Neck Examination

History:

commonest swelling in neck: enlarged lymph nodes

Age: Newborn baby: Sternomastoid 'tumour" (H/O difficult labour)

Infancy or Early childhood: Cystic Hygroma

Early adults: Inflammatory swellings

Adult: Branchial Cyst and Branchial fistula though congenital are more often seen in early adult life.

Old: Carcinomatous swelling

Swelling: careful history to know the mode of onset and duration.

swelling with long history are generally benign.

Tuberculous lymphadenopathy & Cold abscess -usually history of more than a month.

Qickly grown swellings within a short span of time are mostly malignant tumours.

Pain: whether the swelling is painful or not?

inflammatory swellings are always painful.

This distinguishes acute lymphadenitis from a malignant growth as the former is extremely painful whereas the latter is painless unless in late stages when there may be nerve involvement

A swelling in the submandibular triangle particularly seen during meals with pain is due to calculus obstruction.

LOCAL EXAMINATION

INSPECTION: For proper inspection of the neck, it has to be exposed upto the level of the nipples.

Swelling:

    • Note the number, situation, size, shape, surface etc as in other swelling examination.

    • multiple swelling - enlarged lymph nodes.

    • Branchial Cyst - is situated in the upper part of the neck with its posterior half lying under cover of the upper 3rd of the sternomastoid muscle.

    • in the submandibular triangle, besides lymph nodes, there may be enlarged submandibular salivary gland and deep or plunging ranula.

    • a dermoid cyst occurs in the midline of the neck, either in the most upper part giving rise to double chin or in the most lower part in the space of Burns.

    • Cystic hygroma is commonly seen in the posterior traingle of the neck in its lower part.

    • sometimes in the lower part of the posterior triangle one may look for the prominence of a cervical rib.

    • an aneurysm is likely to be seen in the line of the carotid artery.

    • an oval swelling along the line of the sternomastoid muscle in a newly-born baby is probably a sternomastoid tumour.

    • a carotid body tumour lies under the anterior margin of the sternomastoid at the level of bifurcation of the common carotid artery, i.e. at the level of the upper border of the thyroid cartliage.

    • at last the swellings that occur over the known sites of the lymph nodes should be considered to have arisen from them unless some outstanding clincal findings prove their origin to be otherwise.

    • the patient is asked to swallow and note whether the swelling moves on deglutition or not.

    • the swellings which are adherent to the larynx and trachea move upwards on swallowing, eg. thyroid swelling, thyroglossal cyst and subhyoid bursitis.

    • tuberculous and malignant lymph nodes when they become fixed to the larynx or trachea will also move on deglutition.

Skin:

    • a sinus, fistula, ulcer or scar should be noted during inspection of the skin of the neck.

    • Tuberculous sinus or ulcer arising from bursting of caseous lymph nodes is not uncommon in the neck. Undermining edge is typical of this ulcer. Puckering scar may also be found on the skin after healing of these ulcer or sinuses.

    • Sinus due to osteomyelitis of the mandible is usually single and lies a little below the jaw, whereas multiple sinuses over an indurated mass at the upper part of the neck would suggest actinomycosis. sulphur granules in the pus is very much confirmatory of actinomycosis.

    • a Branchial fistula is seen just in front of the lower 3rd of the anterior border of the sternomastoid muscle.

    • Gummatous ulcer rarely occurs in the sternomastoid muscle.

    • when there is a swelling, the condition of the skin over the swelling should be carefully noted. Redness and oedema are the features of inflammation. presence of subcutaneous dilated veins indicate lymphosarcoma. skin may be infiltrated by the malignant growth and the skin is stuck down to the growth causing a fold of skin to stand out above it. This is a characteristic feature of secondary carcinoma of lymph nodes.

    • One should also inspect for presence of visible and dilated cutaneous veins. These are sometimes present around malignant tumours especially the lymphosarcoma.

Differential Diagnosis of swelling of the neck

For differential diagnosis, swellings of the neck can be divided into (a) midline swellings and (b) lateral swellings according to their site of origin.

Midline Swellings of the neck from above downwards are:

    • Ludwig's angina

    • Enlarged submental lymph nodes

    • Sublingual dermoid

    • Lipoma in the submental region

    • Thyroglossal cyst and subhyoid bursitis

    • Goitre of the thyroid isthmus and pyramidal lobe

    • Enlarged lymph nodes and lipoma in the suprasternal space of Burns

    • Retrosternal goitre and thymic swelling

    • a dermoid cyst may occur anywhere in the midline.

Lateral Swellings according to their sites may be divided into the following regions:-