History Taking and Physical Examination

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The history-taking is important and should include questions about external irradiation to the head, neck, and upper chest. A history of goitrogen exposure should be also sought. Information regarding the rate of growth of the mass or masses, local or systemic symptoms, and hoarseness or dysphagia should be obtained. The family history should be explored for the presence of thyroid disease, hyper-parathyroidism, and features compatible with pheochromocytoma. Rapid painless growth of a nodule suggests the presence of carcinoma. Pain or tenderness in the thyroid gland is an unusual complaint in the context of a malignancy but may be severe in postviral (subacute) or suppu-rative thyroiditis. A rapidly enlarging nodule with transient pain suggests hemorrhage into a cyst.

Careful palpation of a thyroid nodule helps define its nature. A soft, compressible nodule is less likely to be malignant, and more likely to be a cyst. However, some cysts can be quite firm on palpation. Conversely, some PTCs undergo cystic degeneration. Tenderness in a nodule suggests hemorrhage into a cyst or an inflammatory process. Malignancy should be suspected if the nodule is hard or if there is fixation to surrounding structures or vocal cord paralysis. Lymphadenopathy, particularly low in the neck and away from the midline, increases the likelihood of malignancy. In most pediatric patients with a malignant nodule, the surrounding thyroid tissue feels normal, and the gland is not globally enlarged.

Children with MTC generally have no clinical symptoms but are rather evaluated either because they have a thyroid nodule or palpable cervical lymphadenopathy, or - more commonly - because they are a member of a kindred affected with MTC and are found to have either a positive RET germline mutation or increased plasma calcitonin levels. Patients with MEN2A have a normal appearance; whereas those with MEN2B have marfanoid body build and demonstrate multiple neuromas of the lips, eyelids, and tongue. In MEN2B, slit-lamp examination of the cornea may show enlargement of the corneal nerves. Moreover, ganglioneuromas may be present throughout the gastrointestinal tract and cause symptoms, including constipation and diarrhea, the latter often beginning in infancy.

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