>> i'm dr. andrew bauer, the medical directorof the thyroid center of the children's hospital of philadelphia. the children's hospital thyroidcenter is one of the busiest thyroid centers in the united states and we see the full rangeof thyroid diseases within pediatrics from newborns up until age 23; to include congenitalhypothyroidism, 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 tryto highlight what a normal thyroid exam should be and to highlight what some of the abnormalfindings are in an exam that we hope will raise awareness for the importance in whatto look for in physical exams for pediatric

thyroid disease. so we're gonna start today. lauren was kindenough to be our model for what a normal thyroid exam is so the first thing we do for the examis just have a patient hopefully sit comfortably on the table and their shoulders back andjust in a chin neutral position. so in that position the thyroid gland sitsjust above the collarbone in the middle portion of the neck and the neck is divided into variouslevels. the american thyroid association in 2009 published a consensus on that and themiddle part of the neck is designated as level vi. so if we just go through the levels ofthe neck (which there is a diagram that's going to be in the video), level i is underthe chin, iia and iib are going along the

mandible - the angle of the jaw and iib isback here and coming down the strap muscles (the sternocleidomastoid) iib's up here, leveliii is here, level iv is here. level v is the posterior triangle which theposterior surface or margin of sternocleidomastoid is the front part of the level v and thenas that back triangle back here which is level v. level vii is down here so again just togo quickly through it -- i, iia, iib, iii, iv, v is back here, vi is the middle partof the neck where the thyroid is and vii is just that sternal notch. so the thyroid gland sits above the collarbone and it has an h or butterfly shape which we cannot see in lauren because she has anormal thyroid exam.

the next part of the exam, we'll just havelauren look up at the ceiling and when she looks up this is now neck extension and againyou should not be able to see the outline of the thyroid lobe or the thyroid gland whichwe cannot see which again says that it's a normal exam by inspection. while we're inthis position we also look for neck symmetry. so we're looking for lymph nodes that mightbe enlarged on one side compared to the other so what we can see from lauren's exam againif we look along the lateral neck, even on both sides. there's no fullness when we lookalong the medial aspect of the sternocleidomastoid or in the middle part of the neck so a completelynormal exam by inspection. the next part of the exam is to have laurendrink some water and we can watch her swallow

and we can see if we can see the outline whileshe's swallowing. so take a sip and then look up and swallow at the same time. and we cansee motion in the neck but you cannot see the thyroid gland and again that's anotherreassuring part of the exam that says that it's normal. okay, we can do it one more timeand again all you see is motion but you don't actually see the thyroid gland itself movingup and down because it's not enlarged. so the thyroid gland is not visible, thereare no lymph nodes that are visible and the width of her neck is symmetric both on theleft 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 thepiece of tissue that connects the left side

to the right side. so i find that and theni just use my fingers and gently roll the thyroid lobe under my fingers and try to feelif there's any fullness -- if there's something that would feel like a nodule and what thetexture of the tissue itself is. so here's a superior aspect. lauren's gland is easyto feel, it's soft, there are no nodules and i found the anterior aspect and again feelthe 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'llcomplete the lymph node exam as well so i usually start while my hands are in the lowerportion of the neck the medial aspect of the sternocleidomastoid and just rub along theanterior aspect, along where the carotid is

coming up and just feeling for any lymph nodesor masses which i do not feel. going up in level iii and heading up intoiib and then once up in iib then i just go along the belly of the sternocleidomastoidback down and no lymph nodes behind the muscle itself and then find the inferior -- i mean the posterioraspect and no lymph nodes that are hiding back there as well. and then into level v -- look down just alittle bit lauren -- sometimes level v you have to have them come out of neck extensiona little bit so you can get a full exam. good, now i'm gonna switch sides. again, get myself reoriented so lauren ifyou can look up. come down and find the cricothyroid

membrane and then find the isthmus just righthere and gently let the thyroid lobe roll under your fingers as you move out laterallyalong the superior aspect, along the belly of the lobe, on the inferior aspect and similarto the left lobe, the right lobe feels normal. easy to feel, no nodules, normal texture onexam. then doing the lateral lymph node exam, startingin level iv of the medial aspect of the sternocleidomastoid, no lymph nodes. level iii and then comingup into the iia, iib region then along the belly of the sternocleidomastoid coming backdown and then the inferior aspect of the sternocleidomastoid coming back up and then look down again alittle bit lauren, there you go and into level v and no lymph nodes back there.

and if you find something that's abnormalin 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 jawwhich is a common place to find them but if you feel one -- some on one side then youshould also feel to see if there's symmetry in the other. but nothing on lauren's examand 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 aspirationbiopsy which we know is positive for papillary

thyroid cancer so we're gonna go through theexam today to try to highlight some of the areas on jennifer's exam that we want peopleto be aware of. one particular, important part for jennifer's exam is that she doesnot have a distinct nodule. her thyroid gland is not visibly enlarged but she presentedwith lateral swollen glands which are a common finding in pediatrics. most of the time it'sinfection but part of the differential diagnosis is papillary thyroid cancer so we're tryingto highlight jennifer's exam to raise awareness that when people feel swollen glands theyneed to think about the thyroid gland and potentially thyroid cancer and not just apotential -- for infection which is definitely more common but this in an important partfor people to be aware of.

all right, good morning. so we're gonna startby repeating our thyroid exam today. so the first part that we're gonna do is just theinspection part of the exam so you're in a perfect position sitting up straight on thetable and looking forward with your chin in a neutral position and from this area we can'tsee any specific enlargement of the thyroid which sits in the middle part of the neckbut we can see some asymmetry that the right side of jennifer's neck is not as full asthe 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 jenniferlook up at the ceiling just with neck extension. so level vi is the hyoid bone down to thesternal notch which is level vii down here

and then the medial aspects of the sternocleidomastoidand in the lower part of level vi is where the thyroid gland sits. now on jennifer's exam we cannot see the outlineof the thyroid gland and if we ask jennifer to take a drink of water, if you could dothat -- and then get back in that neutral position and swallow -- you can see the thyroidgland 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 outlineof 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 nextpart of the exam we'll feel on inspection to see if there's something else going onin the thyroid that might explain the fullness on the left side of the neck. we'll start the exam, i'm going to switchsides and start here (you can put your water down if you'd like) and look up again. forthat portion i start in the middle -- i find the cricothyroid membrane and then find theupper portion of the isthmus and then i start marching along -- along this would be theright side so the right thyroid lobe and i notice a little fullness right here that feelslike potential lymph node above the right thyroid lobe and then along the belly of theright thyroid lobe which feels fine. feels

like a normal thyroid lobe on this side andthen the posterior aspect -- or inferior aspect of the right thyroid lobe. so the right side looks fine. the tissue itselffeels normal except there's one little area right above the right thyroid lobe right herewhich 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 medialaspect 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 strapmuscle and no lymph nodes on the right side. can we move your head a little bit more thatway? good and then the posterior triangle,

this is level v back here and uncommon placeto 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 startin the middle, find the cricothyroid membrane and then find the isthmus and start to feelalong the left lobe and when i'm feeling on the left side which is again hard to see it'sjust more fullness. there's just a lot of fullness on the left side. not a distinctnodule but fullness and then the belly of the left thyroid lobe and the inferior aspectof 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 anarea right here which is actually kind of

similar to the other side. that again feelslike a lymph node that's just above the left thyroid lobe and then going up the lateralneck starting in level iv along the medial aspect of the sternocleidomastoid, level iiiand then up here is where we start to see that full -- feel that fullness that we cansee and once i start to feel something that seems a little bit different on one side thanthe other then i kind of put my fingers in the opposite sides of the neck to see if itssymmetric. on jennifer's exam, there's some -- thereare a few lymph nodes up here which i do not feel on this side and then the largest areais just this area right -- kinda level iib behind the strap muscle, behind the sternocleidomastoidso fullness. and then come down the belly

of the muscle in the inferior aspect and thenagain in level v and nothing in va or vb. so fullness to the left lobe. fullness tothe left lateral neck, especially up in level iib and then two little lymph nodes abovethe isthmus in the middle -- one on the left and one on the right. all right and that'sit. >> good morning. >> good morning >> how are you? >> i'm good, how are you? >> all right.this morning we're gonna takeadvantage of amanda having a nodule in her

right thyroid lobe and try to highlight whata nodule looks like on exam and then kind of go through the exam to see what i'm lookingfor. some of this is already taken care of on ultrasound but the physical exam's thefirst step and the most important. so amanda noticed her nodule in june of last year andwhat you can see when her chin is in neutral position is just some fullness in the rightside cause that's where the nodule is -- it's in the right lobe. and then if amanda goesto full neck extension that's when you get a little bit more sense that there's somefullness that's here in this area than it is in the left side. and now if you have enough saliva, we canswallow -- you can swallow and you can see

the nodule move up and down and that's thefirst part of the exam -- just looking, having the patient swallow and watching the thyroidmove 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 theisthmus of the thyroid -- the upper part of it and then i usually start on the normalside which in amanda's case is going to be on the left side so i'm just gonna gentlyroll my fingers over her left thyroid lobe to try to get a sense of what the tissue feelslike. is it enlarged or smaller? is there a nodule or no nodule? and in this case thereis only a nodule on the right lobe. so part of that is well as the lymph nodeexam. so if we go from levels iv, iii and

ii we're just moving up the medial part ofthe sternocleidomastoid and now from level iii into level ii and there's no lymph nodeson the left side and then along the muscle belly down again from ii to iii to iv andthe posterior aspect of the sternocleidomastoid as well. and that's the side that's unaffected andlevel v is back here. and also no abnormal lymph nodes are noted on the left side. now onto the right side just gently roll yourfingers over the nodule. see what it feels like -- in this case it's smooth, kind ofrubbery and then there's only one that i can feel on exam and then again feeling for lymphnodes so we're now in level iv, iii and ii

up here and again just gently roll your fingersover the medial aspect of the sternocleidomastoid and no lymph nodes. then along the muscle belly and along theposterior aspect and usually the patient's in a sitting position on a table but feelingback here again in level 5 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 lymphnodes are concerned. thank you. >> thank you. >> good morning chloe. >> so this morning we're gonna briefly goover 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 whenyou walk into the room you can see that they're hyperthyroid but chloe is currently on medicineso her hyperthyroidism is relatively well controlled. but the things that you wouldsee is someone who is restless, fidgety, they can't sit still on the table and then oftentimes 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 timesenlarged. probably five to six times enlarged. so even in a chin neutral position you cansee chloe's thyroid gland. it's even -- the

left side and the right side are even andso if we have you look up at the ceiling, then you can start to see this real largethyroid 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 withhyperthyroidism is to look at their signs and symptoms. so chloe still has a littlebit of a tremor so if you ask the patient to lift -- just to extend their arms straightout you can see that there's a little tremor. sometimes it's even on both sides and youdon'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 morefatigued 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 sometimesdon't with medical therapy. so chloe's been on medicine for how long? >> i think -- i'm not sure. i've been on methimazole. >> right, methimazole the anti-thyroid medicineand we've decided now to do permanent or definitive therapy by surgically removing chloe's thyroidgland for the trade-off of permanent hyperthyroidism. so for the thyroid exam, what i'm gonna dois first start with just as i said looking. so you can look and see that the thyroid glandis enlarged and see what the person looks

like. otherwise seemingly relatively calmand collected besides the tremor and then we're gonna listen. so the first part is listening to see if youcan 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 murmurlike sound. a little bit more on the right than on the left and sometimes you can accentuateby having the person take in a deep breath and hold it. so can you take in a deep breathand hold it and then you can let it out and when chloe did that the pitch went up andyou could hear the bruit a little bit more prominently. and one more time on the leftside and you can let it out. good.

so that's really the only exam that we thinkabout for hyperthyroidism. listening for blood flow. the next part of the exam is similar to theother 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 cartilageand right below it is the isthmus and so the isthmus starts up here and you almost can'teven feel the bottom of it -- it's way down here so if you looked up a little bit i mightbe able to get my finger under there but it's -- as you can see very enlarged. alright lookback 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 theleft lobe, trying to feel if there's any nodules so any lumps that are more prominent as youdo that and for a hyperthyroid exam the tissue is usually kind of rubbery -- soft to rubberyin sensation in contrast to thyroid cancer where the tissue often times is hard. so thisis a very rubbery gland. that's the left side. for the right side, i'll just have to switchsides and again so when i'm pushing any pain or discomfort? >> i can feel some pain to more on the leftside i think so yeah.

>> so again, just feeling along the wholesurface 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 lymphnodes associated with autoimmune thyroid disease. for chloe's gland being so large it's a littlemore difficult to feel but if you start up in kind of the iia, iib region and then againjust let the tissue roll under your fingers and try to move down you can't get too muchand 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 bothhyperthyroidism and thyroid cancer. so the lymph node exam is always a part of the thyroidexam when you find an abnormality in the thyroid

gland. you have one little lymph node therebut not concerning feeling and then here iib going into iii, level iv, up the strap musclethe sternocleidomastoid and then back into level v and no lymphadenopathy. excellent.and that's it, so do you have any questions? >> yeah, will i have ice cream after my surgery? >> i think we can arrange for ice cream afterthe surgery. great, thanks for cooperating.

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