Palpation

Question 1

Skull and face

Answer 1

1) Run fingers around the orbital margins:
- Irregularities?
- Orbital notch?

2) Check for tenderness along the temporal artery
3) Palpate of the T-M joint, asking the patient to open and close and then move side to side

Question 2

Nose

Answer 2

1) Nasal cartilage
2) The paranasal sinuses:
- Maxillary
- Ethmoidal
- Frontal

Question 3

Ears

Answer 3

1) Press in front of the meatus to trying to illicit pain a sign of infection
2) Pull on the pinna once again to try and illicit pain
3) Palpate over the mastoid process

Question 4

Neck?

Answer 4

1) Lymph nodes:
> Determine the clinical level I -V
> If midline is it a thyroglossal cyst or mass
> Lateral is it anterior or posterior triangle
> Determine if it is mobile, vascular (pulsatile), cystic (compressible), nodular

2) Glands:
> Thyroid
> Parotid
> Submandibular

Question 5

Assessing the thyroid gland?

Answer 5

1. Place the three middle fingers of each hand along the midline of the neck below the chin
2. Locate the upper edge of the thyroid cartilage (“Adam’s apple”)
3. Move inferiorly until you reach the cricoid cartilage/ring
4. The first two rings of the trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area
5. Palpate the thyroid isthmus using the pads of your fingers
6. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus
7. Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass)
8. Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it will rise during tongue protrusion)
9. If a thyroid mass is present, feel above and below it. Assess retrosternal extension by percussion on the sternum and assess vascularity by auscultation.

Question 6

What may you auscultate in the neck?

Answer 6

1) The carotid artery - Using the diaphragm of the stethoscope listen for carotid bruit, an indicator of carotid stenosis
2) Listen over enlarger thyroid - Using the diaphragm whilst the patient hols their breath listen to each lobe of the thyroid - In Graves’ disease a soft bruit may be heard.

Question 7

Assessing a neck lump?

Answer 7

Size – width / height / depth

Location – can help narrow the differential – anterior triangle / posterior triangle / 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 – tethering/mobility (ask to turn head)

Auscultation – to assess for bruits – e.g. carotid artery aneurysm

Question 8

Mouth?

Answer 8

Bimanual palpation:
1) Don gloves

2) With one finger palpating the neck externally and the other gloved finger in the oral cavity, gently palpate any identified lumps from both sides
3) Palpate the lateral wall of the mouth: parotid gland and duct
4) Palpate the floor of the mouth: submandibular gland and sublingual gland
5) Any intraoral swelling should be described according to site, size, thickness, colour, texture, consistency and tenderness

Question 9

Location of the preauricular lymph nodes?

Answer 9

Just anterior to the ear and superior to the parotid gland/nodes

Question 10

Location of the parotid lymph nodes?

Answer 10

Just anterior to the ear and inferior to the preauricular lymph nodes

Question 11

Location of the postauricular lymph nodes?

Answer 11

Posterior to the ear just around the mastoid process

Question 12

Location of the tonsillar lymph nodes?

Answer 12

Along the most posterior aspect, of the inferior aspect of the mandible, inferior to the parotid lymph nodes/gland

Question 13

Location of the submental lymph nodes?

Answer 13

Most anterior aspect, of the inferior aspect of mandible

Question 14

Location of the superficial cervical lymph nodes?

Answer 14

Over the superior aspect of the sternocleidomastoid muscle

Question 15

Location of the deep cervical lymph nodes?

Answer 15

Along the length of the sternocleiomastoid muscle

Question 16

Location of the posterior cervical lymph nodes?

Answer 16

Found within the posterior triangle

Question 17

What do the superficial cervical lymph nodes drain?

Answer 17

The Lower ear and parotid gland

Question 18

What do the deep cervical lymph nodes drain?

Answer 18

Other nodes of the head and neck, occipital scalp, ear, back of the neck, tongue, trachea, nasopharynx, nasal cavities, palate, oesophagus

Question 19

What do the submandibular lymph nodes drain?

Answer 19

Cheek, side of the nose, lower lip, gums, anterior tongue

Question 20

What do the submental lymph nodes drain?

Answer 20

Lower lip, floor of the mouth, apex of the tongue

Question 21

What lymph nodes are found in the clinical level I of the neck?

Answer 21

Submental and submandibular

Question 22

What lymph nodes are found in the clinical level II of the neck?

Answer 22

Superficial cervical and Upper deep cervical

Question 23

What lymph nodes are found in the clinical level III of the neck?

Answer 23

Mid deep cervical

Question 24

What lymph nodes are found in the clinical level IV of the neck?

Answer 24

Lower deep cervical

Question 25

What lymph nodes are found in the clinical level V of the neck?

Answer 25

This is the posterior triangle and therefor the posterior cervical

Question 26

What lymph nodes are found in the clinical level VI of the neck?

Answer 26

Pre-tracheal nodes

Question 27

If a mass over the thyroid moves upon tongue protrusion how can this help your differential?

Answer 27

Helps to point towards a thyroglossal cyst rather than a mass that wouldn’t move.