Examination of a Neck Lump

Introduction

  • Introduce yourself to the patient
  • Wash your hands
  • Briefly explain to the patient what the examination involves

Approach the examination in a systematic way, yet be prepared to be instructed to move on quickly to certain sections by any examiner.


Inspection

Ensure adequate exposure of the entire neck and the patent is looking straight ahead

Inspect for:

  • Obvious lumps
  • Scars or skin changes

If any mass noted on inspection:

  • Ask the patient to stick their tongue out
    • Any mass in the midline that rises on tongue protrusion is likely to be a thyroglossal cyst
  • Ask the patient to swallow (offer the patient a glass of water to use)
    • Any mass(es) in the midline that rises on swallowing are likely to be thyroid mass(es) or a goitre
Fig 1 - A multinodular thyroid goitre. This would typically rise upon swallowing, but not upon tongue protrusion.

Fig 1 – A multinodular thyroid goitre. This would typically rise upon swallowing, but not upon tongue protrusion.

Any lump identified should be assessed for:

  • Size
  • Shape
  • Location
  • Consistency
  • Fluctuance
  • Trans-illumination
  • Pulsatility
  • Temperature
  • Overlying skin changes
  • Mobility
  • Auscultation

Palpation

Stand behind the patient to palpate the neck, informing the patient when you do this.

Using the tips of the fingers, palpate lymph nodes of the head and neck.

  • Submental, Submandibular, Pre-auricular, Anterior Cervical, Supraclavicular, Posterior Cervical, Post-Auricular, and Occipital

Lymph nodes of the neck can also be divided into 5 levels:

  • I – submental and submandibular triangles
  • II – upper jugular nodes
  • III – middle third jugular
  • IV – lower jugular nodes
  • V – posterior triangle lymph nodes

Parotid Gland

Palpate the parotid gland (between the sternocleidomastoid and the mandible)

  • Palpate gently for any tenderness, swellings, or lumps
  • Examine the other side

Submandibular Gland

Bimanually palpate the submandibular gland (inferior and posterior to the body of the mandible)

  • Using a gloved hand, press the index finger onto the floor of the patients mouth
  • Place your other index finger at the inferior body of the mandible, slightly away from the midline
  • Ballot the submandibular gland between your fingers
  • Repeat for the other side

Thyroid Gland

Palpate the thyroid gland

  • Start at the midline, move your hands inferiorly to pass over the thyroid cartilage, until you feel the cricoid cartilage and the two inferior tracheal rings
    • The thyroid and thyroid isthmus overlies this region
  • Using the pads of your fingers, gently pass them over this area to palpate
    • Isthmus
    • Thyroid lobes
  • Ask the patient to swallow (offer the patient a glass of water to use), assessing for equal rise of the thyroid

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform:

  • An ultrasound scan (USS) and fine needle aspirate (FNA) of any lump identified (unless pulsatile)
  • An examination of the temporomandibular joint

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