Thyroid nodule physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
Physical examination should focus on the thyroid gland and the lateral and central neck and should assess for supraclavicular and submandibular adenopathy. | Physical examination should focus on the [[thyroid gland]] and the lateral and central [[neck]] and should assess for [[supraclavicular]] and [[submandibular]] [[adenopathy]]. The most important finding in [[physical examination]] that need a more attention include assessing the nodule's size and consistency, localized [[tenderness]] in the nodular area, [[lymphadenopathy]], and [[Physical exam|physical exams]] coordinated with hypo- or [[hyperthyroidism]]. | ||
==Physical Examination== | ==Physical Examination== | ||
a rapid pulse rate may suggest hyperthyroidism | Physical examination of patients with thyroid nodule is usually remarkable for:<ref name="pmid20510711">{{cite journal |vauthors=Bomeli SR, LeBeau SO, Ferris RL |title=Evaluation of a thyroid nodule |journal=Otolaryngol. Clin. North Am. |volume=43 |issue=2 |pages=229–38, vii |year=2010 |pmid=20510711 |pmc=2879398 |doi=10.1016/j.otc.2010.01.002 |url=}}</ref><ref name="pmid12115799">{{cite journal |vauthors=Lawrence W, Kaplan BJ |title=Diagnosis and management of patients with thyroid nodules |journal=J Surg Oncol |volume=80 |issue=3 |pages=157–70 |year=2002 |pmid=12115799 |doi=10.1002/jso.10115 |url=}}</ref><ref name="pmid22443979">{{cite journal |vauthors=Popoveniuc G, Jonklaas J |title=Thyroid nodules |journal=Med. Clin. North Am. |volume=96 |issue=2 |pages=329–49 |year=2012 |pmid=22443979 |pmc=3575959 |doi=10.1016/j.mcna.2012.02.002 |url=}}</ref><ref name="pmid21460787">{{cite journal |vauthors=Milas Z, Shin J, Milas M |title=New guidelines for the management of thyroid nodules and differentiated thyroid cancer |journal=Minerva Endocrinol. |volume=36 |issue=1 |pages=53–70 |year=2011 |pmid=21460787 |doi= |url=}}</ref> | ||
=== Appearance of the patient === | |||
* [[Tachycardia]] | |||
** A rapid pulse rate may suggest [[hyperthyroidism]] | |||
* [[Hypertension]] | |||
** May occur in the context of [[Multiple endocrine neoplasia|multiple endocrine neoplasia type II]] ([[Multiple endocrine neoplasia type 2|MEN II]]) | |||
* [[Tachypnea]] may occur in the case of [[shortness of breath]] secondary to [[tumor]] enlargement effect | |||
=== HEENT === | === HEENT === | ||
* Thyroid nodule | * Thyroid nodule | ||
** Solitary or dominant in a multinodular goiter | ** Solitary or dominant in a [[multinodular goiter]] | ||
** Characteristics of the nodule, including: | ** Characteristics of the nodule, including: | ||
*** Size | *** Size | ||
*** Consistency (e.g., soft, firm, woody, or hard) | *** Consistency (e.g., soft, firm, woody, or hard) | ||
**** Nodules that are firm or immobile are more likely to harbor cancer than those that are soft or mobile | **** Nodules that are firm or immobile are more likely to harbor cancer than those that are soft or mobile | ||
**** Large, firm cervical nodes ipsilateral to the thyroid nodule should suggest the possibility of local metastases from thyroid cancer | **** Large, firm [[Cervical lymph nodes|cervical nodes]] ipsilateral to the thyroid nodule should suggest the possibility of local [[metastases]] from [[thyroid cancer]] | ||
**** | **** Firm to hard, irregular, fixed, non-[[Tenderness (medicine)|tender]] nodule is more likely to be a thyroid [[malignant]] [[neoplasm]] | ||
**** A smooth, soft, easily mobile nodule suggests | **** A smooth, soft, easily mobile nodule suggests a [[benign]] lesion, as does the presence of [[tenderness]] | ||
**** | **** Some [[benign]] nodules can be very hard because of [[Calcification|calcifications]] | ||
**** Multinodularity, especially if the nodules all have the same | **** Multinodularity, especially if the nodules all have the same consistency, is consistent with a [[benign]] [[multinodular goiter]]. A nodule or mass that is dominant in size or has a different consistency than other nodules within the [[Thyroid Gland|gland]] should be evaluated for [[malignancy]] more precisely | ||
**** A midline nodule over the hyoid bone that moves up with protrusion of the tongue is likely to be a thyroglossal duct cyst. | **** A midline nodule over the [[hyoid bone]] that moves up with protrusion of the [[tongue]] is likely to be a [[Thyroglossal cyst|thyroglossal duct cyst]]. | ||
*** Involvement with adjacent structures | *** Involvement with adjacent structures | ||
* Cervical lymph nodes, including: | * [[Cervical lymph nodes]], including: | ||
** | ** [[Submental lymph nodes|Submental]] and [[Submandibular lymph nodes|submandibular nodes]] | ||
** | ** Upper [[Jugular lymph nodes|jugular nodes]] | ||
** | ** Midjugular nodes | ||
** | ** Lower [[Jugular lymph nodes|jugular nodes]] | ||
** | ** Posterior triangle and [[Supraclavicular lymph node|supraclavicular nodes]] | ||
** | ** [[Pretracheal lymph nodes|Pretracheal]], [[Prelaryngeal lymph nodes|prelaryngeal]], and [[Paratracheal lymph nodes|paratracheal nodes]] | ||
* Deviation of the trachea, which suggests a mass | * Deviation of the [[trachea]], which suggests a mass | ||
* [[Hyperthyroidism]] | |||
** Secondary to [[Thyroid-stimulating hormone|TSH]] secreting [[adenomas]] | |||
** [[Palpitations]] | |||
** [[Insomnia]] | |||
** [[Anxiety]] | |||
** [[Weight loss]] | |||
| | ** Heat intolerance | ||
** [[Diarrhea]] | |||
Differentiated [[thyroid carcinoma]] (particularly [[Papillary carcinoma of the thyroid|papillary carcinoma]]) involves [[cervical lymph nodes]] in 20–50% of patients in most series using standard [[histopathological]] techniques, and may be present even when the primary [[tumor]] is small and intrathyroidal.<ref name="pmid1455316">{{cite journal |vauthors=Hay ID, Grant CS, van Heerden JA, Goellner JR, Ebersold JR, Bergstralh EJ |title=Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period |journal=Surgery |volume=112 |issue=6 |pages=1139–46; discussion 1146–7 |year=1992 |pmid=1455316 |doi= |url=}}</ref> | |||
Differentiated thyroid carcinoma (particularly papillary carcinoma) involves cervical lymph nodes in 20–50% of patients in most series using standard | |||
1455316 | |||
The frequency of micrometastases may approach 90% | The frequency of micrometastases may approach 90%.<ref name="pmid28289664">{{cite journal |vauthors=Chang YW, Kim HS, Jung SP, Kim HY, Lee JB, Bae JW, Son GS |title=Significance of micrometastases in the calculation of the lymph node ratio for papillary thyroid cancer |journal=Ann Surg Treat Res |volume=92 |issue=3 |pages=117–122 |year=2017 |pmid=28289664 |pmc=5344800 |doi=10.4174/astr.2017.92.3.117 |url=}}</ref> | ||
==== Respiratory ==== | |||
*[[Dyspnea]] | |||
*[[Coughing]] | |||
** May become continous | |||
** [[Dysphagia]] | |||
** [[Hoarseness]] | |||
==References== | ==References== | ||
Latest revision as of 12:28, 6 June 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Physical examination should focus on the thyroid gland and the lateral and central neck and should assess for supraclavicular and submandibular adenopathy. The most important finding in physical examination that need a more attention include assessing the nodule's size and consistency, localized tenderness in the nodular area, lymphadenopathy, and physical exams coordinated with hypo- or hyperthyroidism.
Physical Examination
Physical examination of patients with thyroid nodule is usually remarkable for:[1][2][3][4]
Appearance of the patient
- Tachycardia
- A rapid pulse rate may suggest hyperthyroidism
- Hypertension
- May occur in the context of multiple endocrine neoplasia type II (MEN II)
- Tachypnea may occur in the case of shortness of breath secondary to tumor enlargement effect
HEENT
- Thyroid nodule
- Solitary or dominant in a multinodular goiter
- Characteristics of the nodule, including:
- Size
- Consistency (e.g., soft, firm, woody, or hard)
- Nodules that are firm or immobile are more likely to harbor cancer than those that are soft or mobile
- Large, firm cervical nodes ipsilateral to the thyroid nodule should suggest the possibility of local metastases from thyroid cancer
- Firm to hard, irregular, fixed, non-tender nodule is more likely to be a thyroid malignant neoplasm
- A smooth, soft, easily mobile nodule suggests a benign lesion, as does the presence of tenderness
- Some benign nodules can be very hard because of calcifications
- Multinodularity, especially if the nodules all have the same consistency, is consistent with a benign multinodular goiter. A nodule or mass that is dominant in size or has a different consistency than other nodules within the gland should be evaluated for malignancy more precisely
- A midline nodule over the hyoid bone that moves up with protrusion of the tongue is likely to be a thyroglossal duct cyst.
- Involvement with adjacent structures
- Cervical lymph nodes, including:
- Submental and submandibular nodes
- Upper jugular nodes
- Midjugular nodes
- Lower jugular nodes
- Posterior triangle and supraclavicular nodes
- Pretracheal, prelaryngeal, and paratracheal nodes
- Deviation of the trachea, which suggests a mass
- Hyperthyroidism
- Secondary to TSH secreting adenomas
- Palpitations
- Insomnia
- Anxiety
- Weight loss
- Heat intolerance
- Diarrhea
Differentiated thyroid carcinoma (particularly papillary carcinoma) involves cervical lymph nodes in 20–50% of patients in most series using standard histopathological techniques, and may be present even when the primary tumor is small and intrathyroidal.[5]
The frequency of micrometastases may approach 90%.[6]
Respiratory
- Dyspnea
- Coughing
- May become continous
- Dysphagia
- Hoarseness
References
- ↑ Bomeli SR, LeBeau SO, Ferris RL (2010). "Evaluation of a thyroid nodule". Otolaryngol. Clin. North Am. 43 (2): 229–38, vii. doi:10.1016/j.otc.2010.01.002. PMC 2879398. PMID 20510711.
- ↑ Lawrence W, Kaplan BJ (2002). "Diagnosis and management of patients with thyroid nodules". J Surg Oncol. 80 (3): 157–70. doi:10.1002/jso.10115. PMID 12115799.
- ↑ Popoveniuc G, Jonklaas J (2012). "Thyroid nodules". Med. Clin. North Am. 96 (2): 329–49. doi:10.1016/j.mcna.2012.02.002. PMC 3575959. PMID 22443979.
- ↑ Milas Z, Shin J, Milas M (2011). "New guidelines for the management of thyroid nodules and differentiated thyroid cancer". Minerva Endocrinol. 36 (1): 53–70. PMID 21460787.
- ↑ Hay ID, Grant CS, van Heerden JA, Goellner JR, Ebersold JR, Bergstralh EJ (1992). "Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period". Surgery. 112 (6): 1139–46, discussion 1146–7. PMID 1455316.
- ↑ Chang YW, Kim HS, Jung SP, Kim HY, Lee JB, Bae JW, Son GS (2017). "Significance of micrometastases in the calculation of the lymph node ratio for papillary thyroid cancer". Ann Surg Treat Res. 92 (3): 117–122. doi:10.4174/astr.2017.92.3.117. PMC 5344800. PMID 28289664.