Clinical- neck examination

General Neck Examination

Examine neck? (usually L.N. or Normal neck)

Introduce yourself

Exposure:  to clavicle

Position: Sitting (Push the chair away from wall)

1-         Inspection (From Front) look at front & sides 3 positions

Rest

Tongue protrusion → move/ does not move with tongue protrusion.(skip if lat. swelling)

Swallowing اشرب الماء ولا تبلعه الا لما اقول لك (skip if lat. swelling)

→ 5S ☺”Swelling at (upper/lower), (front/Lat.), at (parotid region/ant.triangle/ post.triangle) of  neck, ….X…cm, … shape, no other sweelings, skin…, not attached to ms, not move with….., not pulsatile”

2-         Palpation (From Front → From back)

From Front · TT (temp. & tenderness)

            · Tracheal position (from front or from back) → central/ deviated to (Rt/Lt)

From Back

Rest

Tongue protrusion → move/ does not move with tongue protrusion. (skip if lat. swelling)

Swallowing for midline swellings (skip if lat. swelling)

Up & Down technique (for masses & Cervical L.N.s)

a-      Start from the chin, along the lower border of the mandible till the ear

b-     Along the anterior border of Sternomastoid → upper border of clavicle (ant.triangle)

c-      Along the posterior border of Sternomastoid (post. Triangle)

d-     Back of the skull (occipital L.N.s)

 → Swelling (TT- ESCRS)

Unilateral Lumps in the NECK

Multiple	Solitary
L.N.s	Anterior Triangle				Posterior Triangle
	Midline Moves with swallowing		Doesn’t move with swallowing		Solid	Cystic
	Solid	Cystic	Solid	Cystic	L.N.	1- Pharyngeal pouch 2- Cystic hygroma
	Thyroid             gland	Thyroglossal cyst	1-L.N.  2-Carotid body tumor	1-Branchail cyst 2-Collar stud abscess

  

  

Thyroid Gland

General Examination (Thyroid Status: Hyper or Hypo)

Hand Signs	Eye Signs (fix head)	Leg Signs
· Fine Tremors ورقة · Sweaty hands · Pulse →     Tachycardia(Hyperthyroidism)   or Bradycardia(Hypothyroidism) · Water Hammer Pulse (elbow 90° & feel volar forearm)	· Lid Retraction, Staring look & infrequent blinking (Stelwag s) · True Exophthalmos 1                                                                                            · Lack of Wrinkling (Joffroy’s)2                                                          · Lid Lag (VonGrave’s) - Lack convergance (Mobiu’s)3        · Exophth by (Naffziger’s)	Pretibial myxedema

· Examine eyes movements (close one eye)

    to exclude ophthalmoplegia

Neck Examination

Introduce yourself

Exposure:  till clavicle (remove scarf & googles)

1-         Position  (Push the chair away from wall)

2-           Inspection (From Front) look at front & sides in 3 positions

Rest

Tongue protrusion (skip if butterfly swelling) → does not move with tongue protrusion.

Swallowing اشرب الماء ولا تبلعه الا لما اقول لك → moves with swallowing.

     → 5S ☺”Swelling at the lower part of the front of the neck, ….X…cm, butterfly in shape, no other sweelings, moves with swallowing, but not with tongue protrusion”

3-         Palpation (From Front 3→ From Back 3) Ask about pain

From Front · TT (temp. & tenderness)

            · Tracheal position (from front or from back) → central/ deviated to (Rt/Lt)

From Back

· Thyroid : TT- ESCRS

- Rest: Edge → well defined/ ill, Surface →Diffuse / Nodular, Consistency → firm/ hard,     not attached to skin (pinch skin) or sternomastoid ms (وشك الناحية الثانية+ feel), Mobility

- Swallowing: moves with swallowing & Lower edge → felt/ not (not= retrosternal extension)

· Cervical Lymph Nodes

       Circular gr.: submental, submandibular, pre-auricular, post-auricular, occipital

       Midline gr.: pre-laryngeal, pre-tracheal

       Longitudinal gr. (along sternomastoid- relax it): upper deep cerv. & lower deep cerv.

       Supraclavicular L.N.s (while shrugging shoulder)

· Carotid pulsation (med. to sternomastoid- relax it) → felt & equal/ felt & displaced/ not felt  (for infiltration)

4-         Percussion (over upper sternum) → resonant/ dull (for Retrosternal extension)

5-         Auscultation (over upper pole thyroid) → No bruit/ Bruit (Bruit in Primary Toxic Goiter)

I would like to finish my examination by:

1- Examination of thyroid status (if not done yet)

Causes of thyroid enlargement (Goitre)

Diffuse		Nodular
Toxic	Non-Toxic	Solitary Nodule	Multi Nodular
Grave’s disease	1- Simple colloid Goiter    2- Thyroiditis

1 Sclera visible all around the iris    2 Looking up without wrinkling of forehead skin    3 Difficulty in conversion

Parotid Gland

Introduce yourself

Exposure:  till clavicle (remove scarf & googles)

Position the patient (Push the seat away from the wall)

1-           Inspection (From front- Look at front & sides in 2 positions)

Rest

Clench teeth  عض على سنانك

     → ☺”Swelling at the parotid region in anterior triangle of the neck (Rt/Lt/Bilat.) elevating the lobule of the ear, more prominent with cont. masseter ms”

2-         Palpation (2 from the back & 3 from front)

From Back

· Parotid: TT- ESCRS عض على سنانك  

  → ☺”Swelling at the parotid region, not hot, not tender, measure …X…, edge well defined, surface smooth, firm consistency, not attached to overlying skin or muscle”

· Cervical Lymph Nodes :

       Circular gr.: submental, submandibular, pre-auricular, post-auricular, occipital

       Midline gr.: pre-laryngeal, pre-tracheal

       Longitudinal gr. (along sternomastoid- relax it): upper deep cerv. & lower deep cerv.

       Supraclavicular L.N.s (while shrugging shoulder)

From Front

· Facial nerve examination:

     Inspection: face symmetry, nasolabial folds, angle mouth → preserved

     Muscles:

Occiptofrontalis: raise eyebrows ارفع حواجبك (not affected in UMNL)

Orbicularis occuli: close your eyes tightly against resistance اقفل عينك جامد

Orbicularis oris: whistle صفر

Buccinator: blow out your cheeks انفخ خدك 

Depressor angularis: show me your teeth ورينى سنانك 

      → facial muscles symmetrical & intact                            

·  Superficial temporal artery: feel infront tragus by 3 fingers longitudinally → felt

·  Parotid duct: open mouth & inspect opposite upper 2^nd molar

     → no inflammation, no discharge  (Donot palpate duct bec. stones rare,  Pain, difficult &)

I would like to finish my examination by:

1- ENT examination

2- examination scalp (if L.N.)

3- examination teeth & tongue (if L.N.)