Abnormal findings

Shape. Simple goitres may be relatively symmetrical in their earlier stages but usually become irregular with time. The gland is usually symmetrical in Graves' disease, whereas il is irregular in multinodular goitre.

Mobility Most goitres move upwards with swallowing: however, an invasive thyroid carcinoma may result in fixation of the gland to other surrounding structures and very large goitres may be immobilised because they expand to occupy all the available space in the root of the neck.

HYPERTHYROID

HYPOTHYROID

Fig. 2.47 Features of hyper- and hypothyroidism.

Consistency, The consistency, texture anil the smoothness of the surface of the gland may vary from one part to another. Nodules in the substance of the gland may be large or small, single or multiple. If the consistency is "stony hard', carcinomatous change is likely. The presence of large, firm or hard lymph nodes near a goitre also suggests the possibility of a thyroid malignancy.

Tenderness. Diffuse tenderness usually implies thyroiditis: localised tenderness may occur following bleeding into a cyst.

Colour changes. These are most unusual unless the goitre is very big, when distended veins may be responsible for a dusky, blue appearance.

Vascular bruit. This indicates an abnormally large blood flow and is sometimes associated with a palpable thrill. Increased blood flow occurs in hyperthyroidism, but the use of antithyroid drugs may also increase the vascularity of the gland sufficiently to produce a murmur. A thyroid

CASE HISTORY

A14-year-old schoolboy presented with increasing lethargy over the previous 12 months. Over Ihe past 2-3 years, his performance at school has been noted to deteriorate. Or examination he had the characteristic lacia) features ol primary hypothyroidism (Fig, 2.48A), Biood tests confirmed primary hypothyroidism with a normochromic normocyte anaemia (haemoglobin 8 g/dl). The facial change disappeared within 6 months of starting treatment with thyroxine (Fig. 2.48B).

Learning points

Because the facial and other features of thyroid disease develop over a period of time, they may be overlooked by those in regular contact with the patient.

Tremor

Facial Features Hypothyroidism Images

Delay in tendon relaxation time

Hypolhermia

Gruff voice, dry skin, coarse features

Goitre (no bruit)

Pericardial effusion

Ascites

Bradycardia

Carpal lunnel syndrome

Fig. 2.47 Features of hyper- and hypothyroidism.

Delay in tendon relaxation time

Goilre (± bruit) Atrial fibrillation/ tachycardia Proximal myopathy Bowel Irequency Hot, sweaty hand

Tremor

Hypolhermia

Gruff voice, dry skin, coarse features

Goitre (no bruit)

Pericardial effusion

Ascites

Bradycardia

Carpal lunnel syndrome

Pretibial Nodules MyxedemaHypothyroid Goitre

Fig. 2.48 Hypothyroid fades HI before and [H 6-months alter thyroxine therapy.

should be distinguished from a murmur arising in ihe carotid artery or transmitted from the aorta and from a venous hum originating in the internal jugular vein.

Other features. The presence or absence of a goitre is a poor index of thyroid function, but the systemic features and the facial appearance (Fig. 2.48A) may be an excellent guide to the diagnosis. It is necessary, however, not to confuse the signs of thyrotoxicosis with those of autoimmune thyroid disease (Fig. 7.2, p. 245). These may include proptosis, exophthalmos, ophthalmoplegia and pretibial myxoedema. Although these signs are features of Graves' disease, they may be found in subjects who are euthyroid, or even hypothyroid.

Some of the systemic features of thyroid disease are summarised in Figure 2,47.

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