Neck

Question 1

Findings of neck inspection ?

Answer 1

Structure and shape of neck, alignment relative to torso, symmetry and atrophy :
- trachea : alignment relative to median line, Adam’s apple should be discernible

Skin : color, scars, defect, swelling, venous, pigmentation
- swellings : near lymph node, in parotid/thyroid gland normally not visible
- thyroid swelling : ask patient to shallow note if swelling move upward

Look at visible blood vessel

Question 2

Palpation of the trachea and larynx :

Answer 2

Place thumb, index and middle finger around thyroid.
- central fissure should be palpable
Hyoid is above thyroid, horseshoes shape
- stick tongue out => it move upward
Cricothyroid ligament : between thyroid and cricoid.

Question 3

What should you not do during lymph node palpation ?

Answer 3

Palpate with both hands. Can lead to carotid massage which will cause decrease in heart rate due to vagus nerve stimulation.
Palpate with one hand while holding the head with the other.

Question 4

Description of lymph node swellings ?

Answer 4

Location, size, shape, surface, characteristics, consistency, pain, fullness, mobility, delineation from surrounding tissue.

Question 5

Palpation of lymph node in the neck :

Answer 5

Finger flat, extended, parallel to the skin, move that in circular motion.

• submental node then move upward on the chin until parotid gland
• ask patient to turn their head to see the sternocleidomastoid muscle, palpate the front
• palpate supraclavicular region from medial to lateral
• palpate infraclavicular region from lateral to medial
• palpate posterior edge of sternocleidomastoid until behind the ear
• palpate towards occipital region

Question 6

Normal lymph node findings :

Answer 6

Usually fusiform, smooth, sharply demarcated, elastic in consistency, not fused with skin not painful.
- barely palpable should be able to slide around.

Question 7

Palpation of submandibular gland ?

Answer 7

Finger against mandible body and wrap terminal phalanges around it
- normal palpable smooth mobile

If indicated : perform bimanual palpation, use other hand to press down from floor of the mouth

Question 8

Palpate parotid gland ?

Answer 8

Place hand on the cheek in font of ear, use finger in circular motion.
- usually not palpable

Examination of parotid duct : clench jaw, palpate anterior area to parotid gland
=> palpable as horizontal cylindrical structure

Question 9

Palpation of the sublingual gland ?

Answer 9

Palpation from within the oral cavity beneath the tongue.

Question 10

Palpation of the thyroid gland ?

Answer 10

Symmetrical method : stand behind sitting patient use both hands. Palpate beneath thyroid and above manubrium. Make circular movement.

Asymmetrical method : stand behind patient. Palpate one side of trachea with small circulating movement. Place other hand on contralateral side of sternocleidomastoid muscle and push larynx and trachea towards palpating hand.

Ask patient to shallow => thyroid rise

Question 11

Result of the palpation of thyroid gland ?

Answer 11

Normal : soft, jelly like with bumpy surface but often non palpable.
Look out for : nodules, swellings (size, shape, location, temperature, delineation, painfulness)

Question 12

What are the supplementary investigation possible for lymph gland ?

Answer 12

CT & MRI : glandular size, position and growth
Ultrasound guided FNAC (fine needle aspiration cytology) : nature, enlargement

Question 13

What are the supplementary investigation possible for salivary gland ?

Answer 13

Radiology : if chronic inflammation or stone formation is suspected
Ultrasound guided FNAC

Question 14

What are the supplementary investigation possible for thyroid gland ?

Answer 14

Scintigraphie : inject small quantity of radioactive iodine
MRI : determine boundaries and spatial relationships
Ultrasound guided FNAC : investigate solitary thyroid nodule.

Question 15

Clinical significant findings in lymph node ?

Answer 15

Enlargement as a response to infection but the size isn’t a guide to the seriousness of disease.

Pain : active infection with red and warm skin
- fluctuation indicible => abscesses tissue

Fusion : enlarged lymph node that fuse with each other or the skin => active infection of malignancy.

Consistency & Location

Question 16

Clinical significance of lymph node consistency ?

Answer 16

Soft : benign enlargement
Extreme solidity : metastasis, Hodgkin’s disease, granulomatous infection
Rubbery : malignancy lymphoma, chronic leukaemia

Question 17

Clinical significance of lymph node enlargement location ?

Answer 17

Virchow’s node enlargement : metastasis in an organ that drains into the thoracic duct
Lung and breast cancer metastasis develop on the same side as the source.

Question 18

Causes of lateral deviation of trachea ?

Answer 18

Enlarged hyoid
Space occupying process in the mediastinum : tumor metastasis, atelectatic lung, pneumothorax

Question 19

Clinical significant findings in salivary gland examination ?

Answer 19

Unilateral enlargement of parotid : malignancy, infection, secondary stone related problem

Salivary stone : painful swellings in front of ear, develop quickly and disappear spontaneously , duct opening will be swollen and red with pus blood

Tumor of parotid gland : gradual, painless permanent swelling in front of ear. Solid/elastic with irregular boundaries. Fusion with skin may be detectable.

Parotitis : enlarged salivary gland, sensitive.
- epidermis parotitis = mumps : bilateral swelling clearly visible

Enlargement of parotid : metastasis of primary skin carcinoma in the head/neck region

Question 20

Common concerning symptoms of the neck :

Answer 20

Neck mass or lump :
- >40 y old + persistent neck mass => malignancy
- enlarged tender lymph node => pharyngitis

Thyroid mass, nodule, goiter
- hypothyroidism : intolerance to cold, weight gain, dry skin, slowed heart rate
- hyperthyroidism : in tolerance to heat, weight loss, moist velvety skin, palpitation

Neck pain
Headache