Download Examine the neck - Ask Doctor Clarke

Examine the neck
Lumps in the neck
• Midline
- goitre
- thyroglossal cyst
- pharyngeal pouch
•
Lateral
- lymph node
- sebaceous cyst / lipoma
- cystic hygroma/ branchial cyst
- vascular: aneurysm, tumour
- nerve: neurofibroma
Thyroid : inspect
• From in front
• From the side
• Ask patient to sip water, hold it, then swallow
• Goitre moves up on swallowing
• Stick out tongue: thyroglossal cyst moves up (linked to foramen caecum: back of
tongue)
Thyroid: palpation
• From in front
• From behind: swallow again
• Dimensions: ?diffusely enlarged ?single nodule ?size
• Edge: can you get below?
• Surface: ?smooth ? nodular
• Consistency: soft, firm, hard
Local structures
• Palpate for cervical nodes (from behind)
• Look over top of head for proptosis
• Check for tracheal deviation
• Percuss clavicles and upper sternum
•
•
Finally, auscultate
Ask to check thyroid status
Graves’ disease
• Goitre
• Eye signs
• Thyrotoxicosis
 Dr R Clarke
www.askdoctorclarke.com
1
Indications for surgery
• Patient choice
• Failure of medical treatment
• Poor compliance with medication
• Intolerance of medication (eg rashes)
• Large goitre
Complications of surgery
• Bleeding (laryngeal or tracheal compression)
• Thyroid crisis (fast atrial fibrillation/ pulmonary oedema)
• Hypoparathyroidism- hypocalcaemia
• Damage to recurrent laryngeal nerve
• Late hypothyroidism
• Recurrent hyperthyroidism
Hashimoto’s
• Goitre
• Hypothyroidism
• Positive microsomal antibodies
The thyroid: view from the front
Recurrent laryngeal
nerve
Oesophagus
Trachea
External carotid a
Superior thyroid a
Inferior thyroid a
Subclavian a
 Dr R Clarke
www.askdoctorclarke.com
2
Transverse section through
the neck
Vagus n.
Internal
jugular v
Carotid a
Parathyroid
Recurrent
laryngeal nerve
Thyroid
Pre-tracheal fascia
Commonest large goitre
• Multinodular goitre
• Patient usually euthyroid
• Rarely can go thyrotoxic (toxic multinodular goitre or Plummer’s syndrome)
• Indications for surgery include cosmetic, patient choice and compression of local
structures (change in voice or stridor)
Question stop!
What are the causes of lymphadenopathy?
 Dr R Clarke
www.askdoctorclarke.com
3
Cervical lymph nodes: horizontal ring
• Submental
• Submandibular
• Pre-auricular
• Post-auricular
• Occipital
Cervical lymph nodes: vertical chain
• Supraclavicular
(eg Virchow’s node, Troissier’s sign)
• Posterior triangle
• Deep cervical
Cervical lymph nodes: check
• Face and scalp for source of sepsis etc
• Mouth, especially “coffin corner” of tongue plus throat and ears
• “I would ask for full ENT assessment, to include oropharynx and larynx”
• Check axillary, inguinal, epitrochlear (antecubital) nodes
• Ask to check breasts and abdomen
Other neck lumps
• Where: which triangle
• Red: skin colour, ulceration etc
• DESC + lamp
• Local structures: tense st-mastoid by asking patient to push chin against your hand
• Check for lymphadenopathy
Causes of cervical nodes- local
• Acute infection eg tonsillitis, otitis externa
• Chronic infection eg “cold abscess” of TB
• Neoplastic: local spread from head and neck, lung, breast, abdomen
Causes of cervical nodes- generalized
• Acute infection eg acute mononucleosis
• Chronic infection eg TB, syphilis, HIV
• Neoplasms: primary and secondary carcinoma
• Hodgkin, non-Hodgkin, CLL
• Sarcoid
• Amyloid
 Dr R Clarke
www.askdoctorclarke.com
4
Cystic hygroma
• Rare except in examinations!
• Cavernous lymphangioma
• Derived from jugular lymph sac (embryological precursor of thoracic duct)
• Noted at birth or early childhood
• Multiloculated cystic mass
• Usually in posterior triangle
• Brilliant transillumination
Branchial cyst
• Develops from pharyngeal pouch remnants
• Usually develops in teens or young adults
• Lateral structure, appearing from behind upper st-mastoid at level of hyoid bone
• Distinct regular edge
• Smooth surface
• Usually transilluminates
Three cysts in the neck
Branchial cyst
Thyroglossal cyst
C ystic hygrom a
 Dr R Clarke
www.askdoctorclarke.com
5
Carotid aneurysm
• Localized, pulsating and laterally expansile
• Differential from tortuous carotid (common in elderly) and from
• Carotid body tumour
Carotid body tumour
• Slowly enlarging lobulated mass
• High in neck in carotid triangle
• Arises at bifurcation
• Hard, solid, non-transilluminable
• Transmits carotid pulsation but not expansile
Lipoma
• Subcutaneous
• Soft
• Mobile, not attached to skin
• Fluctuant
• Anywhere but palms, soles and scalp
Epidermoid (sebaceous) cyst
• Smooth, round
• Attached to skin at punctum
• Mobile over deep tissues
• Fluctuant
• All sites except palms and soles
Neurofibroma
• Solitary or generalized
• Check for axillary freckling
• Plus café au lait spots
• Associated with acoustic neuroma (check facial nerve, corneal reflex and hearing)
Salivary glands
• Where: parotid or submandibular
• Check inside mouth: parotid duct by 2nd upper molar; submandibular duct under
tongue on either side of frenulum
• Bimanual palpation of submandibular distinguishes it from lymph node
• Check VII if suspect parotid swelling
 Dr R Clarke
www.askdoctorclarke.com
6
Enlarged salivary gland
• Acute viral infection eg mumps
• Acute bacterial infection eg staph secondary to dehydration, diabetes, malnutrition,
dry mouth of phenothiazines, alcoholism, pancreatitis
• Calculi + distal infection
• Sicca syndrome and Sjogrens eg with rheumatoid arthritis
• Tumours
Parotid & submandibular glands
Stenson’s duct
parotid
tonsillar lymph node
sterno-mastoid
submandibular gland
Parotid tumour
• Submandibular tumours very rare
• “Mixed parotid tumour” commonest
• Suspect malignancy if pain, fixation, VII etc
The main points…
• Goitre is the commonest short case
• If obvious Graves, say so and ask for clarification: examiners like dialogue!
• If not, just “examine the neck” and say you would go on to assess thyroid status
Goitre
• Multinodular goitre: usually euthyroid; gland may be large; firm consistency;
surface may feel smooth or nodular; commonest goitre UK
• “Simple goitre, colloid goitre, non-toxic goitre”- same but smaller and smoother
• Graves- smooth, soft goitre +/- bruit
• Hypothyroidism- usually no goitre
• Hashimoto’s- hypo with firm goitre, usually small/ medium size
 Dr R Clarke
www.askdoctorclarke.com
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