Chapter 11: Head & Neck

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Welcome back to the Deep Dive.

We are back in the library, back with the books, and today we are tackling a region of the body that is quite literally the face of the matter.

It really is.

We are pulling apart chapter 11 of Bates Guide to Physical Examination and History -Taking, the 13th edition.

A critical chapter.

We're looking at the head and neck.

The head and neck.

And, you know, it sounds simple enough, but as soon as you open the pages you realize this is some of the most high stakes real estate in the human body.

Oh, absolutely.

We aren't just talking about a skull and some skin here.

We're talking about the gateway to the respiratory system, the digestive system.

The endocrine system, the central nervous system.

It's all right there.

It's a major intersection.

It is.

It's a dense, complex area.

And honestly, it's where a lot of systemic diseases first reveal themselves.

You know, you look at a patient's face or you feel their neck and suddenly you have a clue about their kidneys or their heart or their hormonal balance.

So it's diagnostic gold.

It's absolute diagnostic gold.

So for everyone listening, let's just sort of set the stage.

Our mission today is very specific.

We're going to act as your audio guides through this one chapter of Bates.

I'm going to play the role of the curious learner, the student who wants to understand not just the what, but the how and the why.

And I'll be here as the clinical mentor.

My goal is to help you navigate the text, to help you interpret the diagrams and really understand the clinical reasoning that turns a physical exam from just a checklist into a powerful diagnostic tool.

We want you to walk away from this deep dive with a real mastery of the anatomy, the history taking, the physical skills, and importantly, the health promotion guidelines specific to the head and neck.

Okay.

Before we enroll the anatomy map, I want to address something that I think confuses a lot of students right off the bat.

In clinical rotations or even in other textbooks, you almost always hear the acronym HEAT.

Head, eyes, ears, nose, throat.

Right.

The HEAT exam.

It's always grouped together as this one giant unit.

But in Bates, and for our deep dive today, we're separating the head and neck from the eyes, ears, nose, and throat.

Why do we do that?

Why the split?

Well, it's a very deliberate choice.

Clinically, you are absolutely right.

They are a functional unit.

Yeah.

They feel connected.

Of course.

The anatomy is proximal.

The symptoms overlap.

A sinus infection can cause a headache and swollen neck nodes.

But for the purpose of learning physical assessment, trying to tackle the intricate cranial nerve testing of the eyes or the internal exam of the ear at the same time as the thyroid and lymphatics, it's just cognitive overload.

This is too much at once.

It's way too much at once.

So for this chapter, what we do is we isolate the head and neck to focus on the structural foundation.

We're basically building the frame of the house before we start installing the complex windows and wiring of the sensory organs.

Oh, I like that analogy.

Master the container before you master the contents.

Exactly.

We need to master the skull, the geography of the neck triangles, the lymph nodes, and the thyroid gland first.

Then we can move on.

That makes perfect sense.

Okay.

So here's our agenda for this deep dive.

We're going to follow the chapter structure exactly.

So you can follow along if you have the book.

We'll start with section one, anatomy and physiology, the roadmap.

The foundation.

Then we'll do a deep dive into section two, the lymphatic system, which is just huge in this region.

Then section three, the health history.

What questions do we ask?

That's right.

Sections four, five, and six will be the physical examination itself.

Head, nodes, and trachea thyroid.

Then we'll hit section seven, recording findings.

And we'll wrap up with section eight,

health promotion and counseling.

It's a comprehensive plan.

Let's get into it.

Let's get started with the roadmap, the head.

And I don't just mean the brain inside it.

I mean the skull itself.

Bait starts by orienting us to the regions of the head.

Right.

And this might feel basic, but your documentation, your ability to communicate with other clinicians, it all depends on this.

You can't just write, patient has a bump on their head.

No, that's not going to fly.

Not at all.

You need to be precise.

And the regions of the head are named after the underlying bones of the skull.

It's pretty logical.

So we have the frontal region.

Correct.

That's the forehead area overlying the frontal bone.

The parietal region.

That's the top and the upper sides of the head.

The temporal region.

The sides right near your temple.

And then wrapping around the back, the occipital region.

Exactly.

The back of the head all the way down to the base of the skull.

So knowing these regions allows us to create a kind of mental grid of the head.

If you find a lesion, a mass, a scar, you map it to these bony landmarks, a two centimeter laceration in the right parietal region.

It's a common language.

It is the common language.

Now overlaying this bony grid, we have some important soft tissue structures.

Specifically, Bates highlights the salivary glands.

There are two paired glands he wants us to know for the head and neck exam.

Yes.

And the salivary glands are essential.

The first one is the parotid gland.

This is the big one, the largest of the salivary glands.

And where exactly does it sit?

I feel like this one's a little tricky to visualize.

It lies superficial to so on top of and behind the mandible or the jawbone.

It's located just in front of the ear.

But here's the critical clinical point you have to remember.

In a healthy person, the parotid gland is essentially invisible and usually not palpable.

So if I can see it, that's a problem.

Generally, yes.

That's an abnormal finding.

If the parotid gland is enlarged, it becomes visible as a swelling anterior to the ear and above the angle of the jaw.

Like with the mumps.

That's the classic example.

You might know this from seeing pictures of children with mumps or adults with certain tumors or inflammatory conditions.

That swelling is the enlarged parotid.

And Bates mentions a duct associated with this gland.

Yes, the parotid duct, which is also known as the Stenson duct.

It runs forward from the gland and opens up inside the cheek in the buccal mucosa, usually opposite the second upper molar.

So we check that opening when we do the mouth exam, but the gland itself is examined from the outside.

Okay, then we have the second gland, the submandibular gland.

Now, this one seems to cause more confusion for students during palpation.

It does because of its location and what's around it.

The submandibular gland is located deep to the mandible.

It's tucked up underneath the jawbone.

Right.

And Bates gives this very specific instruction on how to locate it, or at least how to be sure that's what you're feeling.

It involves the patient's tongue.

Yes, this is a fantastic maneuver, a great clinical pearl.

If you're palpating under the jaw and you aren't sure what you're feeling, is it a node?

Is it a gland?

Is it a muscle?

You ask the patient to press the tip of their tongue against their lower incisors.

So just push hard against the back of the bottom front teeth.

Yes.

When they do that, the muscles on the floor of the mouth contract and they tighten up.

If you have your fingers placed correctly under the mandible, that muscle contraction actually pushes the lobular surface of the submandibular gland down against your hand.

And what does it feel like?

What's the texture?

It feels lobular,

irregular, not smooth.

Think of a cluster of small grapes or a bumpy surface.

And why is it so important to know that specific texture?

Because a very, very common error for students is mistaking the submandibular gland for a swollen lymph node.

And they feel very different.

Lymph nodes, even when swollen, tend to be rounder and smoother.

The gland is lobulated.

So if you feel that lumpy texture, especially when the patient tenses their tongue, you can be confident you're on the gland and not a node.

Being able to distinguish the two is a key skill.

Got it.

One last structure on the head before we move down the neck, the temporal artery.

Another crucial vascular landmark.

The superficial temporal artery passes upward just in front of the ear.

So if I put my finger right in front of the tragus of my ear, that little bump of cartilage, I can feel a pulse there.

You should be able to, yes.

You can feel a pulse there.

And in many people, specifically thinner patients or the elderly, you can actually trace the course of the artery as it winds its way across the forehead.

It can look quite torturous, kind of snake -like under the skin.

And clinically, why are we palpating this?

Is it just to check for a pulse?

No, it's more specific than that.

We palpate this if we suspect something called temporal arteritis or giant spell arteritis.

So if a patient comes in with a new headache, maybe some vision changes, and that artery feels tender, hard, or thickened when you palpate it, that raises some serious red flags for temporal arteritis, which is a medical emergency.

So knowing where it lives is really important.

Wow.

Okay, let's move down to the neck.

The geography here gets a little more complex.

Bates talks about triangles, and it feels like we're back in geometry class, but it seems like a really useful way to map a very crowded area.

It is the only way to map the neck accurately.

The neck is just packed with vessels, nerves, glands, muscles.

To navigate it, we use the major muscles as borders.

And the key landmark here, the structure that defines everything, is the sternocleidomastoid muscle.

The SCM.

We call it the SCM.

That's that big strap muscle that pops out when you turn your head, right?

From your ear down to your collarbone.

Exactly.

It runs diagonally from the sternum and clavicle up to the mastoid process, that bone behind the ear.

That single muscle divides the entire side of the neck into two distinct triangles, the anterior triangle and the posterior triangle.

Let's define the borders of those triangles really strictly, because this matters for where we look for specific lymph nodes and other structures.

Let's start with the anterior triangle.

Okay, the anterior triangle is the space in front of the SCM.

So the borders are the mandible, the jaw on top.

It's the superior border.

Correct.

The SCM forms the lateral border, and the midline of the neck is the medial border.

So it's kind of the front yard of the neck.

That's a great way to think of it, yes.

And it contains the trachea, the thyroid gland, the carotid artery, and the anterior lymph nodes.

All the midline structures are in there.

And the posterior triangle.

That is the space behind the SCM.

So the borders are the SCM muscle in the front.

The anterior border of that triangle.

Correct.

The trapezius muscle, that big muscle on top of your shoulder, forms the back border.

And the clavicle, your collarbone, is the bottom.

So SCM is the fence between the front and back yards.

That is a perfect analogy.

It is the fence.

And there's a really important cautionary note in the text about the posterior triangle that we should mention.

Deep in this triangle, running across the bottom of it, is a small muscle called the omohyode muscle.

And why does Bates flag the omohyode?

What's the trap here?

The trap is that if you're palpating deeply in the posterior triangle, you might feel this little muscle belly and mistake it for a lymph node or some kind of mass.

Another look -alike.

It's another look -alike.

It's another instance of know your normal anatomy so you don't panic or misdiagnose something that's supposed to be there.

That makes sense.

Okay.

Now, deep underneath that big SCM muscle, we have the heavy hitters, the great vessels.

Yes.

The carotid artery and the internal jugular vein.

They run deep to the SCM so they're protected by it.

You usually can't see the internal jugular vein directly, although you can sometimes see its pulsations transmitted through the skin.

We discuss that extensively in the cardiovascular chapters when we talk about jugular venous pressure or JVP.

But there is a jugular vein we can see on the surface, right?

Yes.

The external jugular vein.

It runs superficially to the SCM, crossing it diagonally from the angle of the jaw down toward the clavicle.

It's a very helpful landmark for identifying venous pressure, especially if it's distended.

Okay.

Let's travel down the midline of the neck.

Bates calls this section the midline structures.

And I like to think of it as a ladder.

If I start at the chin and just walk my fingers down the center of the throat, what structures am I hitting and in what order?

Let's walk down that ladder.

This is a crucial sequence for the thyroid exam.

First, just below and deep to the mandible, you'll find the hyoid bone.

And that's the one that's not connected to any other bone, right?

It just floats.

It's the only one.

It's a floating bone held in place by muscle, so it's very mobile when you palpate it.

Okay.

Next rung down.

The thyroid cartilage.

This is what we commonly call the Adam's apple.

It's much more prominent in men, but it's there in everyone.

It's shield -shaped, and you can identify it really easily by the V -shaped notch on its superior edge.

You can feel that notch right now.

Okay.

I feel the notch moving down from there.

Right below the thyroid cartilage is the cricoid cartilage.

It feels different.

It feels like a solid, complete ring.

And below the cricoid.

Now you're on the tracheal rings, the windpipe itself.

You can feel those C -shaped cartilaginous rings.

And then spanning across those rings, usually around the second, third, and fourth tracheal rings, is the thyroid gland itself.

Specifically,

the isthmus, the thyroid.

Okay.

The thyroid gland is a major star of this chapter.

We're going to spend a lot of time on the exam technique later on, but just anatomically, let's visualize it.

It's not just a single button.

It has a very specific shape.

Yes.

It's shaped like a butterfly or a shield.

The body of the butterfly is the isthmus, which crosses the midline over the trachea.

The wings are the lateral lobes.

And how big are those lobes?

They're about four to five centimeters long, and they curve posteriorly around the sides of the trachea and the esophagus.

Now they're just sitting there right under the skin, easy to feel.

Not quite.

The isthmus is usually palpable, but the lateral lobes are covered by these thin strap -like muscles, and more laterally, by that big SEM muscle we talked about.

Ah, so the SEM covers the lobes.

It does.

So when you're palpating the lobes of the thyroid, you're actually feeling through those muscle layers, which is why it can be so challenging and why technique is so important.

That explains why the exam requires so much finesse.

Okay, that's our roadmap.

We have the skull regions, the glands, the triangles, the vessels, and the midline ladder.

Now we need to move to section two, the lymphatic system of the head and neck.

This is arguably one of the most important systems to master in this region for general practice.

The lymph nodes are the sentinels.

They drain fluid from the mouth, the throat, the face, the scalp.

They are the first line of defense and often the very first sign of trouble.

Right, and Bates provides a clinical pearl regarding drainage that I think really frames this entire section.

What is the golden rule of lymph node assessment?

The rule is this.

Downstream tells you about upstream.

Okay, what does that mean?

It means if you find a node that is enlarged or tender or hard, you have to play detective.

You can't just stop there.

You need to look for the source of the infection or the malignancy in the area that that specific node drains.

So if I find a swollen node, I shouldn't just stare at the node.

I should be looking at where the fluid is coming from.

Exactly.

For example, the submental nodes, the ones right under the chin, they drain the floor of the mouth and the front teeth.

So if they're swollen, check the teeth, check the gums, check the tongue.

Don't just document a swollen node and move on.

You have to look for the cause.

The node is the clue, not the final answer.

I love that.

The node is the clue.

Okay, baseless 10, yes, 10 groups of lymph nodes we need to know.

Figure 11 to 8 in the text visualizes these really well.

I want to walk through these geographically so the listener can visualize them on their own neck.

Let's do the node tour.

All right, let's do the tour.

Stop number one on our tour.

Submental nodes.

These are midline, just a few centimeters behind the tip of the mandible, right under the point of your chin.

Stop number two.

Submandibular nodes.

These are about midway between the angle of the jaw and the tip of the chin along the underside of the jawbone.

And remember, these sit right on top of that submandibular gland we talked about.

This is where you have to use your palpation skills to distinguish the smooth round node from the lumpy lobular gland.

Right.

Stop number three.

Pre -auricular nodes.

Pre means before, auricular means ear.

So these are right in front of the ear.

Simple enough.

Stop number four.

Posterior auricular nodes.

And post means behind, so behind the ear.

They are superficial to the mastoid process, that big bony bump you can feel behind your earlobe.

Stop number five.

Tonsillar nodes.

Bates also calls these the jugulodogastric nodes.

This is a big one.

It's located right at the angle of the mandible, the corner of your jaw.

When people say, my glands are swollen because they have a sore throat, this is usually the spot they are pointing to.

It drains the tonsils.

Okay.

Stop number six.

Occipital nodes.

These are way back at the base of the skull, posteriorly, in the occipital region.

Now we move down into the neck proper.

Stop number seven.

Anterior superficial cervical nodes.

These lie on top of superficial to that big SCM muscle.

And stop number eight.

Posterior cervical nodes.

These are located along the anterior edge of the trapezius muscle, so they are located in that posterior triangle area we defined earlier.

Okay.

Stop number nine.

The deep cervical chain.

This sounds ominous.

Well, they're just tricky.

They are deep to the SCM muscle, so they are often inaccessible to simple, light palpation, because they're buried under that big muscle belly.

You have to hook your fingers around the muscle to even have a chance of feeling them.

Okay.

And finally, stop number 10.

The supraclavicular nodes.

These are deep in the angle that's formed by the clavicle, your collarbone, and the SCM muscle, right in that little hollow.

Now Bates puts a major warning sign, a huge red flag on these supraclavicular nodes.

Why are they so critically important?

Because of where they drain from.

The lymphatic drainage pattern changes dramatically here, especially on the left side.

An enlarged left supraclavicular node has a special name.

It's called Virchow's node.

Virchow's node.

And finding it suggests metastasis from a thoracic or an abdominal malignancy.

Whoa.

Hang on.

So a lump near my collarbone could indicate cancer in my stomach or my lungs?

Yes.

The lymphatic drainage from the thorax in the abdomen eventually routes up the thoracic duct, which empties into the venous circulation right in that area.

So finding a hard fixed node there is a major red flag that warrants an immediate, thorough investigation.

It's a distant signal of a very central problem.

That is such a powerful example of why we learn anatomy to connect those distant dots.

Okay.

We have the map.

Now let's talk to the patient.

Section three, the health history.

The general approach here when you're taking a history for the head and neck is to remember that the symptoms often involve major structures, sensory organs, cranial nerves, big vessels.

Our job is to distinguish the common benign processes, like a viral upper respiratory infection from a serious underlying disease.

Let's start with the most common symptom,

a neck mass or lump.

What is the first thing we need to know about asking this question?

It's all about terminology.

Patients don't usually say, excuse me, doctor.

My anterior cervical lymph nodes are enlarged and tender.

Laughing, laughing.

No, they use lay terms.

They'll say I have swollen glands or I found a lump in my neck.

So we have to use their language.

We ask, have you noticed any new lumps or swollen glands anywhere?

Right.

And then once they say yes, we drill down with our classic oldy cart style questions.

When did you first notice it?

How did you notice it?

Does it hurt?

Has it grown or changed in size?

And you want to ask about associated symptoms too.

Absolutely.

And here's a critical functional question.

Does this lump interfere with your swallowing or your breathing?

Dysphagia or dyspnea.

Exactly.

That tells us about potential compression.

If a mass is pressing on the esophagus or the trachea, that elevates the urgency immediately.

That's a much bigger problem.

Is there a red flag for neck masses that's based on age?

There is.

And it's a really good rule of thumb to keep in your head.

A persistent neck mass in an adult who's older than 40 years should raise your suspicion for malignancy until proven otherwise.

In a child or a young adult, neck masses are very, very often just reactive lymph nodes from infections, strep throat, mono, things like that.

But in an adult over 40, you have to rule out cancer first.

Okay.

That's sobering, but very important.

The second major symptom category that Bates focuses on is the thyroid.

Any mass, nodule, or goiter.

And this is really interesting because the thyroid regulates metabolism for the entire body.

So the symptoms aren't just local lumps in the neck.

They're systemic.

They affect the whole body's thermostat and energy levels.

So I had to ask about temperature.

Yes, exactly.

We assess the thyroid's function by asking about temperature intolerance and sweating.

If your thyroid is under active hypothyroidism, your metabolism is slow.

You aren't generating enough heat.

So you feel cold when everyone else in the room is perfectly comfortable.

So the question to the patient is something like, do you find you have to dress more warmly than other people?

Do you use more blankets at night?

Exactly.

Or have you noticed any changes in the texture of your skin?

Is it drier than it used to be?

Has your hair become coarser or more brittle?

These are all clues.

Bates has a fantastic table, table 11 to 1, that clusters all these symptoms together.

Let's break down the classic presentation for hypothyroidism first.

Okay.

For hypothyroidism, think slow and cold.

Slow and cold.

Intolerance to cold.

Weight gain, sometimes even with a loss of appetite, which is very strange.

Dry,

rough, pale skin.

A slowed heart rate, which we call bradycardia.

Coarse, brittle hair.

Fatigue.

Lethargy.

Constipation.

You might also see swelling of the face and hands.

Everything is slowing down.

And then the flip side, hyperthyroidism.

The exact opposite.

Think fast and hot.

Fast and hot.

Intolerance to heat.

They're always sweating.

Weight loss.

Despite an increased appetite, they're eating all the time but losing weight.

Their skin is moist, velvety, and warm.

They have palpitations or a rapid heart rate.

Fine, silky hair.

They feel nervous, anxious, irritable.

They might have a tremor.

Frequent bowel movements.

Everything is sped up.

It really is a perfect mirror image of hypothyroidism.

It is.

But Bates has a really important nuance here, especially regarding aging.

Bates reminds us that older adults naturally sweat less and tolerate cold less than younger adults.

So if an 80 -year -old patient complains of being cold, don't automatically jump to a diagnosis of hypothyroidism, it could just be normal physiology for their age.

Context is everything.

You have to look at the whole cluster of symptoms, not just one isolated complaint.

Right.

All right, we've taken the history.

Now we wash our hands and we start the physical examination.

Section four.

Physical examination of the head, face, and skin.

And the very first step is proper preparation.

You cannot examine the neck if the patient is wearing a turtleneck, a scarf, or a high collared shirt.

The neck must be fully visible all the way down to the clavicles.

Okay, proper exposure.

We start at the very top.

The hair.

We inspect the quantity, the distribution, and the texture.

And this connects directly back to the history we just took about the thyroid.

Fine, silky hair can be a sign of

hypothyroidism.

Coarse, dry, brittle hair can be a sign of hypothyroidism.

And we're also looking for a stitch.

Yes.

You're looking for knits.

Tiny white ovoid granules that adhere tightly to the hair shaft.

Those are the eggs of head lice.

And you need to be able to distinguish them from dandruff, which just flakes off easily.

Knits are stuck on there.

Then we move to the scalp itself.

Bates says we have to actually part the hair in several places.

You can't just look at the hair.

You have to look at the skin underneath it.

Part the hair and look for scaliness, which could be seborrheic, pneumatitis, or psoriasis.

Look for lumps.

Pellar cysts are common.

And critically, look for pigmented nevi, or moles.

To check for melanoma.

Absolutely.

Melanoma can hide on the scalp.

And because it's covered by hair, patients often don't see it themselves, so it's part of our job to do a thorough check.

Good point.

Then we examine the skull.

You observe the general size and contour.

Is it symmetric?

Is it deformed?

Is there a depression from an old trauma?

You can gently palpate.

Is it tender anywhere?

An enlarged skull, for example, could suggest something like hydrocephalus or pageant disease of the bone.

Okay, now the face.

We're inspecting expression, contours, asymmetry, and eodema.

And Bates has this incredible section on selected facies.

These are facial appearances that are really characteristic of specific diseases.

Let's run through table 11 to 2, because these are classic spot diagnoses.

They really are.

These are patterns that once you see them a few times, you'll recognize them instantly for the rest of your career.

First one on the list, Cushing syndrome.

This is associated with increased adrenal cortisol production.

The face becomes very round.

It's often called a moon face.

The cheeks are red, and there's often excessive hair growth or hirsutism in the mustache area, the sideburn areas, and on the chin in women.

Second, nephrotic syndrome.

This is a kidney issue, right?

A serious kidney issue where you're losing a lot of protein.

The face becomes edematous, puffy, and often very pale.

The swelling usually appears first around the eyes and is characteristically worse in the morning after they've been lying down all night.

When it's severe, the eyes can appear slit -like.

Third on the list, mixed edema.

And this is severe hypothyroidism.

Yes.

This is what happens when hypothyroidism goes untreated for a long time.

You see a dull, puffy face.

The edema is often pronounced around the eyes, but it's a non -pitting edema.

The skin is dry and thickened, and a classic sign that Bates mentions is the loss of the lateral third of the eyebrows.

The outer part of the eyebrows just

disappear.

It just thins out and disappears.

It's a very specific and helpful sign for mixed edema.

Wow.

Okay, what about parotid enlargement?

We talked about the gland earlier.

If it's enlarged from mumps or sometimes obesity, diabetes, or cirrhosis, you'll see these swellings anterior to the earlobes and above the angles of the jaw.

It makes the face look wider at the bottom.

Then we have acromegaly.

This is from increased growth hormone, usually from a pituitary tumor.

The head becomes elongated.

There's a bony prominence of the forehead, the nose, and the lower jaw.

The soft tissues of the nose, lips, and ears also enlarge.

The facial features appear generally coarsened over time.

Then finally, Parkinson's disease.

This is linked to a loss of dopamine in the brain.

You see a decreased facial mobility, which leads to what we call a mask -like facies.

No expression.

Very little expression.

There's decreased blinking and a characteristic stare.

Since the neck and trunk tend to flex forward, the patient often seems to be peering upward toward the observer.

The skin may also be oily, and they can drool.

It's just amazing how much the face can tell you before you even touch the patient.

But now we do touch...

Section 5.

Physical examination of the lymph nodes.

This is such a high -yield skill, but it absolutely requires the correct technique.

Bates is very specific here.

You want to use the pads of your index and middle fingers.

Not the tips.

Not the tips.

The tips can be too sharp, too pokey.

You want the pads.

And the motion.

What's the motion we're using?

A gentle rotary motion.

You're trying to move the skin over the underlying tissues.

You aren't just sliding your fingers over the skin.

You're trying to roll the underlying structures against the deeper muscles and bones.

That's how you'll feel.

A small node.

And the patient's position is important here, too.

Very important.

The patient should be relaxed, with their neck flexed slightly forward.

And if you're examining one side, let's say the right side, you can ask them to turn their head slightly toward that side.

Toward the side you're examining?

Yes.

That relaxes the SCM muscle on that side, making it much easier to feel the nodes that are deep to it.

Okay.

And we go through the 10 groups we mapped out earlier.

Is there a specific sequence we should follow?

Bates suggests a logical sequence just to ensure you don't miss any groups.

Usually you start with submental, then subendibular, then up to the tonsillar, pre and posterior, occipital, and then you work your way down the cervical chains to the supraclavicular nodes.

And for that deep cervical chain, you really have to hook your fingers around the SCM muscle to find them, right?

You do.

You have to be a little more aggressive, gently, to get underneath that muscle belly.

Okay.

So this is the million dollar question.

What are we feeling for?

What distinguishes a normal lymph node from a problematic one?

Great question.

We describe any node we find by its size, shape, delimitation, meaning is it a single discrete node, or are they matted together?

Its mobility, its consistency, and its tenderness.

Let's start with normal.

What does a normal healthy lymph node feel like?

Small, mobile, discrete, and non -tender.

These are frequently found in normal people, especially in the neck.

We sometimes call them shoddy nodes, like small BB pellets or buckshot under the skin.

They're just signs of past battles with germs.

And what are the characteristics of an abnormal node?

Well, tender nodes suggest inflammation or infection, hard or fixed nodes, meaning they feel like a rock and they're stuck to the underlying tissues, you can't move them around.

That suggests malignancy.

Matted nodes also raise concern for malignancy or something like tuberculosis.

Okay.

There's a great troubleshooting tip in the text.

Sometimes you feel a band of muscle or an artery and you think, wait, is this a lymph node?

How do you tell the difference?

This is the roll test.

It's a great little trick.

You can roll a lymph node in two directions, up and down, and then side to side.

Like a little marble under the skin.

Exactly.

Neither a muscle nor an artery will pass this test.

You can't roll a muscle cross grain easily in the same way.

It won't move in two planes like that.

That is a great practical tip.

If it rolls, it's likely a node.

Okay.

Moving on to section six, physical examination of the trachea and the thyroid.

We start with the trachea, we inspect, and then we palpate for any deviation from its usual midline position.

How do we check for that?

You can place your finger along one side of the trachea and note the space between it and the SCM muscle.

Then you compare it with the space on the other side.

The spaces should be symmetric.

And if it's not, if the trachea feels like it's pushed over to one side.

That's a significant finding.

It suggests a mass in the neck or, more commonly, something significant happening in the thorax.

A mediastinal mass, atelectasis, which is a collapsed lung or a large pneumothorax, can either push or pull the trachea to one side.

And we also listen to the trachea.

We auscultate it.

Yes.

You can hear breath sounds over the trachea, but specifically, we are listening for stridor.

And what is stridor?

It is an ominous, high -pitched musical sound, usually heard on inspiration.

It indicates severe sublotic or tracheal obstruction.

If you hear this, it signals a respiratory emergency.

It means the airway is closing up and you need to act fast.

Okay.

Now for the main event of the neck physical exam,

the thyroid gland.

This is notoriously one of the most difficult physical exam skills for students to master.

It is.

It really requires practice and finesse.

We start, as always, with inspection.

You want to tip the patient's head back slightly and use tangential lighting.

So shine a light from the side or directed downward from the tip of the chin.

This helps highlight any subtle shadows and contours of the gland that might be visible just below the cricoid cartilage.

And then the famous swallow test.

This is the key to inspection.

You hand the patient a cup of water.

You ask them to take a sip and hold it in their mouth.

Then ask them to extend their neck back just slightly and swallow.

And you watch the midline of their neck very closely as they do.

What should we see happening?

You should see the thyroid cartilage, the cricoid cartilage, and the thyroid gland all rise with the act of swallowing and then fall back down to their resting positions.

Why do they all move together like that?

Because the thyroid gland is tethered to the trachea and the larynx, that connective tissue.

So when the swallowing mechanism lifts the larynx up, the thyroid has to go along for the ride.

And if there is a goiter, an enlarged gland, or a prominent nodule, you might see it pop out or see an asymmetry as it moves upward.

It makes it more visible.

It accentuates it, exactly.

Okay, then we palpate.

Bates describes two main approaches.

The posterior approach and the anterior approach.

Let's describe the posterior approach first as it's very commonly used.

For the posterior approach, you stand behind the seated patient.

You ask them to flex their neck forward just slightly to relax those SCM muscles.

Then you place the fingers of both of your hands on the patient's neck so that your index fingers are just below the cricoid cartilage.

And then you ask them to swallow again while your fingers are there.

Yes.

As they swallow, you should feel for the thyroid isthmus rising up under your finger pads.

It's often, but not always, palpable.

It feels like a little band of rubbery tissue.

What about the lobes?

This is always the tricky part for me.

It is.

So to feel the patient's right lobe, you use your left hand to gently push the trachea slightly to the right.

You're actually displacing the windpipe.

Gently, yes.

By pushing the trachea to the right, you slide the right lobe of the thyroid gland out from behind the SCM muscle.

It makes it more accessible to your other hand.

Then use your right fingers to palpate laterally for that right lobe in the space between the displaced trachea and the now relaxed SCM muscle.

So it's a push and feel maneuver.

You push with one hand to expose the lobe and you feel with the other.

That is the perfect way to describe it.

Then you reverse your hands to do the left lobe.

You push the trachea to the left with your right hand and you feel for the left lobe with your left fingers.

What does a normal thyroid feel like?

What are we hoping to find?

The anterior surface of a normal lateral lobe is approximately the size of the distal phalanx of the thumb and it feels somewhat rubbery and soft, not hard.

And what about that other method, the anterior approach?

For that, you stand in front of the patient.

You can use one hand to, again, slightly retract the SCM muscle while you use the fingers of your other hand to palpate the thyroid.

Again, it's often helpful to have the patient swallow a sip of water while you're feeling.

Some clinicians find this easier.

Some prefer the posterior approach.

You should probably learn both.

Bates gives us another great table of findings, table 11 -3, for the thyroid exam.

What are the major categories of abnormalities we might find?

First, you have diffuse enlargement.

This means the isthmus and both lateral lobes are enlarged.

The whole gland is just big.

Causes for this include Graves' disease, Hashimoto's thyroiditis, and endemic goiter.

Second category.

A single nodule.

This could be a cyst, a benign tumor, or it could just be one prominent nodule within a larger multinodular gland.

But finding a single nodule always raises the question of malignancy.

And what are the features that make us worry about malignancy in a nodule?

The risk factors are a history of prior irradiation to the neck, a nodule that feels hard or firm, one that's growing rapidly, one that's fixed to the surrounding tissues, if there are enlarged cervical lymph nodes nearby, and if it occurs in men.

And the third category of findings.

A multinodular goiter.

This is an enlarged gland that has two or more distinct nodules.

This usually suggests a long -standing metabolic process rather than a neoplastic one.

And the consistency of the gland or nodule helps us differentiate, too.

It does.

A soft gland suggests Graves' disease, a firm gland suggests Hashimoto thyroiditis or malignancy,

and a tender gland suggests thyroiditis, which is an inflammation of the thyroid.

There's also a note in the text about a retro -sternal goiter.

What is that?

That means the thyroid gland has grown downward, below the superstern.