Go to the goitre


Hyperthyroidism cartoon
If only patients presented with handy thought bubbles… Illustration by Surabhi Khanna

Giselle Oyter is a 49 year old woman who complains of sweaty palms, hot flushes and anxiety for the past 2 months. Her periods have been a bit irregular for the past 4 months. She is convinced she is going through the changes and has taken black cohosh.

You put on your 1950s detective jacket, smoke your e-pipe and ponder if the real problem is the thyroid.

You stare at her neck, and her neck stares back at you without telling you where its thyroid gland is. You’ll have to find it yourself…

In other words, feel down the neck looking for the following landmarks:

What are the goals of the thyroid examination? 

  1. What is the patient’s thyroid status?
  2. Is there a thyroid lump, and if so, what is it?
  3. Is there evidence of Grave’s disease specifically?

I’ve summarised the examination on this handout, as well as explained the rationale behind each step. This video is the shortest summary I found:

What is a goitre?

A fancy was of saying an enlarged thyroid gland. It is generally diffuse, whereas nodules are focal.

What did that patient have then?

A large, diffuse goitre combined with a hyperthyroid state.  This is most likely to be Grave’s disease. It’s not uncommon for this to be masquerading as the menopause. Other signs you might expect (generally in advanced disease) include thyroid acropatchy (which looks exactly like clubbing, and may extend a bit more proximally to include swelling of the digits), Grave’s ophthalmoplegia and pretibial myxodema.

Which is Grave’s ophthalmoplegia called a complex ophthalmoplegia? All opthalmoplegias seem complex to me…

Ophthalmoplegia refers to any weakness of the eye muscles. Any opthalmoplegia which cannot be attributed to any one cranial nerve is called a complex ophthalmoplegia. In Grave’s, there is impairment of specific extra ocular muscles as opposed to a cranial nerve. This is similar to myasthenia gravis.

Palpation of any lump

This is simple 🙂

  • Inspection
  • Palpation
  • Special tests
  • Lymph nodes

The main way you can go wrong is if you forget lymph nodes. Lymph nodes are everything. If there is a regional lymph node, suspect a cancer. For example, NICE guidelines for breast cancer referral state to consider referring even in the absence of any breast lump if:

Aged 30 and over with an unexplained lump in the axilla

That’s how intense unexplained lymph nodes are.


  • Size
  • Shape
  • Surface
  • Surface changes
  • Consistency
  • Contours
  • Colour
  • Compressibility
  • Temperature
  • Tenderness
  • Transillumination
  • Tethered

Special tests:

  • Reducibility
  • Pulsatility

Then don’t forget regional LYMPH NODES.