Clinical examination of swelling

1. Clinical examination of
swelling
Deep samaria
AIIMS Patna

2. Examination
Inspection-
1.General features
Site
Shape
Size
Surface
Skin over swelling
Margins
Pulsations

3. 1.Site
A few swellings are peculiar in their position such as
Dermoid cyst are mostly seen in the midline of the body or on the line of fusion of
embryonic processes like at the outer canthus of the eye(external angular dermoid) or
behind the pinna(post auricular dermoid).
Meningocele- over the back in midline.
*also the exact position and extent in vertical and horizontal direction should be noted.

5. Number
Multiple- Neurofibromatosis,Diaphyseal
aclasia etc.
Solitary- Lipoma,Dermoid cyst etc.

6. Shape
● don't use circular or oval word for describing shape as
swelling also have a 3rd dimension.
● it can be ovoid, pear shaped, kidney shaped, spherical or
irregular.
● cystic and benign tumor are usually spherical or ovoid in
shape.
● irregular shape indicates malignant tumor. exception keloid
and hemangioma are irregular but are benign.

7. Size
Mentioned in vertical and horizontal dimension.
Surface- on inspection,it may be difficult to have a clear idea
about the surface of swelling . But in some cases it is diagnostic .
e.g. cauliflower surface of squamous cell carcinoma.
irregular numerous branched surface of a papiloma.

9. Skin over swelling
1.Colour - black-melanoma
purple or red -hemangioma
2.Scar mark- Recurrent swelling
3.Red and edematous- Inflammatory
4.Black punctum- Sebaceous cyst
5.Ulcer over swelling- Malignancy
* if no such thing is present we comment that skin over swelling is normal

10. Margins
Margins may be clearly defined or indistinct.
Clearly defined- in benign tumor, cysts etc
Indistinct- in acute inflammatory swelling

11. Pulsation
1. Swellings arising from arteries are pulsatile.e.g aneurysms and vascular growth,
such as carotid body tumour. These are called as Expansile Pulsation.
2. Swellings which lies just superficial to the artery in close relation to it,will be
pulsatile.This pulsations is called Transmitted pulsations.
* but can't be differentiated so only comment, swelling pulsatile or non pulsatile.

12. Special features
● Impulse on coughing- Hernia, Meningocele, Encephelocele
● Peristalsis- congenital hypertrophic pyloric stenosis
● Movement with respiration
● Movement with deglutation- thyroid swellings, thyroglossal
cysts, subhyoid bursitis and pre or paratracheal lymph node
enlargement
● Movement with protrusion of tongue- thyroglossal cyst

13. Palpation
Temperature-
Tenderness-
Size, Shape and
Extent-
local temperature is raised due to infection
(abscess,cellulitis) or due well vascularised
tumour(sarcoma)
present in inflammatory and traumatic swelling.
by palpation we find the deeper dimension of the
swelling, which remains unknown in inspection.
the vertical and horizontal diameters are also
better clarified by palpation.

14. Surface-
Edge-
Smooth(cyst), lobular with smooth bumps(lipoma),nodular
(a mass of matted lymph nodes) or irregular and
rough(carcinoma).
Defined- regular(benign growth)
irregular(malignant growth)
Indistinct- acute inflammatory
swellings.

15. Slip sign
● To differentiate between Lipoma and Cystic swelling(both have well defined
margins , regular borders)
● When edge of a swelling is palpated if it slips,does not yield to it, it is a lipoma.
If it yields to finger, it is a cyst.

16. Consistency- soft- Lipoma
cystic- cyst and chronic abscess
firm- Fibroma
hard but yielding- Chondroma
bony hard- Osteoma
stony hard- Carcinoma
variable consistency- malignancy
● Moulding- indicates that the content is putty like mater. present
in sebaceous cyst, dermoid cyst or in abdominal(colonic)swelling
containing fecal mass.
● sometimes the swelling pits on pressure which indicates there is
oedematous tissue and most often the swelling is inflammatory
one.

17. Fluctuation- A swelling fluctuates,when it containes liquid or gas.
● Paget’s test
● Pseudo fluctuation- lipoma, myxoma etc
● Cross fluctuation- psoas abscess, plunging ranula

18. Translucency- ● Means that the swelling can transmit light through it. For this it
must contain clear fluid e.g. water, serum, lymph, plasma, csf,
saliva, urine or highly refractile fat.
● Absent when it contains opaque fluid such as blood, pus, bile or
pultaceous material(dermoid and sebaceous cyst).
Present in- Cystic hygroma, ranula,
congenital hydrocele, menigocele etc.

19. Cough impulse-
Reducibility-
Performed in swellings likely to be in contact with
abdominal cavity(herniae), cranial cavity or spinal canal
(spinal or cranial meningocele)or pleural cavity(empyema
necessitatis).
Swelling reduces in size and completely disappears when it
pressed upon but regains its original size and shape when
opposite force comes in action(coughing or crying).
present in- hernia, meningocele, vericocele, saphena varix
etc.

20. Compressibility-
Pulsatility-
When pressure is applied to a swelling it decreases in size(but
would not be disappeared completely) and when pressure is
released swelling regains its size itself without any external
factor like coughing or crying.
Vascular haemangiomas and Lymphangiomas.
Expansile pulsation- seen in swellings arising from
arteries.e.g.Aortic aneurysm.
Transmitted pulsation- seen in swellings present near an artery
.e.g. CA stomach lump near Abdominal Aorta.

21. In an Abdomianl Lump
● Knee Elbow Position-
-Pulsation disappear- Transmitted pulsations
-Pulsation persisit- Expansile pulsations

22. Fixity to Skin- Skin pinched over different parts of 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.
Swelling arising from skin are fixed to skin. e.g. papilloma,
epithelioma, sebaceous cyst.

23. Relation to surrounding structures
1. Subcutaneous Tissue
-Swellings in subcutaneous tissue are not adherent to skin or underlying muscle.
1. Deep fascia
-Swelling arising from deep fascia will not be as mobile as subcutaneous swellings.
-It is difficult to make out fixation to deep fascia as deep fascia cannot be made taut.

24. 3. Relation to muscle
- Relationship to muscle is known by throwing the concerned muscle into contraction against resistance
Tumour in sub cutaneous tissue- Becomes more prominent and remain mobile.
Tumour arising from muscle/Incorporated in muscle- Fixed and Immobile.
Tumour deep to muscle- Less prominent, or disappears, difficult to palpate.
4. Relation to tendon
- moves along with tendon and becomes fixed when muscle contracts.
5. In connection with vessels or 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.

25. Percussion
● Limited value in swellings
-1. Tympanic note- Enterocele, Pharyngocele
-2. Hydatid thrill - hydatid cyst
-3. Dull - solid swellings
Auscultation
● Bruit over pulsatile and vascular swellings.
● Machinery murmur in an aneurysmal varix.

26. State of the regional lymph nodes
-Draining lymph nodes should be examined, if involved next higher group should be
examined.
- If the swelling itself is a lymph node examine-
1. Other lymph nodal groups
2. spleen
3. liver

27. Pressure effects
1. Weak distal pulses- pressure over the main artery of the limb.
2. Paresis and muscle wasting- Pressure over nerves
3. Erosion of subjacent bone due to pressur e.g. seen in aneurysm and dermoid cyst
on the skull.
Movement of joint
The movement of nearby joint is to be examined to exclude any impairement. To find
out if the swelling has involved the joint or not.

28. General examination
In case of malignant swelling- gives idea about metastasis, if any.
The chest should be examined very carefully for presence of consolidation and pleural
effusion.
Examination of abdomen should be carried out to exclude the possibility of liver or
peritoneal metastasis.
The spine, the pelvis, the trochanters of the femur, the skull should be examined to
exclude bony metastasis.

29. Thank you