Examination of the Neck

General Inspection and Palpation:

Note gross appearance of the neck and examine for any visible masses and scars.
Mobility of the neck can be assessed by having the patient rotate the head from side to side and tilting the head forward and backward. Conditions such as radiation-induced fibrosis of the neck or osteoarthritis may restrict neck motion.
The neck should be palpated in a systematic fashion, starting in the submental region and proceeding posteriorly to the angle of the mandible. The anterior neck is then palpated from superior to inferior, followed by the posterior neck in a superior to inferior fashion, and finally the supraclavicular region. Palpation should be performed while standing behind the patient, using both hands to examine the two sides simultaneously for comparison.
The thyroid gland should also be palpated with the examiner standing behind the patient. The paratracheal regions on both sides should be examined at the level of the cricoid cartilage. The patient may be asked to swallow, so that the trachea rises and falls.
The parotid glands are palpated anterior and posteroinferior to the auricle. Note any masses or tenderness. The parotid duct (Stensen’s duct) opening can be examined intraorally (opposite the second maxillary molar) if there is suspicion for sialolithiasis (salivary duct stones) or parotitis (inflammation of the parotid gland).
The submandibular glands can be palpated inferior to the angle of the mandible and should also be examined via bimanual palpation of the floor of mouth (see Chapter 7: Examination of the Nose and Oral Cavity).
Auscultation: The carotid pulse may be palpated and the neck can be auscultated for bruits. A carotid body or vagal paraganglioma may present in this location, typically as a vertically fixed mass that may be pulsatile and associated with a bruit. A bruit over the thyroid gland may be a sign of hyperthyroidism (e.g., Grave’s disease).

Assessing for Cervical Lymphadenopathy:

Level I of the neck is examined by palpating the submental and submandibular region. This may be facilitated by bimanual examination of the floor of mouth to assist in distinguishing the submandibular glands from adenopathy.
Level II consists of the upper third of the jugulodigastric chain from the skull base to the inferior border of the hyoid bone. These lymph nodes can be palpated deep to the sternocleidomastoid muscle at the anterior border.
Level III consists of the middle third of the jugulodigastric chain, extending from the inferior border of the hyoid bone to the inferior border of the cricoid cartilage.
Level IV consists of the lower third of the jugulodigastric chain, extending from the inferior border of the cricoid cartilage to the clavicle.
Level V, or the posterior triangle of the neck, contains the supraclavicular and spinal accessory lymph nodes. It should be palpated from the lateral border of the sternocleidomastoid anteriorly to the trapezius muscle posteriorly.
Level VI contains the pretracheal, paratracheal, precricoid, and perithyroid lymph nodes. This level is palpated in the midline from the level of the hyoid bone superiorly to the suprasternal notch inferiorly. Laterally, this level extends on either side to the carotid artery.
Additional lymph nodes may be palpated in the preauricular, retroauricular, and suboccipital regions.