CRANIAL NERVE EXAMINATION

Example: 37 year old lady who has noticed visual disturbance progressively worsening over the past
three months

Structure:
1. Introduction
2. Gather equipment
3. General inspection
4. CN I
a. State would test with coffee
5. CN II
a. Visual acuity
b. Visual fields
c. Blind spot
d. Fundoscopy
e. Pupillary light reflex
f. Accommodation
g. Sensory inattention
h. Colour vision
6. CN III, IV + VI
a. H – test
7. CN V
a. Sensory in V1, V2, V3
b. Motor muscles of mastication
c. Corneal Reflex
d. Jaw jerk reflex
8. CN VII
a. Inspect for asymmetry
b. Check for hyperacusis
c. Muscles of facial expression
9. CN VIII
a. Gross hearing
b. Rinnes
c. Weber’s test
10. CN IX + X
a. Ask if any troubles swallowing
b. “Say Ahh” – look for symmetrical movement of ulvua and palate
c. Swallowing assessment
d. Gag reflex
11. CN XI
a. Shrug shoulder (trapezius)
b. Turn head against resistance (SCM)
12. CN XII
a. Tongue inspection wasting / fasciculation
b. Tongue protrusion
c. Tongue strength (into cheek)
Introduction
- Wash hands
- Introduce self
- Confirm name and DOB
- Explain examination and gain consent
- Ask if patient has any pain
- Ask patient to sit on chair (around an arms length away)

Equipment
Gather equipment (likely won’t have all of these available in exam)
- Pen touch
- Snellen chart
- Ishihara plates
- Opthalmoscope (mydriatric eye drops)
- Cotton wool
- Neuro-tip
- Tuning fork
- Glass of water

General inspection
Inspect patient for:
- Facial asymmetry
- Eyelid ptosis
- Visual aids:
o Glasses / hearing aids
o Walking aids
- Strabismus

CN I – Olfactory Nerve
- Any changes to your sense of smell?
- Can test with coffee / peppermint etc

CN II – Optic Nerve
“Very Very Big Fat People Are Sexy Creatures”

V Visual acuity
V Visual fields + Neglect
B Blind spot
F Fundoscopy
P Pupillary light reflex
A Accomodation
S Sensory inattention
C Colour vision
Visual acuity
- Snellen chart
o Stand 6 metres away (cover one eye – read the lowest line possible)
- Denoted as distance from chart (in metres) over the lower line read
- E.g. at 6 metres if reads four line = 6/4 vision
- In examination can assess how many fingers holding up / reading from page or book

Visual Fields
- Cover one eye with their hand (you do same and mirror patient)
o Ask patient to focus on tip of nose and keep focusing their throughout assessment
- Can use hatpin / fingers
- Test upper and lower quadrants of each eye

Blind Spot
- Cover one eye with their hand (you do same and mirror patient)
- Focus on nose don’t move eyes / head
- Red hatpin used at EQUAL distance between you
- Move across visual field until disappears for patient (compare to your own) then continue
until reappears
- Perform twice in medial-lateral plain and superior-inferior plane

Note: all people have blind spot where the optic nerve passes through the optic disc – lack of
photoreceptor cells

Fundoscopy
- State would perform funcdoscopy
- To look at optic disc pathology (e.g. papilloedema) + retina

Pupillary light reflex

- Shine light in patients eye and observe for pupillary restriction in the ipsilateral eye (should
contrict)
- Then observe for pupillary restriction in the contralateral eye (consensual pupillary reflex)
- SWINGING LIGHT TEST looking for a relative afferent pupillary defect

Accommodation reflex
- Ask patient to focus on object behind you (e.g. clock)
- Place finger 20-30cm in front of eyes
- Then ask patient to focus on finger
- Should see:
o CONSTRICTION + CONVERGENCE

Sensory Inattention
- Ask patient to remain focused on a fixed point on your face
- Hold your hands out laterally to occupy both left and right sides of visual fields
- Wiggle fingers to see If patient is able to correctly identify which hand has moved
- Finally wiggle both fingers at same time to see if patient can identify which hand moved
CN III, IV + VI – Occulomotor, trochlear, abducens
- H-test
- Ensure patient keeps head still whilst following your finger with their eyes
- Ask patient:
o “Any double vision or pain”
- Observe:
o For any signs of nystagmus

CN V – Trigeminal Nerve
Sensory
- Assess with light tough / pin -prick (or hard touch) in different areas of trigeminal nerve
- Compare with opposite side
- Can use cotton wool and pen to differentiate hard Vs soft touch

- Ophthalmic Nerve (V1) – Sensation of forehead

- Maxillary nerve (V2) – Sensation of cheek
- Mandibular nerve (V3) – Lower mid jaw (avoid angle of mandible)

Motor
- Palpate temporalis and masseter muscles whilst asking patient to CLENCH Teeth
- Open jaw and observe for deviation
- Open jaw against resistence tests the lateral pterygoid muscles
- Jaw side to side against resistance

Reflex:
- CORNEAL Reflex: gently touch the edge of cornea with cotton wool – should observe
blinking (CN V+VII)
- JAW JERK reflex: State would perform in exam (unlikely to need to do it). Patient opens
mouth, place finger across jaw and tap finger with tendon hammer = closure of mouth.

Note: in abnormal jaw jerk reflex e.g. UMN lesions. The jaw will move briskly causing the mouth to
close completely

CN VII – Facial Nerve

- Ask if patient had any changes to hearing / TASTE
o Stapedius paralysis causes hyperacusis
o Chorda tympani anterior 2/3s of tongue
- Inspect patient for any signs of facial asymmetry

Muscles of facial expression:

- Raise Eyebrows frontalis temporal branch

- Close eyes tightly and try and open with your fingers orbicularis oculi zymgomatic
branch
- Blow out cheeks orbicularis oris buccal branch
- Show me your teeth depressor anguli oris Marginal branch
- Tense skin of neck platysma cervical branch
CN VIII – Vestibulocochlear nerve
Gross hearing assessment
- Place hands on either side of ear
- Rub fingers together next to each ear
- Ask patient which side
- Then rub fingers together on both sides

Rinne’s Test
- Place vibrating 512hz tuning fork on mastoid process to test bone conduction
- When patient can no longer hear the sound move in front of external auditory meatus to
test air conduction

Weber’s test
- Place 512Hz tuning fork in midline of forehead
- Ask patient were sound is heard loudest

CN IX + X – Glossopharyngeal and Vagus nerves

- Any issues with swallowing
- Inspect soft palate and uvula
o Say “Ahhhh”
o The palate and uvula should elevate symmetrically
- Swallow assessment
o State would perform
o If glass of water available ask patient to swallow small sip
o Note any present of cough
- Gag reflex
o State would perform
o Stimulate with tongue depressor at base of tongue / oropharynx

Note: A vagus nerve lesion will cause the uvula to deviate away from affected side

CN XI – Accessory Nerve
- Inspect of trapezius / SCM wasting
- Trapezius
o Ask patient to raised shoulders against resistance
- SCM
o Ask patient to turn head to side whilst resisting movement
o Repeat bilaterally

CN XII – Hypoglossal nerve

- Ask patient to open mouth inspect tongue for any wasting / fasciculations
- Ask patient to stick out tongue look for any deviation
- Place your finger on patient’s cheek ask patient to push tongue into cheek (compare
bilaterally)
Complete examination
- Thank patient
- Wash hands
- Summarise findings
- Further tests
o Full peripheral neurological examination (upper and lower limbs)
o MRI Head
o Formal audiometry (hearing) assessment
- State would do tests you couldn’t formally perform
o E.g. Snellen charts / fundoscopy / gag reflex
Questions

Findings in scenario: Bitemporal hemianopia

What might the lesion be to cause this lady’s symptoms?

Lesion of optic chiasm:

- Pituitary adenoma
- Craniopharyngioma

A craniopharyngioma tends to compress from above initially causing an bitemporal inferior

quadrantopia
Conversely, masses arising from below the chiasm may present at first with bitemporal superior
quadrantopia

What do lesions of the optic nerve between the eye and the chiasm cause?

- Unilateral blindness

What do lesions between the chiasm and visual cortex cause?

- Homonymous hemianopia

What other symptoms might be seen in patient’s with pituitary tumours?

- Papilloedema: raised ICP

- Hormonal changes: two most common are prolactinoma and growth hormone secreting
tumours (acromegaly)
- Prolactinoma
o Increase lactation
o Decreased libido + erectile dysfunction
o Ammenorrhoea in females
- Acromegaly
o Large jaw / brow / macroglossia / skin thickening / Large hands + feet
What are the causes of anosmia?

- Mucous blockage
o Polyps
o Nasal tumours
- Head trauma: can result in shearing of olfactory nerve
- Intracranial tumours
o E.g. Meningioma
- Genetics: congenital anosmia
- Parkinson’s disease: anosmia is an early feature of Parkinson’s disease

What are homonymous field defects due to?

- Affect the same side of the visual field in each eye

- Stroke / tumour / abscess affecting the visual tract posterior to the optic chiasm

What nerves are involved in pupillary light reflex?

1 Afferent limb: CN II optic nerve

2 Efferent limbs: bilateral CN III nerves (via Edinger-Westphal Nucleus) ciliary ganlgion

Thus the direct pupillary light reflex assesses the ipsilateral afferent limb and ipsilateral efferent limb
of the pathway.

The consensual pupillary reflex assesses the contralateral efferent limb of the pathway.

What is the swinging light reflex used for?

- To assess for relative afferent limb defects

How would a CN III (oculomotor) nerve palsy present?

1. Loss of accommodation
2. Fixed DILATED pupil (loss of PS supply)
3. Ptosis
4. Eye deviated down and out

How would a lesion in the fourth cranial nerve present clinically?

- Inability to look downward and inwards diplopia when doing so

- Eye deviated upwards

How would a lesion in the sixth cranial nerve present clinically?

- Eye deviated mediated

- Inability to look laterally

How would you locate the facial nerve intra-operatively?

- Distal to the styloid foramen / medial to styloid process

What is the difference between an upper and lower motor neurone injury to facial nerve?

- UMN lesion: can raise eyebrows

o Due to dual innervation of frontalis

- LMN lesion: unable to raise eyebrows

o Total unilateral paralysis of facial muscles

What is visual neglect / sensory inattention due to?

- Typically occurs in parietal lobe injury after a CVA

- The side affected is contralateral to the location of the parietal lesion

What are the findings of Rinne’s test?

Normal: air conduction > bone conduction (Postive Rinne’s confusingly)

Sensorineural deafness: air conduction > bone conduction (positive Rinne’s) – due to both air and
bone conduction being reduced evenly

Conductive deafness: bone conduction > air conduction (Rinne’s negative)

What are the findings of Weber’s test?

Must be used in context of the results of Rinne’s test

Normal: sound equal in both ears

Sensorineural deafness: air conduction > bone conduction (positive Rhinne’s) – due to both air and
bone conduction being reduced evenly

Conductive deafness: bone conduction > air conduction (rhine’s negative)

Which way does tongue deviate towards in hypoglossal nerve palsy?

Deviates towards the affected side

What is the route of glossopharyngeal nerve?

- Exits via jugular foramen

- Passes between IJV and ICA
- Passed between superior and middle constrictor to supply pharynx

What does glossopharyngeal nerve supply?

- Posterior 1/3 tongue

- + Soft palate
- Oro + laryngopharynx (part of pharyngeal plexus)
- Parasympathetic innervation to parotid (otic ganglion)

In vagus nerve lesion would the uvula deviate away or towards the affected side?

- Deviates AWAY from the affected side

EAR EXAMINATION
Example: 42 year old with head injury – no evidence of focal neurological deficit, other than hearing
loss in his right ear.

Structure:
- Inspection
- Palpation
- Otoscope
- Crude hearing test
- Rinne’s test
- Weber’s test
- Facial Nerve
- Romberg’s test

Introduction
- Wash hands
- Introduce self
- Confirm name and DOB
- Explain examination and gain consent
- Ask if patient has any pain
- Ask patient to sit on chair

Inspection
General
- Hearing / walking aids
- Glasses

External ear inspection

- Pinna
o Deformity / asymmetry (couliflowwer ear)
o Ear piecing
o Erythema (?otitis externa)
o Bruising
- Mastoid
o Bruising (basillar skull fractures battle’s sign)
o Erythema (mastoiditis)
- Pre-auricular
o Lymphadenopathy
- Conchal bowl
o Signs of active infection as erythema / ear discharge

Head injury patients:

- Look for CSF rhinnorhea
- Peri-orbital bruising
- Battle’s sign
Palpation
- Tragus
- Regional lymph nodes (pre and post-auricular)
- Mastoid process

Otoscopy
Examine the “normal” ear first

Insertion
- Check light working and turn on
- Pull pinna upwards and backwards to straighten the auditory canal
- Note: otoscope should be in right hand if examining the right ear (and vice versa)

Assess external auditory canal

- ?Ear wax
- Erythema and oedema
- Discharge
- Foreign bodies

Assess tympanic membrane

- Colour
o Normal colour grey and translucent
o Erythema (suggest inflammation around the ear
- Shape
o Bluging (seen in AOM)
o Retraction (Eustahcian tube dysfunction)
- Light reflex
o CONE OF LIGHT
o Should appear in anterior inferior quadrant
- Perforation / Scarring

Repeat examination on other side

Discard of the otoscope speculum into the clinical waste bin

Crude Hearing test

- Stand behind patient
- Rustle fingers next to ear
- Ask patient to tell you which side
- Test both sides then at same time

Can give basic information and laterality of defect

Rinne’s Test
Rinne’s Test
- Place vibrating 512hz tuning fork on mastoid process to test bone conduction
- When patient can no longer hear the sound move in front of external auditory meatus to
test air conduction
- Air conduction should be louder than bone conduction

If air conduction is louder (Rinne’s positive) either:

- NORMAL
- Or sensorineural deafness in that ear

If bone conduction is louder (Rinne’s negative) conductive deafness in that ear

Note: Rinne’s test is one of the few medical tests where a normal result is referred to as positive

Weber’s Test
Weber’s test
- Place 512Hz tuning fork in midline of forehead
- Ask patient were sound is heard loudest
- It should be same on both sides

Weber’s test must be interpreted with Rinne’s test to get accurate result

Normal: sound is heard equally in both ears

Sensorineural deafness: sound is heard louder in normal ear
Conductive deafness: sound is heard louder in affected ear

Facial Nerve
Ask patient:
- Any change in hearing hyperacusis (stapedius muscle palsy)
- Any change in sense of taste chorda tympani

Test muscles of facial expression

- Raise eyebrows
- Close eyes and don’t let me open them
- Blow out cheeks
- Purse lips
- Show me your teeth
- Tense skin of neck
Romberg’s Test
- Stand with feet slightly apart
- Hands across chest
- Close eyes
- Stand close to patient for support

Interpretation of loss of balance

- Eyes open = cerebellar dysfunction
- Eyes shut = defective proprioception

Note: one could also perform the heel-toe test and see if he can walk in a straight line, or if he loses
his balance

Complete examination
- Thank patient
- Wash hands
- Summarise findings
- Further tests
o MRI Head
o CT head (if suspicious of fracture)
o Formal audiometry (hearing) assessment
o Cervical lymph node examination (if any evidence of infection)
Questions
The following was seen during otoscopy. What does it show?

HAEMOTYMPANIUM

What would you be worried about in this context?

- Basilar skull fracture

- Other signs:
o Battle’s sign (mastoid bruising)
o CSF otorrhoea
o CSF rhinorrhoea
o Raccoon’s eyes (peri-orbital bruising)

What would you next investigation be?

- Urgent CT head
- Exclude basilar skull fracture
Which ear is the below otoscope image taken from? Describe it’s different anatomical parts

The cone of light occurs in the ANTERIOR INFERIOR QUADRANT therefore this ear is from the
right hand side.

Anatomy:
- Malleus
o long and visible against the tympanic membrane
o Has the umbo at inferior aspect
- Cone of light
o Anterior inferior quadrant
- Par tensa
o Inferior covering of TM
- Pars flaccida
o Superior to malleus
What diagnosis does the above picture show?

- Acute otitis media (with effusion)

Can you name any causes for conductive hearing loss?

This is easiest divided by anatomical location:

External auditory canal

- Wax
- Otitis Externa
- Tumour in ear canal
- Tympanic membrane perforation

Middle ear
- Acute otitis media
- Haemotympanum
- Cholestatoma
- Otoscleorsis

Name three causes of tympanic membrane perforation?

- Trauma (e.g. diving related)

- Acute otitis media
- Cholesteatoma

What is the difference between conductive Vs sensorineural hearing loss?

Conductive hearing loss

- Sound is unable to transfer between external auditory canal to middle ear ossicles
- Causes:
o Excessive ear wax
o Otitis externa
o Perforated TM
o Otosclerosis

Sensorineural hearing loss

- Due to dysfunction of the inner ear cochlea and/or vestibulocochlear nerve
- Causes:
o Increasing age (presbycusis)
o Excessive noise exposure
o Genetic mutations
o Viral infections
o CN VIII palsy (vestibular schwannoma)
o Ototoxic agents (e.g. gentamicin)
What is cauliflower ear?

Due to repeated blunt trauma (e.g. scrummaging in rugby). Bleeding under the perichondrium
strips airway the ear’s cartilage. Which then become fibrotic causing distortion of the ear’s
architecture.

What is Ramsay Hunt Syndrome?

- Herpes Zoster infection of facial nerve

- Reactivated within the GENICULATE GANGLION of facial nerve

Symptoms:
- Pain
- Tinnitus
- Dizziness
- Facial drooping
- Sensorineural hearing loss

May observe evidence of vesicles around EAM

Pictures
THYROID EXAMINATION
Example: 60 year old lady noticed lump in her neck

Structure:
- General Inspection
- Hands + Radial Pulse
- Face + Eyes inspection
- Thyroid Inspection
- Thyroid Palpation
o Trachea + LN palpation
- Thyroid Percussion
- Thyroid Auscultation
- Special tests
o Reflexes
o Pretibial myoedema
o Proximal myopathy

Introduction
- Wash hands
- Introduce self
- Confirm name and DOB
- Explain examination and gain consent
- Ask if patient has any pain
- Ask patient to sit on chair
- Expose patient’s neck and upper sternum

Equipment:
- Stethoscope
- Glass of water
- Tendon hammer
- Piece of paper

General Inspection
- Weight
o Weight loss = hyperthyroidism
o Weight gain = hypothyroidism
- Behaviour
o Anxious + hyperactivity = hyper
o Low mood = hypo
- Clothing
o Is patient dressed appropriately for the weather
o Heat intolerance = hyper
o Cold intolerance = hypo
- Hoarse voice
o Can be due to compression of RLN due to thyroid enlargement (e.g. malignancy)
 - Mobility aids
o Sign of proximal myopathy
- Prescription charts
o May have medications (e.g. levothyroxine) that give useful indicator

Hands + Radial pulse

Inspection

- Dry skin (hypo)

- Excessive sweating
- Thyroid acropachy
o Similar appearance to finger clubbing
o But caused by periosteal bone overgrowth in Graves’ disease
- Oncholysis (hyper)
- Palmar erythema (hyper)

Peripheral tremor
- Ask patient to place arms out in front of them
- Place a piece of paper across the back of the patient’s hands
- Observe for a peripheral tremor

Note: a peripheral tremor is a feature of hyperthyroidism reflecting sympathetic nervous system

overactivity

Radial pulse
- Check for regular rhythm
- Atrial fibrillation associated with hyperthyroidism
- Hypo = bradycardia
- Hyper = tachycardia

Face + Eyes inspection

Face inspection

- Dry skin (hypo)

- Excessive sweating (hyper)
- Eyebrow loss (hypo)
o Absence of the outer third of the eyebrows
Eye inspection

Examine for Grave’s disease eye signs

- Lid retraction
o Thought to be due to sympathetic hyperactivity in Grave’s leading to activation of
superior tarsal muscle
- Exophthalmos
- Eye movements OPTHALMOPLEGIA
o H-test
o May get diplopia and pain during eye movements in Grave’s
- Lid lag
o Hold your finger superiorly and ask patient to follow with their eyes
o If lid lag present the eyelid will lag behind the eye

Thyroid Inspection
General inspection
- Inspect midline of the neck
- Masses
- Scars (e.g. previous thyroidectomy)

Further inspection of mass

1. SWALLOWING
a. Ask patient to swallow some water
b. Observe movement of mass
c. Thyroid masses move up with swallowing
d. Lymph nodes little movement
e. Thyroid malignancy may not move with swallowing if tethered to surrounding
structures
2. TONGUE PROTRUSION
a. Thyroglossal cysts will protrude upwards on tongue protrusion
b. Thyroid masses will not

Thyroid Palpation
- Stand behind patient
- Three middle fingers along midline of neck and below chin
- Locate Adam’s apple move fingers downwards until reach cricoid cartilage
- Palpate:
o Thyroid isthmus
o Left + right loves of thyroid
o ASK PATIENT TO SWALLOW WATER see if mass moves
o ASK PATIENT TO STICK OUT TONGUE ?movement
Whilst palpating the thyroid gland should assess:

- Size
- Symmetrical?
- Consistency
o ?multinodular goitre
- Masses?
o Position
o Shape
o Consistency
o Mobility

Lymph node + Trachea palpation

Palpate lymph nodes:
- Submental
- Submandibular
- Pre + post auricular
- Anterior cervical chain (anterior border of SCM)
- Posterior cervical chain (posterior border of SCM)
- Supraclavicular
- Infraclavicular

Note: don’t “piano play” the lymph nodes. Use the pads of the second, third and fourth fingers to
press and roll the lymph nodes over the surrounding tissues.

Trachea
- Inspect for evidence of tracheal deviation which by be caused by a large goitre

Thyroid (sternal) percussion

- Percuss down the sternum
- For evidence of a retrosternal goitre retrosternal dullness

Auscultation of the thyroid gland

- Auscultate each lobe the thyroid gland for a bruit using the bell of the stethoscope
- Bruits
o Indicate increased vascularity which typically occurs in Graves’ disease
Special tests
1. Reflexes
a. Knee jerk reflex / biceps
b. Test knee jerk in exam
c. Hyporeflexia associated with hypothyroidism

2. Pretibial myoxoedema
a. Accumulation of excess glycosaminoglycans in the subcutaneous skin
b. Waxy, discoloured induration of shins
c. Seen in GRAVE’S disease (rarely)

3. Proximal myopathy
a. Ask patient to stand from sitting position with their arms crossed
b. Seen with multinodular Goitre and Graves’s disease

Complete examination
- Thank patient
- Wash hands
- Summarise findings
- Further tests
o TFTs, PTH, Ca2+
o ECG: exclude AF
o USS thyroid: assess any thyroid lumps

Questions
What are the types of goitre?

- Diffuse goitre: the whole gland is enlarged due to hyperplasia of the thyroid tissue
- Uni-nodular goitre: presence of single thyroid nodule (e.g. toxic adenoma)
- Multi-nodular goitre: presence of multiple thyroid nodules (may be active or inactive)

Patient has a right sided thyroid mass. Irregular and around 2cm. What is your differential
diagnosis?

- Thyroid adenoma
o Can be toxic / inactive
- Thyroid malignancy
- Multinodular goitre
- Grave’s disease
- Iodine deficiency

Note: would need to exclude thyroid malignancy as part of 2 week wait in this patient
How would you manage this patient?

All thyroid lumps should undergo TRIPLE Assessment

Hx+Ex
- Including TFTs, PTH, Ca2+
- + ECG
Imaging (USS)
Biopsy (FNAC / Core biopsy)

What types of thyroid malignancy are there?

- Papillary thyroid cancer (70%)

o Younger patients
o Good prognosis
o Lymphatic spread
- Follicular thyroid cancer (20%)
o Older 50 years
o Haematogenous spread
o Poorer prognosis
- Medullary thyroid cancer (5%)
o Familial in 25%
o Para-follicular C cells
o Associated with Men 2a+b syndrome
- Anaplastic thyroid cancer (1%)
o Elderly patients
o Aggressive worst prognosis

Can you name a histological feature that is pathognomic for papillary thyroid cancer?

PSAMMOMA BODIES

FNA report comes back showing a follicular cell tumour. Report unable to differentiate from
adenoma. Why is this?

Follicular carcinoma is differentiated from a follicular adenoma by invasion of the tumour capsule or
surrounding vessels.

Therefore histology is needed to show tissue invasion

What is the key difference between cytology and histology?

Cytology assessing the individual cells only

Histology assessing the cells within the tissue architecture

What is the next step in the patient’s management following this histological result?

This lady needs to be discussed in the MDT

likely to need total / hemithyroidectomy

Pictures

Thyroid acropachy (hyper)

NECK LUMP EXAMINATION
Example: 53 year old male, noticed lump in neck. Please examine

Structure:
- General Inspection
- Neck lump inspection
- Neck lump palpation
- Neck lump auscultation
- Lymph node assessment
- Submandibular gland
- Oral cavity
- Thyroid gland palpation

Introduction
- Wash hands
- Introduce self
- Confirm name and DOB
- Explain examination and gain consent
- Ask if patient has any pain
- Ask patient to sit on chair
- Expose patient’s neck

General Inspection
- Scars: ?previous thyroid surgery
- Cachexia:
- Hoarse voice
- SOB / Stridor
- Behaviour
o Hyperactivity – hyperthyroid
o Lethargy – hypothyroid
- Clothing
o Is patient appropriately dressed for the weather

Neck lump inspection

Ask patient to point out the neck lump’s location
Inspect the neck lump from the front and side, noting its location (anterior/posterior triangle /
midline)

- Swallowing
o Ask patient to swallow some water
o Thyroid masses move with swallowing (unless invasive malignancy of thyroid)
- Tongue protrusion
o Thyroglossal cyst will protrude with tongue
Neck lump palpation
- Site
o Anterior / posterior triangle / midline
- Size
- Shape
o Mobile?
o Punctum?
- Consistency
o Fluctuant or hard masses
o Fluid filled cyst
- Contour
o Borders regular or irregular
- Colour
o Erythema
- Temperature
o Inflammatory or infective causes (e.g. infected epidermoid cyst)
- Tenderness
o Inflammatory or infective causes
- Tethered
o To underlying tissues

Others:
- Pulsatile?
o Suggestive of vascular origin (carotid body tumour / aneurysm)
- Transillumination
o If transilluminated suggests fluid filled
o E.g. cystic hygroma

ALSO PALPATE ADDITIONAL PARTS OF NECK TO SEE IF ANY OTHER LUMPS PRESENT

Neck lump Auscultation

- Vascular bruit
o Suggestive of vascular aetiology
o E.g. carotid artery aneurysm

Submandibular Gland
Submandibular gland
- Inferior and posterior to the body of the mandible
- Tilt patients head forwards
- Work forwards from angle of mandible
- With bimanual palpation
o One palpating floor of mouth
o One hand palpating underneath the mandible
Oral Cavity
- Tongue
o Hairy leukoplakia
o Oral candiasis
o Glossitis
o Ulceration
- Floor of mouth
o Ask patient to lift up tongue to roof of mouth
o Look at floor of mouth
o Inflammation
o Pus
o Visible stone
- Dentition
o Look for any evidence of dental infection
- Posterior oral cavity
o Use tongue depressor
o Inspect the palate / uvula / tonsils and pharyngeal arches
- Nerves
o Sensory: any changes to sensation to tongue (lingual nerve involvement)
o Motor: ask patient to produce tongue movements

Note: submandibular gland swellings are usually singular, whereas lymphadenopathy typically
involves multiple nodes. Salivary duct calculi are relatively common and may be felt as a firm mass
within the gland.

Lymph node + Trachea palpation

Palpate lymph nodes:
- Submental
- Submandibular
- Pre + post auricular
- Anterior cervical chain (anterior border of SCM)
- Posterior cervical chain (posterior border of SCM)
- Supraclavicular
- Infraclavicular

Note: don’t “piano play” the lymph nodes. Use the pads of the second, third and fourth fingers to
press and roll the lymph nodes over the surrounding tissues.
Thyroid Palpation
May or may not need to examine

- Stand behind patient

- Three middle fingers along midline of neck and below chin
- Locate Adam’s apple move fingers downwards until reach cricoid cartilage
- Palpate:
o Thyroid isthmus
o Left + right loves of thyroid
o ASK PATIENT TO SWALLOW WATER see if mass moves
o ASK PATIENT TO STICK OUT TONGUE ?movement

Whilst palpating the thyroid gland should assess:

- Size
- Symmetrical?
- Consistency
o ?multinodular goitre
- Masses?
o Position
o Shape
o Consistency
o Mobility

Complete examination
- Thank patient
- Wash hands
- Summarise findings
- Further tests
o Examinations
Thyroid Ex
Oral cavity Ex
o Bloods
TFTs, PTH, Ca2+, CRP
o USS thyroid: assess any neck lumps
o FNAC
o Early referral to ENT 2 week wait if suspicion of malignancy
Questions
Which features are RED FLAGS for malignancy with neck lump?

RED FLAGS:
- >35 years age
- Hard and fixed mass
- Presence of mucosal lesion in head or neck
- Persistent hoarsness
- Dysphagia
- Trismus
o Inability to open mouth
- Unilateral ear pain

Example: Patient has 2 month history of submandibular gland swelling, that increases in size around
meal times. On Ex enlarged left submandibular gland approximately 4cm in diameter. No
associated lymphadenopathy. Neck examination otherwise normal.

What is your differential diagnosis?

- Submandibular salivary stone (sialolithiasis)

- Submandibular neoplasm

How would you investigate this patient?

- Bloods:
o TFTs, PTH, Ca2+, Phos, CRP
- OPG
o Assess dentition
- USS
o Salivary glands
- Specialist test
o Sialogram
o FNAC: if malignancy suspected

A sialogram showed a stone within the body of the submandibular gland. What is a sialogram?

- Sialogram is radiographic examination of the salivary glands

- The submandibular duct (Wharton’s duct) is cannulated and contrast is injected into the
gland and a radiograph is taken
- Obstruction demonstrated by filling defect

Note: sialography is contraindicated if there is active infection

What proportion of submandibular gland stones are radio-opaque?

- 80%
o High concentration of calcium + phosphate
What are the treatment options for salivary stones?

Conservative
- Analgesia
- Oral Abx
- Good hydration + gland massage
- Suck on citrus fruits aids expulsion

Surgical:
- Sialotomy
o If within duct salivary duct can be laid open and stone retrieved
o The duct is then laid open as suturing it would result in a stricture
- Sialendoscopy
o Stone retrieval via endoscopic techniques
o Basket retrieval
- Submandibular gland excision
o If chronic and recurrent

Note: sialotomy and sialendoscopy can both been done under local anaesthetic

Where is skin incision made when performing excision of submandibular gland?

- 2cm below lower border of mandible

- The marginal mandibular branch of facial nerve can then be preserved by lifting in a skin flap
superiorly

What other nerves are at risk during submandibular gland excision?

- Mandibular branch of facial nerve

- Lingual nerve
- Hypoglossal nerve

Note: facial artery and vein also pass close to submandibular gland

What are the boundaries of submandibular triangle?

- Anterior: anterior belly of digastric

- Posterior: posterior belly of digastric
- Superior: lower border of mandible
Go through cervical lymph node levels diagram

Example: 19 year old with left sided neck mass on anterior border of lower third of SCM. 4x4cm,
non-tender, smooth, mobile fluctuant mass associated with a sinus tract. No overlying inflammation
and it does not trans luminate.

What is your differential diagnosis?

- Epidermoid / pilar cyst

- Branchial cyst
- Neck abscess
- Others:
o Thyroglossal cyst
o Carotid body tumour
o Lipoma

Which branchial cleft (pouch) is most commonly involved in branchial cysts?

- The second branchial cleft

What are the complications with branchial cysts?

- Infection
o Can get intermittent swelling of cysts
o Commonly associated with URTIs
- Mass effect
- Sinus tract
- Small risk of malignant transformation

What imaging might be useful in this patient?

- USS +/- FNAC

- MRI / CT
o To delineate involvement of underlying structures
o Aids pre-operative planning

Is there any investigation specific to the sinus tract that can be performed?

- A SINOGRAM
- Radio-opague dye can be injected to delineate the course of the tract and demonstrate the
size of the cyst

What may you find if you aspirate the lump?

- Straw coloured fluid

o May contain high amounts of cholesterol granules in branchial cyst
- If acute infection may be pus-filled

What is the management of branchial cysts?

- Surgical excision
- Via ‘stepladder incision approach. Within 6 months of presentation

Note: if acutely infected will need antibiotics first prior to surgery

What is surgery advised for branchial cysts?

- Do not spontaneously regress

- High rate of recurrent infection
- Risk of malignant transformation
What can cause a submandibular are swelling

- Infection
o Submandibular lymphadenopathy
o Lymphadenitis
o Ludwig’s Angina
- Salivary stones
- Neoplasm
o E.g. pleomorphic adenoma
- Developmental
o Dermoid cyst
o Cystic hygroma
o Rannula (mucocele)
CEREBELLAR Examination
Example: 50 year-old man comes into clinic unsteady on his feat. Please examine his lower limb
neurology and cerebellar system.

Areas to cover
- Dysdiadochokinesia
- Ataxia (gait + Romberg’s)
- Nystagmus
- Intention tremor
- Slurred speech
- Hypotonia / Heel-shin test

Structure:
- General inspection
- Gait
o Normal walking + turning
o Heel-to-shin test
- Romberg’s
- Central signs
o Dysdiadochokinesis
o Nystagmus (H-test)
o Intention tremor
o Slurred speech
- Lower Limb
o Tone
o Heel-to-shin
o Reflexes

Introduction
- Wash hands
- Introduce self
- Confirm name and DOB
- Explain examination and gain consent
- Ask if patient has any pain

General Inspection
Perform a brief general inspection of the patient, looking for clinical signs:

- Abnormal posture
o E.g. truncal ataxia
- Speech abnormalities
- Scars
o May indicate previous neurosurgery
- Aids:
o Walking Aids
o Hearing aids
Note: hearing loss and loss of balance both associated with cerebellar pathology (ataxia) or
pathology close to cerebellar that may impact in (e.g. acoustic neuroma)

Gait + Rombergs (assessing for ATAXIA)

Patient’s with cerebellar pathology are at increased risk of falls so stay close to them.

Normal gait
- Ask patient to walk to end of the room and the turn back
- Observe gait:
o Stance: broad-based ataxic gait associated with midline cerebellar pathology (e.g.
MS)
o Stability: staggering, slow and unsteady gait is typical of cerebellar pathology
o Turning: will struggle with turning manoeuvre

Heel-to-toe
- Ask the patient to walk to the end of examination room with their heels to their toes
- This exacerbates unsteadiness making it easier to identify more subtle ataxia

Romberg’s test
- Assesses for loss of proprioception / vestibular function SENSORY ATAXIA
- Does not assess for cerebellar function
- Keep patient in arms reach
- Patient places arms by side / across chest
- Ask to close eyes observe for imbalance

Central Signs

1. Dysdiadochokinesis
Dysdiadochokinesia is a term that describes the inability to perform rapid, alternating movements.
It is a feature of ipsilateral cerebellar pathology.

- Ask patient to put palm on top of right palm

- Turn over rapidly
- So touch back of hand then return to original position
- Ask patient to repeat movements as fast as they can
- REPEAT WITH OTHER HAND

Note: if cerebellar pathology movements may seem slow and irregular.

2. Intention Tremor
Finger-to-nose test
- Ask patient to touch with the tip of their index finger and touch your finger tip
- Make sure at extremes of reach
- Move around finger and ask patient to do this as fast as possible
 3. Slurred Speech
Ask patient to repeat:

“British Constitution”
“Baby Hippopotamus”

Cerebellar lesions can cause ataxic dysarthria. Slurred speech is often mistaken for patient’s being
intoxicated.

4. Nystagmus
H-test
- Ask the patient if they report any double vision
- Observe the patient’s eyes for nystagmus

Lower Limbs

1. Tone

Leg Roll
Knee lift
- Lift each knee briskly off the bed (warn patient first)
- Observe movement of leg
- With normal tone the heel remains in contact with bed
- Increased tone heel will lift of the bed

Note: hypotonia is seen with cerebellar pathology

2. Heel-to-shin test

Heel-to-shin test is a test of lower limb co-ordination

- Ask patient to place their heel onto opposite knee

- And run their heel down to ankle in a straight line
- Ask them to repeat motion in a smooth motion
- REPEAT examination on opposite limb

3. Reflexes
Knee jerk reflex
- Sat off bed + relax
- Hit patella tendon with tendon hammer
- Ask patient to look to opposite corner of room and clench hands together distraction
technique whilst hitting with tendon hammer
Complete examination
- Thank patient
- Wash hands
- Summarise findings
- Further tests
o Full neurological examination
Central nerve examination
Peripheral nerve examination (upper and lower limbs)
o Formal audiometry
o Imaging:
MRI head (if concerns of space occupying lesion)

Questions
What is the difference between upper or lower motor neurone injury on clinical examination?

UMN Signs LMN Signs

Example Brain lesion / injury Nerve roots
Spinal cord injury Peripheral nerve injury
Causa equina
Wasting No Yes
Fasciculation No Yes
Tone Increased Decreased
(spaticity / rigidity) (hypotonia)
Power Decreased Decreased
Reflexes Hyper-reflexia Hypotreflexia
Exaggerated / brisk Reduced / absent
Plantar reflexes Upgoing Downgoing
(Babinki’s +ve) (Babinski’s -ve)

What is proprioception?

The awareness of one’s body position in space

What is Romberg’s test based on?

Based upon the premise that a patient requires at least two of the following three senses to
maintain balance whilst standing?

- Proprioception
- Vestibular function
- Vision

When closing eyes will test functioning of vestibular and proprioception. Loss of balance = sensory
ataxia.
What is cauda equina syndrome?

Compression of the cauda equina nerves within the spinal canal after termination of the spinal cord
at L1/2. Presents with lower motor neurone lesion signs, saddle anaesthesia plus urinary and bowel
dysfunction.

What can cause cauda equina syndrome?

- Posterior disc prolapse

- Malignancy
o Including metastatic disease
- Trauma
- Spinal Abscess
- Epidural haematoma

What are the five red flag symptoms of causa equina syndrome?

- Saddle anaesthesia
- Urinary / bowel dysfunction
- Sexual dysfunction
- Severe lower back pain
- Bilateral LMN signs

What is the investigation and management of suspected cauda equina?

- Investigation
o URGENT MRI
- Management
o Emergency referral to neurosurgeons
o If confirmed cauda equina on MRI
o Needs urgent decompression