What components should be included in a detailed neurological neck exam?

Detailed Neurological Neck Examination

A comprehensive neurological neck examination must include systematic assessment of all 12 cranial nerves with particular focus on CN V, VII, IX, X, XI, and XII, combined with thorough inspection and palpation of neck structures, mucosal surfaces, and evaluation for signs of serious pathology. 1

Essential Cranial Nerve Assessment

The cranial nerve examination is the cornerstone of neurological neck evaluation and must be itemized and systematic 1:

Lower Cranial Nerves (Most Critical for Neck Pathology)

• CN IX (Glossopharyngeal): Assess palate elevation, presence of gag reflex, and evaluate for oropharyngeal pain 1
• CN X (Vagus): Examine vocal fold movement and palate elevation; vocal cord paralysis requires imaging from skull base to mid-chest given the nerve's extensive course 1
• CN XI (Accessory): Test shoulder elevation and assess strength of sternocleidomastoid and trapezius muscles 1
• CN XII (Hypoglossal): Evaluate tongue mobility and look for weakness or paralysis 1

Upper Cranial Nerves

• CN V (Trigeminal): Assess facial sensation across all three divisions 1
• CN VII (Facial): Test facial movement symmetry and strength 1

Comprehensive Mucosal and Structural Examination

This component is critical when evaluating neck masses or suspected head and neck malignancy 1:

Oral and Pharyngeal Assessment

• Oral cavity: Perform both visual and digital (bimanual) examination of the ventral and lateral surfaces of the oral tongue and floor of mouth 1
• Oropharynx: Visually examine the soft palate, tonsillar fossae, and posterior pharyngeal wall; palpate the tongue base and tonsillar fossae 1
• Nasopharynx: Visualize the eustachian tube orifices and superior and posterior walls using mirror or endoscope 1
• Hypopharynx: Examine the pyriform sinuses and posterior pharyngeal wall 1
• Larynx: Visualize the epiglottis, vocal folds, and subglottis 1

Additional Head and Neck Structures

• Nasal cavity: Visual examination of the septum, floor, and turbinates 1
• Otoscopy: Examine for unilateral serous otitis media, which may suggest nasopharyngeal malignancy 1
• Skin and scalp: Inspect for cutaneous malignancy 1

Neck Palpation and Assessment

• Neck mass characteristics: Assess firmness, size, fixation to underlying structures, and precise anatomical location 1
• Lymphadenopathy: Systematically palpate all cervical lymph node chains for additional adenopathy 1
• Bimanual palpation: Perform bimanual examination of the floor of mouth and entire neck to detect deep masses 1
• Salivary glands: Palpate parotid and submandibular glands to assess for masses 1
• Thyroid gland: Palpate to assess for masses or nodules 1

Functional Motor Assessment

• Range of motion: Evaluate cervical spine mobility in all planes, though the validity of these tests for non-operative decision-making remains scientifically unproven 2
• Muscle strength: Test shoulder and neck muscle function, particularly sternocleidomastoid and trapezius (CN XI) 1
• Sensorimotor control: Consider cervical joint position error testing in patients with chronic neck pain, as proprioceptive impairment is a major contributor to persistent symptoms 3

Red Flag Screening

Critical red flags requiring immediate advanced imaging 4:

• Neurological deficits: Myelopathy signs, progressive weakness, bowel/bladder dysfunction 4
• Infection risk: IV drug use history, immunosuppression (diabetes, HIV, chronic steroids), elevated inflammatory markers (WBC, ESR, CRP) 4
• Malignancy indicators: History of cancer, unexplained weight loss 4
• Vascular concerns: Age >50 with vascular disease, suspected dissection 4
• Structural injury: Trauma with high-energy mechanism, coagulopathy 4

Clinical Pitfalls and Caveats

• Avoid relying solely on imaging: The American Academy of Otolaryngology emphasizes that imaging is not a substitute for complete mucosal surface examination 1
• Multiple cranial nerve involvement: Due to close anatomic proximity at the skull base and brain stem, mass lesions frequently affect multiple cranial nerves simultaneously 1
• Otalgia evaluation: Patients with ear pain may require evaluation of CN V, VII, IX, X, and upper cervical nerves C2-C3, as any can be the pain source 1
• Reliability limitations: Many common neck examination tests have poor to fair reliability; bimanual sensitivity testing demonstrates the best kappa values and should be prioritized 5
• Neurogenic dysfunction prevalence: Approximately 80% of patients with neck/shoulder problems have neurogenic dysfunction in the affected area and should be systematically screened 5