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Examination of a Swelling/Lump
https://t.me/med1917
A B C
Figs 3.9A toC: Neurofibromas and sebaceous cysts can be multiple. In scrotum multiple sebaceous cysts are common.
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Edge of the swelling whether well-defined or illdefined/whether pedunculated or sessile should be
looked for.
Pulsation over the Swelling
Arterial swelling has got expansile pulsation (It is
checked by keeping two fingers over the swelling
during palpation). Swelling which is very close to artery
or adherent to it also can show pulsation but it is
transmitted pulsation. On inspection it is possible only
to tell whether swelling is pulsatile or not.
Presence of expansile impulse on coughing signifies
hernia or communication into the deeper cavity like
abdomen or thorax or cranium (Fig. 3.10).
Skin over the Swelling
Skin over the swelling should be inspected.
Skin over the swelling may be tense, glossy with
prominent veins as in sarcoma and malignancy. It is
red oedematous in inflammatory swellings. Pigmentation, ulceration/fungation/discharge from ulcer/
bleeding from the fungation should be inspected. Bluish
colour is seen over the skin in haemangioma. Black
punctum over the summit of the swelling suggests
sebaceous cyst. In sarcoma skin will be tense with
dilated veins over the surface. Peau d ‘orange over
the swelling is due to cutaneous lymphoedema
following blockage of cutaneous lymphatics usually
Fig. 3.10: In a swelling related to cavities like thorax, abdomen
or cranium, expansile impulse on coughing should be
checked to identify the possibility of intracavitary extension.
by malignant cells. It is commonly seen in carcinoma
breast.
Scar if present: Its size, features whether healed by
primary intention or secondary intention should be
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SRB’s Clinical Surgery
mentioned. Scar may be linear and regular/broad,
puckered and irregular has to be noted (Figs 3.11 to
3.13).
Fig. 3.11: Recurrent soft tissue tumour (sarcoma) thigh.
Note the scar of previous surgery. This scar has healed
by primary intention. It is a linear, smooth and supple scar.
Fig. 3.12: Sarcoma right chest wall. Note the swelling
with dilated veins on the surface.
Movements of the Swelling/Mass
Upper abdominal masses like from liver, gallbladder ,
stomach, spleen move with respiration.
Thyroid swellings, thyroglossal cyst, subhyoid
bursa, pre-tracheal lymph nodes which are attached
to trachea/larynx move with deglutition.
Thyroglossal cyst also moves with protrusion of
tongue due to its relation through the thyroglossal tract
Fig. 3.13: Sebaceous cyst surface-punctum and
content sebum is extruding through the punctum.
which is attached to the base of the tongue—foramen
caecum.
Falling forward of the lump like in breast should
be looked for.
Inspect the local area as well as distally especially
when swelling is in the limbs for pressure effects and
wasting. Wasting should be confirmed by proper
measurement of the part from equal distance from a
bony point.
Palpation
It is done properly to define the swelling anatomically
and also to find out the nature of the content and its
pathology.
Local Raise of Temperature
Local raise of temperature is checked using back of
the fingers which is more sensitive than palmar aspect
(Fig. 3.14). The temperature should be checked in
the beginning of palpation as in later part of palpation
swelling may feel apparently warmer due to manipulation. It may be due to inflammation (infection) or
due to tumours with increased vascularity. Sarcoma
is warmer; cellulites, pyogenic abscess are warm. Cold
abscess (due to tuberculosis) is not warm as there are
no signs of acute inflammation. But secondary infection
in a cold abscess can make it warm.
Tenderness
Tenderness is checked while palpating the swelling
by observing the face of the patient. Patient expresses
Examination of a Swelling/Lump
https://t.me/med1917
Fig. 3.14: Back of the fingers is used to
check the local raise of temperature.
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the tenderness. Inflammatory conditions are tender.
Neoplastic conditions are initially non-tender but later
can become tender. Tenderness should be elicited
gently.
Size
Size is measured using tape (vertical in cm X horizontal
in cm) (Fig. 3.15); shape is confirmed and extent of
the entire swelling and its anatomical location should
be mentioned properly.
Edge or Margin
Edge or margin of the swelling can be well-defined
(distinct) or ill-defined (indistinct). It is ill-defined in
acute conditions and deep swellings. It is well-defined
in superficial swellings. Margin may be irregular in
malignancy and may be regular in benign swellings.
Fig. 3.15: Swelling should be measured using a measuring tape or scale. Usually the measurement is
described in centimeter. First, vertical measurement is mentioned, later horizontal measurement.
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SRB’s Clinical Surgery
Edge of the swelling is examined using pulp of the
index finger. Erosion of the mar gin into the deeper plane
like bone is also checked. Dermoid cyst commonly
shows erosion into the bone. In lipoma margin slips
away from the finger—slip sign (Fig. 3.16). In
sebaceous cyst margin gets yielded by the finger .
Fig. 3.16: Typical slip sign is positive in lipoma.
Surface of the Swelling
It is done with the palmar surface of the fingers. It
may be smooth like in a cyst/nodular in lymph nodes/
lobular in lipoma/matted in tuberculous nodes/irregular
in carcinoma. It may be variable and if so should be
mentioned which part is smooth and which is nodular
(Fig. 3.17).
Consistency
It may be very soft (like jelly)/soft (like consistency
of lip/relaxed muscle)/may be firm (like consistency
of nose/contracted muscle)/may be hard (like
consistency of forehead). Lipoma, cystic swellings,
abscess are soft. Fibromas, neurofibromas, certain
nodal enlargements are firm. Chondroma, osteomas
are bony hard. Malignant swellings are stony hard.
V ariable consistency may be observed in one swelling.
In such occasion which area is soft, and which area
is firm or hard should be confirmed properly. Variability
may be due to tumour necrosis/inflammation. Swelling
Fig. 3.17: Large lipoma over buttock which is well
localised, smooth, soft and lobulated.
like sebaceous cyst or dermoid cyst which contains
pultaceous (porridge like) material or putty like
material gets moulded.
Fluctuation
Swelling is usually fixed by holding with both thumbs
and middle fingers. With the index finger of one hand
one side of the swelling is pressed and index finger
of the other hand placed diagonally on the opposite
side feels fluid movement and also a raise. Procedure
is repeated in perpendicular direction to confirm
fluctuation (two right angle planes). Finger used to
press the swelling is called as displacing finger and
finger that is used to feel (which is kept as passive)
is called as feeling finger. This is standard fluctuation.
Positive fluctuation signifies presence of fluid. Thumb
and forefingers of one hand can be used to fix the
swelling and fingers of the other hand can be used
to displace and feel the fluid. Examples are hydrocele,
cysts, etc. (Note: Often muscle gives fluctuation like
feeling when elicited in one direction but not in two
perpendicular directions) (Figs 3.18A to D).
In swelling which cannot accommodate two fingers
to do standard fluctuation test, margin of the swelling
is fixed using two fingers (index and ring) and using
middle finger summit/centre of the swelling is pressed/
indented to feel displacement of the fluid/yielding
sensation. This test is called as Paget’s test of
fluctuation (Figs 3.19A and B).
Examination of a Swelling/Lump
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A
C
B
D
Figs 3.18A to D: Swelling should be fixed before eliciting the fluctuation. Fluctuation cannot be elicited in intra-abdominal
swelling as it cannot be fixed. It should be done in two perpendicular directions. With one finger swelling is pressed
to displace the fluid content and its movement is felt with other finger placed.
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A
SRB’s Clinical Surgery
translucency. It is positive means swelling illuminates
to light and also means it contains clear fluid. It is
negative when it contains blood, pus, pultaceous
material. Torch light is placed on one side of the
swelling and illumination is observed on the diagonally
opposite side using a rolled paper or rolled X-ray.
Lymph cyst, cystic hygroma, ranula, meningocele,
hydrocele are transilluminant swellings (Figs 3.20 to
3.22B).
B
Figs 3.19A and B: Paget’s test is done for a small
swelling to elicit fluctuation.
Fluctuation may be present in a cystic swelling
which contains fluid with two components on either
sides of an anatomical barrier (across an anatomical
barrier). It is called as cross fluctuation. Ranula (across
mylohyoid muscle), psoas abscess (across inguinal
ligament), compound palmar ganglion (across flexor
retinaculum), bilocular hydrocele (across a band or
superficial inguinal ring) are cross-fluctuant.
Sense of fluctuation may be elicited in lipoma,
myxoma and vascular swellings.
Transillumination Test
When light is illuminated over the swelling it transmits
light through it. It is called as transillumination/
Fig. 3.20: Transillumination should be elicited using pen
torch and dark visualisation tube (folded X-ray tube/
scotoscope). All fluctuant swelling should be checked for
transillumination.
Fig. 3.21: Brilliantly transilluminating swelling. While checking
transillumination, transillumination of normal skin should be
carefully eliminated.
Examination of a Swelling/Lump
https://t.me/med1917
Swellings which are brilliantly transilluminant
• Ranula
• Cystic hygroma and lymph cyst
• Hydrocele
• Epididymal cyst (Chinese-lantern pattern)
• Meningocele
• Hydrocele of the canal of Nuck
A
57
Pulsatility
T wo fingers are placed over the swelling with adequate
gap between two fingers. If fingers over the swelling
are raised and separated with each beat of the artery
it means pulsation is expansile. If fingers are only
raised but not separated from each other then pulsation
of the swelling is said to be transmitted. Pure arterial
swelling like aneurysm shows expansile pulsation (Fig.
3.23). Swelling which is close to the artery may show
pulsation because of its close proximity and it is only
transmitted pulsation. Pseudocyst in the abdomen
shows transmitted pulsation because of it’s close
proximity to aorta.
B
Figs 3.22A and B: In hydrocele transillumination should
be checked by placing torch and tube in opposite directions
(side-to-side) in the front aspect of the swelling. It should
not be carried out from front to back as testis will prevent
light to pass and make transillumination test improper.
Reducibility
When swelling is pressed gets reduced completely
and disappears is said to be reducible swelling. Hernia
is reducible.
Compressibility
Swelling on pressure reduces in size only partially
but will not disappear completely and on releasing
the pressure swelling again comes back to its original
size and shape immediately. Usually vascular and
lymphatic swellings are compressible, e.g. haemangioma, lymphangioma.
Fig. 3.23: Aneurysm in the elbow which can mimic
abscess. Aneurysm shows expansile pulsation.
Fixity to the Skin
Mobility of the skin over the swelling is checked or
skin over the swelling is pinched to confirm whether
skin is free or attached to swelling underneath (Figs
3.24A and B). Sebaceous cyst has adherent skin over
the summit with a punctum (70%) often present. In
dermoid cyst skin is always free. In lipoma skin is
usually free. In neurofibromas skin may be adherent,
but depends on from which nerves neurofibroma arises,
whether from deeper plane or from cutaneous nerves.
Fixity to Deeper Structures
If swelling is freely mobile it could be in subcutaneous
plane (Figs 3.25A to E). Lipoma, sebaceous cyst, often
neurofibroma are subcutaneous swelling.
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SRB’s Clinical Surgery
A
Figs 3.24A and B: Skin over the swelling should be pinched/held to check whether
swelling is adherent to skin or not.
If swelling is adherent to muscle underneath, then
when muscle is contracted against resistance mobility
of the swelling is restricted but it becomes more prominent. When muscles relaxes swelling will be mobile.
If swelling is arising from the muscle or deep to
muscle then size of the swelling decreases (less
prominent) when muscle is contracted. Again mobility
which is present initially will disappear completely
during contraction of the muscle. Disappearance occurs
much more significantly in swelling which is deeper
to the muscle (Fig. 3.26).
Swellings arising from vessels or nerves will move
only in horizontal direction/perpendicular to the line
of nerve but will not show any mobility in longitudinal
direction, e.g. neurofibroma, aneurysm.
Swelling arising from the bone is hard and absolutely fixed and cannot be moved separately from the
bone (Fig. 3.27).
Methods of Contractions of Different Muscles
Against Resistance
Figures 3.28 to 3.44 describe contraction methods
of various types of muscles against resistance.
Examination distally and proximally is essential
to see pressur e effects; wasting. Pressure effects may
be on adjacent artery (absence/feeble pulse; ischaemic
changes); nerves (wasting; paresis; altered sensation;
deformities, etc); over the bone (pressure erosion of
the adjacent bone like in aneurysm, dermoid cyst,
malignancy, etc).
B
Percussion over the swelling in relevant areas
like hernia should be done. Laryngocele in the neck
is resonant. Abdominal mass should always be
percussed. Often tenderness may be elicited by
percussion (Fig. 3.45).
Auscultation
It is done to look for bruit over the swelling like in
A-V malformation, arterial stenosis, aneurysms.
Machinery murmur is heard in AV fistulas.
Joints above and below the swelling should be
examined both for active and passive movements.
Regional Lymph Nodes
Regional lymph nodes should be examined for
significant enlargement. Other groups/proximal groups
should be examined in relevant/systemic clinical
indications (Figs 3.46A and B).
Relevant Systemic Examination
Systemic examination is a must like respiratory (to
look for pleural effusion, consolidation, cavity),
cardiac, skeletal (bones and joints for osteomyelitis,
gibbus, kyphosis, scoliosis, deformities) and abdomen
(for mass, fluid).
Proper diagnosis of the swelling should be given.
Relevant Investigations
FNAC, U/S of part, CT scan, MRI for bony and joint
swellings, angiography and Doppler in vascular
swellings, biopsy in soft tissue sarcomas.
Examination of a Swelling/Lump
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A
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B
D
Figs 3.25A to E: Mobility of swelling should be checked to find out the
plane of the swelling.
C
E
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Fig. 3.26: Bony swelling in sternum which is nonmobile. In
this patient it is secondaries from osteosarcoma of lower
femur (thigh amputated).
SRB’s Clinical Surgery
A
A
Figs 3.28A and B: Contraction of extensors of ankle.
Fig. 3.27: Secondaries in the skull in a patient with primary
in the thyroid (follicular carcinoma). Follicular carcinoma of
thyroid causes localised, warm, vascular, pulsatile, smooth,
hard/soft, (nonmobile) secondaries in skull.
Fig. 3.29: Contraction of flexors of the ankle.
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