INSPECTION The patient should ideally be exposed from the clavicles. Observe for lumps, skin changes and scars. Ask the patient to point to any lump if one is not obvious. Patients with midline lumps should be observed whilst drinking a sip of fluid and protruding the tongue. The thyroid gland is enveloped in pre-tracheal fascia along with the trachea. It will rise with laryngeal elevation during swallowing. Ask the patient to hold the fluid in the mouth before swallowing, giving the examiner time to concentrate on any movement. A thyroglossal cyst will elevate with tongue protrusion, being attached via the thyroglossal duct remnant to the foramen caecum of the tongue. Ask the patient to open their mouth, observe the lump and then ask them to protrude the tongue. Pemberton’s sign is elicited by asking the patient to sit and raise the arms.1 Venous congestion with facial plethora or cyanosis may indicate thoracic outlet obstruction for which a retrosternal goitre
is a cause. Examination of the oral cavity to assess the parotid and submandibular ducts should accompany a thorough neck examination.