Thyroid nodule physical examination
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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.
Physical Examination
a rapid pulse rate may suggest hyperthyroidism, and hypertension may occur in the context of multiple endocrine neoplasia, type II (MEN II)
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, nontender nodule is more likely to be a thyroid malignant neoplasm
- A smooth, soft, easily mobile nodule suggests benignancy, 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 con¬ sistency, is consistent with a be¬ nign 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
| follicular adenoma or carcinoma | compressive symptoms such as dyspnea, coughing, choking sensation, dysphagia, inability to lie flat, or hoarseness | hyperthyroidism
1% of follicular adenomas are toxic adenomas, causing symptomatic hyperthyroidism |
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Differentiated thyroid carcinoma (particularly papillary carcinoma) involves cervical lymph nodes in 20–50% of patients in most series using standard pathologic techniques, and may be present even when the primary tumor is small and intrathyroidal.
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 112:1139–1146; discussion 1146–1147
The frequency of micrometastases may approach 90%
Qubain SW, Nakano S, Baba M, Takao S, Aikou T 2002 Distribution of lymph node micrometastasis in pN0 welldifferentiated thyroid carcinoma. Surgery 131:249–256