This document provides guidance on examining a patient's neck. It describes introducing yourself, cleaning hands, inspecting the neck from all sides, and palpating different lymph node levels. Specific instructions are given to examine the thyroid by having the patient swallow and assess voice. Red flags mentioned include a hard fixed mass, patient over 35, head/neck mucosal lesions, persistent hoarseness/dysphagia, trismus, or unilateral ear pain. Further assessments like blood tests, imaging, and biopsy are recommended depending on findings.

1. Examination of
the neck
Dr.Khalil Nasr Elkahlout
R3 ENT , Alshifa hospital

2. Introduction
• Introduce yourself and gain consent for examining the
patient’s neck
‘Hello, I am Dr Khalil . Would it be OK if I could
examine your neck and swallowing?’
• Clean your hands
• any pain in the neck
• Make sure the patient is away from the wall .

3. Inspection
• Inspect the neck from all sides.
• Adequately exposure to the clavicles.
• Look for any obvious masses, scars or radiotherapy changes , Cachexia ,
Dyspnoea or stridor , Behaviour, Clothing & Exophthalmos.
• Ask the patient to stick out their tongue (assess for midline lumps that
move with tongue protrusion, e.g. thyroglossal cyst).
• Ask the patient to take a sip of water, hold it in their mouth and swallow
on command. Assess for neck masses that move with swallowing (e.g.
thyroid masses).
• Assess the patient’s voice by asking them to count to 10.

12. Palpation
• Palpating the neck from behind.
• Start midline over the trachea and assess that it is central.
• Move up the trachea over the larynx and level 6 nodes.
Then palpate level 1 , move down levels 2, 3 and 4 and
palpate supraclavicular and infraclavicular nodes.
• Then up to level 5 until you reach the occipital nodes.
• Palpate post- and pre- auricularly and, finally, palpate the
parotid.

22. Continue Examination
• Examine the parotid duct (opposite the upper second molar) and
palpate the gland.
• It is also important to examine the facial nerve.
• Thank the patient and close by using the alcohol gel.
Any lump should be assessed for:
site, size and surface
Colour, contour and consistency
tenderness, temperature and transilluminability
pulsatility.

28. • If a mass is felt in the submandibular region then
attempt bimanual palpation of the gland through the
floor of the mouth.
• If a midline mass is felt, it is appropriate to take a
thyroid history and examination.
• Examine the patient’s hands for tremor, sweating,
palmar erythema, thyroid acropachy and clubbing.

35. Red flags
•A hard and fixed mass.
•The patient with the neck lump is over 35-years-old.
•The presence of a mucosal lesion in the head or neck.
•A history of persistent hoarseness or dysphagia.
•The presence of trismus.
•The presence of unilateral ear pain (referred from tongue
base).

36. Further assessments and investigations
• Thyroid status examination and thyroid function tests (TSH, T3, T4): if a
midline lump is present.
• Examination of the lymphoreticular system: if lymphoma or leukaemia is
suspected.
• Examination of oral cavity, oropharynx and nasal cavity: to exclude a
mucosal lesion.
• Routine blood tests such as FBC, U&Es, CRP: useful if considering infection
or malignancy.
• Ultrasound scan and other imaging (e.g. CT/MRI): to determine etiology.
• Fine needle aspiration: to allow histological diagnosis.

37. Thanks
any question ?