Neck and Lymphatics Exam

Examination of the Neck and Lymphatics

• Examination of the neck and lymphatics, including history and physical exams, carotid stenosis recognition, anatomy of neck triangles, characteristics of lymph nodes, differential diagnosis, lymphatic exams of other areas, midline structure examinations, neck masses, and congenital neck masses should be understood

Order of Neck Exam

• Inspect the neck for lesions, masses, symmetry, and trachea alignment, with the neck slightly extended
• Range of motion assessment involves active and passive flexion, extension, side-bending, and rotation
• Auscultate the carotid arteries and thyroid gland for bruits using the bell of a stethoscope to identify possible carotid stenosis or thyroid abnormalities by asking the patient to hold their breath
• Palpate anterior structures while taking carotid bruit into account, potentially dislodging plaque, beginning with the hyoid bone, thyroid notch, thyroid and cricoid cartilages, tracheal position, thyroid gland by having the patient swallow, and then the carotid arteries one at a time
• Lymphatic palpation should encompass the cervical and head areas
• Cover the patient with a sheet when examining the axillary, epitrochlear, and inguinal regions and also inspect and palpate the posterior neck for lesions, masses, cervical spinous, paraspinal muscles, and transverse processes, assisting patients during the exam, always covering them with a sheet

Carotid Bruit

• Carotid bruits manifest as swishing sounds during auscultation, indicative of carotid artery stenosis, AV malformation, carotid body tumor, or aneurysm
• Thyroid gland bruits suggest toxic multinodular goiter or Grave's disease
• Stenosis less than 40% diameter is unlikely to produce an audible bruit if the stenosis is greater than 90%, flow may be too low to be heard
• A palpable thrill may accompany the bruit
• Detecting bruits occurs incidentally in asymptomatic patients
• It is essential to auscultate before palpating the carotid to prevent dislodging plaque
• Use of the bell of the stethoscope is key to distinguish it
• Best area to auscultate; palpate carotid artery is medial to the top half of the sternocleidomastoid muscle, as the SCM covers the inferior aspect of the carotid

Internal Jugular Vein (IJV) vs. Carotid Artery Pulsations

• Internal jugular vein pulsations are rarely palpable, soft, and rapid pulsations
• Pulsations disappear with light pressure and can be felt changing level with position and usually descends with inspiration
• Carotid artery pulsations are palpable, yielding a vigorous thrust in a single outward component
• Pulsations persist despite pressure, remain unchanged by position and unnafected by inspiration

History, Symptoms, and Signs Related to Neck

• Neck stiffness can originate from overuse, posture, sleep position, spasms, or torticollis
• Neck pain assessment should include onset, trauma, duration, location, severity, quality, and other factors
• Neck pain can be due to infections (tonsillitis, laryngitis, pharyngitis), or bone/joint issues (degenerative spine disease, herniated disc, arthritis), or referred pain from myocardial infarction/angina
• Patients should be asked to pinpoint precise pain location for further examination

Neck Mass - Differential Diagnosis

Neck masses can have wide range of causes:

• Inflammatory
• Infectious
• Congenital
• Neoplastic
• Traumatic

Features of Lymph Nodes

Nine criteria characterize lymph nodes:

• Size normally, less than 1 cm, except in the inguinal area, where less than 2 cm is normal
• Shape round or oval
• Note surface qualities for erythema and warmth use the back of your fingers for this
• Check for lymph node site or location
• Symptoms like tenderness
• Soft, hard, or fluctuant
• Determine stuck/fixed mobility
• Spread/location
• Sensations

Lymph Nodes and Neck Masses

• Investigate history of ear/sinus/skin to find the cause for any neck node/mass, as well as drug use (phenytoin/Dilantin) for nodal hyperplasia, and IVDA for hepatitis/HIV risks
• Family history of thyroid or radiation exposure to the neck must be noted for malignancy suspicions
• Salivary gland duct obstruction is characterized by an increase in size while eating
• Harder, non-tender, discreet fixed nodes are more likely to be malignant
• Rapid enlargement without inflammation could suggest malignancy versus slow enlargement that suggests benign process
• Lack of enlargement should suggest a benign/congenital mass

Lymph nodes are more related to certain information:

• Matted lymph nodes: tuberculosis
• Enlarged, firm lymph nodes: lymphoma
• Hoarseness: recurrent laryngeal nerve damage, tumor, infection
• Small, mobile nodes: normal
• Enlarged nodes in children: cold virus
• Nodes don't pulsate (arteries do)

Differential Diagnosis of Lymphadenopathy

• Lymphadenopathy etiologies: bacterial, viral, malignancy, parasitic, immune, inflammatory, drugs
• Bacterial causes can be staph, strep, gram negative, or mixed
• Viral causes can be EBV, Herpes Simplex, HIV, COVID, rhinovirus, or influenza
• Parasitic causes are related to toxoplasmosis from cats and ticks
• Drugs such as phenytoin are often the cause

Testing for Lymphadenopathy/Abscess/Mass

To test for related items, consider the following:

• Imaging
• Labs CBC
• Invasive Method via Needle

Additionally:

• Get cultures if infection may be underway
• With respect to resistant organisms, be sure to test and determine the type for treatment

Physical Examination of Neck

In the neck, be sure to inspect and palpate and:

• Head/facial structure
• Masses/lesions/scars/fullness
• Sternocleidomastoid
• Anterior and posterior triangles
• View of thyroid and cricoid while swallowing

Also note:

• Normal thyroid/trachea; extend neck if obscured
• Note any distention or deviation

Common Neck deformities:

• Torticollis
• Webbed Neck
• Brevicollis

Anatomy of the Neck

• Sternocleidomastoid divides neck into two triangles
• Anterior Triangle: bounded by-mandible above, laterally by SCM, medially midline of neck
• Posterior Triangle: extends back from SCM, to trapezius, bounded inferiorly by the clavicle.
• Omohyoid Muscle crosses lower portion of the triangle- can be mistaken for mass

Lymph Node Chain Overview

• Preauricular nodes drain skin
• Submandibular drain oral cavity
• Supraclavicular drain GI Tract, pulmonary
• Deep cervical nodes are located paratracheal and anterior Jugular
• Infraclavicular nodes assist drainage of breast cancer

Physical Examination of Neck

• Utilize light palpation unless otherwise noted or suspected
• With slight head flexion
• Use fingertips in a circular pattern
• Use multiple fingers, avoid single finger approach
• Nodes highly variable
• Perform thorough exams to assess specific conditions

Palpate in sequence:

• Anterior auricular
• Posterior Auricular
• Occipital
• Prepartoid
• Submandibular
• Submental
• Anterior/Posterior Cervical
• Supraclavicular
• Infraclavicular

Masses of the Neck

• Lymph nodes can be rubbery and hard
• Lipoma soft and slow growing
• Sebaceous and dermoid cysts may also contribute to the formation of neck masses

Lymph Node Distinctions

• The difference between lymphadenitis and lymphangitis

Infection caused by lymph glands is described as:

• Bacterial
• Swelling with potential drainage
• Firm/Tender (Lymphadenitis)
• Red Streaks (Lymphangitis)

Further masses in this region can be due to :

• Tumors, both primary and secondary

Vocal Tumors

Masses/ Lumps in node can be related to:

• Vocal Tumors causing primary or secondary tumors

Additionally:

• Supraclavicular Lymph Nodes are found in the area
• Virchow's Node, is a primary node of concern:
• Trouiser's Sign located to the left as well

Pancoast Tumor

• A tumor related to the pulmonary apex
• Has risk of metastasis
• Can be benign/malignant

It is important to note:

• Those affected may develop Horner's syndrome

Axillary Exam

• Palpate the high axilla with full underarm down
• Wear gloves as part of your safety

Exam of Axillary Nodes

• Don gloves
• Palpate axilla with arm up or down
• Examine from all directions

Other Lymphatic Exam Sites

• Exam of Epitrochlear and Inguinal for exam

Other Lymphatic Exam Sites

• Epitrochlear Lymph Nodes are related to the upper lib and elbow
• Lymphatic drainage of the upper lib

Other Lymphatic Exam Sites

• Inguinal Lymph Nodes often tied to infection
• HIV, EBV for examples

Midline Structures, Neck

• Key structures include: -Hyoid bone -Thyroid cartilage -Cricoid cartilage -Cricothyroid membrane (crucial landmark) -Thyroid gland (above suprasternal notch), with the isthmus -Tracheal rings

Thyroid and Airway Consideration

• It is integral the anatomy and position are considered
• Extend up the neck to asses thyroid
• Isthmus location varies, ensure it is in a proper position
• Ensure cricoid is palpable

Fractured Hyoid

• Only bone not connected
• Supported by muscles ligaments
• Fractured hyoid is strangulation marker

Palpation Guide

Be mindful of position and approach:

• Auscultate first
• Gently use fingers along both sides
• Assess spaces
• Masses affect position

Examination Notes for Tracheal Shift

• Tracheal shifts related to lungs
  • Towards problems means decrease of pressure
  • Aways from lung equals increased pressure - From tumor, effusion with a shift