Approach to swelling

Presented by:Dr Nikil Jain

CONTENTSINTRODUCTIONEXAMINATION OF SWELLINGSWELLINGS IN OROFACIAL REGIONCERVICAL LYMPHADENOPATHYCONCLUSION

•Swelling in the head and neck and orofacial region is very common

•It is necessary to approach a swelling to illicit the correct diagnosis for the correct treatment plan.

•Swelling- An abnormal Enlargement or

protuberance in the body

Two types – Generalized e.g. congestive heart failure Localized e.g. cellulitis

•An integral aspect of patient evaluation and management is the development of a clinical diagnosis.

•Diagnosis should be done in sequential manner

1. Complete history2. Clinical examination3. Radiographic and other investigation4. Diagnosis

•Case history includes:•Name /age /sex•Chief complaint•History of presenting illness•Past medical history/past dental history•Family history•Personal history•Clinical examination: General

examination Local

examination

Examination of swelling• History• Duration – If swelling is present since birth,it might be

meningocoel or sacrococygeal

Shorter duration swellings are inflammatory and painful

Shorter duration – rapid growth –malignancy

Long duration - not painful - might be neoplastic but more likelihood of being benign

•Mode of onset-Appears immidiately after trauma eg

hematoma

Develop spontaneously and grow rapidly eg inflammation

Steadily growth eg.malignancy

Very slowly eg benign growth

•Exact size and shape –•It gives clue to the anatomical

structure from which the swelling has originated

•Progress of swelling –Enquire swelling growing slowly or

remained stationary for a long time

If growing again after a stationary period of time ,indicates malignant transformation of a benign tumor

•Pain – Note siteLocalized/Genralized/ReferredThrobbing /Dull/ Aching Throbbing pain suggests an

inflammatory lesion tending to suppurate

Pain before swelling – inflammationSwelling before pain – growth Pain absent in benign and early

carcinomas When pain appears in carcinoma,it

signifies complications such as ulceration,deep infiltration ,involvement of nerve .

•Secondary changes – If ulceration,fungation ,softening

present enquire when they first appeared

Similar swelling – elsewhere in body

Loss of body weight – since appearance of swelling

Local Examination

•Inspection•Palpation•Percussion •Auscultation •Measurement •Examination for pressure effects•Aspiration

Inspection

•Number

•Situation or site – observe the extent of swelling in horizontal and vertical directions or in relation to landmarks present in vicinity of the swelling

•Shape and size – ovoid/spherical /pyriform /irregular

•Colour – •Red or purple eg heamngioma•Blue eg ranula , mucous cyst•Black eg melanoma

•Surface – • smooth / lobulated /nodular

/irregular

•Edge – •Circumscribed or diffuse•Base pedunculated or sesile

•Skin over the swelling – •Smooth or discharge•Engorged vein or visible pulsation•Pigmentation•Any scar formation

Palpation

•Defined as examination with hands

•It implies a deliberate attempt to elicit physical signs and includes the performance of certain tests

•It confirm the results of inspection and provides additional information

•Local temprature- local temprature always raised in inflammatory swellings

•Tenderness – tenderness is a sign•Ask pt.to show the tender area so

unnecessary discomfort avoided•Locate the point of max. tenderness

•Position ,size & extent – all inspectory findings confirm by palpation

•Feel all around the swelling and estimate the depth to estimate the 3 dimensions

•Surface – •Smooth – cyst•Lobular – lipoma• nodular – mass of large lymph node•Rough and irregular- carcinoma

•Edges or margins – may be clearly defined or diffuse, fading into surrounding tissues

•Consistency •Soft- lipoma •Cystic – cyst or chronic abscess•Firm – fibroma •Stony hard – secondary carcinoma of

lymph nodes•Bony hard - osteoma

•Fluctuation – valuable sign indicating the presence of fluid with in the swelling

•When pressure applied to mass on one side ,a transmitted impulse felt on other side.

•Translucency - to determine fluid inside the swelling clear or otherwise

•Swelling containing clear fluids e.g. ranula meningocoel

•Anatomical plane and fixidity• determine whether swelling attched

to ,adherent or fixed to skin, subcutaneous tissue,deep fascia, muscles, tendon, vessel nerve ,bone,

•Pulsation- two types 1. Transmitted – whole swelling moves en

mass due to pulsation in some near by structure usually a artery

2. Expansile - swelling itself expand and contracts with heart beats ,e.g.aneurysm of artery

Percussion

•Mainly usedd to differentiate gaseous swelling from fluid swellings,former being resonant and later dull

•Sometimes percussion is used to elicit renderness over a bony swelling

Auscultation

•All pulsatile swelling should be examined with stethoscope for any murmur

•Determine whether it is distolic systolic or continous

Measurements

• should be taken to ascertain the size of tumor and to determine its rate of growth by taking measurements at intervals

•Approximate measurement gives an idea of extend of swelling or tumor

Lymphnodes

•Draining area of the tumor or swelling must be examined

Aspiration

•Primary value of aspiration is to investigate the fluid contents of soft ,cheesy or rubbery masses

•Nature of material contained in mass contribute significantly to the formulation of appropriate differential diagnosis

Types of Aspirate

Diagnosis

Clear , pale , straw coloured fluid with cholesterol crystals

Dentigerous cyst

Creamy white , thick aspirate

Odontogenic cyst

Yellowish ,foul smelling fluid

Infected cyst

Blood 1. Needle in blood vessel2. Vascular lesion

Air 1. Maxillary antrum2. Traumatic bone cyst

•LAB INVESTIGATIONS▫This can be done according to suggested

diagnosis from history and the clinical Examinations. Blood Tests : CBC, Urea and

Electrolytes, RBS, T3, T4, TSH

▫Tuberculin test▫CXR, Cervical X-rays▫FNA▫USS▫Thyroid Scan▫Head and Neck CT-Scan▫MRI

•Swelling in oral cavity•The primary disease processes that

give rise to swellings and tumors of the oral cavity include cysts, mucous extravasation and retention in the minor salivary glands, foci of granulation tissue and inflammation,abscesses and connective-tissue proliferations that are well defined or encapsulated, as well as infiltrative sarcomas.

•As for location, certain diseases tend to occur in specific sites to the exclusion of others.

Orofacial Soft-Tissue Swellings according to Site

•Lips and buccal mucosa - Fibroma, Mucocele, Mesenchymal tumor, Salivary tumor, Squamous cell

carcinoma

•Gingiva - Parulis, Pyogenic granuloma, Peripheral fibroma, Peripheral Giant cell granuloma, Peripheral Ossifying fibroma, Gingival cyst, Peripheral Odontogenic tumors,Ssquamous cell carcinoma

•Palate - Abscess, Torus, Salivary gland tumor

•Dorsolateral tongue - Fibroma, Granular cell

tumor, Pyogenic

granuloma, Squamous cell

carcinoma

•Ventral tongue and oral floor - Mucocele, Ranula, Lymphoid aggregates, Lymphoepithelial cyst, Osteocartilagenous

choristoma, Squamous cell carcinoma

•Masseteric region - Cellulitis, Space infection, Jaw cysts and

tumors, Masseteric

hypertrophy

•Parotid region - Sialadenitis, Sialolithiasis, Salivary neoplasm

•Submandibular region - Lymphadenopathy, Sialolithiasis, Salivary neoplasm•Lateral neck - Lymphadenopathy, Mesenchymal neoplasm, Branchial cleft cyst, Metastatic carcinoma, Lymphoma, Carotid body tumor

•Anterior neck - Goiter, thyroid neoplasm, thyroglossal cyst•Face – Seborrheic keratosis, basal cell carcinoma, adnexal skin tumors, squamous cell carcinoma, melanoma

•In terms of frequency, the majority of oral mucosal masses are reactive proliferations, such as fibrous hyperplasias, pyogenic granulomas, and mucous extravasation reactions.

• Mesenchymal and salivary neoplasms are uncommon, and lymphomas and sarcomas are rare causes of oral swelling.

• take note of the location, coloration, surface texture, and palpable nature of the mass before attempting to secure a definitive diagnosis.

• Sound rule that all the acute swellings about the face should be considered to be dental origin until proved to be otherwise

• occasionaly angioneuratic oedema and an allergic reaction produces facial swelling but usually history and the absence of infection clarify the diagnosis

Intra oral swellings

• Traumatic fibroma•round, dome shaped sessile, soft

asymptomatic masses•In line of occlusion or lip caused by

repeated irritation

•Mucoceles•soft and fluctuant swelling• due to minor salivary gland duct

severage with resultant escape of mucus into the submucosal connective tissues

•Mucoceles rarely involve the upper lip yet may occur at any site where minor salivary glands are located.

•Inflammatory fibrous (denture) hyperplasia

•multinodular flabby masses along the maxillary or mandibular vestibule

•in the palatal vault denture hyperplasias are

•diffuse and papillary, a lesion termed inflammatory papillary hyperplasia.

•Mucous retention cyst•True cysts of the minor salivary

ducts•develop as a consequence of ductal

obstruction or occlusion by mucous plugs.

•Reactive gingival tumefactions

•Proliferation of granulation tissue gives rise to pyogenic granulomas, which may fibrose to peripheral fibroma

• periodontal ligament cells give rise to cells capable of osteogenesis and cementogenesis, causing the ossifying fibroma; periosteal progenitor cells, including osteoblasts and osteoclasts, proliferate, producing a lesion termed peripheral giant cell granuloma

•Pyogenic granulomas and peripheral ossifying fibromas are common in pregnancy.

•The pyogenic granuloma is usually red; fibromas and ossifying fibromas are pale pink and giant cell granulomas are bluish

•Peripheral odontogenic cysts and tumors

•most common entity is the gingival cyst of the adult,a lesion that appears as a nodule on the attached gingiva and may erode the underlying cortex

•Benign odontogenic tumors also occur here, the peripheral odontogenic fibroma being the most common

•Rare peripheral odontogenic tumors that appear as gingival masses include ameloblastoma,dentinogenic ghost-cell tumor, and calcifying epithelial odontogenic tumor.

•Diffuse gingival enlargement •Gingival hyperplasias can be nonspecific,

drug-induced,hormonally-related, granulomatous, or even neoplastic.

•Parulis•Odontogenic infections that evolve

into periapical inflammatory lesions may perforate the cortex, with drainage into the oral soft tissues.

• Focal drainage of an acute inflammatory process creates a tract that delivers suppurative material into the gingival submucosa.

•These drainage tracts may occur anywhere from the free gingival margin down to the vestibule

•Ectopic lymphoid tissue is commonly seen in the oral cavity where it appears as a yellow nodular or multinodular mass

•The common sites are the floor of the mouth and the soft palate.

•Many of these lymphoid aggregates emulate tonsilar tissue in that epithelial lined crypts extend into the lymphoid tissue and some become impacted with keratin, exhibiting a cystic appearance.

Varix•Focal varices are most common in the lower

lip and are probably the consequence of trauma, such as lip biting, to the submucosal vessels.

• Venous channels proliferate and become dilatated. These lesions may be flat or, more often, raised blue or purple masses

Salivary gland

•Some types that are commonly found in the major glands are rare or may never be found in the minor glands of the mouth,

• There are minor salivary gland tumors that rarely arise in the major glands.

•The most common site is the palate,

where the mass is off the midline, arising in the posterior aspect of the hard palate or at the hard–soft palate junction

•The buccal mucosa, upper lip, and ventral tongue are also common sites for these neoplasms.

• The benign tumors that occur in minor glands include the pleomorphic adenoma, monomorphic adenoma, and canalicular adenoma,

•Clinically, the benign adenomas are typically smooth surfaced, nonulcerated nodules that are movable, unless located in the palate, where the tumor is trapped between the palatal bone and mucosa.

Clinical features of facial tumorsand swellings

•Two major types:1. Diffuse 2. Focal nodules

•Diffuse swellings are usually inflammatory lesions, such as edema, emphysema, space infection, or cellulites.

•Facial asymmetry also may be seen when there is an underlying central lesion of the maxillary or mandibular bone

•Focal nodules of the face may be covered by normal skin or they may be verrucous, ulcerated, or pigmented.

•Most small facial nodules are sebaceous cysts, basal cell carcinomas, nevi, and seborrheic keratoses.

•Odontogenic infections•Buccal drainage from a periapical

abscess can result in significant facial swelling, which may localize over the mandible or, less frequently, below the zygoma.

•diffuse swelling , soft or fluctuant and tender on palpation.

•The clinical distinction between cellulitis and space infection is germane to treatment, since the former cannot be incised and drained

•Depending upon the status of the tooth, endodontic therapy or extraction must be performed, and antibiotic therapy is indicated

•Acute infection arising from dental origin •Pericoronitis•Acute alveolar abscess•Periodontal abscess•Cellulitis•Space infections•Ludwig angina

•Chronic inflammatory growths •Epulis•Giant cell hyperplasiaInfections of jaw bonesOstitisOsteomylitisPagets disease

Common cyst in oral cavity•Soft tisue cyst:•Gingival cyst•Mucoceles•Ranula•Dermoid cyst•Odontogenic cysts:•OKC• Dentigerous•Calcifying odontogenic kerato cyst

•Conditions involving maxillary sinus:•Fibrous dysplasia•Paget’s disease•Ossifying fibroma

•Swellings in salivary glands:•Major salivary gland swelling- acute sialo

adenitis, recurrent swelling persistent swelling

•Benign odontogenic tumors•Ameloblastoma•Adenomatoid odontogenic tumor•C.E.O.T.•Cementoma

•Mandible and Predominant Region•Ameloblastic fibroma (molar,

premolar)•Ameloblastoma (80%; posterior, 70%)•Aneurysmal bone cyst (much more

common in molar)•Benign nonodontogenic tumors (molar,

ramus)•Caffey's disease•Calcifying odontogenic cyst (70%)•Cancer•Acute leukemia (molar)•Ewing's sarcoma

•Metastatic carcinoma (95%; molar, premolar)

•Osteogenic sarcoma (body)•Squamous cell carcinoma•Peripheral (3: I, molar)•Central (2: I)•Cementifying and/or ossifying fibroma

(molar, premolar)•Cementoblastoma (first molar, premolar)•Cementoma (90%; incisor)

•Central giant cell granuloma (65%; two thirds are anterior to molar)

•Central hemangioma (65%; ramus, premolar)

•Cherubism (ramus, third molar)•Complex odontoma•Condensing osteitis•Eosinophilic granuloma•Follicular cyst

•Odontogenic fibroma•Odontogenic keratocyst (65%)•Odontogenic myxoma (molar, premolar)•Osteomyelitis (7: I; body)•Pindborg tumor (2: I; molar, premolar)•Postextraction sockets•Primordial cyst (third molar)•Proliferative periostitis•Sclerosing cemental masses

•Maxilla and Predominant Region•Adenomatoid odontogenic tumor (canine)•Chondrosarcoma (2: I)•Compound odontoma•Fibrous dysplasia (4:3)•Paget's disease (20:3)•Residual cyst (65%)

•Rare in Maxilla•Caffey's disease•Cementifying and/or ossifying fibroma•Ewing's sarcoma•Osteomyelitis•Proliferative periostitis•Reticulum cell sarcoma•Traumatic bone cyst

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