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beyond the inferior margin of teres major. The largest branch of the axillary artery
is the subscapular artery which supplies the intercostal muscles, latissimus dorsi,
and the serratus anterior. The suprascapular artery, a branch of the thyrocervical
trunk, supplies the rotator cuff muscles. The axillary artery also gives rise to the
anterior and posterior humeral circumex arteries which supply the head of the
humerus, and teres major, teres minor, deltoid, and triceps muscles respectively.
The brachial plexus, formed by the anterior primary rami of C5 to T1, provides
sensory and motor innervation of the upper limb. It consists of 5 roots, 3 trunks, 6
divisions, 3 cords, and 5 branches. The 3 cords are described in relation to their
position relative to the axillary artery (medial, lateral, and posterior). The ve
branches include the musculocutaneous, axillary, radial, median, and ulnar nerves.
Lymph nodes in the axilla are arranged into 5 groups as follows: anterior (pecto-
ral), lateral, central, apical and posterior (subscapular). Collectively, they drain the
breast, thoracic wall, arm, and upper abdominal wall above the level of the umbilicus. Axillary lymph nodes are of particular clinical importance as they may harbor
metastases from breast cancer. Patients diagnosed with breast cancer who have
clinically or radiologically normal axillary lymph nodes should undergo a sentinel
lymph node biopsy to stage the axilla. The sentinel lymph node is the rst node into
which the breast tumour drains. The status of the sentinel node provides important
prognostic information and is used to guide further management e.g. surgery in the
form of an axillary lymph node dissection or radiotherapy. Patients with biopsy
conrmed axillary metastases may require an axillary lymph node dissection. The
anatomical levels of axillary lymph nodes are dened by their relationship to pectoralis minor and are used to describe the extent of surgery in an axillary lymph node
dissection (level I: inferolateral to pectoralis minor, level II: posterior to pectoralis
minor, level III: superomedial to pectoralis minor). The long thoracic nerve and
thoracodorsal neurovascular pedicle should be identied and protected. Injury to the
long thoracic nerve may cause winging of the scapula. Axillary lymph nodes may
also be enlarged in the setting of haematological malignancy, infection, autoimmune conditions, and post-vaccination.
A. M. Zaborowski and A. D. K. Hill
Examination oftheAxilla
Introduction
• Introduce yourself to the patient, explain what the examination involves and
obtain consent. Ensure a chaperone is present.
• Ask the patient to remove their clothing from above the waist to expose the chest.
Provide a surgical gown for the patient to cover themselves when not required to
expose the breasts.
• Ask the patient to sit upright on the examination table.
22 Examination oftheAxilla
217
Inspection
• Inspect the patient from the end of the bed and assess for any obvious asymmetry, masses, scars or skin changes.
• Ask the patient to place both hands behind their head and repeat the inspection
of both axillae.
• Ask the patient to place both hands on their hips and repeat the inspection.
Palpation
• Examine both axilla in turn.
• Support the arm on the side being examined and abduct the arm to an angle of
approximately 45°. Ask the patient to fully relax the arm to aid identication of
any enlarged lymph nodes.
• Palpate the axilla with the tips of your 2nd, 3rd and 4th ngers for any lymphadenopathy. There are 5 stations of axillary lymph nodes: apical, anterior, central,
posterior, and medial.
• Palpate the supraclavicular and infraclavicular lymph nodes. The right supraclavicular nodes may be involved in thoracic or oesophageal carcinoma. Metastases
to left supraclavicular nodes may occur in gastric carcinoma (Virchow’s node,
Troisier’s sign).
• Complete the examination by examining the breasts and all lymph node groups,
the abdomen for hepatomegaly and splenomegaly, the testes for testicular masses,
and the skin and nails for melanoma.
Lymph Node Characterization
Assess for the following characteristics during examination.
• Site: localized vs. generalized.
• Size: >1cm is abnormal.
• Consistency: hard lymph nodes suggest malignancy whilst rubbery lymph nodes
suggest lymphoma.
• Mobile or xed: lymph nodes xed to underlying or surrounding structures suggest malignancy.
• Tenderness: tender lymph nodes are typically found in the setting of infection or
acute inammation. Abnormal lymph nodes due to malignancy are usually
non-tender.
• Overlying skin changes: erythema of the skin suggests infection or inammation, whilst tethering suggests malignancy.
218
A. M. Zaborowski and A. D. K. Hill
Differential Diagnosis ofanAxillary Mass
1. Lymphadenopathy
• Haematological malignancy such as lymphoma or leukaemia.
• Metastases from invasive carcinoma e.g. breast.
• Infection (acute or chronic).
• Bacterial e.g. tuberculosis, staphylococcus or streptococcal cellulitis, bartonella henselae (cat scratch disease).
• Viral e.g. human immunodeciency virus, cytomegalovirus, infectious
mononucleosis.
• Protozoal e.g. toxoplasmosis.
• Autoimmune disorders such as systemic lupus erythematosus, rheumatoid
arthritis.
• Sarcoidosis.
• Post-vaccination.
2. Subcutaneous lesions such as lipomas or accessory breast tissue.
3. Cutaneous lesions such as sebaceous cysts or hidradenitis suppurativa.
Radiological Assessment oftheAxilla
Ultrasonography (US) is the most commonly used imaging modality to assess the
axilla. It is widely available, well tolerated, and does not involve ionizing radiation.
The patient is positioned supine with the arm above the head, abducted and externally rotated. If imaging reveals a suspicious nding e.g. abnormal lymph node,
percutaneous sampling techniques such as ne needle aspiration (FNA) or core
biopsy can be performed under US guidance with local anaesthetic. FNA specimens
provide a sample for cytological assessment whilst core biopsy specimens provide
tissue for histological assessment. Limitations of FNA include that it is operator
dependent and has a relatively high false negative rate of up to 25%. A repeat FNA
or core biopsy should be performed if there is high clinical or radiological suspicion
despite normal cytology. Core biopsy is highly accurate and can provide information on the type and grade of carcinoma as well as molecular subtype. Further imaging should be guided by clinical ndings and the differential diagnosis e.g.
mammography for suspected breast cancer or computed tomography of thorax,
abdomen and pelvis for a potential lymphoproliferative disorder.
Chapter 23
Examination oftheHead andNeck
HusamHosny andAhmedFarag
Abstract The Face is attached to the undersurface of the Cranium hanging in front
of the cervical spine where the hard palate is opposite the C1 Vertebra and the
Lower border of the Mandible is opposite C2. The Pharynx is attached to the back
of the nose―Naso-Pharynx‖ and back of the mouth―Oro-pharynx‖ like a
mask placed on the nose and mouth but opposite the Cervical Vertebrae. Lower
down It is opposite the Larynx “Laryngo-pharynx”.
Keywords Face · Neck · Examination · Sheet · Mass · Ulcer · Pharynx · Larynx ·
Lymph · Node
Anatomical Background (Figs.23.1 and23.2)
The Face is attached to the undersurface of the Cranium hanging in front of the
cervical spine where the hard palate is opposite the C1 Vertebra and the Lower border of the Mandible is opposite C2. The Pharynx is attached to the back of the nose
“Naso-Pharynx” and back of the mouth “Oro-pharynx” like a mask placed on the
nose and mouth but opposite the Cervical Vertebrae. Lower down It is opposite the
Larynx “Laryngo-pharynx”.
Just above the Larynx is the Hyoid bone opposite C3 Vertebra.
Larynx is opposite C\4 and C5 Vertebrae, and Cricoid Cartilage is opposite the C
6 Level, which is a Very important landmark in the Neck both anatomically and
clinically.
Knowledge of the Lymphatic drainage of the Neck is of paramount importance
in Clinical Examination both the drainage area s and Lymphatic groups:
H. Hosny
Cairo University, Cairo, Egypt
e-mail: husamhosny@kasralainy.edu.eg
A. Farag (*)
Kasr Alainy Hospital, Cairo University, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_23
219© The Author(s), under exclusive license to Springer Nature
220
Fig. 23.1 The Cranium is
above the spine and the
face is hanging from the
base of the skull in front of
the cervical vertebrae
H. Hosny and A. Farag
Fig. 23.2 The Pharynx occupies the space between the back of the face in front of the cervical
vertebrae
23 Examination oftheHead andNeck
221
Neck Examination
Introduction
Neck masses are frequent presentation to the clinician and include plethora of possible causes as many anatomical structures in the neck or adjacent areas e.g. scalp,
face and thorax that may present their pathological abnormalities in the neck. It is
always the clinician duty to limit those possibilities into a one or two most likely
possible causes (provisional diagnosis) to help formulating a targeted plan of management without exhausting the patient or the nancial system resources with undue
investigations.
Key Points
• Age is a risk factor by itself. While most masses in children are benign, those
presenting in adults have higher incidence of malignancy and should be consid-
ered malignant until proved otherwise.
• Thorough knowledge of neck anatomy including neck triangles is essential to
predict possible causes of neck abnormalities. However for purposes of simplic-
ity, dividing the neck into central and lateral parts is practical in restricting
differential diagnosis possibilities.
• “Common things occur commonly, but uncommon diagnoses do occur”. So it
is always judicious to assess common pathologies before embarking in searching
for an uncommon or rare disease.
• Neck masses are common in children and adults. The etiology can be generally
classied into congenital, inammatory/infectious or neoplastic. However those
occurring in children vary much from those in adults.
• Lymph node enlargement is the commonest swelling in the neck in all ages.
Failure to respond to treatment for 2–3weeks mandates further procedures to
detect a specic infection or reveal a hidden malignancy.
• Hidden areas e.g. base of the tongue, hard palate, tonsils, nasopharynx, orophar-
ynx and the submucosa should always be in mind especially when a primary
cause cannot be identied.
• Fine needle aspiration cytology (FNAC), is useful in identifying the nature of
neck masses and avoid complications of open wound biopsy. In cases of meta-
static disease of unknown primary, PET-CT should be done rst to identify areas
of high metabolic activity (suspicious areas) then endoscopic or open biopsies
can be done accordingly, otherwise false positive results may be obtained from
sites of previous biopsies if done rst.
222
H. Hosny and A. Farag
Triangles oftheNeck
The neck is bordered by the inferior border of the mandible (above), the midline of
the neck (in front), the superior border of the clavicle (below), and the anterior margin of the trapezius muscle (behind).They are of paramount importance for anatomical DD in neck swellings. The neck is divided by the sternocleidomastoid
muscle into.
Anterior Triangle
The anterior triangle of the neck is bordered by the inferior border of the mandible
(superiorly), the midline of the neck (medially), and the anterior border of the sternocleidomastoid muscle (laterally). It is further subdivided into three paired triangles (submandibular, carotid, and muscular) and one unpaired submental triangle.
• Submental Triangle:
• Bordered inferiorly; by hyoid bone, laterally; by the anterior belly of the digas-
tric muscle, medially; by midline of the neck. Its oor is made by the mylohy-
oid muscle.
• Contents: the most important is the submental group of lymph nodes. These
lymph nodes are responsible for the central wedge of the face i.e. central lips,
tongue, oor of the mouth and mandibular symphysis menti.
• Digastric/Submandibular Triangle: The submandibular triangle is a triangular
region of the neck bordered by the inferior border of the mandible (above), the
anterior belly of the digastric muscle (in front), the posterior belly of the digastric
muscle (behind), and the hyoid bone (below). The oor of the triangle is formed
by the mylohyoid muscle.
• Contents: the most important structures include the submandibular salivary
gland, submandibular lymph nodes, the facial artery and vein, the marginal man-
dibular nerve underneath the Platysma muscle, the hypoglossal and the lingual
nerves deep in the triangle.
• The submandibular triangle is clinically signicant because it is a common site
for neoplasms, infections, and immunologic pathologies. The submandibular
salivary gland can be affected by sialadenitis or neoplasms (50% malignant),
lymph node enlargement can occur with facial middle wedge infections or
tumors, marginal mandibular nerve can be affected by trauma or iatrogenic injury
during previous surgery in this area.
• Carotid Triangle: is bounded by the posterior belly of digastric muscle, the
superior belly of omohyoid muscle and the anterior border of sternomas-
toid muscle.
• Contents:
23 Examination oftheHead andNeck
223
• Arteries: common carotid artery and its bifurcation into internal and external
carotid arteries, and the latter branches namely; superior thyroid, lingual, facial,
occipital, and ascending pharyngeal arteries.
• Veins: internal jugular vein, superior thyroid, lingual, facial, ascending pharyn-
geal, and occipital veins.
• Nerves: external and internal branches of the superior laryngeal nerve arising
from the Vagus nerve (CN X), hypoglossal nerve (CN XII).It worth mentioning
that the carotid triangle is a very important region of the neck, as it contains
many vital structures. The internal jugular vein, for example, is a major vein that
drains blood from the brain and neck. The common carotid artery is also a major
artery that supplies blood to the brain and face. The hypoglossal nerve is respon-
sible for controlling the tongue muscles.
• Muscular Triangle: bounded anteriorly by midline of the neck from the hyoid
bone above to the sternum below, the anterior margin of sternomastoid infero-
posterior, and the superior belly of omohyoid posterosuperior.
• Contents:
• Organs: esophagus, trachea, thyroid gland, and the lower part of the larynx.
• Blood vessels: superior thyroid artery, anterior jugular and inferior thyroid veins.
• Lymphatics: anterior cervical, infrahyoid, prelaryngeal, thyroid, pretracheal,
paratracheal lymph nodes.
• Muscles: thyrohyoid, sternothyroid, sternohyoid, omohyoid muscles.
• Nerves: ansa cervicalis (C1-3).
Posterior Triangle
Bounded by posterior border of sternomastoid muscle anteriorly, anterior border of
trapezius muscle posteriorly and middle third of the clavicle inferiorly. It is further
subdivided into occipital and supraclavicular triangles.
• Occipital Triangle:
• Anterior border: posterior margin of sternocleidomastoid muscle.
• Posterior border: anterior margin of trapezius muscle.
• Inferior border: the inferior belly of the omohyoid muscle.
• Floor: levator scapulae, splenius capitis, and middle and posterior scalene
muscles.
• Contents:
224
H. Hosny and A. Farag
• Artery: transverse cervical artery.
• Lymphatics: accessory lymph nodes and inferior deep lateral cervical
lymph nodes.
• Nerves: accessory nerve (CN XI), cutaneous and muscular branches of the cervi-
cal plexus, the uppermost part of brachial plexus, supraclavicular nerves.
• Clinical Signicance: It houses major nerves that innervate muscles vital for
head and neck functions
• Subclavian (supraclavicular) Triangle:
• Superior border: the inferior belly of the omohyoid muscle.
• Anterior border: posterior edge of the sternocleidomastoid muscle.
• Inferior border: clavicle.
• Contents:
• Blood vessels: Subclavian artery and vein.
• Nerves: brachial plexus trunks.
• Lymphatics: supraclavicular lymph nodes.
• Clinical Signicance: Virchow’s node, the left-sided supraclavicular lymph
node, should raise the suspicion of carcinomas originating from the abdomen.
Troisier’s sign (an enlarged, rm, non-tender Virchow’s node) can indicate can-
cer arising from the stomach, ovaries, testicles, and kidneys.
• The right-sided supraclavicular lymph node drains lymphatic uid from the tho-
rax. A rm, enlarged, non-tender right-sided supraclavicular lymph node can
indicate metastasis from lung or esophageal cancer and Hodgkin’s lymphoma.
Lymphatic Drainage oftheHead andNeck (Fig.23.3)
Knowledge of the Lymphatic drainage of the Neck is of paramount importance in
Clinical Examination both the drainage areas and Lymphatic groups:
The Head and Face can be divided into wedges:
• The Central wedge: The Chin, most of the Lower Lip, Filtrum and center of the
upper Lip with underlying structures including Central incisors and Gum, ante-
rior central wedge of the palate and Floor of the mouth as well as the tip of the
tongue. They drain into the Submental Lymph Ns, which drains into the upper
deep cervical LNs.
• The Middle wedge: which starts between two lines; a line anteriorly; at a point
below made by the Facial artery on lower border of the mandible anterior to the
masseter muscle and ends high at the inner canthus of the Eye. Posteriorly; a line
23 Examination oftheHead andNeck
Fig. 23.3 Lymphatic
drainage of the head
and face
225
joining angle of the mandible to the external auditory meatus. It includes the
angle of the mouth, outer parts of upper and lower lips, the cheeks and nose. It
includes the wedge of the underlying tissues including the Canine teeth,
Premolars and Molars with their gums, Sides of the tongue and Floor of the
mouth, Sides of the palate as well as the Maxillary Sinus and Turbinate bones
with their mucosa. They drain into the Submandibular LNs which drains into the
upper deep Cervical Lymph nodes. Parotid gland, posterior face, anterior auricle,
and anterior scalp can drain rst to parotid lymph nodes then to upper deep cervi-
cal nodes.
• The posterior (Outer) wedge: the posterior scalp, posterior auricle and nape of
the neck drain rst to post auricular and occipital lymph nodes then to upper deep
cervical lymph nodes.
The Lymphatic System oftheNeck Is Arranged inThree Circles
andThree Vertical Chains (Fig.23.4)
Outer Circle: Submental, Submandibular, Parotid, Post auricular and Occipital LNs.
Inner Circle: Adenoids, Pharyngeal Tonsils, and Lingual Tonsils.
Middle Circle: Para-pharyngeal and Retropharyngeal LNs. (not clinically
accessible).
Anterior Chain: Pre-Laryngeal, Pre-tracheal and Suprasternal LNs.
Posterior Chain: Accessory group of LNs.