gt;gt; i’m andrew bauer, the medical director of the thyroid center of the children’s of Philadelphia. The Children’s 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 tutorial is an educational tutorial 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 tutorial), 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.