Pediatric Exams: Normal and Abnormal Thyroid

Andrew Bauer, MD, an endocrinologist at The Children's Hospital of Philadelphia, demonstrates technique for the pediatric thyroid exam. In addition to performing an exam on a teenager with a normal, healthy thyroid, Dr. Bauer shows what to look for during exams on children with abnormal thyroids. Dr. Bauer is medical director of the Pediatric Thyroid Center at CHOP, the busiest pediatric thyroid center in the United States. The center provides care for thyroid nodules; thyroid cancer – papillary, follicular and medullary (MEN 2); non-medullary familial thyroid cancer syndromes – familial DTC, PTEN Hamartoma syndrome, DICER1/PPB, familial adenomatous polyposis, and others.

Transcript

Pediatric Exams: Normal and Abnormal Thyroid

Andrew Bauer, MD: I'm Dr. Andrew Bauer, the medical director of the Thyroid Center of The Children's Hospital of Philadelphia. The Children's Hospital Thyroid Center is one of the busiest Thyroid Centers in the United States and we see the full range of thyroid diseases within pediatrics from newborns up until age 23; to include congenital hypothyroidism, acquired hypothyroidism, hyperthyroidism we see about 50 new Graves patients per year, thyroid nodules and thyroid cancer and thyroid cancer syndromes. 

So this video is an educational video to try to highlight what a normal thyroid exam should be and to highlight what some of the abnormal findings are in an exam that we hope will raise awareness for the importance in what to look for in physical exams for pediatric thyroid disease.

So we're gonna start today. Lauren was kind enough to be our model for what a normal thyroid exam is so the first thing we do for the exam is just have a patient hopefully sit comfortably on the table and their shoulders back and just in a chin neutral position.

So in that position the thyroid gland sits just above the collarbone in the middle portion of the neck and the neck is divided into various levels. The American Thyroid Association in 2009 published a consensus on that and the middle part of the neck is designated as level VI. So if we just go through the levels of the neck (which there is a diagram that's going to be in the video), level I is under the chin, IIA and IIB are going along the mandible — the angle of the jaw and IIb is back here and coming down the strap muscles (the sternocleidomastoid) IIB's up here, level III is here, level IV is here.

Level V is the posterior triangle which the posterior surface or margin of sternocleidomastoid is the front part of the level V and then as that back triangle back here which is level V. Level VII is down here so again just to go quickly through it — I, IIA, IIB, III, IV, V is back here, VI is the middle part of the neck where the thyroid is and VII is just that sternal notch.

So the thyroid gland sits above the collar bone and it has an H or butterfly shape which we cannot see in Lauren because she has a normal thyroid exam.

The next part of the exam, we'll just have Lauren look up at the ceiling and when she looks up this is now neck extension and again you should not be able to see the outline of the thyroid lobe or the thyroid gland which we cannot see which again says that it's a normal exam by inspection. While we're in this position we also look for neck symmetry. So we're looking for lymph nodes that might be enlarged on one side compared to the other so what we can see from Lauren's exam again if we look along the lateral neck, even on both sides, there's no fullness when we look along the medial aspect of the sternocleidomastoid or in the middle part of the neck so a completely normal exam by inspection.

The next part of the exam is to have Lauren drink some water and we can watch her swallow and we can see if we can see the outline while she's swallowing. So take a sip and then look up and swallow at the same time. And we can see motion in the neck but you cannot see the thyroid gland and again that's another reassuring part of the exam that says that it's normal. Okay, we can do it one more time and again all you see is motion but you don't actually see the thyroid gland itself moving up and down because it's not enlarged.

So the thyroid gland is not visible, there are no lymph nodes that are visible and the width of her neck is symmetric both on the left side and on the right side.

So now starting with the physical exam portion, we find the cricothyroid membrane and then right below it is the isthmus which is the piece of tissue that connects the left side to the right side. So I find that and then I just use my fingers and gently roll the thyroid lobe under my fingers and try to feel if there's any fullness — if there's something that would feel like a nodule and what the texture of the tissue itself is. So here's a superior aspect. Lauren's gland is easy to feel, it's soft, there are no nodules and I found the anterior aspect and again feel the entire left lobe which feels normal both in texture and there's no evidence in nodules.

So while I'm over here on the left side, I'll complete the lymph node exam as well so I usually start while my hands are in the lower portion of the neck the medial aspect of the sternocleidomastoid and just rub along the anterior aspect, along where the carotid is coming up and just feeling for any lymph nodes or masses which I do not feel.

Going up in Level III and heading up into IIB and then once up in IIB the I just go along the belly of the sternocleidomastoid back down and no lymph nodes behind the muscle itself and then find the inferior — I mean the posterior aspect and no lymph nodes that are hiding back there as well.

And then into level V — look down just a little bit Lauren — sometimes level V you have to have them come out of neck extension a little bit so you can get a full exam. Good, now I'm gonna switch sides.

Again, get myself reoriented so Lauren if you can look up. Come down and find the cricothyroid membrane and then find the isthmus just right here and gently let the thyroid lobe roll under your fingers as you move out laterally along the superior aspect, along the belly of the lobe, on the inferior aspect and similar to the left lobe, the right lobe feels normal. Easy to feel, no nodules, normal texture on exam.

Then doing the lateral lymph node exam, starting in level IV of the medial aspect of the sternocleidomastoid, no lymph nodes. Level III and then coming up into the IIA, IIB region then along the belly of the sternocleidomastoid coming back down and then the inferior aspect of the sternocleidomastoid coming back up and then look down again a little bit Lauren, there you go and into level V and no lymph nodes back there.

And if you find something that's abnormal in one side which I do not find in Lauren, then you can always check on the other side. So often times, especially in pediatrics we'll feel lymph nodes under the angle of the jaw which is a common place to find them but if you feel one — some on one side then you should also feel to see if there's symmetry in the other. But nothing on Lauren's exam and this is a normal thyroid exam. Cannot see the thyroid, can feel it by palpation, symmetric neck exam, no abnormal lymph nodes. Thank you.

So today we're gonna do an exam on Jennifer. We've already performed an ultrasound and Jennifer has already had a fine needle aspiration biopsy which we know is positive for papillary thyroid cancer so we're gonna go through the exam today to try to highlight some of the areas on Jennifer's exam that we want people to be aware of. One particular, important part for Jennifer's exam is that she does not have a distinct nodule. Her thyroid gland is not visibly enlarged but she presented with lateral swollen glands which are a common finding in pediatrics. Most of the time it's infection but part of the differential diagnosis is papillary thyroid cancer so we're trying to highlight Jennifer's exam to raise awareness that when people feel swollen glands they need to think about the thyroid gland and potentially thyroid cancer and not just a potential — for infection which is definitely more common but this in an important part for people to be aware of.

All right, good morning. So we're gonna start by repeating our thyroid exam today. So the first part that we're gonna do is just the inspection part of the exam so you're in a perfect position sitting up straight on the table and looking forward with your chin in a neutral position and from this area we can't see any specific enlargement of the thyroid which sits in the middle part of the neck but we can see some asymmetry that the right side of Jennifer's neck is not as full as the left side so this is more full, pushing out more towards the side of her shoulder.

So the next part of the exam is to have Jennifer look up at the ceiling just with neck extension. So level VI is the hyoid bone down to the sternal notch which is level VII down here and then the medial aspects of the sternocleidomastoid and in the lower part of level VI is where the thyroid gland sits.

Now on Jennifer's exam we cannot see the outline of the thyroid gland and if we ask Jennifer to take a drink of water, if you could do that — and then get back in that neutral position and swallow — you can see the thyroid gland here — move up again — can you do it one more time Jennifer?  So right here, you can see that movement, very slight movement going up but again not a distinct outline of the thyroid gland which has that H symbol to it.

So again kind of emphasizing that on exam, the thyroid is not very large compared to some of our other patients but again the next part of the exam we'll feel on inspection to see if there's something else going on in the thyroid that might explain the fullness on the left side of the neck.

We'll start the exam, I'm going to switch sides and start here (you can put your water down if you'd like) and look up again. For that portion I start in the middle — I find the cricothyroid membrane and then find the upper portion of the isthmus and then I start marching along — along this would be the right side so the right thyroid lobe and I notice a little fullness right here that feels like potential lymph node above the right thyroid lobe and then along the belly of the right thyroid lobe which feels fine. Feels like a normal thyroid lobe on this side and then the posterior aspect — or inferior aspect of the right thyroid lobe.

So the right side looks fine. The tissue itself feels normal except there's one little area right above the right thyroid lobe right here which is hard to see but I can feel under my fingertip. Then I'd go up the lateral neck — so lateral neck is level IV, level III, IIB and IIA. So I'd start with the medial aspect of the sternocleidomastoid feeling for lymph nodes which I do not feel so far, down the muscle belly coming back down and then along the posterior aspect of the strap muscle and no lymph nodes on the right side.

Can we move your head a little bit more that way? Good and then the posterior triangle, this is level V back here and uncommon place to find lymph nodes but an important part of the exam and no lymph nodes back here. Good.

So I'm going to switch sides and again start in the middle, find the cricothyroid membrane and then find the isthmus and start to feel along the left lobe and when I'm feeling on the left side which is again hard to see it's just more fullness. There's just a lot of fullness on the left side. Not a distinct nodule but fullness and then the belly of the left thyroid lobe and the inferior aspect of the left thyroid lobe which seems to extend a little bit lower and just has some fullness.

Then going up the lateral neck there's an area right here which is actually kind of similar to the other side. That again feels like a lymph node that's just above the left thyroid lobe and then going up the lateral neck starting in level IV along the medial aspect of the sternocleidomastoid, level III and then up here is where we start to see that full — feel that fullness that we can see and once I start to feel something that seems a little bit different on one side than the other then I kind of put my fingers in the opposite sides of the neck to see if its symmetric.

On Jennifer's exam, there's some — there are a few lymph nodes up here which I do not feel on this side and then the largest area is just this area right — kinda level IIB behind the strap muscle, behind the sternocleidomastoid so fullness. And then come down the belly of the muscle in the inferior aspect and then again in level IV and nothing in VA or VB. So fullness to the left lobe. Fullness to the left lateral neck, especially up in level IIB and then two little lymph nodes above the isthmus in the middle —  one on the left and one on the right. All right and that's it.

Dr. Bauer: Good morning.

Amanda: Good morning

Dr. Bauer: How are you?

Amanda: I'm good, how are you?

Dr. Bauer: All right. This morning we're gonna take advantage of Amanda having a nodule in her right thyroid lobe and try to highlight what a nodule looks like on exam and then kind of go through the exam to see what I'm looking for. Some of this is already taken care of on ultrasound but the physical exam's the first step and the most important. So Amanda noticed her nodule in June of last year and what you can see when her chin is in neutral position is just some fullness in the right side cause that's where the nodule is — it's in the right lobe. And then if Amanda goes to full neck extension that's when you get a little bit more sense that there's some fullness that's here in this area than it is in the left side.

And now if you have enough saliva, we can swallow — you can swallow and you can see the nodule move up and down and that's the first part of the exam — just looking, having the patient swallow and watching the thyroid move to look for symmetry.

So now I'm going to do the physical exam. We're going to start with the thyroid cartilage, the membrane and then come down and find the isthmus of the thyroid — the upper part of it and then I usually start on the normal side which in Amanda's case is going to be on the left side so I'm just gonna gently roll my fingers over her left thyroid lobe to try to get a sense of what the tissue feels like. Is it enlarged or smaller? Is there a nodule or no nodule? And in this case there is only a nodule on the right lobe.

So part of that is well as the lymph node exam. So if we go from levels IV, III and II we're just moving up the medial part of the sternocleidomastoid and now from level III into level II and there's no lymph nodes on the left side and then along the muscle belly down again from II to III to IV and the posterior aspect of the sternocleidomastoid as well.

And that's the side that's unaffected and level V is back here. And also no abnormal lymph nodes are noted on the left side.

Now onto the right side just gently roll your fingers over the nodule. See what it feels like — in this case it's smooth, kind of rubbery and then there's only one that I can feel on exam and then again feeling for lymph nodes so we're now in level IV, III and II up here and again just gently roll your fingers over the medial aspect of the sternocleidomastoid and no lymph nodes.

Then along the muscle belly and along the posterior aspect and usually the patient's in a sitting position on a table but feeling back here again in level V and no abnormal lymph nodes so it’s just that right side — a thyroid nodule. No abnormalities on the left side, no abnormalities as far as lymph nodes are concerned. Thank you.

Amanda: Thank you.

Dr. Bauer: Good morning Chloe.

Chloe: Good morning.

Dr. Bauer: So this morning we're gonna briefly go over a thyroid exam on a patient who has autoimmune hyperthyroidism. Otherwise known as Graves' disease so Chloe's been kind enough to agree to do that. So for some of our patients when you walk into the room you can see that they're hyperthyroid but Chloe is currently on medicine so her hyperthyroidism is relatively well controlled. But the things that you would see is someone who is restless, fidgety, they can't sit still on the table and then often times you'll notice, which you can see in Chloe is that her thyroid is enlarged.

So without even moving her neck or her chin, you can already see the outline of Chloe's thyroid. Her gland is at least four times enlarged. Probably five to six times enlarged. So even in a chin neutral position you can see Chloe's thyroid gland. It's even — the left side and the right side are even and so if we have you look up at the ceiling, then you can start to see this real large thyroid gland even pushing the strap muscles out to the side so not a subtle exam for hyperthyroidism. This is kind of one of the larger glands that we typically see.

The other things we can ask our patients with hyperthyroidism is to look at their signs and symptoms. So Chloe still has a little bit of a tremor so if you ask the patient to lift — just to extend their arms straight out you can see that there's a little tremor. Sometimes it's even on both sides and you don't have to keep going. But Chloe's is a little bit more on the left than the right. You can ask them if they are having problems falling asleep or if they are a little more fatigued than usual. Often times they have an increased appetite but they're losing weight. I don't know if you're weight is still — and those things sometimes get better and sometimes don't with medical therapy. So Chloe's been on medicine for how long?

Chloe: I think — I'm not sure. I've been on methimazole.

Dr. Bauer: Right, methimazole the anti-thyroid medicine and we've decided now to do permanent or definitive therapy by surgically removing Chloe's thyroid gland for the trade-off of permanent hyperthyroidism.

So for the thyroid exam, what I'm gonna do is first start with just as I said looking. So you can look and see that the thyroid gland is enlarged and see what the person looks like. Otherwise seemingly relatively calm and collected besides the tremor and then we're gonna listen.

So the first part is listening to see if you can hear the blood flow through the thyroid gland which is called the bruit. So you can — for Chloe's exam you can hear the blood flowing through which is almost like a murmur like sound. A little bit more on the right than on the left and sometimes you can accentuate by having the person take in a deep breath and hold it. So can you take in a deep breath and hold it and then you can let it out and when Chloe did that the pitch went up and you could hear the bruit a little bit more prominently. And one more time on the left side and you can let it out. Good.

So that's really the only exam that we think about for hyperthyroidism. Listening for blood flow.

The next part of the exam is similar to the other exams and it starts with just the inspection which we've already done so if we just look, there's the thyroid cartilage and then the cricothyroid membrane and the cricoid cartilage and right below it is the isthmus and so the isthmus starts up here and you almost can't even feel the bottom of it — it's way down here so if you looked up a little bit I might be able to get my finger under there but it's -- as you can see very enlarged. Alright look back down, chin neutral position. Actually if you can — can you look up a little bit? Is your mouth moist enough that you can swallow?  So that's good for this morning.

So again I'm gonna find the cricothyroid membrane, the top of the isthmus, and then just gently run your fingers along the lobe. This is the left lobe, trying to feel if there's any nodules so any lumps that are more prominent as you do that and for a hyperthyroid exam the tissue is usually kind of rubbery — soft to rubbery in sensation in contrast to thyroid cancer where the tissue often times is hard. So this is a very rubbery gland. That's the left side. For the right side, I'll just have to switch sides and again so when I'm pushing any pain or discomfort?

Chloe: I can feel some pain to more on the left side I think so yeah.

Dr. Bauer: So again, just feeling along the whole surface of the thyroid gland and Chloe has a very symmetric gland. Rubbery, no nodules. For hyperthyroidism you still feel for lymph nodes because it is possible to have lymph nodes associated with autoimmune thyroid disease. For Chloe's gland being so large it's a little more difficult to feel but if you start up in kind of the IIa, IIb region and then again just let the tissue roll under your fingers and try to move down you can't get too much and I won't push too hard to feel lymph nodes but I don't feel any prominent lymph nodes.

Very rarely we have patients that have both hyperthyroidism and thyroid cancer. So the lymph node exam is always a part of the thyroid exam when you find an abnormality in the thyroid gland. You have one little lymph node there but not concerning feeling and then here IIb going into III, level IV up the strap muscle the sternocleidomastoid and then back into Level 5 and no lymphadenopathy. Excellent. And that's it so, do you have any questions?

Chloe:  Yeah, will I have ice cream after my surgery?

Dr. Bauer: I think we can arrange for ice cream after the surgery. Great, thanks for cooperating.

Topics Covered: Differentiated Thyroid Cancer, Hyperthyroidism, Hypothyroidism, Thyroid Nodules

Related Centers and Programs: Pediatric Thyroid Center