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10.4 Site-Specic Symptoms ofHead andNeck Carcinoma
Table 10.11 Benign soft tissue tumours and their presentation
Benign tumour of soft tissue Presentation/symptoms/history
Fat—Lipoma (lipomas are the most
common benign neoplasm of
mesenchymal origin)
Fibrous tissue—Fibroma,
dermatobroma (bromas are benign
tumours that are composed of brous
or connective tissue)
Blood vessels—Haemangioma
(haemangioma (HM) and venous
malformations of the head and neck
are formidable lesions)
Smooth muscle—Leiomyoma Since head and neck region lacks smooth muscle, the occurrence of
Striated muscle—Rhabdomyoma Neck—It is presented as mass in the region of the neck; they might
Nerve—Neuroma, neurilemmoma
Schwannoma
Lymph vessels—Lymphangioma Lymphangiomas are uncommon, benign malformations of the lymphatic
In the head and neck region, only 13% of lipomas are seen, the posterior
neck space is the most common site.
Lipomas are seen more in men than females (9:1).
Lipoma usually presents as a painless, subcutaneous, mobile mass.
They are mostly solitary but rarely seen multiple.
Lipomas grow slowly and when it is >10cm which called giant lipomas.
A few lipomas present as a giant lipoma.
They can grow in all organs, arising from mesenchyme tissue. Fibromas are
most often seen in adults.
The most common types of bromas include Angiobroma’s—Small
papules across the nose and cheeks that contain brous tissue, oral
bromas.
Dermatobroma—The main symptom of a dermatobroma presents as a
small subcutaneous nodule that may or may not be tender. It may be itchy
or sensitive to the touch, and the colour may change over time. Because it
has a raised surface, it can be irritated by clothing or shaving and may
bleed if it is damaged.
Oral broma
Haemangioma causes cosmetic deformity and psychological problems.
Vascular lesions have a varied appearance and can commonly occur in the
head and neck.
A majority of these lesions are cutaneous and congenital
leiomyoma in this area is rare.
The most common site of leiomyoma in the head and neck region is the
lips (27.46%) followed by the tongue (18.30%), cheeks and palate
(15.49%), gingiva (8.45%) and mandible (5.63%).
experience some hoarseness, difculty breathing, difculty swallowing, or
a combination.
Foetal rhabdomyoma—It is presented as subcutaneous mass.
A neurilemmoma, also known as schwannoma, neurolemmoma and
peripheral bro blastoma, is a benign, encapsulated neoplasm derived from
Schwann cells that presents as slow-growing mass, pain, paraesthesia.
system that can occur anywhere on the skin and mucous membranes
present as a progressive solitary rubbery nodule with no skin changes, deep
subcutaneous cystic swelling.
333
(d) Time or Age of Onset
• Children—brous dysplasia, Juvenile trabecular ossifying broma, Cherubism.
• Adolescent—Ameloblastic broma, benign
cementoblastoma, brous dysplasia,
Juvenile psammomatoid ossifying broma.
• Adult—Odontoma, adenomatoid odontogenic tumour, keratocystic odontogenic
tumour (part of Gorlin Syndrome), odontogenic myxoma, familial gigantiform
cementoma.
• Middle age—Keratocystic odontogenic
tumour (Sporadic solitary), ossifying
broma, periapical osseous dysplasia,
focal osseous dysplasia.
• Old aged—Malignant odontogenic
tumour, orid osseous dysplasia.
(e) Duration of Symptoms
• Short/acute—These are either inammatory swelling like abscess, trauma
(haematoma)
• Long/chronic—Fibrous dysplasia,
broma, cementoblastoma, orid osseous
dysplasia, odontoma
(f) Mode of Onset
• Sudden—Abscess, trauma (haematoma)
334
Table 10.12 Malignant soft tissue tumours and their presentations
Malignant tumours of soft tissue Presentation/history/symptoms
Fat—Lipoma sarcoma It is presented as a new lump/swelling/mass or an
Fibrous tissue—Fibrosarcoma, Dermatobrosarcoma
or protuberance or
Malignant brous histiocytoma or
Spindle cell sarcoma
Blood vessel—Haemangiosarcoma/
haemangiopericytoma/haemangioendothelioma /
angiosarcoma
Smooth muscle—Leiomyosarcoma It is a rare tumour of smooth muscles, presented as slow
Striated muscle—Rhabdomyosarcoma This is the most frequent soft tissue sarcoma in children
Nervous tissue—Malignant schwannoma, neurogenic
sarcoma/malignant peripheral nerve sheath tumour
Lymph vessels—Lymphangiosarcoma It is presented as chronic swelling, painless nodule, or
Clear cell sarcoma It is soft tissue tumours.
Kaposi’s sarcoma Kaposi’s sarcoma is a type of cancer that forms in the
Epithelioid sarcoma It is rare and slow growing soft tissue tumours, presented
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
existing lump that grows faster or becomes painful.
It is a rare highly malignant tumour of mesenchymal cell
origin.
These rare and highly aggressive tumours arise from
lymphatic or vascular endothelial cells.
growing, discrete rm and nonulcerated painless mass.
and is common in head and neck.
Lump, pain in the affected area, weakness of movement
of the affected area.
nonhealing ulcer.
lining of blood and lymph vessels.
as small rm growth.
Table 10.13 Odontogenic tumour
Name of malignant
Types of tumours Name of benign tumour
Cartilaginous tumour Osteochondroma, chondroma, chondroblastoma, chondromyxoid
broma
Osteogenic tumour Osteoid osteoma, osteoblastoma Osteosarcoma
Miscellaneous tumour Adamantinoma Metastatic
Non-odontogenic Aneurysmal bone cyst, simple cyst, brous dysplasia,
osteobrous dysplasia, langerhans cell histocytosis, erdheim
Chester disease
Joint Synovial chondromatosis
Odontogenic tumour
(derived from tooth
forming elements)
Miscellaneous Teratoma
Fibro-osseus Fibrous dysplasia, ossifying broma, osseous dysplasia
Arising from odontogenic epithelium—Ameloblastoma,
squamous odontogenic tumour, Calcifying epithelial odontogenic
tumour (Pingborg tumour), keratocystic odontogenic tumour.
Arising from odontogenic epithelium+ectomesenchyme with
or without hard tissue formation—Ameloblastic broma,
ameloblastic bro dentinoma, ameloblastic broodontoma
Odontoma (complex and compound), calcifying cystic
odontogenic tumour, Dentinogenic ghost cell tumour
Arise from odontogenic mesenchyme—Odontogenic broma,
odontogenic myxoma, cementoblastoma
tumour
Chondrosarcoma
Ameloblastic
carcinoma
Ameloblastic
brosarcoma
Ameloblastic
brodention
sarcoma
Metastasizing
ameloblastoma
Clear cell
odontogenic
carcinoma
Ghost cell
odontogenic
carcinoma
10.4 Site-Specic Symptoms ofHead andNeck Carcinoma
Table 10.14 Cystic lesions of bone and odontogenic origin
Odontogenic Non-odontogenic
Primordial, gingival, periodontal, dentigerous, radicular
Keratinizing or calcifying odontogenic cyst,
odontogenic keratocyst
Table 10.15 Site-specic bone and odontogenic tumours
Mandible
• Body—Ameloblastoma (Caucasians), ameloblastic broma, ameloblastic brodentinoma, benign
cementoblastoma, focal osseous dysplasia
• Ramus
– Anterior—Ameloblastoma (black), central giant cell granuloma, peri apical osseous dysplasia, torus
mandibularis
– Posterior mandible—Ossifying broma, central giant cell lesion.
• Gingiva—Peripheral ameloblastoma
• Wisdom teeth—Dentigerous cyst
• Any part—Odontogenic myxoma, juvenile trabecular ossifying broma,
• Condyle and coronoid—Osteochondroma
Maxilla—Fibrous dysplasia, juvenile psammomatoid ossifying broma, juvenile trabecular ossifying broma.
Sinonasal—Juvenile sesamoid ossifying broma, osteoma.
Both—Odontogenic broma, brous dysplasia, orid osseous dysplasia, familial gigantiform dysplasia, cherubism,
osteoblastoma.
Palatal—Torus palatinus.
Nasopalatine cyst, median palatine cyst
Nasolabial cyst, globulomaxillary cyst
335
Table 10.16 Age-specic bone and odontogenic tumours
Children—Fibrous dysplasia, juvenile trabecular ossifying broma, cherubism
Adolescent—Ameloblastic broma, benign cementoblastoma, brous dysplasia, juvenile psammomatoid ossifying
broma
Adult—Odontoma, adenomatoid odontogenic tumour, keratocystic odontogenic tumour (part of Gorlin syndrome),
odontogenic myxoma, familial gigantiform cementoma
Middle age—Keratocystic odontogenic tumour (sporadic solitary), ossifying broma, periapical osseous dysplasia,
focal osseous dysplasia
Old aged—Malignant odontogenic tumour, orid osseous dysplasia
• Gradual—Fibrous dysplasia, broma,
10.4.15 Lymphoma
orid osseous dysplasia, odontoma
(g) Progression
• Progressive
– Slow progressive—Keratocystic odon-
togenic tumour, ameloblastoma, central
giant cell granuloma, odontogenic myxoma, osteoma.
– Fast progressive—Osteoblastoma, hae-
matoma, abscess.
• Non-progressive
It is a carcinoma of the lymphatic system. It is of
two types, one is Hodgkin’s lymphoma and
another is non-Hodgkin’s lymphoma. HLs frequently involve lymph nodes of the neck and
mediastinum, whereas extra-nodal sites account
for only 5% of HLs for example in the tonsils. In
contrast, approximately 30% of NHLs show heterogeneous extra-nodal manifestations, such as
in the major salivary glands, paranasal sinuses,
336
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
mandible, maxilla and Waldeyer’s ring (largely
depending and often characteristic of the specic
NHL subtype).
(a) History/clinical presentation.
• Hodgkin’s lymphoma—It may affect
people of any age, but is most common
in people between 20 and 40 years old
and those over 55. It is presented as painless swelling of lymph node, persistent
fatigue (Lassitude), fever, cyclical highgrade fever (Pel-Ebstein fever), night
sweat, unexplained weight loss, severe
itching, increase sensitivity to alcohol or
pain in lymph node after drinking
alcohol.
• Non-hodgkin’s lymphoma—This is a
common type of lymphoma.
– Lymphatic system symptoms—NHL is
presented as enlarged painless lymph
nodes in neck, armpits or groin.
– Abdominal symptoms—Abdominal
pain or swelling, feeling full even after
small amount of food, nausea,
vomiting.
– Respiratory symptoms—Chest pain,
coughing or trouble breathing, superior
vena cava syndrome.
– General symptoms—Persistent fatigue,
fever, night sweats, unexplained weight
loss.
B symptoms of lymphoma—Systemic
symptoms such as fever, night sweats, and
weight loss are known as B symptoms; thus,
presence of these indicate that the person’s
stage is, for example, 2B instead of 2A.
(b) Duration of symptoms
• Short duration—High-grade or
intermediate- grade lymphoma.
• Long duration—Low-grade lymphoma.
(c) Associated symptoms—Headache, trouble
thinking, personality change, double
vision, facial numbness, itchy red papule
under skin.
10.5 History/Chief Complaints/
Symptoms/Presentation
Benign Disorders ofNeck
10.5.1 Neck Sweeling/Lump/Mass
(a) Site
• Anterior/central—Submental lymphadenitis, plunging ranula, Ludwig’s angina,
sublingual dermoid, lipoma, subhyoid
bursitis, extrinsic carcinoma of lung,
thyroglossal cyst, thyroid masses, parathyroid swelling, level IV lymph node,
thymic swelling, retrosternal goitre.
• Lateral—Branchial cyst, carotid body
tumour, glomus vagale, jugulodigastric
lymph node, jugulo-omohyoid lymph
node, lower cervical lymph node, bronchogenic carcinoma, sternomastoid
tumour.
• Posterior—Level IV lymph node, lipoma,
cystic hygroma, cavernous haemangioma,
Madelung’s disease, lymphadenitis, secondaries neck, supraclavicular mass.
(b) Mode of onset
• Sudden—haematoma, infection, HIV
• Gradual—carotid body tumour, tuberculosis, cystic hygroma
(c) Time of onset
• Congenital—thyroglossal cyst, branchial cyst, sebaceous cyst, branchial
cleft cyst, lymphangioma, haemangioma, dermoid cyst, ectopic thyroid tissue, laryngocele, thymic cyst,
pharyngeal diverticulum.
• Acquired—Lymphadenopathy, carotid
body tumour, tuberculosis, angioma,
lipoma, thyroid, ranula, secondaries
neck.
(d) Progression
• Non-progressive
• Progressive
– Slow progression—Lymphadenopathy,
carotid body tumours, sebaceous cyst,
branchial cleft cyst, lipoma, tuberculosis, ranula
– Fast progression—Lymphoma, nodal
metastasis
10.5 History/Chief Complaints/Symptoms/Presentation Benign Disorders ofNeck
337
(e) Duration
• Acute—Infection, haematoma, pseudoaneurysm, tuberculosis, acute lymphadenopathy, HIV
• Subacute—amyloidosis, lymphoma, sarcoidosis, Sjogren syndrome, SCC
• Chronic—thyroid swelling, branchial
cleft cyst, carotid body tumour, glomus
jugulare tumour, glomus vagale, laryngocele, lipoma, thyroglossal cyst, parathyroid tumour (rare).
(f) Associated with pain, trauma, fever, sexual
and blood contact, URI symptoms, kitten
exposure, travelling history to endemic area,
skin infection, cat faeces exposure.
10.5.2 Sinus
A sinus may drain mucus or pus following the
rupture of an abscess.
• Site of sinus
– Branchial cyst—It usually opens on the
side of the neck just above the sternoclavicular joint, in front of the sternocleidomastoid muscle.
– Tubercular sinus—any site.
• Time of onset—congenital or acquired
• H/o pus discharge or mucoid discharge—pres-
ent or absent
• Types of abnormalities
– Restricted movement of neck—This is
caused by computer and cell phone use,
reading, driving or sitting for extended
periods, cycling, walking, especially on
uneven terrain, sleeping incorrectly,
sewing, sketching, or writing, carrying a
heavy shoulder bag.
– Painful movement of head—Neck spasm,
Meningitis,
– Tremor, Huntington’s disease.
• Mode of onset
– Sudden—muscle spasm, trauma
– Gradual—spondylosis
• Duration
– Short duration (acute)—spasm,
spondylitis
– Long duration—spondylosis, torticollis
• Time of onset
– Congenital—torticollis
– Acquired—cervical spondylosis, post-
accident
• Associated symptoms—neck swelling, fever.
• Associated history of tuberculosis, trauma.
10.5.4 Neck Pain
Neck pain symptoms can vary widely. The pain
may just be a mild nuisance, or it could be so
excruciating that a person avoids any excessive
movement.
10.5.3 Head Movement
The abnormalities of movement of neck may be
presented as restricted movement, deviated head,
xed head position, painful movement.
338
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
• Site
– Back of neck—cervical spondylosis, mus-
cle spasm
– Side of neck—muscle spasm, lymphadeni-
tis, abscess
– Anterior part of neck—lymphadenitis, thy-
roiditis, trauma
• Duration
– Short (acute)—muscle spasm, lymphade-
nitis, abscess, trauma
– Long/persisting (chronic)—cervical
spondylosis
• Mode of onset
– Sudden—muscle spasm, trauma, abscess
– Insidious—cervical spondylosis, osteoar-
thritis
• Severity of pain
– Mild—muscle spasm, lymphadenitis
– Moderate—cervical spondylosis, osteoar-
thritis, thyroiditis
– Severe—abscess, trauma
• Radiation of pain
– Arm—muscle spasm
– Occipital region—occipital neuralgia, cer-
vical spondylosis
• Type of pain
– Axial pain—This type of pain felt in the
part of the spine that belongs to the neck
(cervical spine), and sometimes spreads to
the shoulders.
– Radicular pain—It shoots (‘radiates’) along
the nerves—for example, up the back of
head or down into one arm. This type of
pain is usually caused by irritated nerves—
for instance, because one of the spinal disks
in the neck area has changed and is pushing
against a nerve. That may also affect arm
reexes and muscle strength or result in a
tingling feeling (‘pins and needles’).
– Sharp, burning pain (neuropathic pain)—
Nerve compression.
– Mechanical pain—Poor posture, neck strain.
– Central neuropathic pain—Stroke, spinal
cord injury, multiple sclerosis.
• Associated and other symptoms are neck muscles stiffness, headache in occipital region,
pain and weakness that shoot down to arm,
loss of neck mobility, Paraesthesia or tingling
in arm, weakness of shoulder, arm and hand,
feeling of numbness (Pin and needles) in arm.
– Stiffness, nagging sore in neck, sound on
moving neck, dizziness (cervical
spondylosis).
• H/o—Whiplash injury, arthritis, obese, stress,
poor posture (smoking, family history, heavy
lifting, bus or truck driver), cervical
spondylosis.
• Aggravating and relieving factors—Neck
movement, swallowing, pressure on neck.
10.6 Examination ofHead
andNeck
10.6.1 Examination ofNeck
1. Clinical anatomy—The neck is limited supe-
riorly by the inferior border of the mandible,
anteriorly by the midline, inferiorly by the
superior border of the clavicle, and posteriorly
by the anterior margin of the trapezius muscle. It is divided into anterior and posterior
triangles; hence, anterior triangle is divided
into submandibular, submental, carotid and
muscular triangles and the posterior is divided
into occipital and supraclavicular triangles.
2. Contents of neck
(a) Areas—Anterior triangle, posterior
triangle
(b) Bones—Cervical spine, hyoid bone
(c) Organs—Pharynx, larynx, oesophagus,
thyroid gland, parathyroid glands, sub-
mandibular gland
(d) Muscles—Suboccipital, Suprahyoid M,
Infrahyoid M., Scalene M., SCM,
Trapezius, digastric muscle, omohyoid
muscle, etc.
(e) Nerves—Phrenic nerve, cervical plexus,
vagus nerve and its branches, last four
cranial nerves
(f) Vessels—Common carotid artery and its
branches, vertebral artery
(g) Other—Fascial layers
(h) Lymph node—There is horizontal and
vertical chain of lymph node. They are
divided into six groups
10.6 Examination ofHead andNeck
339
3. Position of the patient—The neck can be
examined either from anterior or posterior.
Ask the patient to tilt their chin slightly downwards to relax the muscles of the neck and aid
palpation of lymph nodes. You should also ask
them to relax hands in their lap.
4. Instruments for examination—No specic
instruments are required.
5. Examination
(a) Inspection of neck
• Inspect the neck and surrounding area
for obvious swellings, scars,
pulsations.
• Site of swelling—For central masses,
inspect the mass with the tongue protruded (movement suggests thyroglossal cyst) and also assess the mass on
swallowing (suggests thyroid masses).
• Movement of neck
– Normal movement
Flexon of neck—Ask the patient to bend
the head forward towards the chest.
Extension—Ask the patient to bend the
head backward with the face towards
the sky.
Lateral rotation of neck—Turning the
head to the left or the right.
Side-bending: tipping the head to the
side or touching an ear to the shoulder
of the same side.
– Abnormality of neck movement
Spasmodic dystonia
Torticollis—Painful involuntary
contraction of neck causes turning
head to one side.
Laterocollis—abnormal painful lateral bending of head.
Anterocollis—abnormal anterior
bending of neck.
Retrocollis—it is type of cervical
dystonia in which patient has
abnormal neck extension.
– Restricted movement
• Inspection of trachea—The trachea is
inspected for position either midline or
deviated to one side. A midline trachea
is located equal distance from sternocleidomastoid muscle on both side.
• Symmetry of neck—Whole neck is
inspected for any asymmetry.
• Triangle of neck—The neck triangles
are inspected for swelling, sinus,
ulcer.
• Discolouration of skin—for example,
Blue (haemangioma), Red (inammation).
• Lymph nodes—There are six groups of
cervical lymph node.
• Inspection of salivary glands (Chap.
11)
• Inspection of thyroid gland (Chap.
12)
(b) Palpation of neck—The neck is palpated
either anteriorly or posteriorly or both.
• Palpation of trachea-Place the index
nger on trachea in the sternum then
slip it off on each side.
– Tracheal shift—Trachea is the
index of upper mediastinum.
– Deviated toward diseased side—
Atelectasis, agenesis of lung, pneumonectomy, pleural brosis.
– Deviated from disease side—
Pneumothorax, pleural effusion,
and large lung.
– Position—In the neck, trachea is
located in lower central part of neck
and below larynx, slightly displaced towards right by aortic
notch.
• Palpation of thyroid—This part has
been discussed in Chap. 11.
• Palpation of salivary gland—This part
has benn discussed in Chap. 12.
• Palpation of neck node and neck
triangles.
• Anterior triangle—The anterior triangle contains four triangles, submental,
submandibular, carotid and muscular
triangle.
• Posterior triangle—Posterior triangle
contains two triangles, occipital triangle and supraclavicular triangle.
(c) Auscultation of neck
• Auscultation of thyroid—Thyroid
gland is auscultated for bruits.
340
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
10.6.1.1 Method ofPalpation ofNeck
Nodes—Anterior
andPosterior
1. Procedure of examination of neck—The
examiner stands behind the patient and uses
both hands to start palpating the neck. Start in
the submental area and progress through the
various lymph node chains. Any order of
examination can be used, but a systematic
approach will ensure no areas are missed. Use
the pads of the second, third and fourth ngers
to press and roll the lymph nodes over the surrounding tissue to assess the various characteristics of the lymph nodes. By using both
hands (one for each side), you can note any
asymmetry in size, consistency and mobility
of lymph nodes. Take caution when examining the anterior cervical chain so that you do
not compromise cerebral blood ow (due to
carotid artery compression). It may be best to
examine one side at a time here. A common
mistake is a ‘piano-playing’ or ‘spider’s legs’
technique with the ngertips over the skin
rather than correctly using the pads of the second, third and fourth ngers to press and roll
the lymph nodes over the surrounding tissue.
2. Palpation of specic triangles and area of
neck
(a) Submental area/triangle—The submen-
tal triangle, also referred to as suprahyoid
triangle, is an unpaired suprahyoid area
lying inferior to the chin.
• Clinical anatomy—It is limited by the
body of the hyoid bone inferiorly,
body of mandible superiorly and
laterally by the right and left anterior
bellies of the digastric muscles.
• Approach/methods of palpation
– Anterior approach—Examiner sits
in front of patient, hold the head of
patient with left hand and ask
patient to ex the head. Now, the
examiner uses his ngers of right
hand to palpate submental triangle.
– Posterior approach—Examiner
stands behind the patient and uses
his/her thumb to stabilize the head.
The palpation of submental triangle is done with nger tips
(Fig.10.1a, b).
• Differential diagnosis—Submental
lymphadenitis, plunging ranula, dermoid cyst, lipoma, epidermoid cyst,
submental cellulitis, metastatic lymph
node, sublingual dermoid.
(b) Submandibular triangle/area—The
submandibular triangle, also known as
digastric triangle or sub-axillary triangle,
is located superior to the hyoid bone.
• Clinical anatomy—It is bordered:
superiorly by the inferior border of the
mandible and the mastoid process,
posteriorly by the posterior belly of
the digastric and stylohyoid muscles.
• Methods of palpation
– Anterior approach—First, stabilize
the head of patient with one hand
and asked to ex the head. Now,
Fig. 10.1 Palpation of
submental lymph node.
(a) Anterior method, (b)
Posterior method
a
b
ab
10.6 Examination ofHead andNeck
341
examiner use his ngers of other
hand to palpate the lymph node in
submandibular triangle one by one.
– Posterior approach—Examiner
stands behind the patient and rst,
stabilize the patient’s head with
thumb over parietal bone. The palpation is done with nger’s pad.
Palpation of both submandibular
triangles should be done at the
same time. The palpation of tringle
is done for swelling, mass, it’s consistence, tenderness.
– Bimanual palpation—The examiner
stands in front of patient who is
seated on stool. Now, examiner wear
the gloves, for examination of left
submandibular triangle, index nger
of left hand should be placed intra
orally on oor of mouth and ngers
of right hand placed externally on
submandibular triangle. Now, examiner pushes the swelling up if it can
be felt by nger inside the mouth
too. The enlarged submandibular
gland is palpable bimanually but
enlarged submandibular lymph node
not (Fig.10.2a, b).
• Differential diagnosis—Sialolithiasis,
sialadenitis, submandibular lymph node.
(c) Jugulodigastric area/triangle
• Clinical anatomy—It is bounded by
the skull base superiorly, greater cornue of hyoid bone inferiorly, anterior
border of SCM anteriorly and posterior border of SCM posteriorly.
• Methods of palpations
– Anterior approach—Ask the patient
to ex the head now stabilize the
head of the patient with one hand
then palpation is done with other
hand.
– Posterior approach—Examiner
stand behind the patient, stabilize
the head with thumb now the palpation is done with nger tips. Both
the triangles palpated simultaneously (Fig.10.3).
• Differential diagnosis—Jugulodigas-
tric lymph node, carotid body tumour,
Vagal paraganglioma.
(d) Jugulo-omohyoid area
• Clinical landmarks/anatomy—It is
bounded by hyoid bone superiorly, cricoid cartilage inferiorly, Juguloomohyoid area—level 3 lymph node
(jugulo-omohyoid).
• Methods of palpation
– Anterior approach—Asked the
patient to flex the head now stabilize with one hand then palpate with tip of fingers
(Fig.10.4).
– Posterior approach—The examiner
stand behind the patient sitting on
stool. The tip of ngers used for
palpation of level III lymph node.
• Differential diagnosis
Fig. 10.2 Palpation of
submandibular triangle.
(a) Anterior approach,
(b) Posterior approach
Level 1 B - Anterior approachLevel 1 B - Posterior approach
342
Level II A & B - Anterior approach
AL
ab
Fig. 10.3 Posterior
approach for
jugulodigastric triangle
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
Level 2
Level II A & B - Posterior approach
(e) Lower jugular area
• Clinical anatomy/landmarks—This is
bounded cricoid cartilage superiorly,
clavicle inferiorly, anterior border of
SCM anteriorly and posterior border
of SCM posteriorly.
• Methods of palpation
– Anterior method—The head of
patient to be turned to opposite
side to the side to be examined.
Now level IV a & b group (lower
cervical) L.N. to be palpated with
thumb and rst two ngers
(Fig.10.5).
• Differential diagnosis
(f) Posterior triangle of neck—This is
divided into two triangles clinically by
horizontal line drawn at the junction of
Fig. 10.4 Anterior method of palpation of juguloomohyoid lymph node
superior 2/3 and inferior1/3 at the level of
cricoid cartilage.
evel 2 B