Introduction
Wash hands
Introduce yourself
Confirm patient details
Explain examination
Gain consent
Appropriately position & expose the neck for optimal examination
General inspection
Identify any scars on the neck – may suggest previous surgery (e.g. thyroidectomy)
Observe for any obvious masses in the neck
If a mid-line lump is present:
- Ask the patient to swallow some water – the thyroid or a thyroglossal cyst will rise
- Ask to protrude the tongue - thyroglossal cyst will rise with tongue movement, whereas thyroid will not
Look for obvious systemic signs that may relate to neck pathology:
- Cachexia - malignancy
- Exopthalmos / Proptosis - Graves disease
If there is a mid-line lump / scar or systemic signs suggestive of thyroid disease ,ask examiner if a full thyroid status exam should be performed.
Palpation
Lymph nodes
Can be enlarged for a number of different reasons such as infection or malignancy
Normally lymph nodes are smooth & rubbery, with some mobility.
An enlarged, hard, irregular lymph node would be suggestive of malignancy.
- Supra-clavicular - left sided enlarged lymph node – Virchows node
- Anterior cervical chain
- Posterior cervical chain
- Sub-mental
- Sub-mandibular
- Occipital
- Pre-auricular
- Post-auricular
Palpate the neck
Mid-line
- Lymph nodes – often multiple, may suggest infection or malignancy
- Thyroid gland - located below thyroid cartilage
- Thyroid nodule – can be single or multiple – adenomas, cysts, malignancy
- Thyroglossal cysts – painless, smooth, cystic – rises on tongue protrusion
Anterior Triangle – area of the neck anterior to sternocleidomastoid
- Lymph nodes
- Salivary gland swelling (doesn’t move on swallowing)
- Branchial cyst – often located at anterior border of sternocleidomastoid – present since birth
- Carotid aneurysm -pulsatile mass – bruit present on auscultation
- Carotid body tumour – transmits pulsation – can be moved side to side but not up & down (due to carotid sheath)
- Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing
Posterior triangle – area of the neck posterior to sternocleidomastoid
- Lymph nodes – often multiple - can be rubbery or hard depending on etiology
- Subclavian artery aneurysm – pulsatile mass
- Pharyngeal pouch – may present as a reducible mass
- Cystic Hygroma – most commonly on left side – fluctuant mass – trans-illuminates
- Branchial cyst
Assessing the lump
Size – width, height, depth
Location - can help narrow the differential – anterior / posterior triangle or mid-line
Shape – well defined?
Consistency – smooth, rubbery, hard, nodular, irregular
Fluctuance - if fluctuant, this suggests it is a fluid filled lesion – cyst
Trans-illumination – suggests mass is fluid filled – e.g. Cystic hygroma
Pulsatility - suggests vascular origin – e.g. carotid body tumour / aneurysm
Temperature - increased warmth may suggest inflammatory / infective cause
Overlying skin changes – erythema, ulceration, punctum
Relation to underlying / overlying tissue - tethered? mobile? (ask to turn head)
Auscultation – to assess for bruits – e.g. carotid aneurysm
To complete the examination
Thank patient
Wash hands
Summarise findings
Mention further investigations you’d like to perform:
- Ultrasound scan
- Fine needle aspiration
- Full examination of the lymphoreticular system
