The Head & Neck Exam

Inspection
Inspect the Head
Inspect the Neck
Inspect the Thyroid
Auscultation
Palpation
Palpate the Neck
Palpate the Lymph Nodes
Describing Masses
Palpate the Thyroid
Anterior Approach
Posterior Approach
Developing a DDx for Neck Masses
Targeted H&P for Thyroid Disease
Targeted History
Targeted Physical
Start with the Vitals
General Appearance
Systematic Approach
Examine the Thyroid
References

Inspection

Inspect the Head

  1. Note the position and size of the head. In children, note whether it is proportional with the rest of the body.
  2. Note the texture of the hair.
  3. Examine the eyes. Note any abnormalities such as proptosis, periorbital edema, ptosis, lid lag, or eyebrow hair loss.

Inspect the Neck

  1. Note any swelling, erythema, atrophy, asymmetry, deformity (ex: deviation of the trachea), scars or cutaneous changes (petechiae, brusing...)
  2. Note any masses or asymmetry

Inspect the thyroid

  1. Ask the patient to extend their neck and tip their head back to inspect for the thyroid gland. It is not visible in all patients, but will be found inferior to the cricoid cartilage. Note any asymmetry and or prominent veins (superficial venous distension), which is often seen in goiter.
  2. With the patient's neck still extended, ask the patient to swallow. The thyroid gland should elevate during a swallow. Note its contour and symmetry.

Auscultate the neck

  1. Auscultate over the carotid area with the diaphragm of your stethoscope. Bruits in this area are indicative of carotid stenosis.
  2. Still using the diaphragm, auscultate over the thyroid. A thyroid bruit may be a sign of increased blood flow and is sometimes found in hyperthyroidism.

If a carotid bruit is heard, do not palpate the carotid artery. If this is a new finding, further investigations (e.g.: doppler ultrasound) are warranted to determine the cause of the bruit.

Palpation

Palpate the Neck

  1. Position yourself behind the seated patient and palpate the neck with the pads of your fingers. This palpation should be firm and deep. Note any tenderness, masses, nodules or inflammation.
  2. Detect deviation of the trachea by placing your index finger between it and the sternocleidomastoid and note the distance between the two. Repeat on the opposite side and compare distances; they should be nearly identical.

The neck should almost always be palpated while in a neutral position (see below for one exception). The physical exam is much less sensitive if the neck is in flexion or extension.

Palpate the Lymph Nodes

  1. Using the pads of your index and middle fingers, firmly (but gently) apply pressure in a circular motion over the 10 sets of lymph nodes in the neck.
  2. Systematically palpate the preauricular nodes, the posterior auricular nodes, the occipital nodes, the posterior cervical chain, the superficial cervical chain, the deep cervical chain, the supraclavicular nodes, the tonsillar nodes, the submandibular nodes and finally the submental nodes (refer to the Anatomy Review section for a refresher on the location of each set of nodes).

Differentiate between a lymph node and a muscle/artery by rolling your fingers up & down as well as left & right over the structure. Only a lymph node will be mobile in all four directions. Also, compare any findings with the opposite side. Unilateral findings are generally more concerning.

Describing masses

It is vital to properly describe the characteristics of a neck mass as they play an important role in the differential. For every node, mass or nodule felt, note their characteristics using the mnemonic: CCSSS LMNOP:


CCSSS LMNOP

Palpate the thyroid

The thyroid can be palpated using one of two methods. Both approaches are bimanual exams (i.e. they require the use of both hands).

The Anterior Approach

  1. Standing in front of the patient, tip their head forward and to their right and hand them a glass of water.

While it is true that the neck should almost always be palpated in a neutral position (see above), there is one exception to this rule. The thyroid should be palpated with the neck in slight flexion and lateral rotation. These movements help to relax the SCM muscle, making the thyroid easier to palpate.

  1. Place the second and third fingers of your left hand inferior to the cricoid cartilage, between the SCM and the trachea.
  2. Using your right hand, gently displace the trachea to the patient's right.
  3. Ask the patient to swallow. You should feel the right thyroid lobe rise and rub against your fingers (it should be located between your fingers and the SCM). Note the size, surface and consistency of the lobe. Note any induration (hardness), tenderness or nodules.
  4. Reverse the procedure and repeat to palpate the lobe on the other side.

The Posterior Approach

  1. Sanding in front of the patient, tip their head forward and to their right and hand them a glass of water.
  2. Standing behind the patient, place all of the fingers from both hands on the patient's neck. They should be lined up so that the index finger lines up just inferior to the cricoid cartilage.
  3. Ask the patient to sip some water and try to feel the isthmus rise against your fingers.
  4. As with the anterior approach, deviate the trachea towards the lobe you want to palpate. Ask the patient to sip some water and attempt to feel the lobe rise against your fingers on that side. Reverse the procedure and attempt to palpate the other lobe
  5. Note the size, surface and consistency of the isthmus/lobe. Note any induration (hardness), tenderness or nodules.

Developing a DDx for Neck Masses

Neck Mass DDx
Remember the "Rule of 7's"

The mass has been present for:
7 days: Infection/Inflammation
7 months: Think neoplasm
7 years: Think congenital

As is shown in the table below, the characteristics of a mass can play an important role in the formation of a differential diagnosis (DDx).


Common Mass Characteristics by Disease Process
Adapted from Lin, D., Deschler, D. Evaluation of a Neck Mass. UpToDate. Last updated September 29, 2009.

(View Source)

Some masses tend to present in the midline, while others typically present on the side of the neck. The following table outlines the masses that have a characteristic location:


DDx by location

Targeted H&P for Thyroid Disease

Targeted History

Use the mnemonic WE MATCH:

  • Weight changes
  • Energy Changes
  • Mood Changes
  • Appetite Changes
  • Temperature Insensitivity
  • Cognitive Changes
    • If so, consider a MoCA or MMSE
  • Hearing Changes
    • If so, perform an in depth hearing screen including the Rinne & Weber

Targeted Physical

Start with the vitals

Hyperthyroidism:

  • Tachycardia
  • BP changes

Hypothyroidism:

  • Bradycardia
  • Hypothermia
  • BP changes

General Appearance

Note the patient's color, comfort level and muscle bulk. Note any agitation or signs of depression.

Examine Each System:

First start by considering the widespread systems:


Signs of Thyroid Disease by System (Global)

Next, think about the localized systems:


Signs of Thyroid Disease by System (Localized)

Examine the thyroid

Finally, examine the thyroid as described above. As a reminder:

  • Inspect the neck.
  • If a mass is visible, auscultate it.
  • Palpate the thyroid. Describe it's surface (nodular, smooth...) & size.
  • Palpate the lymph nodes of the head and neck.
  • Describe all findings using the mnemonic CSSS LMNOP.

References

Schwartz, M. Textbook of Physical Diagnosis. 6th Edition. Chapter 9.

Bickley, L. Bates' Guide to Physical Examination and History Taking. 10th Edition. Chapter 7.

Martini, F., et al. Human Anatomy. 5th Edition.

Drake, R., et al. Gray's Anatomy for Students. 1st edition.

Tank, P.W. Grant's Dissector. 14th Ed. Page 204.

Lin, D., Deschler, D. Evaluation of a Neck Mass. UpToDate. Last updated September 29, 2009.

Chen, Y., Tran, C. Toronto Notes 2011. Otolaryngology section.

Section Author

Scott Kohlert
Medical Student (MS-4)
University of Ottawa

Section Editors

Laurie McLean, MD1,2
Nita Scherer, MD1,2
Safeena Kherani, MD1,2

1The Ottawa Hospital, Deptartment of Otolaryngology

2Faculty of Medicine, University of Ottawa