Clinical examination of neck swellings

Clinical examination of neck swellings



Expose the patient's neck - loosen their shirt collar





Inspect





 scars

 masses

 patient swallowing

 protruding tounge





It is necessary to define information relating to the:





 site

 mobility in relation to deep structures and with tongue protrusion/swallowing

 relation to muscles

 relation to trachea

 relation to hyoid cartilage





Palpate





 mass (size, shape, consistency and mobility)

 lymph nodes

 thyroid gland

 parotid and submandibular

 with patient swallowing





Ascultation





 carotid

 mass





Illuminate









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Relation of neck swelling to muscles



Lumps in the neck should be palpated with muscles relaxed and then with them

contracted.





Lumps deep to a muscle will become impalpable when the muscle contracts.





Relation of neck swellings to the trachea



If a swelling is fixed to the trachea then it will move when the trachea moves.





The process of swallowing elevates the trachea.





Observe the neck lump as the patient swallows.





Relation of neck swellings to the hyoid cartilage



The hyoid cartilage ascends when the tongue is protruded. It moves only slightly

during swallowing.



If the swelling in the neck moves as the tongue protrudes then it must be fixed

to the hyoid cartilage



Site of neck swelling



It is essential to define the site of a lump in the neck. The neck is divided into two triangles.





The Anterior Triangle is bounded by the anterior border of the sternomastoid muscle,

the lower edge of the jaw and the midline. Structures deep to sternomastoid are

considered to be inside the anterior triangle.



The Posterior Triangle is bounded by the posterior border of the sternomastoid

muscle, the anterior edge of the trapezius and the clavicle.





To define the triangles, the patient must tense the neck muscles:





 sternomastoid - put your hand under the patient's chin and ask him to nod his

head against resistance. This tightens both sternomastoids





trapezius - ask the patient to shrug his shoulders against resistance.







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Neck swellings derived from unpaired midline structures.



These swellings tend to lie in the midline.





The most common causes of a neck swelling derived from a midline unpaired

structure are:





 thyroglossal cyst



Most common midline neck swelling and usually presents as a painless, rounded cystic lump

which moves on swallowing or protruding the tongue. It can occur anywhere along the

thyroglossal tract i.e. from the foramen caecum to the thyroid isthmus, but is most commonly

above the hyoid bone. The cyst is freely mobile and the majority transilluminate. Occasionally

they become infected and present as a thyroglosal cyst.





 Midline dermoid



These usually present as painless solid or cystic masses anywhere between the suprasternal

notch and the submental region. The feature which distinguishes them from a thyroglossal

cyst is that they do not move with protrusion of the tongue.





 pharyngeal pouch

 laryngocoele

 subhyoid bursa

 carcinoma of the larynx, trachea and oesophagus

 plunging ranula





Neck swellings derived from paired lateral structures



These swelling tend to lie laterally in the neck.





The commonest causes of a swelling derived from a lateral paired structure are:





Found in the anterior triangle





 thyroid swellings



diagnosis is biochemical, but hx and ex may point to this. Hx. Any symp of hypo or

hyperthyroidism. Past thyroid surgery/radioiodine treatment. Drug Hx (thyroxine, amiodarone,

lithium, carbimazole. Family Hx thyroid/autoimmune disorders. Ex. Neck and thyroid.







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Inspection goitre, hair loss, tremor, exopthalmos or lid lag. Myxoedema-subcutaneous

mucopolysaccharide accumulation, sweaty palms. Tachycardia or AF. Slow relaxing reflexes.

Check for thyroid bruit Central trachea and retrosternal extension (inability to palpate the

lower margin of the gland).





 branchial cysts

 pharyngeal pouch – unpaired on the left usually. Asymptomatic or may cause

dysphagia and regurgitation

 salivary gland swellinngs

 lymph node enlargement (look for lymphadenopathy else where)

 carotid body tumour (tumors of the chemoreceptor apparatus at the carotid

bifururication. They tend to be oval and non tender, lateral mobility but cant

move them up and down.

 cervical rib (palpate this in the supraclavicular fossa and may be associated

with neurological and vascular symptoms).

 sternomastoid tumour

 cystic hygroma

 carotid artery aneurysms

 arteriovenous fistula

 actinomycosis

 muscle tumours

 clavicular tumours

 spinal abscesses





Superficial swellings



Swellings or lumps which are superficial to the underlying muscle and fascia are

commonly caused by:





 sebaceous cysts

 lipomata

 carbuncles

 neurofibromata









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