The lateral view of the head and neck in figure 113 demonstrates lymph nodes, salivary and thyroid glands, the common carotid artery bifurcation and the internal jugular vein.

Figure 113 Anatomy of cervical lymphatic chains.

1. Superficial temporal artery
2. Masseter muscle
3. Facial artery
4. Submental
5. Submandibular gland
6. Superfical and deep parotid
7. Posterior auricular
8. Occipital
9. Anterior belly of digastric muscle
10. Posterior belly of digastric muscle
11. Jugulodiagastric
12. Sternomastoid muscle
13. Deep cervical lymph chain
14. Omohyoid muscle
15. Jugulo-omohyoid
16. Superifical cervical lymph chain 17. External jugular vein
18. Internal jugular vein
19. Prelaryngeal
20. Pretracheal
21. Supraclavicular
22. Subclavian vein

The cervical lymph nodes are commonly enlarged, secondary to infective conditions of the tonsil, throat, ear and nose, and are the commonest lumps in the neck. They may occasionally undergo suppuration with abscess formation, this is most common with tuberculous infections. Cervical node enlargement may also be the first sign of generalised lymphatic disease or of metastases. The latter may be from anywhere in the head and neck, but also elsewhere in the body and it may require extensive investigation to find the primary lesion: particular attention must be given to the breast and lung.

The submental, submandibular, parotid, postauricular and occipital nodes are examined in their circle around the base of the skull (figure 114a–e).

The deep cervical lymph chain, lies around the internal jugular vein; commence your examination in the submandibular triangle. The chain passes deep to the sternomastoid muscle and, in the lower neck, extends laterally into the supraclavicular region (figure 115a–c).

Although the vast majority of cervical lymphadenopathy is related to head and neck disease, the scalene nodes are an exception. This group of supraclavicular nodes, is situated behind the lower end of the sternomastoid muscle. They are a common site for metastases from breast, lung, gastrointestinal and genitourinary malignancies, particularly on the left side.

The scalene nodes can easily be missed if you do not palpate deep to the sternomastoid. To assess whether a mass is deep, fixed to, or superficial to the sternomastoid muscle, ask the subject to turn their chin away from the side being examined, pressing against your hand. This allows the demonstration of mobility of superficial or deep masses in relation to the tensed muscle (figure 116a–c).

Smaller superficial cervical nodes are frequently palpable along the line of the external (figure 117), and to a lesser extent the anterior, jugular veins.

Palpate the superficial lymph chain along the length of the external jugular vein completing the examination by palpation along the borders of the trachea and larynx for nodes along the anterior jugular vein. Occasionally nodes are encountered on the isthmus of the thyroid gland and over the larynx; these small “delphium” nodes are related to thyroid and other superficial malignancies.