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Approach

• Patient sitting in chair
• Glass of water nearby (take the hint) - be prepared to examine the thyroid in full
• Expose the neck down to clavicles - undo the top buttons of a shirt
• Ask the patient to remove any jewellery

Inpect

1. Site of lump
   • Midline, supraclavicular
   • Size
   • Skin changes
   • Scars
2. Protrusion of the tongue
   • Ask patient to open mouth and stick tongue out as far as possible
   • Moves on protrusion = thyroglossal cyst (related to base of tongue by patent fibrous track running from the central portion to the hyoid bone)
   • Does not move on protrusion = thyroid lump
3. Swallowing
   • Place glass of water in patient's hands
   • Ask to take sip of water, hold in mouth, swallow
   • If moves on swallowing = thyroid gland issue / thyroglossal cyst

Palpate

1. From the back
   • be gentle, watch for discomfort
   • Use fingertips (obviously!) to elicit physical signs
   • Demonstrate the boundaries of the triangles of the neck
2. Palpate the triangles
   • Anterior triangle: anterior border of Sternocleidomastoid, midline, ramus of mandible
   • Posterior triangle: anterior border of trapezius, clavicle, posterior border of sternocleidomastoid
3. Determine whether the lump is solid or cystic
4. Confirm your findings (if necessary) by examining from the front

Percussion

Auscultation

1. Thyroid bruit (Grave's thyroiditis)
2. Carotid bruit (carotid stenosis)

Differential diagnosis of neck lumps

Continuing the examination (depending on appropriateness)

1. Examine the thyroid gland in full
2. Examine the neck thoroughly using the up and down technique
   • Palpate from the chin backwards to below the ears
   • Palpate down the anterior border of sternocleidomastoid to clavicle
   • Move laterally along the clavicle and then up the posterior border of sternocleidomastoid
   • Finish by palpating the back of the scalp for occipital lymph nodes

Cervical lymph nodes:

1. Submental
2. Submandibular
3. Anterior cervical chain
4. Pre-auricular
5. Post-auricular
6. Occipital
7. Jugulo-digastric
8. Posterior triangular (cervical)
9. Supraclavicular
10. Infraclavicular