Note the position of the trachea in the suprasternal region. Ask the patient to relax the sternomastoid muscles by dropping their chin, and to lean slightly forward. Rest your middle finger on the suprasternal notch and pass it on either side of the trachea as deeply and inferiorly as possibly (figure 14a,b). The latter is important because even gross tracheal deviation may be missed if the examining finger comes into contact with the trachea at too high a level. The trachea may be displaced by tumors in the neck or upper mediastinum, by a mediastinal shift due to a pneumothorax, a massive pleural effusion or a collapsed lung.

A tracheal tug (figure 15) indicates the presence of significant lung fibrosis or severe airflow obstruction. Rest your fingers on the trachea to feel it move inferiorly during inspiration.

Palpate the supraclavicular fossae for lymphadenopathy (figure 16). This can be undertaken from the front, but the pulps of the fingers can be inserted deep to the clavicle more easily from behind. Supraclavicular nodes of interest in pulmonary disease include the scalene lymph nodes that lie deep to the sternomastoid muscle insertion (page 267).