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Neck examination

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
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