SOLITARY NODULAR GOITRE

A 30-year-old female patient came with swelling in the right side of front
of neck for past 3 years.
No H/o difficulty in swallowing or breathing.
No other specific symptoms.
Menstrual and family H/o normal.
On local examination of neck, a nodular swelling of size 3*3 cm on the
right side of trachea, moves with deglutition, firm in consistency.
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Name: Kamala
Age/Sex: 30/F
Address: Pallavaram
Occupation: Homemaker
C/C:
Swelling in the front of neck for past 3 years
HOPI:
 The patient was apparently normal 3 years back after which she
noticed a swelling in the front of neck which is insidious in onset,
initially smaller in size and gradually progressed to attain the
current size and is not associated with pain.
 No H/o trauma. (Rule out trauma in any swelling)
 No H/o sudden increase in size. (Rule out malignancy)
 No H/o chronic fever with cough with expectoration. (Rule out TB)
 No H/o suggestive of signs of hypothyroidism or hyperthyroidism.
 No H/o suggestive of pressure symptoms.
 No H/o suggestive of malignancy.
 No H/o swelling elsewhere in the body. (Rule out LN)
Past H/o
 No H/o similar complaints in the past.
 No H/o DM, HTN, TB, Asthma.
 No H/o previous surgeries. (Rule out previous thyroid surgeries)
 No H/o any thyroid drug intake. (Any thyroxine, antithyroid
drugs)
 No H/o any childhood irradiation. (Rule out papillary carcinoma)
Personal H/o
 Mixed diet.
  Normal bowel and bladder habits.
 Normal sleep pattern.
 Non-smoker and non-alcoholic.
 Consumes iodized salt.
Family H/o
 No H/o thyroid disorders in the family. (Thyroid runs in the
family, Medullary ca, Dyshormonogenic goitre)
General examination
The patient is conscious, oriented, well-built and nourished.
No pallor, icterus, cyanosis, clubbing, significant lymphadenopathy
and pedal edema.
Vital signs
 Afebrile.
 Pulse: 74/min, regular in rate and rhythm, normal in volume and
character. No radio radial or radio femoral delay. All peripheral
pulses felt equally.
 RR: 16/min
 BP: 110/70 mm Hg, left upper limb in sitting position.
Examination of thyroid
After getting consent from the patient, the patient was exposed from head
to sternum and examined in a sitting position.
Inspection:
 A single swelling of size 3*3 cm present in the front of the neck,
hemispherical in shape, extending 3 cm from below the thyroid
cartilage, 2 cm above the suprasternal notch, medially up to
midline, laterally along anterior border of sternocleidomastoid
muscle.
 Surface appears to be smooth.
 Skin over swelling appears to be normal.
 Surrounding skin appears to be normal.
 Swelling moves with deglutition, does not move with protrusion of
tongue.
 Trachea appears to be in midline.
 No scars, sinuses, visible pulsations, dilated veins seen.
 No lateral swellings seen.
Palpation:
After asking the patient to slightly flex the neck, palpation is done
standing behind the patient and then from the front.
  No warmth and tenderness.
 All inspectory findings are confirmed on palpation.
 Smooth surface with well-defined margins.
 Lower border is palpable.
 Firm in consistency.
 Not mobile.
 Plane of swelling: Deep to deep fascia.
 Trachea is in midline.
 Carotid pulsation felt equally on both sides. (Mention Kocher’s
test only if the patient has dyspnea)
 No other swellings present.
(Need not do percussion if lower border is palpable)
Auscultation:
No bruit heard.
Examination of lymph nodes:
No enlarged palpable lymph nodes present.
Other systems
CVS: S1S2 hears, No murmurs.
RS: NVBS heard.
Abdomen: Soft, non-tender, No organomegaly.
CNS: No focal neurological deficit.
Provisional diagnosis:
Non-toxic, non-malignant, solitary nodule of thyroid of the right side.
Investigations:
Routine:
 Blood- Hb, TC, DC, ESR, BT, CT
 Blood grouping and typing.
 Urine- Sugar, protein, deposits
 Serum- Urea, creatinine
 ECG
 CXR
Specific:
 USG Neck
 TFT- Free T3, T4, TSH
 X-ray Neck (AP and Lateral)
 FNAC
 Indirect laryngoscopy (medicolegal importance)
MX:
Hemithyroidectomy of right lobe

CASE RELATED VIVA

[Link] are the signs of hyperthyroidism and
hypothyroidism?
Hyperthyroidism Hypothyroidism
CNS: CNS:
 Anxiety  Lethargic
 Irritability  Drowsy(hypersomnia)
 Tremors  Hyporeflex
 Hyperactive (hyper reflex)  Slurred speech
 Insomnia (drunkard/alcoholic speech)
CVS: CVS:
 Palpitations  Bradycardia
 Tachycardia Abdomen:
Abdomen:  Weight gain
 LOW inspite of good appetite  Constipation
 Diarrhoea Genitourinary:
Genitourinary:  Menorrhagia (Excessive
 Oligomenorrhea (Scanty menstruation)
menstruation)  Amenorrhea
 Amenorrhea Miscellaneous:
Miscellanous:  Cold intolerance
 Excessive sweating  No sweating
 Heat intolerance  Dry skin
 Hyperthermia  Cold body
 Moist skin  Loss of hair in the lateral
 Pretibial myxedema third of eyebrows
Eye signs: Exophthalmos
 Stellwag’s sign
 Joffroy’s sign
 Von Graffe sign
 Moebius sign
*
Exophthalmos and pretibial myxedema occurs due to accumulation of
glycosaminoglycans. (d/t loose connective tissue present)
2. How to assess
Tremors (Hand):
 Ask the patient to extend limb and shoulder joint.
  Must be parallel to the floor.
 If tremors are visible, then coarse tremors.
 If not, place a piece of paper on the dorsum of hand or a pen in
between fingers. (Done to assess for fine tremors)
Tremors (Tongue):
 Ask the patient to partially open mouth.
 Put out tongue and the whole tongue should not come out of mouth.
Then assess for tremors.
Heat intolerance:
Female: Unable to cook continuously, takes rest frequently.
Male: Unable to work continuously, takes rest frequently.
Cold intolerance: The patient will ask to switch off the fan inspite of the
heat.
3. How do you rule out pressure symptoms?
 Difficulty in breathing
 Difficulty in swallowing
 Change in voice
 Horner’s syndrome (Ptosis, Miosis, Anhidrosis, Enophthalmos)
4. How do you rule out malignancy?
 Loss of appetite
 Loss of weight
 Bone pain
 Jaundice
5. What are the eye signs seen in hyperthyroidism?
 Stellwag’s sign: Staring look (D/t toxic contraction of LPS muscle)
 Joffroy sign: Absence of wrinkling of forehead
 Von Graffe sign: Lid lag sign. Upper lid lags when the patient is
asked to look up and down.
 Moebius sign: Absence of accommodation.
6. Why does thyroid move with deglutition?
When swallowing, larynx moves up, cricoid cartilage also moves up pulling
the thyroid upwards. This occurs due to the attachment of the cricoid and
thyroid cartilage by BERRY’S LIGAMENT.
(Berry’s ligament: Condensation of lower border of pretracheal fascia)
HOW TO ASSESS: Give the patient some water and ask him to swallow****
7. Why does thyroid not move with protrusion of tongue?
Median thyroid anlage descends along with the thyroglossal duct to form
the thyroid. The thyroglossal duct is connected to foramen caecum in
tongue.
During normal development, the thyroglossal duct gets obliterated. If it
persists, then the condition is called as thyroglossal cyst, which moves
with protrusion of tongue.
8. How do you assess whether trachea is in midline?
 Place your index and ring finger on sternal end of the clavicle and
run the middle finger down from cricoid cartilage till the
suprasternal notch.
 Palpate for cricoid cartilage.
 Then try to insinuate the finger under the anterior end of
sternocleidomastoid muscle.
 Normally, if trachea is in midline, we cannot admit the finger. When
trachea is shifted, then the opposite side will be empty and will
admit a finger.
(Trail’s sign: Inspectory finding. Prominence of SCM on the side of tracheal
deviation)
9. How do you assess for plane of swelling?
 Ask the patient to turn his neck against resistance. (The deep fascia
is put into contraction by putting the SCM into contraction)
 If the swelling becomes less prominent, Then it is deep to deep
fascia.
 If both the lobes are enlarged, then ask to patient to flex his neck
against resistance. (Chin test)
10. Where do you look for carotid pulsation?
Between the cornu of thyroid cartilage and anterior border of upper 1/3rd
of SCM, corresponding to C6 vertebra.
11. Where do we look for bruit?
 Occurs due to increased continuous blood flow to thyroid.
 Seen in upper pole of thyroid because the superior thyroid artery is
more superficial.
12. Seven levels of cervical lymph nodes
Level 1: Submental and submandibular
Level 2: Upper jugular
Level 3: Middle jugular
Level 4: Lower jugular
Level 5: Posterior triangle:
Level 6: Pretracheal and pre laryngeal
Level 7: Anterior mediastinal
13. Signs and tests for pressure symptoms
 Kocher’s test: Slight push on the lateral lobes will produce stridor
 Scabbard trachea: Slit like trachea (Xray neck AP and lateral view is
done to appreciate this)
 Berry’s sign: Malignant thyroid will engulf the carotid sheath and the
pulsation of the carotid artery may not be felt.
 Pemberton’s sign: Engorgement of neck veins seen when patient is
asked to raise arms above the head and the arms touch the ears.
(D/t SVC obstruction)
14. What are the normal TFT values?
TSH: 0.3-3.3 mU/L
Free T3: 3.5-7.5 µmol/L
Free T4: 10-30 nmol/L
[Link] are the uses of USG neck?
 Solitary or multinodular goiter
 Solid or cystic
 Uniform or irregular walls (Suspect malignancy)
 Any solid elements within cyst (Suspect malignancy)
 Microcalcifications
16. What are the uses of Xray neck?
 To find out trachea position
 Calcifications
 Spondylosis
17. What is hemithyroidectomy?
Lobectomy of the affected side and removal of the isthmus
(Isthmus is removed to prevent recurrence as it is more prone for nodule
formation)
ANATOMY OF THYROID
18. Extent:
 Gland lies against C5-C7 and T1.
 Each lobe extends from middle of thyroid cartilage to 4 th/5th tracheal
ring.
[Link] are the capsules of thyroid gland?
  True capsule: Peripheral condenstion of connective tissue of the
gland.
 False capsule: Derived from pretracheal layer of deep cervical
fascia. Forms the berry’s ligament on the inner surface of the gland.
19. What is the difference between capsule of prostate and thyroid?
The venous plexus in the thyroid lies deep to the deep fascia hence both
the capsules can be removed in a thyroidectomy.
The venous plexus in prostate lies between the two capsules and hence it
is not removed in a prostatectomy.
20. What is the blood supply of thyroid?
 Superior thyroid artery (from ECA)
 Inferior thyroid artery (from thyrocervical trunk of subclavian artery)
 Thyroidea Ima artery (from arch of aorta)
21. What is the venous drainage of thyroid?
 Superior thyroid vein (Drains into IJV)
 Middle thyroid vein (Drains into IJV)
 Inferior thyroid vein (Drains into brachiocephalic vein)
 Kocher vein (Drains into IJV)
22. Course of Recurrent laryngeal nerve
The right RLN branches from the vagus, loops around the right subclavian
artery from posterior to anterior, crosses behind right CCA and ascends
near the tracheoesophageal groove, enters into larynx and the inferior
constrictor muscle.
The left RLN arises where the vagus nerve crosses the aortic arch, loops
under the ligamentum arteriosum and the aorta and ascends in the same
manner as the right nerve.