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 MOVEMENTswellings 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 swellingmoving 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 SWELLINGSparotid adenoma recurred after surgery

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

LOSS OF BODYWEIGHT-malignant&tuberculosis LOSS OF APPETITE-malignant&tuberculosis HISTORY OF FEVERacute& 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,PL ASMA 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 CAVITYEMPYEMA 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

SWELINGS WHICH HAVE CONTINUITY WITH ABDOMINAL CAVITY-HERNIA

SWELLINGS WHICH HAVE CONTINUITY WITH SPINAL CORDMENINGOCELE

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 PULSATIONANEURISM

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 NODESno 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