1. Why do you need to palpate the thyroid gland? To clarify the size, location, shape, symmetry and mobility of the gland that were previously installed during the examination. Palpation also allows you to determine the structure and consistency of the gland, focal or diffuse soreness, the presence of fluctuations. For example, gland tissue is dense most often in cancer, and softened to rubber density in Hashimoto’s disease. On palpation in the thyroid gland, you can also find a single node or multiple tubercles of a multinodular goiter, or a diffuse, small, round, tuberous (like raspberry) surface in Graves disease. In this case, a diffusely enlarged thyroid gland of a soft consistency (similar to surrounding tissues) usually corresponds to abundantly vascularized toxic Graves goiter, while a dense goiter indicates thyroid infiltration at a late stage of the disease. Finally, the tenderness of a compacted, diffusely enlarged gland with multiple nodes indicates subacute thyroiditis, while tracheal displacement and enlarged neck lymph nodes are characteristic of cancer of the gland. 2. What does the doctor feel on palpation of the normal thyroid gland? To the touch, the thyroid gland resembles the flesh of an almond nut. Each lobe of the gland in size corresponds to a whole nut and does not exceed the size of the distal phalanx of the thumb (the “rule of the thumb”). 3. Is it always possible to palpate the normal thyroid gland? Not always. It is difficult to palpate the thyroid gland weighing 15-20 g (the upper limit of the norm), and a smaller one (10-15 g) is usually not possible at all. The size of the thyroid gland in a population is largely determined by the intake of iodine with food, and is usually increased in areas with a deficiency. Thanks to iodine nutritional supplements in the USA, the upper limit of the norm has recently been reduced from 35 to 20 g, but in areas with iodine deficiency, the weight of the gland is equal to 35 g. Thus, even a “normal” thyroid gland can be palpated in some regions of the world . 4. What are the average sizes of the thyroid gland. The width of the thyroid lobes is 2 cm, the length is 4-5 cm, the thickness is 2.5 cm. The width (and length) of the isthmus of the gland is 1.25-2 cm, the thickness is less than 0.6 cm. The mass of the gland reaches 10- 20 g, volume – less than 20 ml. However, it is most convenient (both for doctors and patients) to subdivide the thyroid glands into normal and palpable and into normal and non-palpable. An experienced doctor can easily palpate a small goiter, only one and a half times the size of a normal thyroid gland (25-30 g). However, in some areas with iodine deficiency, such gland sizes may be considered normal. Thyroid glands weighing 40 g (i.e., two times the norm) are usually so large that they are accessible for palpation even to a first-year student. a – bimanual palpation of the thyroid gland, posterior approach b – palpation of the opposite lobe of the thyroid gland, posterior approach 5. How to palpate the thyroid gland? Unlike visual examination, thyroid palpation can be performed in various ways, including with one or two hands, from the front or rear access. The effectiveness of all options is considered the same. • Start by positioning the patient correctly. In contrast to the examination, a slight tilt and rotation of the patient’s head in the examined direction facilitates palpation of the formations, nodes and asymmetric sections of the thyroid gland. That is, when palpating the right lobe of the gland, ask the patient to tilt and turn his head to the right; on palpation of the left lobe – to the left. However, as during examination, a slight extension of the neck (up to 10 °) may be useful, raising the apex of the sternal goiter and facilitating its palpation. Nevertheless, most experts prefer the position of flexion rather than extension of the neck. Then the patient is asked to make several swallowing movements, while palpating the moving gland. • Most often, the gland is palpated with both hands from the rear access. The doctor stands behind himthe patient and puts the index and middle fingers of both hands on the patient’s neck in the midline, under the chin. The fingers should be located 2 cm above the notch of the sternum and 0.5 cm inward from the medial edges of the SCSM. From this position, the thyroid cartilage is first isolated, then gently advancing down to the horizontal groove separating it from the cricoid cartilage. The groove is covered by a ring-thyroid membrane located above the first ring of the trachea and serves as a guideline for emergency tracheostomy (cricothyroidotomy) due to obstruction of the upper respiratory tract. Scroll down until you reach the next, easily recognizable tracheal ring. At this point, you will find yourself above the isthmus of the thyroid gland, located between the cricoid cartilage and the notch of the sternum; it is almost never possible to palpate it. To reach the two main lobes of the gland, slide your fingers along the isthmus of the gland sideways, 2-3 cm in both directions. Palpate gently to reduce discomfort for the patient and increase the information content of the study. If the gland is enlarged, evaluate its consistency, symmetry of the increase, determine whether it is nodular goiter or diffuse, whether it is fused to surrounding tissues and is accompanied by an increase in lymph nodes. At the same time, fix the trachea with one hand and palpate the lobe of the gland with the other. Practice on yourself: place the index and middle fingers of both hands above the notch of your sternum and move them 2 cm above the clavicle (to the lower poles of the gland), then carefully palpate each lobe. • Palpation with one hand from the front access. Stand facing the patient and palpate with your thumb and forefinger of one hand each lobe of the gland on the inside of the patient’s SCSM. Palpation of the thyroid gland, anterior approach 6. List the options for the normal location and size of the thyroid gland. • In women, the thyroid gland is larger and easier to palpate. • In 1% of the population, the left lobe of the gland (or its lower half) is absent. • The right lobe is often larger than the left. • The pyramidal lobe has the shape of a triangle extending from the isthmus of the gland and reaching the hyoid bone. By consistency, the pyramidal lobe does not differ from the rest of the thyroid gland tissue, and shifts when swallowed. • In 5% of people behind the normal thyroid gland, an ectopic piece of tissue may appear outside the capsule, extending from the back of the tongue to the pyramidal lobe and sometimes descending to the mediastinum.