Neck Examination and Injury د.نضال يونس

Neck Examination and Injury

المحاضرة للدكتور نضال يونس

كتبها لنا الاخ:حمزة زيدان - جزاه الله خيراً

http://www.4shared.com/file/67053291/2d26ca53/Neck_examination.html

بالتوفيق

Neck Examination and Injury

Most prominent structure in the neck in males is the thyroid cartilage and in females is cricoid
Sternocleidomastoid is found laterally in both male and female

Borders of neck:
Mandible  superiorly
Clavicle meeting along the sternum  inferiorly

The distance btn the sterna notch and submental point is called transcervical plane
This plane divides the neck into 2 halves (upper & lower)
Q: Where is the thyroid cartilage found? Upper half
Q: Where is the cricoids cartilage found? Lower half

In Cross section in the neck, we find:
1- Aerodigestive: trachea and esophagus
2- Vascular: carotid and jugular
3- Nerves
4- Muscles
5- Vertebral Column

Divisions of the neck:
Anatomists divide the neck into 2 triangles by sternocleidomastoid
Physical examiners divide into 2 regions:
 Central region (within 2 cm from the midline)
 Lateral region (beyond central region)

Trauma people divide the neck into 3 zones by:
 Cricoids cartilage & clavicle  Zone #1
 Cricoids cartilage & angle of mandible  Zone #2
 Above the angle of mandible  Zone #3
>> Remember the adequate exposure of chest, abdomen when examining them
Examination:
When we want to examine something in the neck, it might be thyroid swelling, lymph swelling, lateral swelling, and central swelling
 Before we start don’t forget to take permission, introduce yourself, SMILE
(تبسمك في وجه اخيك صدقة) and talk about the environment, exposure, and lightening ……… etc
(1) Inspection
We ask the patient to HYPEREXTEND the neck to uncover the hidden areas in the neck
If we want to examine the thyroid gland we concentrate on the lower half of the neck
Normally the thyroid gland is not visible except in some females
If we notice a swelling don’t forget to talk about it like any swelling (ASPECTS of TIM)
A = Attachments
S = Size
P = Position
E = Edge
C =Consistency
T = Translumination
S = Surface
T = thrills, bruits and noises
I = Inflammation signs (redness, hotness and tenderness)
M = Movement (with swallowing for example)
Remember the following:
 the isthmus which is found below the cricoid cartilage
(Feel it on yourself below the cricoids cartilage as a smooth thing: P very clear)
 Thyroid gland moves with swallowing (we can see the shadow of thyroid or see goiter)
 Goiter can be noticed by either with inspection or palpation or both
 Endemic goiter is found in Asia & South Africa (> 10%)


(2) Palpation
Start palpation anteriorly or laterally NOT from behind because it’s NOT convenient for the patient (it seems that you are trying to KiLL HiM )
Put your INDEX finger on thyroid, MIDDLE finger on cricoid, and by that you know most important landmarks in the neck
>> Thyroid Swellings is either solitary, diffuse, or multinodular
>> Retrosternal goiter tips:
1- Can’t get above it
2- Associated with dysphagia, dyspnea
3- 50% must be behind the sternum
4- If the patient raises his upper limbs, venous distention in the neck due to congestion
(Penpirtin Sign ?)
>> In graves disease, you know him from his appearance and by using the stethoscope to hear bruits
>> 4 – 5% of population has thyroid nodules …. And that is OK!
Did we finish?? NOOOOOOOOO
Now we must examine the Lymph nodes
We have 2 types of LN in the neck; Superficial and Deep (more important and found above the jugular vein)
In the OSCE, you must examine the supraclavicular, Virchow, Submental, Submaxillary LNs …etc
(i.e. examine all neck LNs)

Thyroglossal Cyst
- Found close to the central line (not exactly at the central line, maybe deviated to the right or left)
- Related to Hyoid Bone or below it (hyoid bone is found above the thyroid cartilage, you can feel it)
Embryology
>> Thyroid gland is similar to the testicles bcoz both of them migrate from their original place to their final place
Thyroid begins to develop during the 3rd week as an endodermal thickening in the midline of the floor of the pharynx btn tuberculum impar and the copula (lateral portions of the thyroid gland from the 4th pharyngeal pouch)
With further development, it descends down and reaches its final position in the 7th week. It begins to function at the end of the 3rd month
 Thyroid Parafollicular (“C”) Cells are derived from the Ultimobranchial Bodies (from the 5th pharyngeal pouch) and Neural Crest

Neck Injury:
Types of injury:
1- Penetrating (i.e. anything that goes through the platysma) (very serious)
2- Blunt
3- Hyperextension, Flexion injury (Web lash injury) in car accidents

Neck injury is either isolated or mostly multiinjury, so the approach to neck injury is by BLS (basic life support), ATLS (advanced trauma life support), and ACLS (advanced cardiac life support)  so start with ABCDE

How to deal with Neck injury (in the past and in the present)
A) In 1900
By ligation of the carotid artery to stop bleeding but that lead to CVA
B) In WWII (world war II)
By mandatory exploration but there were many –ve explorations
C) In the Present
By Selective exploration
o Bleeding
o Respiratory Discomfort
o Surgical emphysema(air underneath the skin), Stridor
o Expanding hematoma
 Other than that (dysphagia, tachycardia), investigate and evaluate the trachea, esophagus, vessels by CT, endoscopy, angiography …. etc. for surgical exploration
Lastly Do 2ry evaluation (Head to Toe examination)

Checkout Browse (for physical examination) and eMedicine.com (for neck injury)

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حمزة موسى زيدان

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