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Neck examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patientโ€™s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose neck and sit patient in centre of room
  • General inspection: well/unwell, cachexia, lethargic, sweaty, signs of hypo-/hyperthyroidism, abnormal voice etc.
  • Check that the examiner does not want you also to examine thyroid status (if so, see notes on thyroid exam)

Inspection

  • Obvious masses or lymphadenopathy
  • Surgical scars
  • Overlying skin (erythema, rashes)
  • Goitre
  • Ask patient to swallow and then stick tongue out while watching thyroid gland (thyroid lumps and thyroglossal cysts rise on swallowing; thyroglossal cysts rise on tongue protrusion)

Palpation

  • Check for any pain and explain you will be examining from behind initially

From posteriorly

  • Anterior lymph nodes, salivary glands and thyroid:
    • Submental lymph nodes
    • Sublingual gland
    • Submandibular lymph nodes and gland (gland swelling may occur due to salivary duct calculi that may be palpable)
    • Jugulodigastric (tonsillar) lymph nodes
    • Parotid gland
    • Down anterior cervical chain of lymph nodes
    • Stop at thyroid gland (over 2nd-4th tracheal rings): note size, consistency and any abnormal masses. Feel the two lobes and isthmus. With your fingers over the thyroid gland:
      • Ask patient to swallow (thyroid masses and thyroglossal cysts will rise)
      • Ask patient to stick out tongue (thyroglossal cyst will rise)
    • Complete the anterior cervical chain
  • Posterior lymph nodes
    • Feel posterior cervical chain of lymph nodes from the bottom of the posterior triangle to the mastoid process
    • Occipital lymph nodes
    • Postauricular lymph nodes
    • Preauricular lymph nodes

Palpation technique

  • Palpate for lymphadenopathy with your finger pulps (do not โ€˜play the pianoโ€™, i.e. palpate using finger tips).
  • Palpate as if you are giving a massage, and feel each group thoroughly โ€“ especially the anterior and posterior cervical chains, for which your whole hand should be placed around the patientโ€™s neck.
  • Roll the lymph nodes over the deep muscles/bone to feel them (donโ€™t just press the superficial soft tissues).

From anteriorly

  • Supraclavicular lymph nodes: examine these from in front by placing fingertips in supraclavicular fossae (Virchowโ€™s node is left supraclavicular)
  • Palpate each carotid artery in turn

Describing a mass

For any mass, note its characteristics SSSCCCTTT: Size, Shape, Surface, Consistency, Contours, Colour, Temperature, Tenderness, Transillumination

Itโ€™s important to determine if any palpable lymph nodes are hard (malignancy), rubbery (lymphoma), tethered (malignancy), or irregular (malignancy)

Lymph node groups of the head and neck
Lymph node groups of the head and neck 

Percussion

  • Percuss over sternum for retrosternal goitre

Auscultation

  • Thyroid and carotid bruits

To complete

  • Examine any areas drained by palpable lymph nodes
  • Thank patient and restore clothing
  • Summarise

Common pathology

Anywhere

  • Lymphadenopathy
  • Lipoma: painless smooth soft mass

Midline

  • Thyroid pathology: moves with swallowing
  • Thyroglossal cyst: fluctuant midline lump on thyroid migration path that moves up on tongue protrusion
  • Dermoid cyst: cyst containing dermal structures at embryonic cutaneous junctions; patient usually <20 years

Anterior triangle

  • Branchial cyst: cyst due to non-disappearance of cervical sinus, felt at upper anterior border of sternocleidomastoid; patient usually <20 years
  • Laryngocele: painless air sac at larynx; mobile; worse with blowing
  • Carotid body tumour: pulsatile mass at carotid bifurcation; very rare

Posterior triangle

  • Cystic hygroma (lymphangioma): present since childhood; transilluminates brightly; felt at left base of neck
  • Pharyngeal pouch: pouch from pharynx; may protrude on swallowing

Test your knowledge

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