Head and Neck Examination

PREPARATION

  • Clean your hands

  • Prepare your equipment

  • Introduce yourself (full name and job) and confirm the patient’s identity

  • Explain you want to perform an examination of the neck, to include looking inside the mouth, feeling for any neck lumps and flexible nasolaryngoscopy

  • Check whether there is any pain in the head or neck

  • Obtain verbal consent

  • Position the patient: sitting upright and slightly away from the back of the chair allows full access to the neck

  • Ask the patient to remove any clothing obscuring the neck / undo top shirt button.

  • Check the patient's allergy status and, if using, spray local anaesthetic into the nose, providing an explanation and tissues

 

INSPECTION

Look at patient from the front and both sides.

In particular, note: 

  • Patient age, nutritional status, general condition.

  • Radiotherapy skin changes

  • Scars (collar; peri-auricular; neck dissection; skin excisions; flaps or grafts; tracheostomy or tracheal stoma)

  • Masses (size, colour, punctum, neck level location)

  • If a mass is in the anterior neck, have them take a sip of water, hold it in their mouth and watch for movement of the mass as they swallow on command. Test whether the mass moves on tongue protrusion

  • Functional/motor abnormalities (cranial nerve function; torticollis; trismus)

 

MOUTH EXAMINATION

  • Ideally use two Lack's tongue depressors and a headlight to examine the oral cavity.

  • Systematically examine all the buccal mucosa (pull the lips away from the teeth along their length)

  • Examine the tongue and its underside.

  • Examine the floor of mouth, hard and soft palate, retromolar trigone, tonsils, faucial pillars and posterior oropharyngeal wall.

  • Note the condition of teeth and gums – note any dental pain

  • Bimanually palpate the floor of mouth and cheeks, including salivary glands

  • Palpate the base of tongue / tonsils if able (warn the patient that they might gag)

 

PALPATION

  • Systematically swipe your fingertips gently from the midline to laterally, following the levels of the neck. Gently pull your fingertips under the anterior border of sternocleidomastoid as you palpate the lymph node areas.

  • Repeat swallow and tongue protrusion tests with palpation in an anterior neck mass.

  • Palpate the following areas systematically:

    • Lymph nodes in levels I to VI

    • Thyroid gland

    • Major salivary glands

    • Tracheal position

    • Presence of laryngeal crepitus

 Lump-specific features: Site, Size, Surface, Consistency, Contour, Colour, Tethering, Temperature, Transillumination, Tenderness, Punctum, Pulsatile

 

PERCUSSION

Percuss for retrosternal dullness if there is an anterior neck lump

 

AUSCULTATION

A bruit could indicate hyperthyroidism or carotid body tumour

 

OTOSCOPY

Perform otoscopy

 

FLEXIBLE NASOLARYNGOSCOPY

The head and neck examination is not complete without a fibreoptic examination of the upper aerodigestive tract.

If indicated, and if a speech and language therapist is present, you could jointly perform a flexible endoscopic examination of swallow (FEES).

 

OTHER EXAMINATIONS IF INDICATED

Full thyroid status examination

Examination of the chest

Cranial nerve examination (usually focused, e.g. IX-XII in possible paraganglioma)

 

POSSIBLE INVESTIGATIONS

Bedside tests: weight and nutritional status; swallowing; voice quality etc.

Blood tests: thyroid function; FBC, calcium status etc.

Radiology: MRI/CT/PET-CT as per MDT protocol for investigation of possible malignancy.  Ultrasound of palpable neck lumps with fine needle aspiration if indicated; barium swallow for dysphagia.

 

 

 Page last reviewed: 9 December 2019