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)

Goitre

Visible posterior cervical lymphadenopathy

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 2^nd-4^th 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 ‘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 deep muscles/bone to feel them (don’t just press the superficial soft tissues).

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

Describing a mass

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

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

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