Palpation of the Thyroid Gland – Part 2 of the Physical Examination

Palpation

Palpation means putting the fingers on the neck and feeling the thyroid gland.  The first objective is to validate the findings on inspection and the second objective is to examine further the thyroid gland to gather more data that will be used in formulating a physical diagnosis.  Diagnosis is an end-of-assessment statement on condition of the thyroid gland – whether normal or abnormal; if abnormal, what kind of abnormality is suspected – disorders in thyroid function: hyperthyroidism or hypothyroidism; disorders in anatomical structure – malignant or non-malignant nodule/s or mass/es.

One can palpate the thyroid gland from the front (anterior), from the back (posterior), or both from the front and back (anterior and back).

The anterior approach of palpation means the physician palpates the thyroid gland from the front of the patient.  The posterior approach means the physician palpates the thyroid gland from the back of the patient.

Pictures: Anterior and Posterior Approaches

ANTERIOR APPROACH

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POSTERIOR APPROACH

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images

One can choose any approach depending the circumstances (whether it can be done – for example, in a bed-ridden patient, palpation from the back cannot be done) and depending on the preference of the examiner (some prefer front over back approach primarily because of the comfortable position in doing the palpation).  The guiding principles in the choice of the approach are one, comfort of the patients to be palpated; two, ease of palpation; and third, accuracy of the palpation.  As mentioned, one can do one palpation approach only (either from the front or from the back).  One can also do a combination of front and back approaches if needed.  The latter is done if there is a need to verify findings after the front or back approach is used.

In ambulatory and conscious patients, palpation is done with the patients usually in a sitting position (not standing).  If the front approach is utilized, the physician is also in a sitting position facing a patient and palpating the latter’s neck.  If the back approach is utilized, the physician stands at the back of a seated patient palpating the latter’s neck.

Before the start of the palpation, the neck of the patient should be flexed to a degree so to lax the skin and soft tissue and muscles on the area of the thyroid gland.  This facilitates the palpation and promotes accuracy.

Since the patients will be asked to swallow during the palpation procedure, to facilitate this, water is preferably made available for the patient to drink and then swallow it. During palpation, the patient will be asked to swallow at least three times.  Swallowing saliva may be difficult for some patients.  Thus, the use of water to facilitate the swallowing maneuver.

In palpation of the thyroid gland, whether anterior or posterior approach, the first thing to do is to locate through palpation the trachea.  The trachea is normally located in the midline of the neck.  In the presence of a huge goiter, the trachea may be pushed to one side and thus, not in the midline anymore.

Locating the trachea can be guided by locating the thyroid cartilage.

Picture showing the thyroid cartilage and the trachea and the thyroid gland.

thyroid_gland_diag

The trachea is below the thyroid cartilage. Once the trachea is located, fingers of both hands are placed along each side of the trachea to simultaneously assess and compare the two lateral lobes of the thyroid gland.  If there is a need to verify findings on simultaneous palpation of the two lobes of the thyroid gland or there is difficulty in assessment using this simultaneous palpation (such as in the presence of huge nodular goiter), palpation of one-side or one lobe then the other side or lobe can or should be done.  In such a situation, fingers of one hand are placed on one side of the trachea first.  After this, the same technique can be done on the other side of the trachea to assess the other thyroid lobe.

With the fingers on the side of the trachea, the patient is asked to swallow (at least three times to show  the patient one is doing a meticulous examination; the end-point of asking the patient to swallow which could be five times or more is until the physician is confident of his findings and assessment).  With each swallowing, the physician tries to feel for any bulging thing that will glide between the examining fingers and the trachea.

The thyroid gland is said to be physically normal in size and configuration if there is no bulging thing that will glide between the examining fingers and the trachea to suggest diffuse enlargement or presence of nodule/s.  The thyroid gland is also said to be normal in function when there are no unusual bulge to suggest enlargement or presence of nodules and there are no signs and symptoms suggestive of hyperthyroidism and hypothyroidism.

If there is a felt bulge, the physician should determine if the bulge is diffuse or nodular.

Diffuse enlargement or diffuse goiter is said to be present if the two lateral lobes are almost symmetrically bulging or enlarged and there are no nodules palpated.

Nodular goiter is said to be present if there is /are palpable nodule/s.  Nodular goiter is also said to be present if the two lobes are significantly asymmetrical in size, say one lobe is at least 2 times bigger than the other lobe.  In such a situation, the bigger lobe usually contains a nodule.

If a diffuse goiter is discovered, the size of the enlargement is measured by estimating the height in centimeters.

There is a clinical grading used by World Health Organization on visibility of the goiter that is reflective of the size of the diffuse enlargement.

  • Grade 1 – if the enlargement is not visible on hyperextending the neck.
  • Grade 2 – if the enlargement is visible only upon hyperextending the neck.
  • Grade 3 – if the enlargement is visible even if the neck is not hyperextended.

If there is a nodule or there are nodules discovered, the size is measured by estimating the size in its greatest diameter in centimeters.  Aside from the size, the following characteristics should be assessed as these will be useful in the formulating the physical and clinical diagnosis.

  • Consistency – whether hard or non-hard (soft or firm)
  • Nature – whether cystic or solid
  • Fixation – whether fixed or not fixed (if fixed, determine whether fixed to trachea or even to the prevertebral fascia)
  • Border – whether margin is well-defined or poorly-defined
  • Tenderness – whether present or absent

The clinical grading used by World Health Organization on visibility of the diffuse goiter  can also be used for nodular goiters.

  • Grade 1 – if the nodule/s is/are not visible on hyperextending the neck.
  • Grade 2 – if the nodule/s is/are visible only upon hyperextending the neck.
  • Grade 3 – if the nodule/s is/ae visible even if the neck is not hyperextended.

The quality parameters of palpation of the thyroid gland are the following:

  1. Completeness of palpation (at least the two lateral lobes of the thyroid gland)
  2. Accuracy in the interpretations of findings
  3. Gentleness in palpation
  4. Reasonable length of time in palpation (usually not more than 5 minutes)

After palpation of the thyroid gland, to complete the focused physical examination of the thyroid gland so as to be able to come out with a physical diagnosis, the physician should palpate the lateral side of the neck for any enlarged lymph nodes.  The physician should also count the pulse or heart rate.

If lymph nodes are palpated, these should be described as to location, number, size, fixation, tenderness, and other characteristics.

After the focused physical examination of the thyroid gland which consists of inspection and palpation of the thyroid and the neck and counting the pulse or heart rate, one is ready to go to the next step, which is formulation of the physical diagnosis.

Note:

  • One is free to repeat inspection after palpation.
  • One is free to repeat inspection and palpation several times.
  • The end-point is when one is confident of the findings and assessment.

 

See also the following:

Minimum Tools in Physical Examination and Physical Diagnosis of the Thyroid Gland

Inspection of the Thyroid Gland – Part 1 of the Physical Examination

Physical Examination, Physical Diagnosis and Clinical Diagnosis of Thyroid Disorder – Part 3 of Physical Examination


ROJ@18feb9

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