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10.6 Examination ofHead andNeck
Fig. 10.5 Methods of palpation of level IV lymph node
• Clinical anatomy—Posterior trian-
gle is bounded anteriorly by posterior border of SCM, posteriorly by
anterior border of trapezius muscle,
superiorly by angle where these two
muscles meet and inferiorly by clavicle, floor formed by scalene muscles and superficially by skin, soft
tissue.
• Methods of palpation (Fig. 10.6)
– Anterior approach—The best way
is to have the patient sitting up,
with his head straight forward and
his arms kept down (this is done
to minimize the risk of misidentifying a cervical vertebra or a neck
muscle for a node). Palpation
from the front, on the other hand,
should be attempted in the supine
patient (in this position, the
change in gravity may mobilize
the node, thus making it more
accessible).
– Posterior approach—Palpation
from behind usually allows the
examiner’s hand to best adapt to the
343
patient’s anatomy, and is probably
preferable.
• Differential diagnosis
– Occipital triangle—level Va group
of L.N.
– Supra-clavicular triangle (level V
b or supraclavicular lymph node)
(g) Central part of neck—level vi (central
group)—This area includes the level 6
lymph node (pretracheal, prelaryngeal
lymph node), thyroid gland, larynx,
trachea.
• Clinical anatomy—It is bounded
superiorly by inferior border of hyoid
bone, inferiorly by superior border of
manubrium (suprasternal notch),
anteriorly by platysma muscle, posteriorly by trachea (medially) and prevertebral space (laterally), laterally
by medial borders of both common
carotid arteries (medial to levels III
and IV). This area includes anterior
jugular, pretracheal, paratracheal,
prelaryngeal/precricoid (Delphian),
and perithyroidal nodes.
• Method of palpation
Anterior method—Lymph node of this
group is palpated either by posterior or
anterior method with ngertip with
exed neck.
(h) Other groups
• Pre-auricular—For palpation of pre-
auricular nodes, The nger should be
rolled in front of the ear, against the
mandible.
• Post-auricular—This group of lymph
node is located behind the ear and palpated over mastoid process.
• Occipital—This group of lymph node
is located over occipital area.
• Scalene node—To feel scalene nodes,
roll your ngers gently behind the
clavicles. Instruct the patient to cough
or to bear down like they are having a
bowel movement. Occasionally an
enlarged lymph node may pop up.
344
aL
Level V aLevel V b
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
Level V - Anterior approach
Level V
Level V - Posterior approach
Fig. 10.6 Palpation of level V lymph node
10.6.1.2 Clinical Interpretation
ofFindings
• Lymph nodes in the head and neck region are
not visible under normal circumstances and
can hardly be palpated. After inammation in
the head and neck area, lymph nodes are often
somewhat enlarged reactively. Lymph nodes
are evaluated on the basis of number, size,
consistency etc.
– Size: The lymph node size says little about
the severity of the condition, only with very
large nodes is the chance of a severe illness
enhanced.
– Pain: Pain during palpation indicates active
inammation. Sometimes the skin above
evel V b
the lymph node will appear red and warm
to the touch.
– Consistency: A soft lymph node is usually
harmless. Very rm lymph nodes are often
based on metastasis, but rmness also
occurs in certain forms of Hodgkin’s disease and granulomatous inammations. A
rubbery consistency ts more with malignant lymphoma and chronic leukaemia.
The matted lymph nodes are indicative of
tuberculosis.
– Localization: The presence of supracla-
vicular lymph nodes is suspected for malignancy. On the left side in the supraclavicular
space is a special lymph node (the gland of
Virchov) which is of special importance,
10.6 Examination ofHead andNeck
because it is located in the drainage area of
the thoracic duct. When this lymph node is
enlarged pathologically, you must consider
a metastasis of a tumour in an area involving lymphogenic drainage via the thoracic
duct (for example stomach, gall bladder,
ovary, pancreas, lung and testis. Lung and
breast cancer often metastasize to the same
side as the source.
– Tenderness: Tender enlarged lymph nodes
are due to viral infection of tonsil and throat.
Methods of palpation of thyroid gland—dis-
cussed in Chap. 11.
Methods of palpation of salivary gland—dis-
cussed in Chap. 12.
Rising Sun Sign
If lower margin of supraclavicular lymph
node is palpable is known rising sun sign.
This is due to secondary metastasis in
supraclavicular lymph node due to primary
in ovary or in stomach.
345
On Examination: Tympanic Paraganglioma
They are diagnosed by careful examination
of the tympanic membrane and identication of the tumour through the translucent
eardrum.
Most TPs are visible as a vascular middle ear mass (bluish-red mass) seen on
otoscopy. if the inferior border of the lesion
can be seen, this is a Glasscock–Jackson
type I tumour, if not, then involvement of
the jugular bulb cannot be ruled out.
Introducing positive pressure in the ear
canal stops the pulsations of the tumour.
Glomus Jugulare: On Examination
• A bruits can be heard over ear
• Mass in neck
• Lateral wall of oropharynx is pushed
medially
• Last four cranial nerve paresis.
Troisier’s Sign
The supraclavicular lymph nodes on the
left side are called Virchow’s nodes. It
leads to an appreciable mass that can be
recognized clinically, called Troisier sign.
Carotid Body Tumour Findings
CBT Mass is expansile and can be emptied
of blood with gentle pressure on examination. CBTs can be moved horizontally rather
than vertically, a nding known as a positive
Fontaine’s sign. Sometimes a carotid bruit
or a pulsating mass can be detected.
Lyre’s sign—There is splaying of both
external and internal carotid.
Carotid sinus syndrome—It is charac-
terized by bradycardia and syncopal attack.
10.6.1.3 Dierential Diagnosis ofNeck
Swelling
• Differential diagnosis according to aetiology
(Table10.17)
• Differential diagnosis of neck swelling
according to time of onset (Table10.18)
• Differential diagnosis of neck swelling
according to site of origin (Table10.19)
• Differential diagnosis of neck swelling
according to triangle involvement
(Table10.20)
10.6.2 Examination ofHead
1. Clinical anatomy—Head comprises of skull
and face. The skull comprises of 22 bones
covered with skin and divided into area like
occipital, parietal, temporal, frontal, facial,
zygomatic, Orbital. The face is the anterior
part of the head, is bounded superiorly by
346
Table 10.17 Differential diagnosis of neck swelling according to aetiology
Category Cause
Inammatory Infection
Head neck infection—Sialadenitis, Adenitis, Thyroiditis, Neck abscess, Parotid abscess,
Ludwig’s angina
Lymphadinitis due to Systemic infection (Infectious mononucleosis, CMV infection, HIV,
Toxoplasmosis)
Adenitis due to Bacterial infection, Tuberculosis, Cat scratch disease.
Antigen mediated
Local hypersensitivity reaction—Sting, Bite
Serum sickness, autoimmune disease
Sarcoidosis
Trauma Haematoma, Subcutaneous emphysema, Acute bleeding, Atrio-venous stula, foreign body,
Cervical spine fracture
Neoplasm Benign
Epidermoid, Lipoma, Fibroma, Keloid, Goitre, Fibroma, Thyroid adenoma, Lipoma
Malignant
NHL, HL, salivary gland tumour, thyroid tumour, nodal metastasis secondary head and neck
carcinoma
Miscellaneous Thyroglossal cyst, branchial cleft cyst, cystic hygroma, haemangioma, dermoid cyst, epithelial
cyst
Table 10.18 Differential diagnosis of neck swelling according to time of onset
Congenital Acquired
Thyroglossal cyst, branchial cleft
cyst, dermoid cyst, cystic hygroma
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
Lymphadenitis, adenitis, sialadenitis, sialolithiasis, Ludwig’s angina, carotid
body tumour, neurobroma, parapharyngeal tumour, laryngocele, thyroid
adenoma, colloid goitre, lipoma, haematoma, subcutaneous emphysema
Table 10.19 Differential diagnosis of neck swellings
Mid-line Lateral
Ludwig’s angina, submental
lymphadenitis,
Sublingual dermoid, lipoma in submental
region, thyroglossal cyst, sub-hyoid
bursitis, goiter, enlarged level IV lymph
node, cystic hygroma, retrosternal goiter,
thymic swelling, dermoid cyst
Submandibular triangle—Sialadenitis, sialolithiasis, submandibular
adenitis, Ludwig’s angina, abscess, metastatic lymph node (Level 1B)
Carotid triangle—Aneurysm of carotid artery, Carotid body tumour,
branchial cyst, bronchogenic carcinoma, sternomastoid tumour,
metastatic lymph node (Level II & III), lymphoma, Wartin’s tumour
Jugulodigastric area—Metastatic lymph node (Level IV), Vagal
paraganglioma,
Jugulo-omohyoid area—Metastatic lymph node (Level III)
Lower cervical area—MetastaticLymph node (Level IV)
Posterior triangle—Supraclavicular L.N., Cervical rib, cystic
hygroma, lipoma, pharyngeal pouch, subclavian aneurysm, abberent
thyroid
hairline, laterally pre-auricular area inferiorly
by lower border of mandible, it contains the
eyes, nose and mouth.
2. Instruments—No special instruments are
required.
3. Examination of head—It includes inspec-
tion of face, scalp, skin, and hair. The facial
features vary in different races and
diseases.
(a) Inspection:
• Inspection of whole head Including
scalp/skull.
– Size—normal microcephaly and
macrocephaly.
– Shape—It varies by age, gender and
race, disease.
– Normal
– Abnormal—Hydrocephalus
10.6 Examination ofHead andNeck
Table 10.20 Differential diagnosis of neck swelling
• Submental triangle
– Submental adenitis, level 1a L.N.
• Submandibular triangle
– Submandibular sialolithiasis, sialoadenitis
– Sebaceous cyst, lipoma, abscess, dermoid cyst
• Anterior triangle
– Lymph nodes most common (coming from mouth, throat, thyroid, skin of head/neck), consider also
metastasis; infection (including TB). If it doesn’t move, consider branchial cyst; cystic hygroma; carotid
aneurysm; tumours (including lymphoma); laryngocele; parotid gland swellings
• Posterior triangle
– Lymph nodes (Level V)
– Cervical rib
– Pharyngeal pouch
– Cystic hygroma
– Branchial cyst
– Virchows node (malignancy)
• Midline neck mass
– Thyroid swellings (including thyroglossal cyst)
– Laryngeal swelling
– Chondroma of thyroid cartilage
– Dermoid cyst
– Level VI group of L.N.
• Lateral neck masses
• Posterior neck masses
347
– Symmetry
– Scalp hair—Scalp is inspected for hair
loss, dandruff, pattern of baldness.
– Additional ndings—Bleeding,
lesions, masses, hamartoma, laceration, signs of trauma.
– Inspection of frontal area—for
swelling, laceration.
– Inspection of parietal area—for
swelling, laceration.
– Inspection of occipital area—signs
of trauma.
– Inspection of temporal area—signs
of trauma.
• Inspection of face—The lateral bor-
ders of the upper face terminate around
the temporal region. The upper face
region contains the forehead, eyes, and
temporal region. The forehead is the
superior region of the upper face
region. Examination of the face
involves inspection for blepharochalasis (eyelid sagging), excess wrinkling,
or redundancy of skin in various areas
of the chin, neck, upper neck, and face.
– Shape
Normal—The normal shape of face
varies within different races.
Abnormal—Deformed or absent
structures, more or less pronounced facial features, facial
palsy, acromegaly, hydrocephalus, moon shaped, Down syndrome face.
– Symmetry—The whole face along
with eyebrow, eyelids, ssures,
nasolabial folds and mouth are
observed for asymmetry, periorbital
oedema.
– Deformity—Head is inspected for
any deformity.
• Inspection of nose—This part has
been discussed in Chap. 4.
• Skin of face—skin of face is inspected
for colour, pigmentation, texture, hair
distribution, rashes and lesions.
• Inspection eye and orbit—This part
has been discussed in Chap. 4.
• Inspection of ear—This part has been
discussed in Chap. 3.
348
Paraganglioma and mesenchymal/stromal tumours
Hemat
Ger
Secondary tumours
10 History andExamination ofHead andNeck (Oncology andBenign Diseases)
(b) Palpation:
• Palpation of skull
– Masses/lump/swelling.
– Site—Head (Table10.21).
– Depression—it is due to fracture.
– Tenderness—fracture, furunculo-
sis, abscess, pyocoele.
– Crepitation—fracture.
Table 10.21 Differential diagnosis of sweeling in head area
Frontal area Frontal osteoma, mucoceles
Parotid area Parotid tumour (pleomorphic adenoma,) pre-auricular lymphadenitis,
Parietal area Dermoid cyst
Temporal area Dermoid cyst
Occipital area Dermoid cyst
Mastoid area Mastoid abscess, osteoma, Lymphadenitis
Zygomatic area Soft tissue tumour,
Infraorbital area Maxillary tumours (SCC), brous dysplasia, Abscess
Mandibular or mental area Adamantinoma, dentigerous cyst, root canal abscess
Fig. 10.7 Classication
of soft tissue tumours of
neck
m cell tumours
• Palpation of face—the face is pal-
pated for step ladder deformities on
bony margins, tenderness.
10.6.3 Soft Tissue Tumour ofHead
andNeck (Fig.10.7)
Paraganglioma
Peripheral nerve sheath tumours (PNSTs))
Schwannoma
Malignant PNST
Benign vascular tumours
Haemangioma
Cavernous haemangioma
Lymphangioma
Angiosarcoma
Smooth muscle tumours
Leiomyoma
Leiomyosarcoma
Solitary fibrous tumour
olymphoid tumours
Langerhans cell histiocytosis
Rosai-Dorfman disease
Follicular dendritic cell sarcoma
Primary thyroid lymphoma
Benign teratoma
Immature teratoma
Malignant teratoma
10.7 Clinical Atlas forHead andNeck Oncology
349
10.7 Clinical Atlas forHead
andNeck Oncology
10.7.1 Benign Tumours ofHead
andNeck (Fig.10.8)
Fig. 10.8 (a) Carotid
body tumour, (b)
Parapharyngeal tumour,
(c) Glomus jugulare
a b c
10.7.2 Malignant Tumours ofHead
andNeck (Fig.10.9)
Fig. 10.9 Clinical pictures of head and neck carcinoma
History andExamination
ofThyroid andParathyroid Gland
Disease (Endocrine Gland ofHead
andNeck)
11
11.1 History/Presentation
andExamination ofThyroid
andParathyroid Disorders
1. Common symptoms/chief complaints of
(a) General symptoms of thyroid disease or
disorders
• Swelling/nodule—This is the most
common symptom with which a
patient with thyroid disorder presents.
Thyroid swelling presents in lower
central past of neck either in one lobe
or in whole gland.
– Site of swelling/lump
• Lobe—Solitary thyroid nodule, colloid nodule, follicular
adenoma
• Isthmus—Colloid nodule, follicular adenoma
• Whole gland—Subacute thyroiditis, autoimmune thyroiditis,
Grave’s disease, multinodular
goiter
– Number of swellings/lump
• Single—Solitary thyroid nodule, colloid goiter, follicular
adenoma
• Multiple—Multinodular goiter, follicular carcinoma, papillary carcinoma
– Duration of swelling
• Short—Subacute thyroiditis,
anaplastic carcinoma, autoimmune thyroiditis
• Long—Colloid nodule, simple
goiter, physiological goiter,
differentiated thyroid neoplasm, thyroid adenoma
– Associated symptoms
• Any h/o pain in swelling, other
site—Anaplastic carcinoma,
haemorrhage in pre-existing
nodule
• Any h/o abrupt or sudden
increase in size—Malignant
transformation of pre-existing
nodule, haemorrhage in colloid nodule
• Swelling other than midline
neck—Metastatic lymph node
• Appetite change (decrease or
increase)—A patient with thyroid
dysfunction might have complaints of
either decrease or increase appetite.
The decreased appetite is noted in
hypothyroidism and increased appetite
is noted hyperthyroidism.
• Pain in the front of the neck, sometimes going up to the ears—Pain is
noted in acute infection or haemorrhage or carcinoma of thyroid gland.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_11
351
352
11 History andExamination ofThyroid andParathyroid Gland Disease…
• Cough with or without blood—This is
also a common symptom of thyroid
disease noted in thyroid nodule. This
long lasting caused by irritation of
throat
• Other symptoms to rule out hyperthyroidism or hypothyroidism like diarrhoea, heat or cold intolerance,
lethargy
(b) Duration of symptoms
• Short—Subacute thyroiditis, anaplastic carcinoma, autoimmune thyroiditis, thyroid abscess
• Long—Colloid nodule, simple goiter,
physiological goiter, differentiated
thyroid neoplasm, thyroid adenoma
(c) Progression of symptoms
• Slow progression—Colloid cyst, benign
tumour, colloid goitre, adenoma
• Fast progression—Anaplastic carcinoma, haemorrhage.
(d) Severity of symptoms
• Mild—Benign tumours, colloid cyst,
colloid nodule
• Moderate—Big size benign tumours,
toxic thyroid nodule
• Severe—Undifferentiated thyroid carcinoma, anaplastic carcinoma
(e) Associated symptoms
• Stridor—This is a symptom of either
pressure effect, direct invasion of larynx or involvement of RLN.
• Dysphagia—This is due to the pressure effect.
• Dyspnoea—This is either due to pressure effect on the trachea or involvement of RLN or tracheal invasion.
• Change of voice—This is a feature of
involvement of recurrent laryngeal
nerve and suggestive of thyroid
carcinoma.
• Neck swelling at other sites—Neck
swelling on other sites rather than thyroid swelling is due to lymph node
involvement by thyroid carcinoma.
The common sites are the lateral part
of neck, posterior triangle and central
part of neck.
(f) Specic symptoms
• Symptoms suggestive of hyperthyroidism/thyrotoxicosis
– Whole body: excessive sweating,
excessive hunger, fatigue, intolerance to heat, weight loss
– Behavioural: hyperactivity, irrita-
bility, or restlessness, tremor
– Heart: abnormal heart rhythm, fast
heart rate, palpitations
– Mood: mood swings, nervousness,
panic attack
– Eyes: abnormal protrusion of eyes
or puffy eyes
– Menstrual: irregular menstruation,
short and light menstruation
– Sleep: difculty falling asleep
(insomnia)
– Others: weight loss, diarrhoea, hair
loss, muscle weakness, tremor, and
warm skin
• Symptoms suggestive of
hypothyroidism
– Whole body: fatigue, loss of energy,
lethargy, weight gain, decreased
appetite, cold intolerance, dry skin,
hair loss, constipation, muscle pain,
joint pain, weakness in the
extremities
– Behavioural: depression, emotional
lability, mental impairment, forgetfulness, impaired memory, inability
to concentrate
– Sleep: sleepiness
– Menstrual: menstrual disturbances,
impaired fertility
– Neurological: paraesthesia, nerve
entrapment syndromes
– Others: blurring of vision,
decreased perspiration, decreased
hearing, fullness in the throat,
hoarseness of voice, painless sym-
metrical thyroid enlargement
(g) H/o ionizing radiation, previous h/o thy-
roid CA, h/o rapid enlarging nodule, nodule develop in <14 years or >65 years,
patient is male, bony pain, age>45 is high
risk, ear pain, hoarseness of voice.
11.1 History/Presentation andExamination ofThyroid andParathyroid Disorders
353
(h) Past H/o—anaemia, history of thyroid
surgery, type 1 DM, radioactive iodine
treatment, radiation therapy for head and
neck cancer, dietary iodine intake, etc.
(i) Family H/O—thyroid disease/cancer
F/H/O—thyroid CA, medullary carcinoma, MEN
(j) Treatment H/O drugs like lithium, sulfo-
nylureas, amiodaron.
2. Local examination of thyroid gland—
Clinical examination of thyroid gland includes
inspection, palpation and auscultation.
(a) Clinical anatomy—location—thyroid
gland located above the suprasternal
notch in midline. Thyroid isthmus spans
second, third and fourth tracheal ring and
lateral lobes curve posteriorly around the
sides of trachea/oesophagus.
(b) Instruments—No special instruments are
required.
(c) Position of patient—The patient is exam-
ined either in the sitting or in standing
position (Fig.11.1).
(d) Examination of thyroid—The ndings of
physical examination of the thyroid gland
enable the clinician to construct a rather
narrow differential.
• Inspection of thyroid (Fig.11.2)
– Methods/approach of inspection
• Anterior approach—The size of
swelling, movement on swallowing, side of swelling, condition of overlying skin, movement
on protrusion of tongue (a thyroglossal cyst move) is noted.
pletion of inspection of the thyroid from front, examiner should
observe the neck from the side to
estimate the smooth, straight
contour from the cricoid cartilage to the suprasternal notch.
Measure any prominence
beyond this imagined contour,
using a ruler placed in the area of
prominence.
c
a
Fig. 11.1 The position of neck during thyroid examination. (a) Neutral position, (b) Head extended position, (c)
Flexon position
b