Examination of the Thyroid

Thyroid examination is an essential clinical skill for all doctors, but is particularly relevant in ENT as thyroid swellings are neck lumps that commonly present to ENT surgeons for assessment and surgery. The examination must assess both the structure of the gland (size, consistency, nodularity, mobility) and the function of the gland (whether the patient is euthyroid, hypothyroid, or hyperthyroid).

This guide has been written primarily for the examination setting, where you narrate your findings aloud to the examiner throughout. It follows the same logical structure used by senior ENT surgeons in clinical practice.

This page is part of Professor Vik Veer's free clinical education resource for junior NHS doctors.

Step 1: Consent and Preparation

Introduce yourself, confirm the patient's identity, and gain verbal consent.

"Is there any pain at all? And would it be all right if, while I am examining you, I speak to the examiner about my findings?"

Ask the patient to expose their neck to below the clavicles and to sit comfortably in a chair. Remove any scarves, ties, or jewellery from the neck. Good exposure is essential — a commonly missed goitre or scar is often the result of inadequate exposure in an exam setting.

Step 2: General Inspection — Peripheries and Systemic Signs

Before approaching the neck, stand back and assess the patient from a distance. Look for systemic signs of thyroid dysfunction. These may be subtle — take a full 5–10 seconds to observe.

"On general inspection, the patient appears comfortable at rest. There is no obvious restlessness, agitation, or anxiety that might suggest hyperthyroidism. The patient is dressed appropriately for the temperature of the room (heat intolerance in hyperthyroidism may lead to inappropriately light clothing). I cannot identify any vitiligo from this distance."

Vitiligo is an autoimmune depigmentation of the skin. Its presence is relevant because autoimmune thyroid diseases (Graves' disease, Hashimoto's thyroiditis) are more common in patients who have other autoimmune conditions, and vitiligo is one of these.

Step 3: Examination of the Hands

Inspect the dorsum of both hands and then the palms. Ask the patient to hold their hands outstretched with fingers spread to assess for tremor.

Dorsum of the Hands

"Examining the dorsum of the hands: there is no evidence of thyroid acropachy, onycholysis, or fine tremor."

• Thyroid acropachy — a rare sign of Graves' disease, resembling clubbing but with an associated periosteal reaction and soft tissue swelling of the digits. It is distinct from true clubbing and almost exclusively seen in Graves' disease.
• Onycholysis — separation of the nail plate from the nail bed, particularly at the lateral and distal edges. This gives the nails a whitened, thickened appearance. Associated with hyperthyroidism (particularly Graves' disease) — the mechanism is likely related to excessive matrix activity from high thyroxine levels.
• Fine resting tremor — a high-frequency, low-amplitude tremor best assessed by placing a sheet of paper on the outstretched hands. Seen in hyperthyroidism due to enhanced beta-adrenergic stimulation.

Palms

Turn the hands over to inspect the palms.

"There is no increased sweating or palmar erythema. The palms feel warm and dry (or warm and moist — consistent with hyperthyroidism)."

Palmar erythema (reddening of the thenar and hypothenar eminences) and excessive sweating are features of hyperthyroidism. Cool, dry, thickened palms may suggest hypothyroidism.

Pulse

"The pulse is regular, with a rate within normal limits." (Note if the pulse is irregular — atrial fibrillation is a well-recognised complication of hyperthyroidism, particularly in the elderly.)

Step 4: Examination of the Eyes

Eye signs are particularly associated with Graves' disease (an autoimmune hyperthyroidism where antibodies stimulate the TSH receptor). The eye disease — termed Graves' ophthalmopathy or thyroid eye disease (TED) — can occur, worsen, or persist even when the thyroid disease is treated, and can threaten vision. Assess the following:

• Loss of hair from the outer third of the eyebrows — classically associated with hypothyroidism (Hertoghe's sign).
• Lid retraction — elevation of the upper eyelid, so that sclera is visible above the iris (normally the upper lid covers the upper limbus). This gives the patient a wide-eyed, "staring" appearance. Caused by sympathetic overstimulation of the superior tarsal muscle (Müller's muscle) in hyperthyroidism, and by fibrosis of the levator in Graves' ophthalmopathy.
• Exophthalmos (proptosis) — forward protrusion of the globe beyond the level of the supra-orbital ridge, so that sclera is visible all the way around the iris. Caused by retro-orbital inflammation with lymphocytic infiltration, glycosaminoglycan deposition, and oedema in Graves' ophthalmopathy, which displaces the eye anteriorly. Formally measured with an exophthalmometer.
• Chemosis — conjunctival oedema, giving the conjunctiva a swollen, wrinkled, glassy appearance. Caused by venous and lymphatic drainage impairment as the globe is pushed forward.
• Lid lag (von Graefe's sign) — ask the patient to follow your finger slowly downward from above eye level. Observe the upper eyelid — in lid lag, the upper lid lags behind the descending globe, briefly exposing sclera above the iris. Caused by sympathetic overstimulation of Müller's muscle and, in Graves' disease, by restrictive myopathy of the levator palpebrae superioris.
• Ophthalmoplegia — paralysis or limitation of the extra-ocular muscles, causing diplopia (double vision). In Graves' ophthalmopathy, fibrosis of the inferior rectus is most commonly affected, limiting upward gaze and causing vertical diplopia.
• Periorbital oedema — puffiness of the periorbital tissues, particularly in Graves' ophthalmopathy.

Step 5: Neck Inspection

Ask the patient to extend their neck slightly so the anterior neck is clearly visible. Ensure there is good overhead or angled lighting.

"On inspection of the anterior neck, I can/cannot see an obvious midline swelling. There are no scars (a Kocher collar incision — a curved horizontal scar 2–3 cm above the suprasternal notch — would indicate previous thyroid or parathyroid surgery). The jugular venous pressure does not appear elevated and I cannot see distended neck veins."

Jugular venous distension with bilateral arm oedema in the context of a neck mass suggests superior vena cava obstruction — a rare but serious complication of large retrosternal goitre or mediastinal malignancy.

Tongue Protrusion Test

"Would you please stick out your tongue for me?"

A midline neck swelling that moves upward when the tongue is protruded is a thyroglossal cyst — an embryological remnant of the thyroglossal duct, which tracks from the foramen caecum of the tongue to the thyroid gland. This distinguishes it from other midline neck swellings (lymph nodes, dermoid cysts, sebaceous cysts) that do not move on tongue protrusion.

Swallowing Test

"I would now like to watch you swallow. Would you please take a sip of water into your mouth, hold it there, and then swallow when I say go? Could you also tilt your head back slightly so that I can see your neck clearly?" (Wait for the patient to take the sip and be ready, then:) "Go."

A thyroid swelling moves upward on swallowing because the thyroid is enclosed within the pretracheal fascia, which is attached to the laryngeal cartilages above. As the larynx elevates during swallowing, the thyroid rises with it. Lymph nodes and other neck masses do not move on swallowing (unless they are adherent to the larynx or trachea — a worrying sign of malignant invasion).

Important technique note: Give the patient the instruction while they still have the glass to their mouth — not after they have swallowed. This common timing error means the glass obscures the neck view at the critical moment.

Voice Assessment

"Please count from one to ten for me."

Listen for hoarseness or voice change, which suggests involvement of the recurrent laryngeal nerve (RLN). The RLN passes in the tracheo-oesophageal groove immediately behind the thyroid lobes and is at risk from malignant thyroid tumours, large benign goitres, and during thyroid surgery. Hoarseness caused by a thyroid mass is a red flag for malignancy until proven otherwise.

Step 6: Palpation of the Thyroid

Ask again whether there would be any pain on touching the neck. Then stand behind the patient and examine with the pulps (pads) of your fingers — not the fingertips. This is the standard ENT/surgical approach, as the examiner can see your hands and the patient's face simultaneously.

Palpate the gland systematically, using both hands to cup the neck gently and feel each lobe and the isthmus. Describe the gland in the same way you would any lump (see Lump Examination):

• Site — anterior neck, centred on or around the midline
• Size — estimate the size of each lobe in centimetres; note if the isthmus is enlarged
• Shape — is the enlargement diffuse (involving the whole gland symmetrically), multinodular (irregular, with multiple palpable nodules), or is there a solitary nodule?
• Surface — smooth (diffuse goitre, Graves', Hashimoto's) or irregular/nodular (multinodular goitre, carcinoma)
• Consistency — soft (normal), firm (Hashimoto's, benign nodule), hard/stony (malignancy, calcification), rubbery (lymphoma)
• Tenderness — tenderness on palpation is characteristic of de Quervain's thyroiditis (subacute granulomatous thyroiditis) and thyroid abscess
• Fixation — is the gland mobile on swallowing? Fixation to surrounding structures is a sinister sign, suggesting malignant invasion of the trachea, oesophagus, or overlying strap muscles
• Pulsatility — a very vascular goitre may demonstrate a palpable thrill (Graves' disease)

"The thyroid gland is diffusely enlarged, approximately twice the normal size, smooth, firm, and non-tender. It moves freely on swallowing. I cannot feel a palpable thrill. There is no cervical lymphadenopathy."

Repeat the Swallowing and Tongue Protrusion Tests During Palpation

With your fingers on the gland, ask the patient to swallow and then to protrude their tongue. You can feel the movement of the gland and confirm it is attached to the laryngeal complex.

Tracheal Deviation

Stand in front of the patient and place one finger into the suprasternal notch. Assess whether the trachea is deviated to one side. A large unilateral goitre or multinodular goitre may push the trachea to the contralateral side. Tracheal deviation combined with stridor or dyspnoea suggests significant airway compromise.

Cervical Lymphadenopathy

Palpate all nodal chains: submental, submandibular, jugulodigastric (upper deep cervical), mid-jugular, lower jugular, posterior triangle, supraclavicular, and prelaryngeal (Delphian) nodes. The Delphian node (prelaryngeal or pretracheal) — a midline node just above the thyroid isthmus — is specifically associated with thyroid carcinoma when enlarged. Supraclavicular lymphadenopathy is a particularly important finding, as it may indicate malignant spread.

Step 7: Percussion for Retrosternal Extension

Percuss directly over the manubrium sterni and the upper sternum, comparing the percussion note on each side.

"I am now going to percuss over the sternum to check for any retrosternal extension of the goitre."

Normally, percussion over the sternum is resonant. Dullness on percussion extending into the retrosternal area suggests a retrosternal goitre (the thyroid has grown downwards, behind the sternum, into the anterior superior mediastinum). This is clinically important as it may be causing tracheal and/or oesophageal compression, and surgical access is more complex (a median sternotomy may be required in addition to the standard collar incision).

Pemberton's manoeuvre can also be used: ask the patient to raise both arms above their head. If facial flushing, cyanosis, or stridor develops, this indicates venous compression by a retrosternal goitre (Pemberton's sign is positive).

Step 8: Auscultation for a Thyroid Bruit

"I am going to listen over the thyroid gland with my stethoscope."

Place the bell of the stethoscope lightly over each lobe of the thyroid. A thyroid bruit is a vascular murmur heard over a highly vascular goitre. It is a characteristic sign of Graves' disease, where TSH receptor antibody stimulation leads to marked hypervascularity of the gland. It must be distinguished from a transmitted cardiac murmur or carotid bruit — a true thyroid bruit is localised to the gland and is continuous (systolic and diastolic).

"I cannot hear a thyroid bruit over either lobe."

Step 9: Completing the Examination — Lower Limb Signs and History

"To complete my examination, I would like to assess for lower limb signs of thyroid disease."

Lower Limb Examination

• Slowly relaxing tendon reflexes (ankle jerk) — the ankle jerk reflex has a characteristically slow relaxation phase in hypothyroidism. This is caused by reduced ATP production and slowed muscle fibre contraction-relaxation. Elicit by striking the Achilles tendon with a tendon hammer and observing the time to relaxation of the plantar flexion response.
• Pretibial myxoedema — despite its name, this is a sign of hyperthyroidism (specifically Graves' disease), not hypothyroidism. It presents as raised, thickened, non-pitting, peau d'orange-textured plaques overlying the anterior shins, caused by glycosaminoglycan deposition in the dermis driven by TSH receptor antibodies acting on fibroblasts.
• Proximal myopathy — weakness of the proximal muscles of the upper and lower limbs. Both hyperthyroidism and hypothyroidism can cause proximal myopathy. Assess by asking the patient to rise from a chair without using their arms. Formal assessment of shoulder abduction against resistance and hip flexion against resistance completes this.

Voice and Vocal Cord Assessment

"I would also wish to examine this patient's vocal cords with a flexible fibreoptic nasendoscope to assess for any recurrent laryngeal nerve palsy. This is essential before any thyroid surgery and whenever malignancy is suspected."

Flexible nasendoscopy allows direct visualisation of the true vocal cords. Unilateral vocal cord palsy causes hoarseness and a breathy voice. Bilateral palsy causes stridor and may require emergency airway management.

Thyroid Status History

A focused history is an integral part of the thyroid assessment. The following questions help determine whether the patient is euthyroid, hyperthyroid, or hypothyroid: