What is the step‑by‑step neck physical examination for a patient presenting with neck pain, swelling, dysphagia, or voice changes?

Neck Physical Examination: Step-by-Step Approach

For patients presenting with neck pain, swelling, dysphagia, or voice changes, perform a systematic examination starting with facial and scalp inspection, followed by oral cavity and oropharyngeal assessment, and concluding with neck and thyroid palpation—this approach identifies red flags for malignancy while ruling out serious pathology. 1

Initial Inspection

Face and Scalp Assessment

• Inspect the face for swelling, edema, ulcerations, or pigmented lesions that may suggest cutaneous malignancy or metastatic disease 1
• Examine the scalp thoroughly for ulcerations or pigmented lesions, as melanoma or other skin cancers can metastasize to cervical lymph nodes 1
• Assess for changes in skin lesion symmetry, border, color, diameter, or presence of ulceration—these findings raise suspicion for melanoma 1

Oral Cavity Examination

Tongue and Floor of Mouth

• Remove dentures completely before beginning the oral examination to allow inspection of all mucosal surfaces 1
• Use gauze to grasp and extend the tongue laterally to visualize the lateral tongue borders, which are common sites for squamous cell carcinoma 1
• Assess tongue mobility—limited movement may indicate muscle or nerve invasion from tumor 1
• Palpate the floor of the mouth bilaterally to identify masses or ulcerations that may not be visible 1

Oropharyngeal Examination

• Use a bright light and tongue depressor, but do NOT ask the patient to protrude their tongue—tongue protrusion obscures the oropharynx and causes the tongue to resist depression, limiting visualization 1
• Ask the patient to open their mouth while keeping the tongue relaxed in the floor of the mouth 1
• Inspect the palate, tonsillar region, and posterior pharyngeal wall for asymmetry, masses, or ulcerations 1
• Palpate the oral tongue, base of tongue, and tonsils if the patient reports symptoms in these areas or if visual inspection raises concern 1
• Recognize that the base of tongue cannot be fully examined without flexible or indirect mirror laryngoscopy—refer to a specialist if the examination is incomplete 1

Neck Palpation

Systematic Neck Examination

• Palpate the entire neck systematically for masses, assessing size, consistency, mobility, and tenderness 1
• Nontender neck masses are more suspicious for malignancy than tender masses—this is a critical distinguishing feature 1, 2
• Assess mass characteristics that increase malignancy risk: size >1.5 cm, firm consistency, and fixation to adjacent tissues 1, 3
• Be aware of normal anatomic structures frequently mistaken for pathologic masses: submandibular glands, hyoid bone, transverse process of C2, and carotid bulb 1

Thyroid Gland Assessment

• Palpate the thyroid gland bilaterally for nodules, enlargement, or asymmetry 1
• Assess thyroid masses in the context of patient age—thyroid cancer is particularly common in women under 40 years 1

Ear Examination for Referred Pain

• In patients with neck mass and otalgia, examine the pinna, external auditory canal, and tympanic membrane 1
• An unremarkable ear examination with persistent otalgia suggests possible referred pain from pharyngeal malignancy 1

Red Flags Requiring Urgent Specialist Referral

High-Risk Features on Examination

• Mass present ≥2 weeks without resolution 3, 4
• Size >1.5 cm (the upper limit of normal for even the largest cervical lymph node, the jugulodigastric node) 1, 3
• Firm or fixed consistency 1, 3
• Associated voice changes, dysphagia, odynophagia, or unexplained weight loss 1, 3, 2
• Tonsil asymmetry or oropharyngeal ulceration 1
• Limited tongue mobility 1

Critical Pitfall to Avoid

Do not prescribe multiple courses of antibiotics without establishing a diagnosis—this delays recognition of malignancy or other serious pathology, particularly in patients over 40 years 4, 2. Physical examination has limitations in identifying malignancy, and approximately half of persistent neck masses in adults are malignant 3.