Thyroid/Head & Neck Lymph Nodes Exam

Thyroid/Lymph Nodes of Head & Neck Exam

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should sitting on the edge of the examining bed
  • Drape the patient so their neck is visible. Intermittant draping will be required to expose the shoulders to examine the supra and infraclavicular lymph nodes

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Thyroid Inspection

Inspection of the thyroid includes inspecting the gland itself, and for any systemic manifestations of thyroid disease:

  • Thyroid gland
    • Inspect the neck for masses such as a goiter
    • Examine for scars from previous thyroid surgery
  • Hyperthyroidism - Systemic manifestations
    • Hair loss or thinning
    • Proptosis or Exophthalmos
    • Tremor
    • Weight loss - This may be better determined during the history
    • Thin skin
    • Perspiration - This may be better determined during the history, however observe to see if the patient is perspiring excessively
    • Lid lag - Ask the patient to follow your finger with their eyes as you bring it down in front of their face. If lid lag is present, their eyelid will drop slower than their eye itself.
  • Hypothyroidism - systemic manifestations
    • Weight gain - This may be better determined during the history
    • Coarse, dry skin
    • Cool extremities
    • Edema - Examine the face, and the legs for signs of edema

Thyroid Palpation

There are two approaches to palpating the thyroid:

  • Anterior approach - Palpate while standing in front of the patient. For patient comfort, stand just to one side of the patient so that you are not directly in front of them
  • Posterior approach - Stand behind the patient and reach around their neck to palpate
  • Method
    • Locate the thyroid cartilage with your fingers and palpate inferiorly to the cricoid cartilage
    • The thyroid isthmus lies just inferior to the cricoid cartilage
    • Palpate to the left of the isthmus for the left lobe
    • Ask the patient to drink some water. As they swallow, feel the thyroid lobe slide under your fingers for any nodules
    • Repeat the above for the right lobe
    • As you palpate, note any areas of tenderness, and any nodules

 Figure 1: Location of the thyroid gland

Figure 1: Location of the thyroid gland

There are systemic manifestations of thyroid disease that should be inspected for:

  • Reflexes - Measure the patient's reflexes
    • Hyperthyroidism: Can exhibit hyperreflexia
    • Hypothyroidism: Can exhibit hyporeflexia
  • Heart rate - Measure the patient's heart rate
    • Hyperthyroidism: Can exhibit tachycardia
    • Hypothyroidism: Can exhibit bradycardia
  • Proximal muscle strength
    • Hyperthyroidism: The patient may have proximal muscle weakness

Thyroid Auscultation

The thyroid should be auscultated for evidence of a thyroid bruit using the diaphragm of your stethoscope

Lymph Node Inspection

Moving on to the lymph node exam, examine for any evidence of lymphadenopathy in the head or neck. Be sure to examine the back of the head in the area of the occipital nodes.

Observe for symmetry between both sides

Lymph Node Palpation

It is important to palpate the head and neck lymph nodes in a systematic way to avoid missing any. Presented here is a common way of conducting the exam, starting with the occipital nodes:

  • Occiptal nodes: Locate the occiptal nodes at the base of the skull
  • Posterior auricular nodes: Palpate just posterior to the ear, above the mastoid process
  • Preauricular nodes: Palpate just anterior to the ear
  • Submental nodes: Palpate just posterior to the tip of the mandible. Work back to the hyoid bone
  • Submandibular nodes: Palpate along the body of the mandible
  • Superficial cervical nodes: Palpate along the sternal head of the sternocleidomastoid muscle
  • Posterior cervical nodes: Palpate along the clavicular head of the sternorcleidomastoid muscle
  • Deep cervical nodes: Palpate deeply along the sternal head of the sternocleidomastoid muscle
  • Supraclavicular nodes: Palpate above the clavicles
  • Infraclavicular nodes: Palpate below the clavicles

 Figure 2: Lymph node locations

Figure 2: Lymph node locations

When a lymph node is found, it is important to comment on the following characteristics

  • Location
  • Size
  • Shape (regular vs irregular border)
  • Mobility (mobile vs fixed)
  • Tenderness (tender vs non-tender)
  • Texture (soft vs firm)

References:

1: Courtesy Drahreg01, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/0/0f/Struma_001.jpg

2: Courtesy Jonathan Trobe, MD, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/8/8f/Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg

3: Courtesy James Heilman, MD, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/c/cf/Lymphadanopathy.JPG