Table of Contents
Introduction
- Wash hands; Introduce self; ask Patient’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
From anteriorly:
- Supraclavicular lymph nodes: examine these from in front by placing fingertips in supraclavicular fossae (Virchow’s node is left supraclavicular)
- Palpate each carotid artery in turn
NB: palpate for lymphadenopathy with your finger pulps (do not ‘play the piano’, i.e. palpate using finger tips). Palpate as if you are giving a massage, and feel each group thoroughly – especially the anterior and posterior cervical chains, for which your whole hand should be placed around the patient’s neck. Roll the lymph nodes over the muscles/bone to feel them (don’t just press the superficial soft tissues).
For any mass, note its characteristics (SSSCCCTTT): Size, Shape, Surface, Consistency, Contours, Colour, Temperature, Tenderness,Transillumination. It’s important to determine if any palpable lymph nodes are hard (malignancy), rubbery (lymphoma), tethered (malignancy), or irregular (malignancy).
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