It is often advantageous to examine the gland while you stand behind as well as on each side of the patient. Identify the thyroid cartilage, the thyrocricoid membrane, and the cricoid cartilage, a horizontal structure 5 mm wide that marks the superior border of the isthmus. Palpate the isthmus (frequently impalpable unless enlarged), and if standing to the side of the patient, slide the tips of your fingers so that their palmar surfaces rest on the trachea with the dorsal surface medial to the sternocleidomastoid muscle.
A frequent mistake is to move the fingers too laterally and trap the body of the muscle between your fingers and the trachea. The ipsilateral lobe can be palpated simultaneously with your thumb or with the other hand from the opposite direction.
When you stand behind the patient, identify the landmarks and isthmus with one hand, and when in position to feel the thyroid lobe on that side, place the fingers of your other hand symmetrically on the other side of the trachea. Again identify each lobe while the patient swallows.
Feel the gland's surface, note any asymmetry, texture, and estimate the size of each lobe (normally 7 to 10 g). When a goitre is present, measure any discrete masses as well as the neck's greatest circumference. A pencilled tracing of the goitre's outline provides a reliable record for future comparison.
One should also palpate the neck for lymphadenopathy and search for masses (especially in the midline for abnormalities of the thyroglossal duct) and surgical scars.
Transillumination is helpful only in confirming the nature of a superficial thin-walled cyst. Occasional patients with Graves" disease present with a bruit and palpable thrill over a diffusely enlarged goitre.
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