clinical examination of swelling
TRANSCRIPT
Benign skin swellings
How to examine?
Various types of benign skin swellings
Classification
According to orgin:• Skin• Subcutaneous tissue• Muscle • Nerves• Blood vessels• Bone
• According to consistency:• Solid swellings: soft, firm, hard• Cystic swelling
CLINICAL EXAMINATION OF SWELLING
History
SizeSiteOnset: Accidental : breast swellings Acute onset: cute inflammation. Gradual onset (weeks or months) :chronic
inflammation or neoplastic swellings
Course Progressive: neoplastic swellings. Stationary: chronic inflammation. Regressive: inflammatory conditions. Fluctuating : chronic inflammation with
acute exacerbation
Duration Short: (days or weeks) inflammatory.
Long: (months or years) neoplastic.
Since birth : congenital
Other swellings Multiple: lipoma, Neurofibroma. Lymph nodes : in inflammatory
conditions Metastasis in malignancy.
Effect on the general condition: Toxic symptoms: Fever
Malignant symptoms: cachexia.
Examination Inspection Palpation Percussion Auscultation
INSPECTION SITE- EXACT ANATOMICAL LOCATION:
IMPORTANT AS SOME SWELLINGS OCCUR IN A TYPICAL POSITION WHICH IS DIAGNOSTIC
EXAMPLES EXTERNAL ANGULAR DERMOID –
LATERAL END OF EYE BROW MENINGOCELE- OVER THE BACK IN
MIDLINE
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EXTERNAL ANGULAR DERMOID
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EXTERNAL ANGULAR DERMOID
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INTERNAL ANGULAR DERMOID – MEDIAL END OF EYE BROW
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MENINGOCELE
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MENINGOCELE
2.NUMBER
SINGLE OR MULTIPLE MULTIPLE EXAMPLES
MULTIPLE NEUROFIBROMATOSIS) MULTIPLE LIPAMATOSIS (DERCUMS
DISEASE)
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MULTIPLE LIPAMATOSIS
3.SHAPE
SPHERICAL
OVOID
KIDNEY /BEAN SHAPED/RENIFORM
IRREGULAR
4.SIZE LONGITUDINAL & TRANSVERSE ON
INSPECTION
DEPTH BETTER JUDJED ON PALPATION
USUALLY NOTED IN CENTIMETRES
5.SURFACE
COLOUR
OVERLYING SKIN
A)COLOUR
ARTERIAL HAEMANGIOMA – BRIGHT RED
VENOUS HAEMANGIOMA— PURPLE
MALIGNANT MELANOMA- BLACK
BENIGN NAEVUS – BLACK
RANULA –BLUE
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CAPILLARY HAEMANGIOMA OVER FORE HEAD
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BENIGN NEVUS
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MALIGNANT MELANOMA
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MALIGNANT MELANOMA OF FOOT
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c)Skin over lying swelling
RED &EDEMATOUS – INFLAMMATORY BLACK PUNCTUM – SEBACEOUS
CYST PIGMENTATION-MOLES , NAEVI SCAR ULCERS
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ABSCESS
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ABDOMINAL WALL ABSCESS
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INFECTED SEBACEOUS CYST WITH PUNCTUM
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POST THYROIDECTOMY SURGICAL SCAR
6.VISIBLE PULSATIONS
PULSATION A MOVEMENT OR INCREASE IN SIZE
SYNCHRONOUS WITH EACH HEART BEAT 2 TYPES
EXPANSILE PULSATIONS – SWELLINGS ARISING FROM ARTERIES EX: AORTIC ANEURYSM , CAROTID BODY TUMOUR
TRANSIMITTED PULSATIONS – SWELLINGS CLOSE TO ARTERIES
REMEMBER NOT TO TOUCH THE PATIENT DURING INSPECTION
7.VISIBLE COUGH IMPULSE
PERFORMED WHEN SWELLING IS OVER ABDOMEN,CHEST,SPINAL CANAL OR CRANIUM
COUGH IMPULSE VISIBLE INCREASE IN THE SIZE OF
SWELLING SYNCHRONOUS WITH COUGH POSITIVE IN SWELLINGS
COMMUNICATING WITH ABDOMEN,THORACIC CAVITY,SPINAL CANAL OR CRANIAL CAVITY
POSITIVE COUGH IMPULSE
HERNIA
MENINGOCELE
VARICOCELE
SAPHENA VARIX IN CHILDREN CRYING ACTS AS
COUGHING
10.Movement with deglutition IN CASE OF NECK SWELLINGS
SWELLINGS MOVING WITH DEGLUTITION THYROID SWELLING THYROGLOSSAL CYST THYROGLOSSAL FISTULA SUBHYOID BURSA PRE/PARA TRACHEAL LYMPH NODES EXTRINSIC CARCINOMA OF LARYNX
WHY THYROID MOVES UP WITH DEGLUTITION?
THYROID IS ENCLOSED IN PRETRACHEAL FASCIA
PTF ATTACHES TO THYROID &CRICOID CARTILAGES(BERRY’S LIGAMENT)
SUPERIOR CONSTRICTOR MUSCLE CONTRACTION DURING DEGLUTITION
THESE CARTILAGES MOVE UP ALONG WITH THESE THYROID MOVES
UP
11)MOVEMENT WITH TONGUE PROTRUSION
IN CASE OF MID LINE NECK SWELLINGS
EG:THYROGLOSSAL CYST &FISTULA
WHY?
ATTACHED TO FORAMEN CAECUM OF TONGUE
12)PRESSURE EFFECTS
WHEN SWELLING IS PRESENT ON LIMBS AN AXILLARY SWELLING WITH LIMB
EDEMA – LYMPH NODAL SWELLING PARESIS – PRESSURE ON NERVES SWELLING IN NECK WITH VENOUS
ENGORGEMENT(RETROSTERNAL EXTENSION)
PALPATION DEFINITE CLUE FOR DIAGNOSIS
METHODICAL,FOLLOW DEFINITE ORDER
BE GENTLE
SHOULD NOT HURT THE PT.
1.TEMPERATURE BEST FELT BY BACK OF THE HAND-
WHY? INCREASED IN
INFLAMMATORY SWELLING WELL VASCULARISED TUMOURS-
SARCOMA
2.TENDERNESS
PAIN DUE TO PRESSURE EXERTED OVER THE SWELLING IS TENDERNESS
PALPATE GENTLY OVER ALL THE AREA
IT IS A FEATURE OF INFLAMMATORY SWELLINGS SWELLING RELATED TO NERVES -
NEUROFIBROMA
3.SIZE& SHAPE CONFIRM VERTICAL & HORIZONTAL
DIMENSIONS
NOTE THE THIRD DIMENSION DEPTH WHICH COULD NOT BE EXACTLY DETERMINED BY INSPECTION
4.SURFACE WITH PALMAR SURFACE
SMOOTH –CYSTIC SWELLINGS LOBULAR -LIPOMA NODULAR –MULTI NODULAR GOITRE MATTED: LYMPH NODES IRREGULAR - CARCINOMA
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SMOOTH SURFACE OF A SEBACEOUS CYST
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5.EDGE 1)WELL DEFINED & REGULAR –
BENIGN NEOPLASMS
2)WELL DEFINED & IRREGULAR –MALIGNANT NEOPLASM
3)ILLDEFINED &DIFFUSE –INFLAMMATORY SWELLINGS
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ABSCESS WITH ILL DEFINED MARGINS
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LIPOMA WOTH WELL DEFINED MARGINS
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LARGE LIPOMA WITH WELL DEFINED MARGINS
6.CONSISTENCY
SOFT – LIPOMA CYSTIC- CYSTS &CHRONIC
ABSCESSES FIRM –FIBROMA BONY HARD-OSTEOMA VARIABLE CONSISTENCY-
MALIGNANCY
HOW TO ASSESS CONSISTENCY
SOFT – EAR LOBULE,ALAE OF NOSE
FIRM- TIP OF NOSE
HARD -BRIDGE OF NOSE, FORHEAD
PAGET’S TEST
DONE FOR SMALL SWELLINGS TO KNOW THE CONSISTENCY(CYSTIC/SOLID)
THE CENTRE AND PERIPHERIES ARE PALPATED WITH INDEX FINGER CYSTIC SWELLING FEELS SOFTER AT
CENTRE THAN PERIPHERY SOLID SWELLING FEELS FIRMER AT
CENTRE THAN PERIPHERY
SPECIAL TESTS
DONE IN CASE OF SOFT/CYSTIC SWELLING 7.FLUCTUATION 8.TRANSILLUMINATION 9.COUGH IMPULSE 10.REDUCIBILITY 11.COMPRESSIBILITY
IN SOLID SWELLINGS DIRECTLY PROCEED TO TEST FOR RELATION TO OTHER STRUCTURES
7.FLUCTUATION
TRANSMISSION OF IMPULSE IN TWO DIRECTIONS AT RIGHT ANGLES TO EACH OTHER
IMPLIES PRSENCE OF FLUID IN THE SWELLING
HOW TO ELICIT FLUCTUATION?
IF THE SWELLING IS MOBILE FIRST FIX IT OR ASK THE ASST. TO HOLD IT
KEEP 2 INDEX FINGERS ON OPPOSITE POLES WHEN ONE FINGER IS PRESSED THE FINGER
AT OPPOSITE END FEELS THE IMPULSE & PASSIVELY LIFTED UP
REPEAT THE MANUVERE IN A PLANE AT RIGHT ANGLES TO THE 1ST ONE
IF IMPULSE IS FELT IN BOTH PLANES IT IS A POSITIVE FLUCTUATION TEST
LAW BEHIND FLUCTUATION!
PASCAL’S LAW PRESSURE EXERTED TO A FLUID IS
TRANSMITTED EQUALLY IN ALL THE DIRECTIONS
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PRINCIPLES WHILE DOING FLUCTUATION TEST
ALWAYS PERFORM IN 2 DIRECTIONS AT RIGHT ANGLES TO EACH OTHER
TWO FINGERS SHOULD BE KEPT AS FAR APART AS POSSIBLE
FREELY MOBILE SWELLINGS SHOULD BE FIXED FIRST(AS IN HYDROCELE)
SMALL SWELLINGS –WATCHING FINGER & DISPLACING FINGER
VERY LARGE SWELLINGS MORE THAN ONE FINGFR SHOLD BE USED
PSEUDO FLUCTUATION
A FALSE SENSE OF FLUCTUATION FELT IN LARGE SOFT SWELLINGS CONTAINING NO FLUID
SEEN IN LARGE LIPOMA
CROSS FLUCTUATION
FLUCTUATION BETWEEN TWO SEPARATE CYSTIC SWELLINGS COMMUNICATING WITH EACH OTHER
SEEN IN COMPOUND PALMAR GANGLION PSOAS ABSCESS
8.TRANSILLUMINATION
DEMONSTRATION OF TRANSMISSION OF LIGHT THROUGH A SWELLING
POSITIVE IN SWELLINGS CONTAINING CLEAR FLUID AND THIN TRANSPARENT WALLS
NO TRANSILLUMINATION IF WALL IS THICK, OR TURBID FLUID IS PRESENT(BLOOD,PUS, LYMPH)
DARK ROOM , TRANSILLUMINOSCOPE
TRANSILLUMINANT SWELLINGS
2.EPIDIDYMAL CYST
3.MENINGOCELE WITH THIN SKIN
4.RANULA
5.CONGENITAL HYDROCELE
11.COMPRESSIBILITY
WHEN PRESSURE IS APPLIED TO A SWELLING IT DECREASES IN SIZE AND WHEN PRESSURE IS RELEASED SWELLING REGAINS ITS SIZE ITSELF
CHARECTARISTIC SIGN OF VASCULAR HAEMANGIOMA
12.PULSATILITY
WHEN FINGER IS PLACED OVER A PULSATILE SWELLING IT RAISESWITH EACH BEAT
TO TYPES OF PULSATIONS TRANSMITTED PULSATIONS- SEEN IN
SWELLINGS PRESENT NEAR AN ARTERY
EXPANSILE PULSATIONS-SEEN IN SWELLINGS ARISING FROM ARTERIES EX:AORTIC ANEURYSM
HOW TO DIFFERENTIATE?
TWO FINGERS ARE PLACED OVER THE SWELLING AND FINGER MOVEMENTS ARE NOTED
TRANSMITTED PULSATIONS – FINGERS ARE SIMPLY LIFTED UP
EXPANSILE PULSATIONS- FINGERS ARE LIFTED UP AND MOVE APART
13.FIXITY TO SKIN
SKIN PINCHED OVER DIFFERENT PARTS OF THE SWELLING -CANNOT BE PINCHED IF FIXED TO SKIN
SKIN IS MADE TO MOVE OVER THE SWELLING- THE SKIN WILL NOT MOVE IF IT IS FIXED TO SKIN
SWELLINGS ARISING FROM SKIN ARE FIXED TO SKIN EX:SEBACEOUS CYST , PAPILLOMA , EPITHELIOMA
14.RELATION TO SURROUNDING STRUCTURES
1)SUBCUTANEOUS TISSUE SWELLINGS IN SUB CUTANEOUS TISSUE ARE
NOT ADHERENT TO SKIN OR UNDERLYING MUSCLE
LIPOMA-PUSHED SIDEWAYS PUCKERING IS SEEN IN SOME PLACES – DUE PRESENCE OF FIBROUS SEPTA
2)DEEP FASCIA SWELLING ARISING FROM DEEP FASCIA WILL
NOT BE AS MOBILE AS SUBCUTANEOUS SWELLINGS
3)RELATION TO MUSCLE
RELATION SHIP TO MUSCLE IS KNOWN BY THROWING THE CONCERNED MUSCLE INTO CONTRACTION TUMOURS IN SUB CUTANEOUS TISSUE-
BECOME MORE PROMINENT &REMAIN MOBILE
TUMOURS ARISING FROM MUSCLE INCORPORATED IN MUSCLE- FIXED&IMMOBILE
TUMORS DEEP TO MUSCLE –LESS PROMINENT, OR DISAPPEARS,DIFFICULT TO PALPATE
4)SWELLING IN RELATION TO TENDON MOVES ALONG WITH TENDON&BECOMES
FIXED WHEN MUSCLE CONTRACTS 5)IN CONNECTION WITH VESSELS
&NERVES DO NOT MOVE ALONG VESSELS OR
NERVES BUT MOVE TO A LITTLE EXTENT AT RIGHT ANGLES TO THEIR AXES
6)IN CONNECTION WITH BONE IS ABSOLUTELY FIXED IRRESPECTIVE OF
MUSCLE CONTRACTION
PERCUSSION
LIMITED VALUE IN SWELLINGS
AUSCULTATION
BRUIT OVER PULSATILE &VASCULAR SWELLINGS
BRUIT SHORT,MEDIUM PITCHED MURMUR
HEARD OVER THE SWELLING WITH EACH PULSE WAVE EX:ANEURYSM THYROTOXIC GOITRE
REGIONAL LYMPH NODES
DRAINING LYMPH NODES EXAMINED IF INVOLVED NEXT HIGHER GROUP EXAMINED
IF THE SWELLING ITSELF IS ALYMPH NODE EXAMINE 1.OTHER LYMPH NODAL GROUPS 2.SPLEEN 3.LIVER
TO EXCLUDE SYSTEMIC CAUSE EXAMINE DRAINAGE AREA TO EXCLUDE
INFECTION
PRESSURE EFFECTS
1.OVER BONE – FEEL FOR BONY EROSION AS IN DERMOID CYST
2.IN LIMBS DISTAL PULSES- PRESSURE OVER
ARTERIES EDEMA &DILATED VEINS – PRESSURE
OVER VEINS PARESIS& MUSCLE WASTING –
PRESSURE OVER NERVES MOVEMENTS OF JOINTS
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WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE
Benign skin swellings
Dermoid cyst
Types Sequestration dermoid cyst Implantaion drmoid Tubuldermoid: Thyroglossal cyst Branchial cyst Teratomatous dermoid
Sequestration dermoid
True cyst Cause :sequestration of piece of
epithelium in subcutaneous tissue Occurs at lines of fusion as Face: external angular (most common) internal angular Ear: pre and post auricular Neck: sublingual, midline , suprasternal
Diagnosis
Painless round subcutaneous Slowly growing At fusion site Soft and cystic Free from skin and deep structures
N.B. There may be communication with dura matter so CT is mandatory to exclude communication before excision
Differentiation from lipoma: it yields with the pressure of finger not slips away TTT: Not infected: ExcisionInfected : incision and drainage followed by excision when swelling subsides
Implanation dermoid
Acquired not conginital Due to pricking wound Common in manual worker and
sewer Overlying skin is sometimes scaring
Thyroglossal cyst
From unobliterated portion of thyroglossal cyst
Painless cystic mass in the midline of front of neck
Moves up and down with deglutation and protrusion of tongue
Inflammatory swellings
Traumatic swelling
Sebacous cyst (Epidemoid cust) Acquired cyst Cause : obstruction of the sebaceous
gland duct ------retention of secretion Site: hairy skin never palm and sole
Diagnosis
Smooth painless slowly growing round swelling
Cystic , yields to palpating finger Attached to skin at a point (Punctum) Single or multiple Fluctuation positive
Lipoma Commonest benign tumor of
subcutaneous tissue Slowly growing painless Soft and lobulated solid swelling At any age Freely mobile over deep structure Solitary or multiple Slippery edge Pseudofluctuant Skin can be piched up
Other types of lipoma
Subfascial : Firm Common in forehead No slippery edge Not attached to skin
SUBmucous lipoma: Dangerous in larynx it cause
respiratory obstruction or intussception
Extradural only spinal cord rETROPERIONEALIntermuscular
DANGEROUS TYPES
SUBMUCOUS Retroperitoneal Extradural
TTT excision
Dercum disease
Rare disease of unknown etiologyy Characterized by: generalized obesity fatty tumors in adipose tissue painful (unknown- pressure on nearby nervesTTT: no specific ttt, analgesic, removal of lesions near joints, liposuction, psychotherapy
NEUROFIBROMATumor contains both neural and fibrous element.Types Generalized multiple firm café au lait patches familial tender mobile across not along the nerve
Solitary firm tender acrosss nerve café au lait
Plexiform cystic common in face causing deformity. occurs in connection with branches of trigeminal nerve.Sensation of bag of worms
