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Examination of Neck
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301
subhyoid bursa, thyroglossal cyst are fluctuant. Cystic
hygroma and lymph cyst are brilliantly transilluminant.
Laryngocele may show expansile impulse or becomes
prominent while blowing. Carotid aneurysm shows
expansile pulsation; carotid body tumour shows trans-
mitted pulsation. Nodular surface, hard consistency
is seen in secondaries in lymph node. Smooth surface
with firm, India rubber consistency is seen in
lymphoma. Carotid body tumour and carotid aneurysm
move only horizontally not in the line of the artery.
Rare tumour (neurofibroma) can occur from vagus
A
nerve on the posterior aspect of the carotid sheath
which causes cough sensation while palpation; swelling
is only horizontally mobile, firm, with typical transmitted pulsation.
Torticollis due to shortening of sternomastoid,
should be differentiated from ocular torticollis. Head
is clasped by examiner’s hand and slowly straightened
observing the eyes. Straightening of the head makes
squint apparent in ocular torticollis.
Other relevant examinations to be done are– protrusion of tongue to look for hypoglossal nerve palsy
(tongue deviates towards affected side); spinal accessory nerve (shrugging of shoulder is defective with
wasting of trapezius) (Fig. 13.7); features of cervical
sympathetic chain involvement (Horner’s syndrome);
carotid artery pulsation; superficial temporal artery
pulsation; tracheal palpation; laryngeal crepitus
A
(normally it is present, but absent in advanced laryngeal
carcinoma) (Figs 13.8A to 13.10). Cervical spine
A
Figs 13.6A to C: Cold abscess, eliciting fluctuation (Paget’s)
and collar stud abscess – due to tuberculosis.
Fig. 13.7: Shrugging of shoulder against resistance to check
trapezius paralysis due to infiltration of spinal accessory
nerve.
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SRB’s Clinical Surgery
A
Figs 13.8A and B: Laryngeal crepitus is present normally. It will be absent in
advanced carcinoma larynx. Trachea also should be examined for deviation.
Fig. 13.9: Superficial temporal artery pulsation should
be checked in front of tragus.
B
Fig. 13.10: Carotid pulsation should be checked to confirm
whether it is infiltrated/encased by tumour or any presence
of thrill (suggests stenosis) and also should be auscultated
for bruit.
Examination of Neck
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should be examined (paraspinal spasm, tenderness,
deformity , movements) especially in case of tuberculosis for primary . In females (rarely in male) carcinoma
breast may be the cause of neck node enlargement,
so breast should be examined in suspected cases.
Oral cavity should be examined in all neck swellings
especially when swelling is thought to be from lymph
node. T onsils may show tubercles in case of tubercular
lymphadenitis. Retropharyngeal abscess in tuberculosis is chronic and lies in midline (Fig. 13.11).
303
posterior triangle nodes; level VI is central nodes
(paratracheal and laryngeal). Level VII is mediastinal
node. Level I and level II are further divided into a
and b. Ia is submental nodes; Ib is submandibular nodes.
Level IIa nodes lies below the spinal accessory nerve
(in sternomastoid muscle) and IIb above the nerve;
Level Va nodes are above the spinal accessory level
(in posterior triangle) and level Vb is below it (Figs
13.12 to 13.18).
Fig. 13.11: Oral cavity should be examined
in all neck swelling patients thoroughly.
Other lymph nodes in the body should be examined–
axillary, para-aortic, iliac, inguinal, epitrochlear (above
the medial epicondyle and on medial aspect of the
arm), and popliteal lymph nodes. Lymphoma may cause
generalised lymphadenopathy.
Drainage area of the specific lymph nodes which
are palpable should be examined. Cervical lymph
nodes drain from lymphatics of head, neck, face, oral
cavity , nasal cavity, paranasal sinuses, pharynx, larynx
and thyroid. Left supraclavicular nodes receive from
left upper limb, left side chest wall, left breast, abdomen
and both testes. Cervical lymph nodes can be superficial
or deep. Nodes are arranged in different levels (Sloan
Catering memorial hospital USA) – Level I to level
VI. Level VII is mediastinal node. Level I is submental
and submandibular nodes; level II is upper deep
cervical nodes; level III is middle deep cervical nodes;
level IV is lower deep cervical nodes; level V is
Fig. 13.12: Levels in cervical lymph nodes.
Inner Waldeyer ’s ring which includes adenoids,
tubal tonsils, faucial tonsils, lingual tonsils also should
be examined.
Outer Waldeyer ’s ring includes retropharyngeal
lymph nodes; jugulodigastric lymph nodes; submandibular lymph nodes; submental nodes.
Healy’s classification of lymph nodes in neck:
SH—superior horizontal chain; IH—inferior
horizontal chain: PV—posterior vertical chain: IV—
intermediate chain: AV—anterior vertical chain.
Percussion
In laryngocele tympanic note may be heard on percussion. Percussion over the sternum is important to elicit
tenderness in lymphoma (bone marrow involvement
– Stage IV) and also in mediastinal nodal mass that
will elicit dullness if present (Fig. 13.19).
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SRB’s Clinical Surgery
A
Figs 13.13A and B: Submandibular lymph nodes are examined from behind with flexion of the neck. Bidigital
palpation is done to differentiate lymph node from submandibular salivary gland. Lymph nodes are not bidigitally
palpable; submandibular salivary gland is bidigitally palpable.
Fig. 13.14: Palpation of level 2 lymph nodes.
B
Fig. 13.15: Palpation of level 3 lymph nodes.
Examination of Neck
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Fig. 13.16: Palpation of level 4 lymph nodes.
305
Fig. 13.18: Palpation of Virchows lymph node in the
neck in between two heads of sternomastoid.
A
B
Figs 13.17A and B: Palpation of level 5 lymph nodes.
It is palpated both from behind and front.
Fig. 13.19: Percussion over sternum for tenderness (in
lymphoma and lymphatic leukaemia) and dullness for
mediastinal mass.
Auscultation
Auscultation is done to hear bruit over carotids in
carotid artery aneurysm; over supraclavicular region
in subclavian artery aneurysm.
Systemic Examination
Abdomen should be examined for splenomegaly and
hepatomegaly in case of lymphoma; hepatomegaly
in case of secondaries.
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Respiratory system is examined for pulmonary
tuberculosis, bronchogenic carcinoma.
Skeletal system – spine and long bones should be
examined for secondaries and in case of lymphoma.
Tenderness, swelling, pathological fracture may be
evident. Neurological deficits and paraplegia with
bowel and urinary incontinence may be present in case
of spine involvement.
Examination of Nasopharynx,
Oropharynx and Hypopharynx
Pharynx has got 3 parts—Nasopharynx; oropharynx;
laryngopharynx. Nasopharynx is uppermost part of
the pharynx situated behind the nose and above the
lower border of the soft palate. Anteriorly it communicates with nasal cavities; inferiorly with oropharynx
through nasopharyngeal isthmus (Passavant’ s ridge).
Lateral wall contains opening of the auditory tube;
tubal elevation; fossa of Rosenmuller/pharyngeal
recess behind the tubal elevation. This is above the
upper edge of superior constrictor. Roof continues
as posterior wall of nasopharynx. Adjacent to base
of occiput nasopharynx contains lymphoid aggregates
called as pharyngeal tonsil which is small or absent
in adult but well developed in children and patho-
logically can be enlarged as adenoids. Tubal tonsil
is collection of lymphoid tissue one on each side behind
the tubal opening. Oropharynx is middle part of the
pharynx which communicates above to nasopharynx
through nasopharyngeal isthmus, in front with the oral
cavity through oropharyngeal isthmus (isthmus of
fauces), below to laryngopharynx at the level of upper
border of epiglottis. Palatine tonsil lies in tonsillar
fossa in the lateral wall one on each side between
palatopharyngeal arch (by palatopharyngeus muscle)
behind, palatoglossus arch (palatoglossus muscle) in
front. Tonsils are seen per orally. Oropharynx is formed
behind by superior, middle and posterior constrictors
of the pharynx. Laryngopharynx or hypopharynx is
laryngeal part of the pharynx extends from the upper
part of epiglottis above to lower margin of cricoid
below. Anterior wall of hypopharynx shows laryngeal
inlet, posterior surfaces of cricoid and arytenoids.
Posterior wall is formed by constrictors. Middle
constrictor overlaps the upper margin of inferior
constrictor; superior constrictor overlaps middle
constrictor in front (superficially). Pyriform fossa is
SRB’s Clinical Surgery
located in the lateral wall of the pharynx as a depression
on each side of the laryngeal inlet; bonded medially
by aryepiglottic fold, laterally by thyroid cartilage and
thyrohyoid membrane.
Carcinoma pyriform fossa may be silent; or presents
as difficulty in swallowing saliva as opposed to food,
later definitive dysphagia, change in voice, laryngeal
fixation (as late feature) or palpable significant cervical
lymph nodes. It is beyond reach for digital examination.
Laryngeal mirror is essential to visualise and examine
it. Sideropaenic dysphagia and postcricoid car cinoma
can also occur.
Oropharynx is examined using two spatulas. T ongue
is depressed with one spatula and with another cheek
is retracted laterally with its tip gently compressing
the anterior pillar of the fauces. T onsillar crypts, size,
surface, discharge, surrounding areas should be
examined. Often tonsils are enlarged so much that
both sides touch in the midline. Tubercles in the tonsils
may be obvious. Ear pain, halitosis, blood stained
saliva, haemorrhage, ulceration, fungation, dysphagia,
trismus, palpable significant neck lymph nodes are
features of carcinoma of tonsils. Lymphosarcoma may
develop in the tonsil in young individual. Painless
swelling in throat, thick speech, large pale tonsil, are
the initial features of lymphosarcoma of tonsil.
Extracapsular spread may cause a palpable and often
visible swelling behind and below the angle of the
mandible as a direct extension of the primary tumour.
But sooner cervical lymph nodes get involved in same
place as secondaries and become palpable.
Nasopharynx is palpated with patient sitting in a
stool. Examiner stands behind the patient with patient
extending his neck and head is supported by examiner’s
body. One side index finger pushes the cheek
inward from outside after opening the mouth (to prevent
biting of the examiner’s hand). Index finger of the
other hand is passed inside, towards nasopharynx to
sweep over the roof and walls of the nasopharynx (Fig.
13.20). Retropharyngeal abscess is always felt and
only often seen after proper depression of the tongue
(can be seen when inspected using a direct laryngoscope). It is felt as an indentable cushion-like projection
to the finger. Acute retropharyngeal abscess is usually
due to suppuration of retropharyngeal lymph node and
occupies a lateral position. Chronic retropharyngeal
abscess is usually due to tuberculosis of cervical spine
Examination of Neck
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Fig. 13.20: Palpation of nasopharynx from behind.
(C6) and is behind the prevertebral fascia and so situated
in midline. However occasionally tuberculosis of
retropharyngeal lymph nodes can occur as a rare entity
and in such situation, it will be in lateral position.
It also may present as swelling/cold abscess in the
neck behind the sternomastoid muscle.
Examination of Nasal Cavities and
Paranasal Air Sinuses
Nasal cavities should be examined using a nasal
speculum. Frontal, ethmoidal and maxillary air sinuses
should be examined for fullness, swelling, tenderness.
Sinusitis is common. Tumours of maxillary and ethmoidal air sinuses should be thought of. Maxillary tumour
causes upward displacement of eye; ethmoidal tumour
causes lateral displacement of the eye. Neoplasm in
frontal air sinuses is practically rare. Proper knowledge
of surgical anatomy of these areas is essential.
Investigations
FNAC of the node. It is useful in secondaries, tuberculosis (epithelioid cells). In branchial cyst cholesterol
crystals are seen (Fig. 13.21).
• Lymph node biopsy in suspected case of
lymphoma.
• Chest X-ray, X-ray cervical spine in tuberculosis.
• Fistulogram in branchial fistula and other fistulas.
• MR fistulogram.
• CT scan Chest and neck for multiple nodal mass.
307
Fig. 13.21: FNAC of neck lymph node is ideal initial
investigation.
• Barium swallow or water soluble contrast study
(better) in pharyngeal pouch.
• Arterial Doppler in aneurysm, carotid body
tumour, subclavian artery aneurysm.
• Carotid or subclavian arteriogram
• Discharge study for AFB, culture, cytology.
• Edge biopsy if ulcer is present.
• Laryngoscopy/bronchoscopy/mediastinoscopy/
oesophagoscopy in relevant causes.
Branchial Cyst
It arises from the remnants of second branchial cleft.
Normally 2nd, 3rd, 4th clefts disappear to form a
smooth neck. Persistent 2nd cleft is called as cervical
sinus which eventually gets sequestered to form
branchial cyst (Figs 13.22A and B).
Features: It is a congenital swelling in the neck but
presents in 2nd or 3rd decade. Swelling is located
in the neck, beneath the anterior border of upper third
of the sternomastoid muscle. It is smooth, soft/tensely
cystic (and so hard), fluctuant, occasionally transilluminant. It feels like ‘half filled double hot water bottle’.
Cyst is not compressible not reducible. Neck nodes
are not enlarged. It contains fat globules and cholesterol
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Different classifications of neck swellings
Midline swellings of the neck Lateral swellings Others
Ludwig’s angina Submandibular triangle Acute
Submental lymph node Submandibular salivary gland enlargement Cellulitis
Sublingual dermoid Submandibular lymph node enlargement Lymphadenitis
Thyroglossal cyst Plunging ranula Ludwig’s angina
Subhyoid bursa Jaw tumours extending down Chronic
Thyroid isthmus swelling Carotid triangle Cystic
Prelaryngeal and pretracheal Carotid aneurysm Cold abscess
lymph nodes Carotid body tumour Cystic lesions of thyroid
Midline dermoids and lipomas Branchial cyst Branchial cyst
Suprasternal lymph node Branchiogenic carcinoma Thyroglossal cyst
SRB’s Clinical Surgery
Thyroid swelling – lateral lobe Cystic hygroma
Sternomastoid tumour Dermoid cyst
Lymph nodal mass Sebaceous cyst
Posterior triangle Solid
Lymph nodal mass Secondaries in neck lymph nodes
Cystic hygroma Thyroid swelling
Pharyngeal pouch Branchiogenic carcinoma
Subclavian aneurysm Sternomastoid tumour
Cervical rib Cervical rib
Lateral aberrant thyroid Soft tissue tumour
Pulsatile
Carotid aneurysm
Carotid body tumour
Subclavian artery aneurysm
Primary toxic goitre
A
B
Figs 13.22A and B: Branchial cyst.
crystals. It is golden yellow in colour. Histologically ,
it is lined by squamous epithelium.
Differential diagnosis: Cold abscess, lymph cyst. It
may get infected to form an abscess. FNAC shows
cholesterol crystals.Cyst lies in relation with carotids,
hypoglossal nerve, glossopharyngeal nerve, and spinal
accessory nerve, posterior belly of digastric and
pharyngeal wall. Medially it is close to the posterior
pillar of tonsils. During dissection, all these structures
should be taken care of.
Branchial Fistula
It is a persistent second branchial cleft with a communication outside to the exterior. It is commonly a
congenital fistula. Occasionally the condition is
secondary to incised, infected branchial cyst. Often
it is bilateral (Figs 13.23A and B). External orifice
of the fistula is situated in the lower third of the neck
near the anterior border of the sternomastoid muscle
(incised infected branchial cyst causes sinus in upper
1/3rd of neck). Internal orifice is located on the anterior
aspect of the posterior pillar of the fauces, just behind
the tonsils. Sometimes fistula ends internally as blind
Examination of Neck
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increases the pressure in the pharynx, mainly during
swallowing which leads to protrusion of mucosa
through the Killian’ s dehiscence causing pharyngeal
pouch (Fig. 13.24A). The protrusion is usually towards
left.
Stages: (1) Small diverticulum. (2) Large, globular
diverticulum causing regurgitation, cough, dysphagia,
respiratory infection. (3) Large pouch which is visible
in the neck as a globular swelling often tender, smooth
and soft. They present with dysphagia, features of
respiratory infections like pneumonia and lung abscess,
weight loss and cachexia. Pouch may itself get infected
and form an abscess. Often the pouch descends
downward and enters the superior mediastinum.
Clinical Features
Regurgitation during night or while turning neck, pain,
dysphagia, recurrent respiratory infection, swelling
in the neck on the left side in posterior triangle which
is smooth, soft and tender. Gur gling noise heard while
swallowing is typical.
309
Figs 13.23A and B: Branchial fistula.
end. Track is lined by ciliated columnar epithelium
with patches of lymphoid tissues beneath it, causing
recurrent inflammation. Discharge is mucoid or muco-
purulent. Investigations: Discharge study , fistulogram.
Pharyngeal Pouch
It is a protrusion of mucosa through Killian’s
dehiscence, a weak area of the posterior pharyngeal
wall between thyropharyngeus (oblique fibres) and
cricopharyngeus (transverse fibres) of the inferior
constrictor muscle of the pharynx. Thyropharyngeus
is supplied by pharyngeal plexus from cranial accessory
nerve. Cricopharyngeus is supplied by external laryngeal nerve. Imperfect relaxation of the cricopharyngeus
Branchial cyst; cold abscess; lymph cyst; haemangioma
neck.
Investigations
Barium swallow—lateral view shows pharyngeal
pouch. Chest X-ray shows pneumonia (Fig. 13.24B).
CT neck.
Complications
Infection either mediastinitis or lung infection
(pneumonia or lung abscess); pharyngeal fistula;
abscess in the neck.
Laryngocele
It is a unilateral narrow necked, air containing diverticulum resulting from herniation of laryngeal mucosa.
It is situated in the anterior third of the laryngeal
ventricle, between the false cords and thyroid cartilage,
herniates through the thyrohyoid membrane. It can
be external; internal or combined. It occurs in professional trumpet players, glass blowers and in people
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A
SRB’s Clinical Surgery
B
Figs 13.24A and B: Pharyngeal pouch – anatomical location and barium contrast X-ray picture.
A
with chronic cough. Swelling is situated in the neck
in relation to larynx adjacent to thyrohyoid membrane
and is smooth, soft, and resonant becomes more
prominent while blowing (Fig. 13.25A). Infection is
quite common in the sac of laryngocele, leading to
the blockade of opening of the sac causing an abscess.
Hoarseness of voice, laryngeal obstruction may
B
Figs 13.25A and B: Laryngocele becomes prominent and resonant after
blowing through nose. X-ray shows air in the neck.
develop. Often there may be repeated discharge of
pus into the pharynx. Diagnosis: Clinical features,
X-ray neck (Fig. 13.25B), laryngoscopy, CT scan.
Cystic Hygroma (Cavernous Lymphangioma)
It is a cystic swelling due to sequestration of a portion
of jugular lymph sac from the lymphatic system, during
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