EXAMINATION OFSWELLING

DR.K.SUGUNAKAR

HISTORY

how long is the lump present?

when was the lump first noticed?

There is a heaven and hell difference

between these two questions.

Pain less lump may present for along time

with out patients knowledge.

SHORTDURATION&PAIN: INFLAMMATORY

SINCE BIRRTH:CONGENITAL

LONGER DURATIONWITH OUT PAIN :BENIGN

LONGER DURATION WITH PAIN AND SHORT DURATION-------------MAYBE MALIGNANT

MODEOF ONSET

HAVE APPEARED AFTER TRAUMA ;fractured displacement of bone,dislocation of joint,haematoma

DEVELOPED SPONTANEOUSLY AND GROWN RAPIDLY WITH PAIN: inflammatory

GRADULLY INCREASING INSIZE: neoplasm

SWELLING APPEARED IN PRE EXISTING CONDITION: keloid from previous scar, malignant melanoma from previous benign nevus

OTHER SYMPTOMS

PAIN----inflammatory or involving nerves

DIFFICULTY IN RESPIRATION---pressure on trachea

DIFFICULTY IN SWALLOWING--- pressure on esophagus

INTERFFERING WITH MOVEMENT—swellings near joint

DISFIGURATION

pain

Nature of pain: throbbing pain suggests inflammation

leading to suppuration.pain may be burning,stabbing,aching.

Site:most offen pain is localised to the site of swelling. referred

pain may be present

Time of onset: in inflammatory swellings.pain appears even

before the swelling.but in case of tumors swelling appears long

before pain.in malignant conditions pain is due to involvement of

nerves,fungation,ulceration,deepinfiltration,which indicates

inoperability

PROGRESS OF THE SWELLING

GROWING SLOWLY-------benign swellings

GROWING QUICKLY--------malignant swellings

SUDDENLY INCREASING IN SIZE AFTER REMAINING

STATIONERY FOR SOME TIME----malignant transformation of

benign swellings

DECREASING IN SIZE------inflammatory swellings

EXACT SITE: site of the swelling tells from

which organ the swelling was originated.

PSENCEOF OTHER LUMPS:

neurofibromatosis,diaphysial

aclasia,hodgkins lymphoma may present

with multiple swellings.

PSENCE OF OTHER LUMPS:

neurofibromatosis,diaphysial

aclasia,hodgkins lymphoma may present

with multiple swellings.

EXACT SITE: site of the swelling tells from

which organ the swelling was originated.

SUB MANDIBULAR REGION

SUB MANDIBULAR GLAND

LYMPH NODE

PLUNGING RANULA

Swelling present since

birth

Neck swelling in posterior and anterior

triangle of neck

Cystic swelling

Swelling present since birth

Neck swelling in posterior and

anterior triangle of neck

Cystic swelling

DERMOID AT THE FUSION OF

SUTURE LINES

-outer canthus of eye

Thyroid swelling—moving upward with digglutition-video

SECONDARY CHANGES LIKE

SOFTENING,ULCERATION,FUNGATION,IN

FLAMMATORY CHANGES----malignant

swellings &T.B.lymphadenitis

SECONDARY CHANGES---------------------------------------------------------- FUNGATION

SECONDARY CHANGES-------------------------------------------------SKIN ULCERATION

SECONDARY CHANGES-------------------------------------------------SKIN ULCERATION

RECURRENT SWELLINGS---malignant

swellings, malignant growth in benign

swellings.certain swellings like pagets

recurrent fibroid,known for recurrence.cystic

swellings may recur if they are not removed

completely.

RECURRENT SWELLINGS—parotid adenoma recurred after surgery

Dermato sarcoma protuberance ----------------------------known for recurrence

LOSS OF BODYWEIGHT--

malignant&tuberculosis

LOSS OF APPETITE--

malignant&tuberculosis -

HISTORY OF FEVER—acute& chronic,

inflammatory swellings, malignant swellings,

lymphomas

PAST HISTORY; important in tuberculosis

FAMILY HISTORY: important in carcinoma breast,medullary carcinoma thyroid,

PERSONAL HISTORY: smoking and alcoholism are risk factures for several malignancies

LOCAL EXAMINATION

SITE OF THE SWELLING: a few swellings are peculiar in their positions such as dermoid cyst are mostly seen in the mid line of the body or on the line of the fusion of embryonic processes.eg.at the outer canthus of eye---that means on the line of fusion between the fronto-nasal process and the maxillary process.or behind the ear (post auricular dermoid)---on the line of fusion of the mesodermal hillocks which form the pinna.

SHAPE OF THE SWENG;ovoid,sperical,irregular

DERMOID AT THE FUSION OF

SUTURE LINES

-outer canthus of eye

DERMOID AT THE FUSION OF

SUTURE LINES

-outer canthus of eye

COLOUR OF THE SWELLING:colour of the

swelling give a definitive hint to the

diagnosis. black color of benign nevus and

malignant melanoma, red/purple color of

haemangioma.

bluish color of ranula are obvious and diagnostic

SURFACE: in certain swellings suface may

be very much obvious and diagnostic.

cauliflower surface of squamous cell

carcinoma, irregular numerous branched

surface of papilloma.

Papilloma from nipple ---------------------------------------------------irregular numerous branched surface of papilloma.

NUMBER: this is important as this may give

a clue to the diagnosis. some swellings are

always multiple such as

neurofibromatosis,diaphysial

aclasia,hodgkins lymphoma

some swellings are more known to be

solitary ,eg.lipoma,dermoid cysts

MULTIPLE SWELLINGS-------------------------------------------NEUROFIBROMATOSIS

MULTIPLE SWELLINGS-

Sebaceous cysts

Lipoma- nape of the neck –most common site- solitary swelling

DERMOID---solitary swelling

BLUE COLOURED SWELLING IN THE FLOOR OF THE MOUTH------RANULA

Redness,oedema,&pain---inflammatory swellings

PULSATION: swellings arising from the arteries are pulsatile,eg.aneurysm and vasculargrowth such as carotid body tumor. These give expansile pulsations.some swellings present over the arteries will be pulsatile.these will give transmitted pulsations

SKIN OVER THE SWELLING: red edematous in inflammatory swellings.tense,glossy with venous prominence in sarcoma with rapid growth. presence of black punctum in sebaceous cyst.presence of scar indicates previous operation(when the scar is linear with suture marks) previous injury(regular scar),previous suppuration(puckered,broad,irregular scar)

Redness,oedema,&pain---inflammatory swellings

Skin------tense,glossy with venous prominence in sarcoma with rapid growth

Sebaceous cysts----------skin is not pinchable,cystic swelling with punctum

Scar---previous surgery

PALPATION

LOCAL RISE OF

TEMPERATURE:

DUE TO INCREASED

VASCULARITY

MAYBE

INFLAMMATORYOR

VASCLAR TUMOR LIKE

SARCOMA

TENDERNESS

GENTLE PRESSURE

OVER SWELLING

SHOULD SEE THE FACIAL

EXPRESSION

INFLAMMATORYSWELLIN

GS ARE TENDER

NEOPLSTIC SWELLINGS

ARE NON TENDER

SIZE ,SHAPE ,EXTENT CAN BE CLEALRY KNOWN WITH

PALPATION

IT IS BETTER TO MENTION IN VERTCAL AND HORIZONTAL

DIAMETRES

SURFACE

SMOOTH

NODULAR

LOBULAR

IRREGULAR

CYSTIC

LYMPHNODAL MASS

LIPOMA

MALIGNANT

SMOOTH SURFACE

NODULAR SURFACE

EDGE

WELLDEFFINED

SMOOTH

IRREGULAR

ILLDEFINED

NEOPLSTIC,CHR.INFL

BENIGN

MALIGNANT

ACUTE

INFFLAMMATORY

SLIP SIGN

BOTH LIPOMA AND CYST

HAVE SMOOTH

MARGINNS

LIPOMA SLIPS AWAY ON

PALPATION

CYST YIELDS ON

PALPATION

CONSISTANCY

IT DEPENDS ON WHAT IT IS MADE UP OF

CYSTIC

FIRM

HARD

UNIFORM IN COSISTACY OR VARIABLE IN CONSISTACY

FLUCTUATION

SWELLING FLUCTUATES WHEN IT HAS FLUID

FIRST TO FIX THE SWELLING

THIS TEST SHOULD BE PERFORMED IN TWO PLANES

PAGETS TEST

TRANSLUSENCY

THIS MEANS SWELLING TRASMITS LIGHT WHEN IT HAS CLEAR FLUID LIKE WATER,LYMPH,SERUM,PLASMA

NOT TRANSULANT WHEN IT CONTAINS OPAQUE FLUID LIKE BLOOD,PUS,PULTAEOUS MATERIOL

Translucency brilliantly Positiveinhydrocele,ranula

,cystic hygroma

IMPULSE ON COUGHING

SWELINGS WHICH HAVE CONTINUITY WITH ABDOMINAL CAVITY-HERNIA

SWELLINGS WHICH HAVE CONTINUITY WITH SPINAL CORD-MENINGOCELE

WHICH HAVE CONTINUITY WITH PLEURAL CAVITY-EMPYEMA NECESSITANCE

SWELLING IS PALPATED IN FINGURES AND ASKED TO COUGH AN IMPULSE WILL BE FELT DUE TO INCREASE PRESSURE IN THESE CAVITIES

INCASE OF CHILDREN THIS IS PERFORMED WHEN THEY CRY

I

SWELINGS WHICH HAVE CONTINUITY WITH ABDOMINAL CAVITY-HERNIA

SWELLINGS WHICH HAVE CONTINUITY WITH SPINAL CORD-MENINGOCELE

REDUCIBILITY

SWELLING REDUCES AND ULTIMATELY DISSAPPEARS AS

SOON AS PRESS UP ON

Does not appear on removal of swelling

Appears after increase in counter pressure

THIS IS A FEATURE OF HERNIA

LYMH VARIX,VARICOCELE,SAPHENA

VARIX,MENINGOCELE ARE REDUCIBLE PARTLY OR

COMPLETELY

SWELLING REDUCES AND ULTIMATELY DISSAPPEARS AS SOON AS PRESS UP ON

HERNIA

COMPRESSIBILITY

THE SWELLING CAN BE COMPRESSED BUT NOT BE

DISSAPPEARED COMPLETELY

THE SWELLING REAPPEAS WHEN PRESSURE IS TAKEN

OFF

HAEMANGIOMA,LYMPHANGIOMA

HAEMANGIOMA

PULSATILITY

ARISING FROM ARTERY--EXPANSILE PULSATION-

ANEURISM

VERY CLOSE TO ARTEY---TRANSMITTED PULSATION

SWELLING IS HIGHLY VASCULAR-----------

TELANGIECTATIC SARCOMA

FIXITY TO THE SKIN

SHOULD TEST WHETHER SKIN OVER THE SWELLING

PINCHABLE OR NOT

SEBACEOUS CYST, PAPILLOMA,EPITHELIOMA ARISE

FROM SKIN THEY MOVE WITH SKIN

IN MALIGNANT SELLINGS IF SKIN IS INFILTRATED SKIN IS

NOT PINCHABLE

SEBACEOUS CYST, ARISE FROM SKIN THEY MOVE WITH SKIN

PAPILLOMA, ARISE FROM SKIN

MOVE WITH SKIN

PLANE OF THE SWELLING

SKIN---SKIN IS NOT MOVED OVER THE SWELLING

SUBCUTANEOU TISSUE----the tumors arising from subcutaneous are free from both skin and underlying contracted muscle.SKIN IS PINCHABLE&SWELLING PROMINENT WHEN MUSCLE IS contracted & MOVES freely over contracted muscle

Swellings arising from the deep fascia are not as mobile as those arising from the sub cutaneous tissue.but it is very difficult to find out whether the tumor is fixed to deep fascia or not as the fascia can not be made taught separately from muscle.

When the tumor arises from sub cutaneous tissue and fixed to

muscle, the tumor will be more prominent and cannot be moved

along the fibres of muscle when the muscle is contracted.

If the tumor incorporated in the muscle, it will be fixed and

decreases in size when the muscle is contracted. If the tumor lies deep to muscle, it virtually disappears as soon

as muscle become taught

Some times swelling appears when the muscle is taught. this is

due to tear in the tendon concerned.

Swellings in connection with the tendon of muscle moves along

with the tendon and become fixed when the muscle is made

taught against resistance.

Swelling in connection with the vessels and nerves don't move

along the line of the said vessel , the but moves a little extent at

right angles to their axes

Swellings arising from bone or absolutely fixed even when the

muscle is relaxed and cannot be moved apart from bone.

Secondary changes to the swelling-----seen in malignant swellings,tuberculous lymph nodal mass

REGIONAL LYMPH NODES—no examination is complete with out the examination of draining lymph nodes. When regional lymph nodes are enlarged it is good practice to examine other group of lymph nodes. to exclude generalized lymphadenopathy.-

PERCUSSION :the importace of this examination is not that much important in swelling. its sole place is to find out the presence of resonant note on percussion over hernia. or to elicit tender ness in brodies abscess.

Auscultation: all pulsatile swellings should be

Auscultated.machinary murmer is heard in an aneurysmal varix.

Movements: joints nearby swelling should be examined for

movements to find out whether the joint is involvedd or not.

Examine for pressure effects: 1)the arterial pulse distal to

swelling some times swelling may press upon main artery of the

limb and cause weak pulse distally.2)the nerves may be

effected by the pressure of swelling, this cause wasting of

muscle,paresis,paralysis.3)swelling may exert pressure on

bone eroding it as in aneurysm,dermoidcyst.

General examination in malignant swellings

Examine the chest for consolidation, pleural effusion

Liver for secondaries

General examination of abdomen to find out peritoneal metastases

The spine,pelvis,the trochanters of femurs,skull to exclude metastases

If one group of lymph nodes are enlarged examine other group of lymph nodes

If swelling is suspected of gumma or condyloma, examine for other syphilitic stigmata

REGIONAL LYMPH NODES

TB breast with

Secondary suppurative

Axillary L.nodes