(1) Generalities

The neck is an important crossroad of anatomic structures and organ systems, the most important of which is the thyroid (discussed in Chapter 8).

1 What neck features should be identified during inspection?

The most important is the contour. Abnormalities include:

2 What is Turner’s syndrome?

A syndrome characterized by ovarian dysgenesis in phenotypic females with X-monosomy, short stature, low-set ears, shield chest, heart defects (especially coarctation), café-au-lait spots, freckles, and a webbed neck. It was first described in 1938 by Henry H. Turner, founder of the Endocrine Society and a University of Oklahoma endocrinologist.

3 What is Noonan’s syndrome?

A syndrome characterized by congenital heart defects (usually pulmonic stenosis) in a setting of pectus carinatum, short stature, mental retardation, hypertelorism, and a webbed neck. Females are fertile, but males tend to be cryptorchic with high gonadotropins. Bleeding and dermatologic abnormalities are common. It was first described in 1963 by U.S. cardiologist Jacqueline Noonan and pediatrician Dorothy Ehmke.

4 What is Bonnevie-Ullrich syndrome?

A syndrome characterized by skeletal and soft tissue abnormalities, such as lymphedema of the hands and feet, nail dystrophy, skin laxity, short stature, and, of course, a webbed neck. It was first described by U.S. geneticist Kristine Bonnevie (1872–1950) and German pediatrician Otto Ullrich (1894–1957). When associated with Klippel-Feil syndrome, it goes under the name of Nielsen disease.

5 What is Klippel-Feil syndrome?

First described in 1912 by the French neurologists Maurice Klippel and André Feil, this syndrome consists of congenital fusion of two or more cervical vertebrae, producing a low posterior hairline and a short neck that often causes retroflexion of the head (opisthotonos). This may even lead to neurologic compromise, such as platybasia (a developmental anomaly of the skull causing the floor of the posterior cranial fossa to bulge upward into the foramen magnum), cord compression, cervical instability, and motility impairment. There also may be cardiac defects, ocular malformations, and various urogenital anomalies (renal agenesis).

6 With what syndrome is a buffalo hump at the base of the neck most commonly associated?

Cushing’s syndrome.

7 What are the anterior and posterior triangles of the neck?

They are important regions of the lateral neck, separated from each other by the sternocleidomastoid muscles (SCMs) (Fig. 7-1). These can be easily located through inspection and palpation, especially if tensed against resistance. The remaining borders of the posterior triangle are the anterior margin of the trapezius and the upper margin of the clavicle, whereas the remaining borders of the anterior triangle are the mandible and midline.

Figure 7-1 Anterior and posterior triangles of the neck.

(From Seidel HM, Ball JB, Benedict GW: Mosby’s Guide to Physical Examination, 3rd ed. St. Louis, Mosby, 1995.)

8 What are the contents of the cervical triangles?

9 Which swellings may be encountered during inspection of the neck?

Many. Classification and origin depend on location (posterior or anterior triangle; and for the latter, midline or lateral aspect) and nature (inflammatory or neoplastic) (Table 7-1).

Table 7-1 Neck Masses

Anterior triangle

Midline

Mostly thyroidal—goiter/nodule(s)

Thyroglossal (duct) cyst

Thyroglossal fistula

Dermoid (cyst)

Lateral aspect

Branchial cleft cyst

Branchial fistula

Branchial hygroma

Cystic hygroma

Laryngocele

Masseter muscle hypertrophy

Posterior triangle

Neoplastic

Lymphomas

Metastatic

Neurogenic

Paragangliomas/glomus tumors

Miscellaneous (ectopic salivary)

Inflammatory: localized

Tuberculous lymphadenitis (scrofula)

Bacterial lymphadenitis (abscess)

Suppurated branchial or thyroglossal cyst

Inflammatory: diffuse

Ludwig’s angina

(2) Swellings of the Anterior Triangle (Midline)

10 What is the origin of midline swellings of the anterior cervical triangle?

They are mostly thyroidal (goiters or nodules). Less commonly, they represent remnants of embryonic structures, such as dermoids or thyroglossal duct cysts (Fig. 7-2). Since only thyroid and laryngeal structures ascend with deglutition, nonthyroidal masses can be easily identified by asking the patient to swallow.

Figure 7-2 Surface projections of several neck masses.

(From Seidel HM, Ball JB, Benedict GW: Mosby’s Guide to Physical Examination, 3rd ed. St. Louis, Mosby, 1995.)

11 What is a thyroglossal (duct) cyst?

A swelling in the remnant of the thyroglossal duct, which in the embryo connects the thyroid to its point of origin at the base of the tongue. The duct usually disappears in the adult, leaving only a pit at its site of departure (the foramen cecum of the tongue). In some subjects, however, it may persist as an anomalous tract connecting the foramen cecum to the thyroid isthmus. In a few patients, this tract may even harbor a cyst or a fistula.

Although a thyroglossal cyst can occur anywhere along the path of the duct, most are found near the hyoid bone and thyrohyoid membrane (i.e., under the deep cervical fascia). These usually present as a tense, nontender, mobile, and nonlobulated midline mass, with acute tenderness and fluctuation, suggesting spontaneous hemorrhage or infection. Thyroglossal cysts may at times be just off the midline, pushed laterally by the convexity of the underlying thyroid cartilage and hyoid bone.

Still, since they are thyroidal in origin, they typically ascend with swallowing. Hence, they can be differentiated from the thyroid by their unique ability to rise with protrusion of the tongue (because of their firm attachment to the tongue’s base). A lingual protrusion can be carried out by holding the suspected cyst between the thumb and index finger and then asking the patient to stick out the tongue as forcefully as possible. Alternatively, one can ask the patient to try to touch the chin with the tongue.

12 Do thyroglossal cysts transilluminate?

No—which is counterintuitive, considering their cystic nature.

13 How common is a thyroglossal cyst?

Quite common. In fact, of all congenital neck masses, 75% are thyroglossal duct cysts.

14 What accounts for the other 25% of congenital neck masses?

Branchial cleft cysts, typically located more laterally, just between the SCM and hyoid.

15 What is a thyroglossal fistula?

A fistulous opening of the thyroglossal duct—a less-common entity than a thyroglossal cyst. It presents as a midline pit over the cricoid, intermittently draining and recurrently infected.

16 What is a dermoid (cyst)?

A bizarre and usually benign tumor that may occur in any line of embryologic fusion. In the neck, it presents as a midline swelling of the anterior triangle, typically in the submandibular region (just above the hyoid) but occasionally in the lower and suprasternal region. It also may cause swelling in the mouth floor, typically pushing the tongue upward. Dermoids are remnants of embryonic skin and thus may contain hair and cheesy epithelial debris, especially when located in the gonads. They are usually small (<2   cm), soft, and occasionally fluctuant. They are not attached to the skin and do not move with swallowing, but they do transilluminate. They present in young adults or children as asymptomatic and slow-growing masses.

(3) Swellings of the Anterior Triangle (Lateral Aspect)

18 Where do branchial cleft cysts originate?

From failed closure of the second branchial cleft. During the fourth week of embryonic life, five paired pharyngeal ridges (called the branchial arches) form the lateral and ventral walls of the embryo’s pharynx. These are separated externally by the branchial clefts and internally by the pharyngeal pouches. Both arches and clefts will ultimately participate in the formation of the various head and neck structures. With time, the second arch grows downward, ultimately covering the third and fourth arches, thus burying clefts, which eventually disappear around the seventh week of development. In some individuals, however, a remnant of the second branchial cleft may persist, leading to the formation of an epithelium-lined cyst (branchial cleft cyst), with or without a sinus tract to the overlying skin (branchial fistula). Note that, phylogenetically, the branchial system is related to the gill slits of fish and amphibians. Hence, the name branchial, which is Greek for gills.

19 Where are branchial cysts located?

Usually between the upper and lower two thirds of the anterior border of the SCM (hence, in the lateral aspect of the anterior triangle). They also may continue deep into the muscle.

20 What does a branchial cyst look like on exam?

As a solitary, painless, and tense globular swelling, just below the angle of the jaw. As the swelling enlarges, the cyst bulges—characteristically (and exclusively) around the anterior border of the SCM. Still, a branchial cyst is never superficial to (or posterior to), the muscle per se. Hence, it’s never in the posterior triangle. Cysts neither transilluminate nor move with deglutition, tend to be smooth, nontender, and usually asymptomatic. Yet, they may cause compressive symptoms, and, if infected, even result in a neck abscess or draining fistula. Note that intermittent swelling and tenderness is not uncommon during URIs.

21 Is adenopathy common in branchial cysts?

No. If present, consider either tuberculous adenitis (scrofula) or a complicating abscess.

22 How does a branchial fistula present?

As a pit over the anterior border of the SCM, usually exiting at the level of the hyoid, but at times even superiorly (anteroinferior to the earlobe) or inferiorly (near the lower part of the SCM)—still, always anterior to the muscle. Note that fistulas also may open internally. Hence, they can cause a mucopurulent discharge onto either the skin or pharynx.

23 What is a branchial hygroma?

A fluid-filled bursa or sac originating from branchial formations. It is usually cervical but may be thoracic, too.

24 What is a cystic hygroma?

A multiloculated and benign cyst composed primarily of budding lymphatics. It may occur anywhere, although neck (75%) and axilla (20%) are the preferred sites. Evident at birth in 65% of the cases (and by age two in the remainder), cystic hygromas present as large and soft structures with no clear margins. Complications include airway obstruction, infections (16%), and hemorrhages (13%).

25 What is a laryngocele?

A laryngeal hernia (from the Greek kele, hernia). This typically presents as an air-filled cervical outpouching, usually chronic and asymptomatic. Yet, at times it may present acutely, with hoarseness, stridor, or infection.

26 How does a laryngocele form?

Like a colonic diverticulum: through increased intraluminal pressure. Hence, it is typical of patients who recurrently “blow” their laryngeal walls, either because of disease (patients with [chronic obstructive pulmonary disease] COPD resorting to pursed-lip respiration) or profession (glass blowers and trumpet players—such as frog-mouthed Dizzy Gillespie). Laryngoceles start as an outpouching of the laryngeal ventricle, at times bilateral. As the exterior of the larynx expands through the constrictor muscles, the air-filled diverticulum becomes visible as a swelling in the lateral wall of the larynx, between hyoid and thyroid cartilages. This may eventually cause a change in voice, and, if complicated by infection, lead to abscess and encystation.

27 What bedside maneuver can be used to identify a laryngocele?

The Valsalva maneuver. Forced expiration against a closed glottis will inflate the laryngocele by increasing intra-airway pressure. This can be easily carried out by asking the patient to “bear down” as if having a bowel movement.

28 How does congenital hypertrophy of the masseter present?

Like a parotid mass. Differentiation can be easily accomplished by palpation.

29 What is torticollis?

An acute spasm of the sternocleidomastoid muscle. This typically presents as lateral prominence and deviation of the neck.

(4) Swellings of the Posterior Triangle

31 What are the most common neoplastic swellings?

32 How can lymphadenitis be differentiated from other inflammatory neck swellings?

It depends on whether it is acute or chronic. Acute lymphonodal inflammation is easily identified by the presence of localized swelling and tenderness, plus the occasional systemic symptoms (fever and malaise). Still, it can be confusing. An acutely inflamed node over the mastoid process, for example, may simulate mastoiditis, while instead being just the result of a banal scalp infection. Occasionally, an acute lymphadenitis may progress to a localized abscess and thus become fluctuant. Knowledge of nodal drainage can help in identifying the primary infection site (scalp, nose, sinuses, oral cavity, throat, or larynx).

33 What are the causes of chronic enlargement of a cervical node?

The most common is chronic infection, although a persistent and hard node should always raise the suspicion of malignancy. Protracted painless cervical adenopathy may occur with tuberculosis, lymphomas, HIV or EBV infection, and sarcoidosis. It can be differentiated from a thyroid mass because of its inability to ascend upon swallowing.

34 How does a tuberculous cervical abscess typically present?

As a chronic, firm, and nontender lump, with a draining sinus tract in the posterior triangle of the neck (although a tuberculous abscess also may present without sinus formation). Relatively common in developing countries (especially Asia), cervical tuberculous lymphadenitis has become rare in the United States, thanks to pasteurization of milk.

35 Where do neck abscesses typically originate?

From suppurative inflammation of lymph nodes. These may grow large and tender, especially in children. Other causes of cervical abscesses are branchial or thyroglossal cysts, also presenting as superficial and fluctuant masses. Identification relies on specific location.

36 Do neck abscesses always present as localized fluctuant masses?

No. When suppuration is not well contained (as in the deeper fascial spaces of the neck), there may be neither fluctuance nor obvious port of entry. This is typical of Ludwig’s angina.

37 What is Ludwig’s angina?

An acute submandibular cellulitis of normal hosts due to extension of a mouth infection into the deep spaces of the neck. Spread is eventually limited by the attachment of the fascial planes to the mylohyoid muscle. This results in a tense and rapidly expanding edema of the cervical soft tissues, ultimately leading to tongue elevation and fatal airway compression.

38 What is the role of dental ailments in Ludwig’s angina?

Major, with 80% of Ludwig’s patients reporting recent dental work or pain. Tooth extraction often precedes it, especially when involving lower molars because the second and third molars have deep roots that reach down into the attachment of the mylohyoid muscle (and usually below it), whereas first molars and anterior teeth have much more superficial roots.

39 How does Ludwig’s angina spread?

Through the interrelation of the various potential spaces of the neck. These are formed by the attachment of the fascial layers to the neck structures and consist of:

An infection that reaches the submandibular space can spread among all potential spaces of the neck, with different presentations depending on the area of involvement:

Infection of the submandibular space may eventually spread posteriorly along the styloglossus muscle and into the pharyngomaxillary space, and from there enter the retropharyngeal space, and, ultimately, the mediastinum.

40 How does Ludwig’s angina present on exam?

As bilateral swelling of submental, sublingual, and submaxillary spaces. Bimanual palpation reveals a characteristically “woody” firmness of the normally soft tissues of the mouth floor. Other common signs include a nonfluctuant (i.e., brawny, indurated) and tender neck swelling around the floor of the mouth, which is red, hard, and accompanied by trismus and tongue protrusion. Death from Ludwig’s angina is usually the result of suffocation (from edema of the mouth, tongue, glottis, and upper airways) or spread of the infection (pneumonia, mediastinitis, and septicemia). Hence, any toxic-appearing and drooling patient with a brawny cervical swelling should be thought of as having Ludwig’s until proven otherwise.

41 Who was Ludwig?

Wilhelm Frederick von Ludwig (1790–1865) was a German surgeon who served in the Allied Army that invaded Russia with Napoleon. Captured at the battle of Vilna, he spent 2 years in a Russian prison before returning to Tubingen, where he became physician to the royal family. There he described in 1836 the angina that was to become his ticket to fame, in Queen Catherine of Würtemberg and four other patients, all presenting with indurated edema of the submandibular and sublingual areas, minimal throat inflammation, and no lymphonodal involvement or suppuration. The swelling eventually spread to the muscles between the larynx and mouth floor, killing the patients. It was Ludwig’s only important observation. A successful physician, he left at his death most of his fortune to a hospital for the poor.

42 What is a submental sinus?

A sinus of chronic granulation tissue, just around the apical infection of a lower incisor tooth. On exam, it presents as a midline pit under the chin.

43 What other inflammatory condition may occur in the neck?

44 Which salivary glands are palpable?

The submaxillary, sublingual, and parotid glands.

45 Where are the parotids?

In front of and below the ears, just behind the mandibular angles. The largest of the salivary glands, they can be easily palpated bilaterally. The facial nerves (and their branches) pass through the parotid glands, as do the external carotid arteries (and their branches).

46 Where are the submaxillary glands?

Medially and anteriorly to the angles of the mandible. They have the size and shape of a walnut and are best appreciated upon swallowing. They can be difficult to palpate in young individuals with firm tissues.

47 Where are the sublingual glands?

In the mouth floor, just under the tongue. They are palpable but not routinely assessed.

48 What is the submandibular triangle of the neck?

The triangle delimited by the mandibular angles. Swellings in this area usually arise from the submaxillary glands or structures directly extending into the triangle, like the parotid tail or an upper cervical node. Differential diagnosis should include cancer and infections (Ludwig’s angina).

49 What are the causes of salivary gland swelling?

It depends on whether the swelling is unilateral or bilateral. Unilateral swelling is usually due to a ductal calculus and its infectious complications (most commonly Staphylococcus sp. or Streptococcus Viridans). Inspection of the Wharton’s duct (under the tongue, just lateral to the frenulum) for the submaxillary glands and Stensen’s duct for the parotids may reveal the stone or simply pus. More rarely, unilateral painless swelling of one salivary gland may indicate tumor.

Bilateral swelling carries a much wider differential diagnosis:

50 How do the parotids feel in acute parotitis?

They become swollen and easily palpable, to the point of pushing the earlobes forward and laterally. In severe cases, the swelling may limit jaw mobility.

51 Is parotitis exclusively limited to the parotids?

Not necessarily. In fact, most conditions causing swelling of the parotids also tend to cause swelling of the other salivary glands.

52 What do parotid tumors look like?

Like a rapid and uncomfortable swelling of the parotideal region, usually with facial palsy. Pleomorphic adenomas are the most common parotid tumor; mucoepidermoid carcinomas cause skin ulceration; whereas lymphomas typically present with facial palsy.

53 How common is a pleomorphic adenoma?

It accounts for 70–80% of all benign parotid tumors, even though 15% of all pleomorphic adenomas occur outside the parotid (in the submandibular and minor salivary glands). It presents in middle-aged women as a painless, well-demarcated, solitary, and slowly growing mass. Irregularity of the tumor usually indicates hemorrhage, calcification, or necrosis. Sarcomatous degeneration is rare, and only in lesions present for 10–15 years.

54 What is Frey’s (auriculotemporal) syndrome?

A syndrome due to a lesion of the auriculotemporal nerve, a frequent sequela of parotid trauma or surgery. It is characterized by recurrent episodes of localized facial flushing and/or sweating in the ipsilateral cutaneous distribution of the nerve (i.e., the cheek and the area anterior to the ear), usually triggered by eating and eventually subsiding within minutes after discontinuation of the food. It also has been termed gustatory sweating syndrome.

55 Who was Frey? When did she describe her syndrome?

Although auriculotemporal syndrome was first described in 1757 by Duphenix, it was not popularized until 1923, when Lucja Frey started researching it. She was a Polish physician and one of the first female academic neurologists in Europe. When her country was invaded by the Russians, Dr. Frey’s husband (a prominent lawyer) was arrested and killed by Soviet police. Then, when Poland was occupied by the Germans, she herself, being Jewish, was “resettled” in the Lwów ghetto. She worked in a Ghetto poliklinik until August 20, 1942, when the entire facility was raided by the Nazis, and all patients and staff were immediately murdered.

56 Describe the physical exam of the trachea.

It consists primarily of an assessment for shifts and mobility (see Chapter 13, questions 136–147).

Acknowledgment

The author gratefully acknowledges the contributions of Janice Wood, MD, to this chapter in the first edition of Physical Diagnosis Secrets.