State university of Zanzibar

1. History and Examination
of Anterior neck
swelling.
MD-3 LECTURE
22/12/2020
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2. Learning objectives
• To Understand history and examination of the anterior neck
swelling
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3. Outline
• Signs and symptoms of anterior neck swelling
• Examination of anterior neck swelling
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4. EXAMINATION OF THE NECK
(EXCLUDING THE THYROID GLAND)
HISTORY.— The commonest cause of swelling in the neck is
enlarged lymph nodes.
AGE-is useful so far as conditions in the neck are concerned.
-Sternomastoid 'tumor' in new born, cystic hygroma
-Positive history of difficulty labour
-Branchial cyst and branchial fistula-seen in early adult life.
-Inflammatory swellings may occur at any age
-Carcinomatosis swellings common in the old.
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5. SWELLING-common symptom of the lesions of the neck.
-mode of onset
-duration ( inflammatory, benign vs malignant
tumors).
PAIN- painful or not?
-Inflammatory swellings are always painful.
Eg; acute lymphadenitis
-Malignant growth –painless initially, at late stage become
painful when nerve infiltration or organ compression.
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6. LOCAL EXAMINATION
INSPECTION--neck has to be exposed up to the level of the nipples.
-Supra-clavicular fossa inspection.
(enlargement of the left supra-clavicular lymph nodes is an
important sign so far as the cancer of breast and cancer of
many abdominal organs .
a) Swelling- note its number, situation, size, shape, surface etc. ---
multiple swellings indicate the diagnosis of enlarged lymph nodes.
b) Skin - a sinus, fistula, ulcer or scar should be noted during
inspection of the skin of the neck.
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7. c) The face and upper part of chest.
-venous engorgement due to pressure of cervical
lymphadenopathy over the jugular vein.
- torticollis
(in a case of acute cervical lymphadenitis or tuberculous
lymphadenitis or in case of sternomastoid tumor.
-enlarged lymph nodes may also press on the nearby nerves
to cause muscle wasting.
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8.  PALPATION- neck swelling best palpated from behind.
- patient's neck is passively flexed with one hand on his head and the other
hand is used for palpating the swelling .
-the head is also flexed passively towards the side of the
swelling for proper palpation.
-This is to relax the muscles and fasciae of the neck.
a) Swelling -noting its situation, size, shape, surface, margin, consistency,
reducibility, impulse on coughing, translucency, mobility, pulsation
(expansile or transmitted) etc.
-A carotid body tumor or an aneurysm can be moved across but not along
the line of the carotid artery.
-Determine the relation of the swelling with the sternomastoid muscle.
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9. b) Lymph nodes - a system should be maintained to palpate all the
groups of lymph nodes in the neck.
- It may be started from below with
 supraclavicular group, then moving upwards palpating the lymph
nodes in the posterior triangle,
 jugulo-omohyoid group, jugulodigastric, submandibular, submental,
preauricular and occipital groups.
 In case of enlargement of LN one should examine the drainage area
for
inflammatory or neoplastic focus,
 Other groups of lymph nodes lying in other parts of the body should
also be examined in case of enlargement of cervical lymph nodes.
 These groups include the axillary, the inguinal and abdominal groups.
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10.  The spleen and the liver should be examined in case of
Hodgkin's disease
 The lungs for tuberculosis
 Examination of the drainage area of the LN.
 If the supraclavicular (Virchow's) nodes are enlarged (Troisier's
sign),
-one should examine not only the arm; breast and chest
(bronchus) but also the abdomen right down to the testis.
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11. Percussion -this is not very important examination,
-yet a rare disease —laryngocele may be revealed by the tympanic note
-the swelling becomes more apparent when the patient blows his nose.
Auscultation -a bruit may be heard over an aneurysm or carotid body
tumor.
Movements -patient with cold abscess of the posterior triangle of the
neck may not be able to move his neck due to tuberculous affection of
the cervical vertebrae.
-All movements of the neck will be restricted.
- Care must be taken to minimize forceful movements of the neck as
sudden death is on record following examination of movements of the neck
in this condition from dislocation of the atlanto-axial joint (the dens
pressing on the medulla).
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12.  Special investigations –
i. The fluid aspirated , eg; branchial cyst
ii. X-ray - of the cervical spine and cervical rib.
(-a radio-opaque fluid (uropac) may be injected into a branchial fistula to determine
its extent. A complete fistula will extend upto the supra-tonsillar fossa.
iii. Barium swallow (a little amount) or urograffin pushed through a Ryle's tube will
diagnose pharyngeal pouch in skiagraphy.
iv. In case of secondary malignant lymph nodes
(a) Laryngoscopy if laryngeal carcinoma is suspected,
(b) bronchoscopy, if bronchial carcinoma is suspected,
(c) X-ray chest and mediastinoscopy if mediastinal growth or lung cancer is suspected,
(d) Oesophagoscopy and barium swallow in esophageal cancer
(e) mammography in case of breast cancer may be performed to come to a definite
diagnosis.
 Above all excision biopsy of the affected lymph nodes is of immense value.
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13. DIFFERENTIAL DIAGNOSIS OF NECK SWELLING
 For DDx -swellings of the neck can be divided into ;
(a) midline swellings
(b) lateral swellings according to their site of origin.
 Midline swellings - from above downwards are : Ludwig's angina,
enlarged
submental lymph nodes, sublingual dermoid and lipoma in the submental
region; thyroglossal cyst and subhyoid bursitis; goiter of the thyroid
isthmus and pyramidal lobe, enlarged lymph nodes and lipoma in the
suprasternal space of Burns, retrosternal goitre and thymic swelling.
o A dermoid cyst may occur anywhere in the midline.
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14.  Lateral swellings - according to their sites may be divided into the following
regions :—
(i) SUBMANDIBULAR TRIANGLE.— Besides the lymph nodes and enlarged
submandibular salivary gland, there may be deep or plunging ranula and
extension of growth from the jaw.
(ii) CAROTID TRIANGLE aneurysm of the carotid artery, carotid body tumor,
branchial cyst and branchiogenic carcinoma may be met with.
 Thyroid swellings will be deep to the sternomastoid, a sternomastoid
tumor may develop in a new-born baby,
(iii) POSTERIOR TRIANGLE — besides enlarged supraclavicular lymph nodes,
there may be cystic hygroma, pharyngeal pouch, subclavian aneurysm,
aberrant thyroid, cervical rib, lipoma (Dercum's disease) etc.
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15.  For clinical diagnosis the swellings of the neck may also be divided into
acute and chronic
swellings.
 Acute swellings are cellulitis including Ludwig's angina, boil, carbuncle
and acute lymphadenitis.
 Chronic swellings may be further subdivided into :
 (a) Cystic — Branchial cyst, thyroglossal cyst, dermoid cyst, cystic
hygroma, sebaceous cyst, cystic adenoma of the thyroid gland, cold
abscess etc.
 (b) Solid swellings are swellings arising from thyroid, branchiogenic
carcinoma, sternomastoid tumor etc.
 (c) Pulsatile swellings are aneurysm of the carotid or subclavian artery,
Carotid body tumor, lymph node swellings lying in close proximity to the
carotid artery to elicit transmitted pulsation and a few primary toxic
goitre.
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16. Class assignment
Qn; Read on brief descriptions of the important swellings of
the neck are listed below :
• Tuberculous lymph nodes.
• Carcinomatous lymph nodes (secondary)
• Lymphoma
• Cellulitis
• Branchiogenic carcinoma
• Branchial cyst
• Cystic hygroma
• Branchial fistula.
• Pharyngeal pouch
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17. EXAMINATION OF THE THYROID GLAND
HISTORY
• Age
• Sex
• Occupation
• Residence
• Swelling
• Pain- ( goitre is usually a painless condition, inflammatory conditions
of thyroid
• gland are painful, malignant diseases of the thyroid gland are painless
to start with, but become painful in late stages)
-In Hashimoto's disease there is discomfort in the neck.
• Pressure effect- dysphagia, dyspnea, horsiness of voice
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18. • Symptoms of primary thyrotoxicosis-(gland not much enlarged)
-loss of weight inspite good appetite,
-preference for cold and intolerance to heat
-excessive sweating
- Nervous excitability, irritability, insomnia, tremor of hands
and muscle weakness.
• Symptoms of secondary thyrotoxicosis
o longstanding solitary nodular
or multinodular or colloid goiter shows presentation of
thyrotoxicosis the condition is called secondary thyrotoxicosis.
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19. -As mentioned above the brunt of the attack falls more on the
CVS than on the CNS.
-Palpitations, ectopic beats, cardiac arrhythmias,
dyspnea on exertion and chest pain .
- CCF may appear at late stage with swelling of ankles.
- Nervous and eye symptoms may be mild or absent
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20. • Symptoms of hypothyroidism
-Increase of weight inspite of poor appetite.
- Fat accumulates particularly at back of the neck and shoulders.
-Intolerance of cold weather and preference for warm climate,
-There is minimal swelling of thyroid.
-The skin may be dry.
-There may be puffiness of the face with pouting lips and dull
expression.
- Loss of hair is a characteristic feature and 2/3rds of the eyebrows
may fall off.
-Muscle fatigue and lethargy
- Failing memory and mild hoarseness due to edema of vocal cords
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21. • Past medical history
• Personal history
• Family history
GENERAL EXAMINATION
1. Build and State of Nutrition - In thyrotoxicosis the patient is
usually thin and underweight.
-The patient sweats a lot with wasting of muscles.
- And in hypothyroidism the patient is obese and overweight.
- In case of carcinoma of thyroid there will be signs of anemia and
cachexia.
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22. 2.Facies -in thyrotoxicosis one can see the facial expression of
excitement, tension, nervousness or agitation with or without variable
degree of exophthalmos.
-In hypothyroidism one can see puffy face without any expression
(mask-like face).
3. Mental state and intelligence -hypothyroid patients are naturally dull
with low intelligence.
-This is more obvious in cretins.
4. Pulse irregularity is more of a feature of secondary thyrotoxicosis,
particularly sleeping pulse rate.
5. Skin - moist particularly the hands in case of primary thyrotoxicosis.
Hot and moist palm to come across in primary thyrotoxicosis. Skin is
dry and inelastic in myxoedema.
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23. 3. Differentials
• Simple goiter
• Toxic goiter
• Neoplastic goiter
• Inflammatory goiter
• Primary thyrotoxicosis
• Secondary thyrotoxicosis
• Hypothyroidism
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24. 4. Local examination- Inspection
• Site? size,
• Shape?
• Surface?
• Skin over the swelling?
• Extent?
• Pulsation?
• Movement with swallowing? (look for lower border if goiter is
suspected)
• Movement with protrusion of the tongue for midline swelling?
• Pemberton’s test.
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25. 4. Local examination- Palpation
• Site, Size, Shape, Surface
• Extent
• Temperature
• Tenderness
• Consistency
• Fixation- to the skin? Neck?
• Palpate trachea and/ or isthmus
• Kocher’s test
• Berry’s test + any palpable thrill
• Crite’s test
• Lahey’s test
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26. 4. Local examination- Percussion and Auscultation
• Percussion over the sternum- Dull? Resonant?
• Auscultation- When and why to auscultate?
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27. Summary
• For an obese or short necked patient, Pizzilo’s method.
• During palpation, incline the head to the side to be examined
in order to relax the sternocleidomastoid muscle.
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28. References
• Das-manual of clinical surgery.
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