Cervicium dolores butyro aut adipe ursino prefricentur, rigores bubulo sebo, quod strumis prodest cum oleo. Dolorem inflexibilem —opisthotonum vocant—levat urina caprae auribus…. (Pains in the neck should be massaged with butter or bear grease, stiffness with beef wax, which latter is good for scrofula if mixed with oil. The painful rigidity—called opisthotonos—is relieved by pouring nanny-goat urine into the ears….)
—PLINY THE ELDER, NATURAL HISTORY, BOOK 28, 52:192
POINTS TO REMEMBER:
The examination of the neck is part of the examination of the cardiovascular system, and of the otolaryngologic, musculoskeletal, and neurologic examinations.
Check the thyroid for size, consistency, nodularity, and the presence of a bruit.
The position of the trachea is important for interpreting findings of lung or pleural disease.
A webbed neck (pterygium colli or winged neck) with a low posterior hairline (Fig. 14-1) should suggest the diagnosis of Turner syndrome in a patient who is less than 5 ft tall and phenotypically female or Noonan syndrome1 in either phenotypic men or women (Mendez and Opitz, 1985). A short neck is seen in Klippel-Feil syndrome (Fig. 14-2). A buffalo hump may occur in endogenous or exogenous Cushing syndrome. Patients with obstructive sleep apnea tend to have short, stocky necks (a fact that was first pointed out to me by Dr Ted Woodward of the University of Maryland). Many of these patients wear unusually large-collared shirts (greater than size 17) and still leave them unbuttoned. A lateral swelling in the neck, which appears during the Valsalva maneuver, is probably a laryngocele. This is a benign condition. It may occur bilaterally. The most pronounced example I have ever seen was in the wellknown trumpet player John Birks (Dizzy) Gillespie. Glassblowers and patients with chronic obstructive airway disease are also prone to these diverticular outpouchings.
There are also other benign congenital cysts of the neck, related to embryonic structures, which may appear at any time in the patient’s life. Branchial cleft cysts are found along the anterior border of the sternocleidomastoid muscle as well as in the pretragal area. Cystic hygromas can appear anywhere on the neck. They are extremely soft and mimic a lipoma but can easily be differentiated by computerized axial tomography (CAT) or magnetic resonance imaging. Thyroglossal duct cysts (vide infra) are always in the midline of the neck above or below the hyoid bone. Dermoid cysts are typically in the suprasternal notch. All of these cysts are fairly movable and nontender unless they become infected.
Deep Space Infections
The deep spaces of the neck include the retropharyngeal and submandibular lateral pharyngeal spaces. Infections may track there directly or via lymphatic drainage from the teeth, tonsils, adenoids, sinuses, pharynx, or parotid gland. Such infections are very serious and can be difficult to diagnose. Diabetics and young children are especially susceptible. Symptoms may include fever, deep neck pain, dysphagia, or odynophagia. Physical findings may include trismus, bulging and displacement of the pharyngeal wall, a stiff neck (Swischuk, 1995), and torticollis (Harries, 1997). In advanced cases, there may be dyspnea and stridor.
It is often possible to see thyromegaly in cases of thyroiditis, hypothyroid goiter, and hyperthyroidism, especially in the last because weight loss has often thinned out the tissues that normally obscure the borders of the thyroid. A number of goitrous individuals were portrayed in paintings about the time of the Renaissance (14th to 16th century); see, for example, Fig. 14-3. Iodine-deficiency goiter can occur even in iodine-replete regions (Nyenwe and Dagogo-Jack, 2009).
Lingual thyroids can be seen at the base of the tongue.
The Maroni sign is redness of the skin, occasionally with itching, over the anterior neck in the topographic projection of the thyroid gland. It is seen in hyperthyroidism.
Most normal thyroid glands are palpable. (Sometimes a Valsalva maneuver will bring a retrosternal goiter up into the neck where it can be felt.)
Ask the patient to sit in a comfortable position.
Hand the patient a large glass of water, saying, “In a moment, I am going to ask you to take some of the water. Hold it in your mouth, and then swallow it when I tell you. That will help me feel your thyroid gland.”
Walk around to the patient’s back, saying, “I won’t hurt you,” as you place your hands on the patient’s neck.
Find the Adam’s apple by palpation. (The first dozen times you do this you may have to look.) Although this is called the thyroid cartilage, the thyroid is actually inferior to this structure. (Thinking that the thyroid is located at the level of the thyroid
cartilage is the reason that many untutored persons are unable to find the lateral lobes.)
Place your right index finger on the right lateral aspect of the thyroid cartilage and place your left index finger on the left lateral aspect. Next, move your two index fingers down to the cricoid cartilage; your index and third fingers are probably now at the level of the middle and upper thirds of the lateral lobes of the thyroid. (This varies with the anatomy of the patient and the examiner.)
Have the patient hold some water in his mouth and stare at the ceiling. (This will cause him to extend his neck.)
Instruct the patient to swallow. As he does so, the isthmus will ride up under your fingers, in the midline, and will then back down again. The normal isthmus is of a soft consistency, and it will be missed if you press too hard. (Palpation of the thyroid is a learned skill, and you should not be too concerned with what you miss on the first dozen attempts, but if you are consistently unable to feel the isthmus after about 20 palpations, you need to have a more experienced person demonstrate for you on a live patient—see “A Note to the Sophomore.”)
Now slip your fingers laterally and try to feel under the two sternocleidomastoids. Sometimes, all you will be able to do is get a feeling for the fullness and consistency of those tissues. (In this way, palpation of the lateral lobes of the thyroid is akin to palpation of the ovaries during a pelvic examination. Interpretation of the fullness encountered by your fingers requires considerable experience.)
With your fingers at the anterior edges of the sternocleidomastoids, pull them laterally just a little. Have the patient maintain his head in some extension but not so completely that the sternocleidomastoids are tensed. Ask him to swallow again. You should feel the upper parts of the lateral lobes ride up under your fingers and then down again. (Try this on yourself.) During your first dozen palpations of normal glands, you may not feel anything discrete.
FIGURE 14-2 Klippel-Feil syndrome. Note the low posterior hairline and short neck displacing the head anteriorly and interiorly. (Drawing of a patient of Dr L. Mermel of Wisconsin.)
An Alternate Method
Approach the patient from the front and feel each lateral lobe in turn by (a) using the fingers of one hand to retract the sternocleidomastoid muscle posteriorly and (b) using the fingers of the other hand to feel the underlying thyroid. Once the lateral lobes are located, the position of the isthmus can be predicted and palpated during swallowing, also with the examiner in front of the patient.
Other neck lesions in the vicinity of the thyroid can be displaced by underlying structures during deglutition and thus be confused with thyroid nodules. A mass within the thyroid will move with the larynx and thyroid during all three phases of swallowing: an upward movement, a stationary phase, and then a descent (Siminoski, 1994).
Try to estimate the size of the patient’s thyroid: “normal,” “twice normal,” “one-and-a-half times normal,” and so on. Large glands may be found in iodine-deficiency states in which the gland attempts to compensate by hypertrophy and hyperplasia even though the patient tends to remain hypometabolic or eumetabolic. More often, however, a diffusely enlarged gland signifies Graves disease (or Plummer-Vinson syndrome, if nodular), and such patients are likely to be hypermetabolic. Enlargement of the thyroid is the most sensitive sign of Graves disease, being found in 81% to 98% of such patients, with the higher sensitivity in younger age groups (Nordyke et al., 1988). The external ocular signs of Graves disease are described in Chapter 10 (see Table 10.2), and additional signs are shown in Chapters 7 and 24. (Note that exophthalmos and pretibial myxedema do not occur in Plummer-Vinson syndrome.)
Small glands are felt in pituitary hypothyroidism and some cases of primary hypothyroidism. No gland is felt in athyreotic hypothyroidism.
Describe the size and location of any nodules. A single nodule requires further evaluation. Many lumps or nodules in a hypermetabolic person may indicate toxic multinodular goiter (Plummer syndrome), one of the most common forms of hyperthyroidism in the elderly patient.
The consistency of the gland should be noted, but its importance should not be overstated until you have done a few dozen examinations, including a few glands of known abnormal consistency.
A firm rubbery gland is felt in some cases of Hashimoto thyroiditis and also in de Quervain thyroiditis. A hard gland is felt in cancer and in Riedel thyroiditis.
The Berry Sign
The Berry sign of malignant thyromegaly is absence of the carotid pulsation (i.e., a malignant tumor tends to encase the carotid so that the pulsation is not detectable). Benign thyromegaly, on the other hand, does not encase the vessel (Clain, 1973).
A Note to the Sophomore
Do not get discouraged. After decades of palpating thyroid glands, I am still learning. The availability of mannequins in my student days would have helped. The only covariable available at that time was the iodine-131 thyroidal uptake scan, which was usually ordered only in hyperthyroidism when the gland was already sufficiently enlarged for even a junior medical student to recognize the condition. At present, the technetium scan, a nonfunctional imager, is available as are thyroidal ultrasounds and CAT scans. These offer an unusual opportunity in physical diagnosis: the use of independent covariables to accelerate the acquisition of skills. However, when comparing your findings with the independent covariable, remember that therapeutic intervention may have changed the size of the thyroid gland since the radionuclide image was recorded, so it is wise to seek the guidance of a faculty member or senior resident. If your institution has a thyroid clinic, you should attend it and practice there.