3.2 Head and Neck Examination

3.2 Head and Neck Examination

Quick Answer: The head and neck examination for Part III combines a focused cranial nerve screen, thyroid palpation, lymph node survey, carotid assessment, TMJ evaluation, and cervical soft tissue palpation. Because so much of chiropractic practice involves the cervical spine, this section is also where the exam tests your ability to recognize vascular and neurological red flags -- especially signs of vertebrobasilar insufficiency -- before cervical manipulation.

The head and neck examination sits at the intersection of general medical screening and chiropractic-specific safety screening. Every structure examined here -- cranial nerves, thyroid, lymph nodes, carotid arteries, the TMJ, and cervical soft tissue -- can either reveal a systemic medical problem or change whether cervical manipulation is safe to perform that day. Part III questions in this domain frequently combine two findings (for example, a cervical bruit plus dizziness) and ask what that combination means for the treatment plan.

Cranial Nerve Screening for Chiropractic Practice

A full 12-nerve cranial nerve exam is rarely necessary in a chiropractic setting, but a targeted screen is essential whenever a patient reports dizziness, visual disturbance, or neck symptoms before cervical treatment.

Before cervical spine manipulation, many clinicians use a screening mnemonic for vertebrobasilar insufficiency (VBI) built around the "5 Ds and 3 Ns": dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, and numbness (perioral or facial). Any of these findings on history or cranial nerve screening should delay or avoid high-velocity cervical manipulation pending further workup.

Thyroid Examination

The thyroid gland is examined by inspection and palpation, typically from behind the seated patient:

• Inspection -- observe the neck for visible masses or asymmetry, then ask the patient to swallow; a thyroid mass characteristically rises with swallowing because the gland is fixed to the trachea.
• Palpation -- palpate each lobe and the isthmus for size, symmetry, nodularity, and tenderness.
• Auscultation -- if the gland is enlarged, auscultate for a bruit, which suggests increased vascular flow (as in Graves' disease).

Diffuse, symmetric, non-tender enlargement suggests a hyperthyroid or hypothyroid goiter; a firm, tender, and possibly asymmetrically enlarged gland suggests thyroiditis; and a discrete, hard, or rapidly growing nodule raises concern for thyroid malignancy and warrants referral.

Lymph Node Examination

Systematic palpation of the head and neck lymph node chains can reveal infection or malignancy that a musculoskeletal exam alone would miss.

When palpating nodes, describe size, mobility, consistency, and tenderness. Mobile, tender, and soft nodes suggest a reactive or infectious process; fixed, hard, and non-tender nodes are more concerning for malignancy, particularly in the supraclavicular chain, and should prompt referral rather than reassurance.

Carotid Artery Examination

Carotid assessment is performed gently, one side at a time, to avoid provoking a vasovagal response or dislodging plaque:

• Palpation -- assess pulse amplitude and symmetry at the angle of the jaw; never palpate both carotids simultaneously.
• Auscultation -- listen with the bell of the stethoscope for a bruit, a turbulent, whooshing sound suggesting significant stenosis.

A carotid bruit, particularly in a patient with vascular risk factors (hypertension, smoking, diabetes, hyperlipidemia) or neurologic symptoms, is a red flag that should factor into both general medical referral and the safety calculus for cervical manipulation.

Temporomandibular Joint (TMJ) Examination

The TMJ is examined with the patient opening and closing the mouth while the examiner palpates just anterior to the tragus:

• Inspection -- observe for deviation of the jaw on opening (suggests unilateral joint or muscle dysfunction).
• Palpation -- feel for clicking, popping, crepitus, or tenderness over the joint.
• Range of motion -- normal maximal mouth opening is approximately 40-50 mm (roughly three finger-widths).
• Auscultation -- an audible click on opening or closing suggests disc displacement.

TMJ dysfunction frequently coexists with cervical dysfunction and tension-type headache, so findings here should be integrated with the cervical spine and headache history rather than treated as an isolated finding.

Cervical Soft Tissue Examination

Palpation of the cervical paraspinal muscles, trapezius, sternocleidomastoid, and suboccipital muscles assesses tone, tenderness, and the presence of trigger points or spasm, and is correlated with active and passive cervical range of motion. While detailed orthopedic and neurological testing of the cervical spine falls under the Neuromusculoskeletal Examination content area, the general physical exam still captures baseline soft tissue findings (guarding, asymmetry, palpable spasm) that inform the overall clinical picture before more specific testing begins.

Putting It Together: Head and Neck Red Flags

Exam Tips

• Learn the "5 Ds and 3 Ns" cold -- VBI screening questions are a recurring Part III theme tied directly to cervical manipulation safety.
• Remember that Virchow's node (left supraclavicular) is the single most tested lymph node finding because of its strong link to abdominal/thoracic malignancy.
• Never palpate both carotids at the same time -- this is both a safety principle and a frequently tested fact.
• Differentiate cranial nerve findings that are musculoskeletal-adjacent (XI, V) from those that are pure red flags for central pathology (III, IV, VI, VIII, IX, X).