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March 8, 1995, Vol 273, No. 10 >
ARTICLE | March 8, 1995

Does This Patient Have a Goiter? FREE

Kerry Siminoski, MD
[+] Author Affiliations

Reprint requests to 362 HMRC, University of Alberta, Edmonton, Alberta, Canada T6G 2S2 (Dr Siminoski).

The Rational Clinical Examination section editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.


JAMA. 1995;273(10):813-817. doi:10.1001/jama.1995.03520340069039
Text Size: A A A
Published online
Article
References

CLINICAL SCENARIOS— HOW LARGE ARE THESE THYROID GLANDS?  For each of the following patients, assessment of thyroid size is an important part of the clinical examination. In case 1, a 32-year-old woman presents with symptoms and findings consistent with hyperthyroidism, but she has no exophthalmos and has always been anxious. In case 2, a 55-year-old man has a diagnosis of Graves' disease, and the choice is made for radioactive iodine ablation therapy. In case 3, a 64-year-old man has a goiter that causes discomfort on swallowing, and thyroxine is to be administered in an attempt to shrink the thyroid gland.

WHY ASSESS THE THYROID GLAND FOR SIZE?  A goiter is simply an enlargement of the thyroid gland and may result from hormonal or immunological stimulation of gland growth or the presence of inflammatory, proliferative, infiltrative, or metabolic disorders (Table 1). A common error among those first learning about the thyroid

REFERENCES

1 +
Eastham RD.  Thyroid disorders.  In: Eastham RD, ed. A Pocket Guide to Differential Diagnosis . 2nd ed. Littleton, Mass: John Wright-PSG Inc; 1985;: 220-221.
2 +
Gurney C, Owen SG, Hall R, Roth M, Harper M, Smart GA.  Newcastle thyrotoxicosis index. Lancet . 1970;;2:1275-1278.
3 +
Winsa B, Dahlberg PA, Jansson R, Agren H, Karlsson FA.  Factors influencing the outcome of thyrostatic drug therapy in Graves' disease. Acta Endocrinol . 1990;;122:722-728.
4 +
Ladenson PW.  Diagnosis of thyrotoxicosis.  In: Braverman LE, Utiger RD, eds. Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text. 6th ed. Philadelphia, Pa: JB Lippincott; 1991;:901.
5 +
Perez C, Scrimshaw NS, Munoz JA.  Classification of goitre and technique of endemic goitre surveys. Bull World Health Organ . 1958;;18:217-232.
6 +
Hennessy WB.  Goitre prophylaxis in New Guinea with intramuscular injections of iodized oil. Med J Aust . 1964;;1:505-512.
7 +
Trowbridge FL, Matovinovic J, McLaren GD, Nichaman MZ.  Iodine and goiter in children. Pediatrics . 1975;;56:82-90.
8 +
Kilpatrick R, Milne JS, Rushbrooke M, Wilson ESB.  A survey of thyroid enlargement in two general practices in Great Britain. BMJ . 1963;;1:29-34.
9 +
Malamos B, Vagenakis AG, Pandros PG, Papapetrou PD, Sfontouris J, Koutras DA.  Comparison of scanning and palpation in the assessment of the weight of the thyroid gland. Endokrinologie . 1970;; 56:232-240.
10 +
Jaffe RH.  The variation in weight of the thyroid gland and the frequency of its abnormal enlargement in the region of Chicago. Arch Pathol . 1930;; 10:887-894.
11 +
Hull OH.  Critical analysis of two hundred twenty-one thyroid glands. Arch Pathol . 1955;;59: 291-311.
12 +
Hintze G, Windeler J, Baumert J, Stein H, Kobberling J.  Thyroid volume and goitre prevalence in the elderly as determined by ultrasound and their relationships to laboratory indices. Acta Endocrinol . 1991;;124:12-18.
13 +
Gutekunst R, Smolarek H, Hasenpusch U, et al.  Goitre epidemiology: thyroid volume, iodine excretion, thyroglobulin, and thyrotropin in Germany and Sweden. Acta Endocrinol . 1986;;112:494-501.
14 +
Berghout A, Wiersinga WM, Smits NJ, Touber JL.  Determinants of thyroid volume as measured by ultrasonography in healthy adults in a non-iodine deficient area. Clin Endocrinol . 1987;;26:273-80.
15 +
Tunbridge WMG, Evered DC, Hall R, et al.  The spectrum of thyroid disease in a community: the Whickam survey. Clin Endocrinol . 1977;;7:481-493.
16 +
Crooks J, Tulloch MI, Turnbull AC, Davidsson D, Skulason T, Snaedal G.  Comparative incidence of goitre in pregnancy in Iceland and Scotland. Lancet . 1967;;2:625-627.
17 +
Silink K, Reisenauer R.  Geographical spread of endemic goitre and problems of its mapping.  In: Silink K, Cerny K, eds. Endemic Goiter and Allied Diseases . Bratislava, Slovakia: Slovak Academy of Science; 1966;:33-47.
18 +
Berghout A, Wiersinga WM, Smits NJ, Touber JL.  The value of thyroid volume measured by ultrasonography in the diagnosis of goitre. Clin Endocrinol . 1988;;28:409-414.
19 +
Williams RH, Towery BT, Jaffe H.  Radioiodotherapeusis. Am J Med . 1949;;7:702-717.
20 +
Smith RN, Wilson GM.  Clinical trial of different doses of 1311 in treatment of thyrotoxicosis. BMJ . 1967;;1:129-132.
21 +
Tannahill AJ, Hooper MJ, England M, Ferriss JB, Wilson GM.  Measurement of thyroid size by ultrasound, palpation, and scintiscan. Clin Endocrinol . 1978;;8:483-486.
22 +
MacLennan R, Gaitan E, Miller MC.  Observer variation in grading and measuring the thyroid in epidemiological surveys.  In: Stanbury JB, ed. Endemic Goiter . Washington, DC: Pan American Health Organization; 1969;:67-77. Publication 193.
23 +
Edwards CRW.  The general examination and external features of disease.  In: Munro J, Edwards CRW, eds. MacLeod's Clinical Examination . 8th ed. New York, NY: Churchill Livingstone; 1990;:66.
24 +
Daniels GH.  Physical examination of the thyroid gland.  In: Braverman LE, Utiger RD, eds. Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text . 6th ed. Philadelphia, Pa: JB Lippincott; 1991;:572-577.
25 +
Greenspan FS.  Thyroid gland.  In: Greenspan FS, Forsham PH, eds. Basic and Clinical Endocrinology . 3rd ed. Englewood Cliffs, NJ: Prentice-Hall International Inc; 1991;:213-215.
26 +
Hollingsworth DR, Hamilton HB, Tamagaki H, Beebe GW.  Thyroid disease in Hiroshima, Japan. Medicine (Baltimore) . 1963;;42:47-71.
27 +
Shapira JD.  The neck.  In: The Art and Science of Bedside Diagnosis . Baltimore, Md: Urban & Schwarzenberg; 1990;:236.
28 +
Kearns JE.  Clinical diagnosis.  In: Treatment of Hyperthyroidism With Radioactive Iodine: A Twenty-Year Review . Springfield, Ill: Charles C Thomas Publisher; 1967;:16-17.
29 +
Siminoski K.  Differential movement during swallowing as an aid in the detection of thyroid pseudonodules. Head Neck . 1994;;16:21-24.
30 +
Cook IJ, Dodds WJ, Dantos RO, et al.  Opening mechanisms of the human upper esophageal sphincter. Am J Physiol . 1989;;257:G748-G759.
31 +
Gwinup G, Morton ME.  The high lying thyroid: a cause of pseudogoiter. J Clin Endocrinol Metab . 1975;;40:37-42.
32 +
Mercer RD.  Pseudo-goiter: the Modigliani syndrome. Cleve Clin J Med . 1975;;42:319-236.
33 +
Burch WM.  Anterior neck masses.  In: Case Studies in Endocrinology . Baltimore, Md: Williams & Wilkins; 1987;:52-53.
34 +
Clain A.  The thyroid gland.  In: Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery . 17th ed. Bristol, England: IOP Publishing; 1986;:155-156.
35 +
Katlick MR, Wang C, Grillo HC.  Substernal goiter. Ann Thorac Surg . 1986;;39:391-399.
36 +
Trotter WR, Cochrane AL, Benjamin IT, Miall WE, Exley D.  A goitre survey in the Vale of Glamorgan. Br J Prev Soc Med . 1962;;16:16-21.
37 +
Dingle PR, Ferguson A, Horn DB, Tubmen J, Hall R.  The incidence of thyroglobulin antibodies and thyroid enlargement in a general practice in Northeast England. Clin Exp Immunol . 1966;;1: 277-284.
38 +
Sackett DL.  A primer on the precision and accuracy of the clinical examination. JAMA . 1992;; 267:2638-2644.
39 +
Brander A, Viikinkoski P, Tuuhea J, Voutilainen L, Kivisaari L.  Clinical versus ultrasound examination of the thyroid gland in common clinical practice. J Clin Ultrasound . 1992;;20:37-42.
40 +
Jarlov AE, Hegedus L, Gjorup T, Hansen JM.  Observer variation in the clinical assessment of the thyroid gland. J Intern Med . 1991;;229:159-161.
41 +
Hegedus L.  Thyroid size determined by ultrasound. Dan Med Bull . 1990;;37:249-263.
42 +
Brown MC, Spencer R.  Thyroid volume estimated by use of ultrasound in addition to scintigraphy. Acta Radiol . 1978;;17:337-341.
43 +
Mandart G, Erbsmann F.  Estimation of thyroid weight by scintigraphy. Int J Nucl Med Biol . 1975;; 2:185-188.
44 +
Hegedus L, Karstrup S, Veiergang D, Jacobsen B, Skosted L, Feldt-Rasmussen U.  High frequency of goitre in cigarette smokers. Clin Endocrinol . 1985;;22:287-292.
45 +
Hegedus L, Hansen JM, Luhdorf K, Perrild H, Feldt-Rasmussen U, Kampmann JP.  Increased frequency of goitre in epileptic patients on long-term phenytoin or carbamazepine treatment. Clin Endocrinol . 1985;;23:423-429.
46 +
Hegedus L, Molholm Hansen JE, Veiergang D, Karstrup S.  Thyroid size and goitre frequency in hyperthyroidism. Dan Med Bull . 1987;;34:121-123.
47 +
Perrild H, Hegedus L, Baastrup PC, Kayser L, Kastberg S.  Thyroid function and ultrasonically determined thyroid size in patients receiving long-term lithium treatment. Am J Psychiatry . 1990;; 147:1518-1521.
48 +
Jarlov AE, Hegedus L, Gjorup T, Hansen JEM.  Accuracy of the clinical assessment of thyroid size. Dan Med Bull . 1991;;38:87-89.
49 +
Tamayo SG, Rickman LS, Mathews WC, et al.  Examiner dependence on physical diagnostic tests for the detection of splenomegaly. J Gen Intern Med . 1993;;8:69-75.
50 +
Williams JW, Simel DL, Roberts L, Samsa GP.  Clinical evaluation for sinusitis: making the diagnosis by history and physical examination. Ann Intern Med . 1992;;117:705-710.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Eastham RD.  Thyroid disorders.  In: Eastham RD, ed. A Pocket Guide to Differential Diagnosis . 2nd ed. Littleton, Mass: John Wright-PSG Inc; 1985;: 220-221.
2 +
Gurney C, Owen SG, Hall R, Roth M, Harper M, Smart GA.  Newcastle thyrotoxicosis index. Lancet . 1970;;2:1275-1278.
3 +
Winsa B, Dahlberg PA, Jansson R, Agren H, Karlsson FA.  Factors influencing the outcome of thyrostatic drug therapy in Graves' disease. Acta Endocrinol . 1990;;122:722-728.
4 +
Ladenson PW.  Diagnosis of thyrotoxicosis.  In: Braverman LE, Utiger RD, eds. Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text. 6th ed. Philadelphia, Pa: JB Lippincott; 1991;:901.
5 +
Perez C, Scrimshaw NS, Munoz JA.  Classification of goitre and technique of endemic goitre surveys. Bull World Health Organ . 1958;;18:217-232.
6 +
Hennessy WB.  Goitre prophylaxis in New Guinea with intramuscular injections of iodized oil. Med J Aust . 1964;;1:505-512.
7 +
Trowbridge FL, Matovinovic J, McLaren GD, Nichaman MZ.  Iodine and goiter in children. Pediatrics . 1975;;56:82-90.
8 +
Kilpatrick R, Milne JS, Rushbrooke M, Wilson ESB.  A survey of thyroid enlargement in two general practices in Great Britain. BMJ . 1963;;1:29-34.
9 +
Malamos B, Vagenakis AG, Pandros PG, Papapetrou PD, Sfontouris J, Koutras DA.  Comparison of scanning and palpation in the assessment of the weight of the thyroid gland. Endokrinologie . 1970;; 56:232-240.
10 +
Jaffe RH.  The variation in weight of the thyroid gland and the frequency of its abnormal enlargement in the region of Chicago. Arch Pathol . 1930;; 10:887-894.
11 +
Hull OH.  Critical analysis of two hundred twenty-one thyroid glands. Arch Pathol . 1955;;59: 291-311.
12 +
Hintze G, Windeler J, Baumert J, Stein H, Kobberling J.  Thyroid volume and goitre prevalence in the elderly as determined by ultrasound and their relationships to laboratory indices. Acta Endocrinol . 1991;;124:12-18.
13 +
Gutekunst R, Smolarek H, Hasenpusch U, et al.  Goitre epidemiology: thyroid volume, iodine excretion, thyroglobulin, and thyrotropin in Germany and Sweden. Acta Endocrinol . 1986;;112:494-501.
14 +
Berghout A, Wiersinga WM, Smits NJ, Touber JL.  Determinants of thyroid volume as measured by ultrasonography in healthy adults in a non-iodine deficient area. Clin Endocrinol . 1987;;26:273-80.
15 +
Tunbridge WMG, Evered DC, Hall R, et al.  The spectrum of thyroid disease in a community: the Whickam survey. Clin Endocrinol . 1977;;7:481-493.
16 +
Crooks J, Tulloch MI, Turnbull AC, Davidsson D, Skulason T, Snaedal G.  Comparative incidence of goitre in pregnancy in Iceland and Scotland. Lancet . 1967;;2:625-627.
17 +
Silink K, Reisenauer R.  Geographical spread of endemic goitre and problems of its mapping.  In: Silink K, Cerny K, eds. Endemic Goiter and Allied Diseases . Bratislava, Slovakia: Slovak Academy of Science; 1966;:33-47.
18 +
Berghout A, Wiersinga WM, Smits NJ, Touber JL.  The value of thyroid volume measured by ultrasonography in the diagnosis of goitre. Clin Endocrinol . 1988;;28:409-414.
19 +
Williams RH, Towery BT, Jaffe H.  Radioiodotherapeusis. Am J Med . 1949;;7:702-717.
20 +
Smith RN, Wilson GM.  Clinical trial of different doses of 1311 in treatment of thyrotoxicosis. BMJ . 1967;;1:129-132.
21 +
Tannahill AJ, Hooper MJ, England M, Ferriss JB, Wilson GM.  Measurement of thyroid size by ultrasound, palpation, and scintiscan. Clin Endocrinol . 1978;;8:483-486.
22 +
MacLennan R, Gaitan E, Miller MC.  Observer variation in grading and measuring the thyroid in epidemiological surveys.  In: Stanbury JB, ed. Endemic Goiter . Washington, DC: Pan American Health Organization; 1969;:67-77. Publication 193.
23 +
Edwards CRW.  The general examination and external features of disease.  In: Munro J, Edwards CRW, eds. MacLeod's Clinical Examination . 8th ed. New York, NY: Churchill Livingstone; 1990;:66.
24 +
Daniels GH.  Physical examination of the thyroid gland.  In: Braverman LE, Utiger RD, eds. Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text . 6th ed. Philadelphia, Pa: JB Lippincott; 1991;:572-577.
25 +
Greenspan FS.  Thyroid gland.  In: Greenspan FS, Forsham PH, eds. Basic and Clinical Endocrinology . 3rd ed. Englewood Cliffs, NJ: Prentice-Hall International Inc; 1991;:213-215.
26 +
Hollingsworth DR, Hamilton HB, Tamagaki H, Beebe GW.  Thyroid disease in Hiroshima, Japan. Medicine (Baltimore) . 1963;;42:47-71.
27 +
Shapira JD.  The neck.  In: The Art and Science of Bedside Diagnosis . Baltimore, Md: Urban & Schwarzenberg; 1990;:236.
28 +
Kearns JE.  Clinical diagnosis.  In: Treatment of Hyperthyroidism With Radioactive Iodine: A Twenty-Year Review . Springfield, Ill: Charles C Thomas Publisher; 1967;:16-17.
29 +
Siminoski K.  Differential movement during swallowing as an aid in the detection of thyroid pseudonodules. Head Neck . 1994;;16:21-24.
30 +
Cook IJ, Dodds WJ, Dantos RO, et al.  Opening mechanisms of the human upper esophageal sphincter. Am J Physiol . 1989;;257:G748-G759.
31 +
Gwinup G, Morton ME.  The high lying thyroid: a cause of pseudogoiter. J Clin Endocrinol Metab . 1975;;40:37-42.
32 +
Mercer RD.  Pseudo-goiter: the Modigliani syndrome. Cleve Clin J Med . 1975;;42:319-236.
33 +
Burch WM.  Anterior neck masses.  In: Case Studies in Endocrinology . Baltimore, Md: Williams & Wilkins; 1987;:52-53.
34 +
Clain A.  The thyroid gland.  In: Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery . 17th ed. Bristol, England: IOP Publishing; 1986;:155-156.
35 +
Katlick MR, Wang C, Grillo HC.  Substernal goiter. Ann Thorac Surg . 1986;;39:391-399.
36 +
Trotter WR, Cochrane AL, Benjamin IT, Miall WE, Exley D.  A goitre survey in the Vale of Glamorgan. Br J Prev Soc Med . 1962;;16:16-21.
37 +
Dingle PR, Ferguson A, Horn DB, Tubmen J, Hall R.  The incidence of thyroglobulin antibodies and thyroid enlargement in a general practice in Northeast England. Clin Exp Immunol . 1966;;1: 277-284.
38 +
Sackett DL.  A primer on the precision and accuracy of the clinical examination. JAMA . 1992;; 267:2638-2644.
39 +
Brander A, Viikinkoski P, Tuuhea J, Voutilainen L, Kivisaari L.  Clinical versus ultrasound examination of the thyroid gland in common clinical practice. J Clin Ultrasound . 1992;;20:37-42.
40 +
Jarlov AE, Hegedus L, Gjorup T, Hansen JM.  Observer variation in the clinical assessment of the thyroid gland. J Intern Med . 1991;;229:159-161.
41 +
Hegedus L.  Thyroid size determined by ultrasound. Dan Med Bull . 1990;;37:249-263.
42 +
Brown MC, Spencer R.  Thyroid volume estimated by use of ultrasound in addition to scintigraphy. Acta Radiol . 1978;;17:337-341.
43 +
Mandart G, Erbsmann F.  Estimation of thyroid weight by scintigraphy. Int J Nucl Med Biol . 1975;; 2:185-188.
44 +
Hegedus L, Karstrup S, Veiergang D, Jacobsen B, Skosted L, Feldt-Rasmussen U.  High frequency of goitre in cigarette smokers. Clin Endocrinol . 1985;;22:287-292.
45 +
Hegedus L, Hansen JM, Luhdorf K, Perrild H, Feldt-Rasmussen U, Kampmann JP.  Increased frequency of goitre in epileptic patients on long-term phenytoin or carbamazepine treatment. Clin Endocrinol . 1985;;23:423-429.
46 +
Hegedus L, Molholm Hansen JE, Veiergang D, Karstrup S.  Thyroid size and goitre frequency in hyperthyroidism. Dan Med Bull . 1987;;34:121-123.
47 +
Perrild H, Hegedus L, Baastrup PC, Kayser L, Kastberg S.  Thyroid function and ultrasonically determined thyroid size in patients receiving long-term lithium treatment. Am J Psychiatry . 1990;; 147:1518-1521.
48 +
Jarlov AE, Hegedus L, Gjorup T, Hansen JEM.  Accuracy of the clinical assessment of thyroid size. Dan Med Bull . 1991;;38:87-89.
49 +
Tamayo SG, Rickman LS, Mathews WC, et al.  Examiner dependence on physical diagnostic tests for the detection of splenomegaly. J Gen Intern Med . 1993;;8:69-75.
50 +
Williams JW, Simel DL, Roberts L, Samsa GP.  Clinical evaluation for sinusitis: making the diagnosis by history and physical examination. Ann Intern Med . 1992;;117:705-710.

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