the sternum may not be fully palpable and requires imaging (CT preferred over ultrasound) for complete assessment 7
- Distinguish from other neck masses: Normal anatomic structures (such as prominent carotid bulbs or hyoid bone) are often mistaken for pathologic masses 1
- Malignancy red flags: Reduced mobility, firm/hard texture, size >1.5 cm, associated cervical lymphadenopathy, or ulceration warrant urgent evaluation 1
When Physical Examination Triggers Imaging
- Obstructive symptoms: Dyspnea, orthopnea, dysphagia, or dysphonia require ultrasound to document size and degree of tracheal/esophageal compression for surgical planning 8, 7
- Discrete palpable nodules: Ultrasound is indicated to characterize malignancy risk using ACR TI-RADS criteria and guide fine needle aspiration decisions 8, 7
- Important limitation: In primary hypothyroidism, ultrasound has no utility for diagnosis or management regardless of goiter presence, as imaging cannot differentiate causes and treatment is levothyroxine replacement regardless of morphology 8, 7