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Examination of a Swelling/Lump
https://t.me/med1917
Fig. 3.30: Contraction of hamstring muscles.
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A
B
Figs 3.34A and B: Contraction of quadriceps femoris.
Fig. 3.31: Contraction of gluteus medius muscle.
Fig. 3.32: Contraction of gluteus maximus muscle.
Fig. 3.33: Contraction of adductors of thigh.
Fig. 3.35: Contraction of wrist flexors.
Fig. 3.36: Contraction of wrist extensors.
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SRB’s Clinical Surgery
Fig. 3.37: Contraction of triceps brachii muscle.
A
Fig. 3.39: Contraction of latissimus dorsi muscle.
A
B
Figs 3.38A and B: Contraction of biceps brachii muscle.
B
Figs 3.40A and B: Contraction of trapezius muscle.
Examination of a Swelling/Lump
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Fig. 3.41: Contraction of serratus anterior muscle.
A
Fig. 3.42: Contraction of pectoralis major muscle.
B
C
Figs 3.43A to C: Contraction of sternomastoid muscles
both sides together and each side independently.
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Fig. 3.44: Contraction of abdominal wall muscles.
SRB’s Clinical Surgery
A
Fig. 3.45: Swelling should be auscultated for any bruit.
Differential Diagnosis
Swellings may be congenital/traumatic/inflammatory/neoplastic. It may be benign or malignant.
In malignancy it may be early or advanced. First
anatomical diagnosis of the swelling should be made
by clinical methods and proper analysis. It means from
which anatomical structure the swelling is arising from
(Fig. 3.47). Anatomical diagnosis can be by various
clinical methods like movements, relation to muscle,
plane of the swelling. Then pathological diagnosis
is made out by examining the surface, consistency,
fluctuation, transillumination, tenderness, warmness.
When features elicited are not suitable for one
diagnosis, it is not possible to give a single diagnosis.
Then differential diagnoses should be given. While
giving differential diagnosis, clinical features which
B
Figs 3.46A and B: Relevant regional lymph node
examination should be done to look for palpable significant
nodes.
Fig. 3.47: Epignathus. It is a type of growth anomaly seen
in neonates wherein growth from the base of skull protrudes
into the mouth.
Examination of a Swelling/Lump
https://t.me/med1917
correlate to most possible condition should be given
as first possible diagnosis; like that second; third, etc.
It is not necessary to give every condition as differential
diagnosis. Only conditions relevant to those clinical
features should be given as differential diagnosis.
Congenital conditions are—haemangiomas; dermoid
cyst, etc. Cellulitis, abscess, boil, carbuncle are inflammatory conditions. Neoplasms can be benign or malignant. Lipoma, papilloma, neurofibromas are examples
of benign swellings. Malignant skin tumours, sarcomas
are malignant tumours. Other swellings like sebaceous
cyst, keloid, pyogenic granuloma are also important.
Different conditions which are discussed here are:
Cysts Cellulites
Sebaceous cyst Erysipelas
Dermoid cyst Abscess
Lipoma Furuncle
Neurofibroma Carbuncle
Schwannoma Condyloma
Papilloma Moles
Seborrhoeic keratosis Basal cell carcinoma
Solar keratosis Squamous cell carcinoma
Pyogenic granuloma Malignant melanoma
Fibroma Sarcoma
Haemangiomas
Lymphangiomas
Keloid
Keratoacanthoma
Corn
Callosity
Cysts
Cyst is a collection of fluid in a sac lined by epithelium
or endothelium. Word meaning of cyst is ‘bladder ’
(Greek). In true cyst, cyst wall is lined by epithelium
or endothelium. If infection occurs cyst wall will also
be lined by granulation tissue. Fluid is usually serous
or mucoid derived from the secretion of the lining.
In false cyst, cyst does not have epithelial lining. Fluid
collection occurs as a result of exudation or degeneration. Examples: Pseudocyst of pancreas, wall of cystic
swelling in tuberculous peritonitis, cystic degeneration
of tumour, after haemorrhage in a haematoma red cells
are lysed, get absorbed and fluid remains as a false
cyst. ‘Apoplectic cyst’ is formed in brain as a result
of ischaemia causing collection of fluid.
Classification of Cysts
a. Congenital cyst: Dermoids: Sequestration dermoid;
Tubulodermoids: Thyroglossal cyst, postanal
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dermoid, ependymal cyst, urachal cyst; Cysts of
embryonic remnants: Cysts from paramesonephric
duct and mesonephric duct; Cysts of urachus and
vitellointestinal duct.
b. Acquired cysts: Retention cysts: They are accumu-
lation of secretion of a gland due to obstruction
of a duct. Examples: Sebaceous cyst, bartholin cyst,
cyst of pancreas, cyst of parotid, breast, epididymis.
Distention cyst: Lymph cyst, ovarian cyst, colloid
goitre. Exudation cyst: Bursa, hydrocele.
c. Cystic tumours: Dermoid cyst of ovary, cystadeno-
mas.
d. Traumatic cyst: Due to trauma, haematoma occurs
usually in thigh, loin, and shin. It eventually gets
lined by endothelium containing brown coloured
fluid with cholesterol crystals.
e. Degenerative cyst: Due to cystic degeneration of
a solid tumour (due to necrosis of tumour).
f. Parasitic cyst: Hydatid cyst, trichiniasis, cysticer-
cosis.
Clinical features of a cyst: Hemispherical swelling
which is smooth, fluctuant, nontender, well-localised.
Some cysts are transilluminant. Presentation varies
depending on its anatomical location.
Effects of a cyst: Compression to adjacent structures:
choledochal cyst compressing over the CBD; infection;
sinus formation; haemorrhage; torsion like in ovarian
cyst; calcification; cachexia: in malignant ovarian cyst
patient goes for severe cachexia.
Dermoids
Types
a. Sequestration dermoids: It occurs at the line of
embryonic fusion due to inclusion of epithelium
beneath the surface which later gets sequestered
forming a cystic swelling in the deeper plane.
Common sites are: Forehead; external angular
dermoid; root of nose; post-auricular dermoid;
sublingual dermoid; in the ear; anywhere in midline or
in the line of fusion. Dermoids occurring in the skull
may extend into the cranial cavity . When it occurs as
external angular dermoid, it extends into the orbital
cavity. Or it can extend into any cavity in relation to its
anatomical location (e.g thorax, abdomen). Dermoid
cyst contains putty like desquamated material. It is lined
by both dermal and epidermal components.
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SRB’s Clinical Surgery
External angular dermoid: It is a sequestration
dermoid situated over the external angular process
of the frontal bone (frontozygomatic suture). Outer
extremity of the eyebrow extends over some part of
the swelling. This typical feature differentiates it from
the swelling arising from the lacrimal gland. It may
extend into the orbital cavity also (Fig. 3.48).
Fig. 3.48: External angular dermoid.
Internal angular dermoid: It is a sequestration
dermoid cyst in central position at the root of the nose.
Dermoid cyst in scalp may lie purely in the scalp or
may cause a defect in the skull with attachment to
dura or may be partly intracranial and partly
extracranial with a stalk between the two parts or very
rarely purely intracranial lying deep to skull and outer
to dura but attached to it (Fig. 3.49).
Fig. 3.50: Dermoid in the ear. It arises due to sequestration
at the fusion line of one of the six developmental ear
tubercles. (Each ear develops from six ear tubercles).
Clinical features: Painless swelling in the line of fusion,
presents in the second or third decade onwards, which
Fig. 3.49: Internal angular dermoid.
Fig. 3.51: Midline dermoid.
is smooth, soft, nontender, fluctuant (Paget’s test
positive, i.e. swelling is fixed with two fingers and
summit is indented to get yielding sensation due to
fluid), nontransilluminating, with free skin often
adherent to the deeper plane (Fig. 3.50). There will
be resorption and indentation of the bone beneath.
Impulse on coughing may be evident if there is
intracranial extension. It should be differentiated from
lipoma and sebaceous cyst. Slip sign and free mobility
are features of lipoma. Skin is adherent in sebaceous
cyst often with a punctum (Fig. 3.51). X-ray part or
CT scan is often needed to evaluate its deeper extent.
Submental dermoid: It is a congenital sequestration
dermoid occurs during fusion of 1st and 2nd branchial
Examination of a Swelling/Lump
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arches. It is deep to deep fascia of neck. It presents
as soft, cystic, fluctuant, nontransilluminating, swelling
in midline in submental region which does not move
with deglutition nor moves while protruding the tongue
out. It should be differentiated from thyroglossal cyst,
cold abscess from submental lymph nodes or sebaceous
cyst.
b. Tubulodermoids: It arises from the embryonic
tubular structures. Examples includes—Thyroglossal
cyst; ependymal cyst; postanal dermoid.
c. Implantation dermoid: Due to minor pricks or
trauma, epidermis gets buried into the deeper
subcutaneous tissue which causes reaction and
acquired cyst formation (trauma is often forgotten). It
is common in fingers (common in tailors), toes and feet
(Figs 3.52A and B). It is slowly progressive swelling
after a trauma which is smooth, soft, mobile, tensely
cystic, nontransilluminating and is adherent to skin. It
contains only squamous epithelium without hair
follicle/sweat glands/sebaceous glands. It can cause
infection, rupture or pressure effects on digital nerves.
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d. Teratomatous dermoid: It arises from all germinal
layers ecto, meso and endoderms. It occurs in ovary
(Fig. 3.53), testis, retroperitoneum, mediastinum. It
contains hairs, teeth, cartilage, and muscle. It can be
benign or malignant.
Sebaceous Cyst (Wen, Epidermal Cyst)
It is a retention cyst. It is due to obstruction at the
mouth of a sebaceous duct, causing a cystic swelling
due to collection of its own secretion. It is common
in face, scalp, and scrotum. It is not seen in palms
and plantar aspect of foot (sole) as there are no
sebaceous glands. Sebaceous cyst contains yellowish
material with fat (sebum), epithelium (thick porridge
like) which is having putty like consistency, with a
parasite in the wall of the sebaceous cyst—demodex
folliculorum. Its lining is only epidermal layer of
squamous epithelium.
Clinical features: Painless swelling which is smooth,
soft, nontender, freely mobile, adherent to skin
especially over the summit, fluctuant (positive Paget’ s
test), nontransilluminating with punctum over the
summit. It moulds on finger indentation. Punctum is
present over the summit in 70% of cases because here
A
B
Figs 3.52A and B: Implantation dermoid in different
places of the body—finger, toe.
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SRB’s Clinical Surgery
Fig. 3.53: Dermoid cyst ovary—on table look
(Teratomatous dermoid of ovary).
sebaceous duct directly opens into the skin which gets
blocked. Punctum is depressed black coloured spot
over the summit of the sebaceous cyst. Because of
the denuded squamous epithelium (keratin) it is black
in colour. In 30% cases sebaceous duct opens into
the hair follicle and so punctum is not seen. Sebaceous
cysts often can be multiple commonly in face and
scrotum. Often hairs are less or skin over the summit
of the sebaceous cyst is bald (Figs 3.54A to C).
Complications: Infection and abscess formation;
Surface may rupture and gets ulcerated with discharge
and chronic inflammation, this discharge often spreads
to surrounding tissues and hardens, and is called as—
Cock’s peculiar tumour which often resembles
epithelioma (Figs 3.56A and B). It is a misnomer.
Occasionally yellowish sebum discharges slowly
through a wide punctum and becomes hardened,
inspissated sebaceous material known as sebaceous
horn (Length greater than its base diameter, is called
Sequestration dermoid – Sebaceous cyst –
• Occurs in the line of fusion • Occurs anywhere except
palm and sole
• Skin is not adherent (free) • Skin is adherent over summit
• Extends often into deeper • Subcutaneous plane – do not
plane or cavities through extend to deeper plane
suture line
• Punctum is absent • Punctum is present – 70%
cases
• Bone resorption and • Freely mobile without bone
indentation is common resorption
• Restricted mobility • Superficial swelling, mobile
• Needs proper evaluation
with X-ray / CT scan
• Excision is done under • Excision is done under local
general anaesthesia anaesthesia
A
B
C
Figs 3.54A to C: Sebaceous cysts in face and scalp.
Note the hair loss over the summit in sebaceous cyst.
Punctum is clearly seen in sebaceous cyst face. Punctum
is present in 70% of sebaceous cysts.
Examination of a Swelling/Lump
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A
A
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A
Figs 3.55A and B: Sebaceous horn in scalp and nape
of neck.
as horn) (Figs 3.55A and B). Calcification also can
occur in sebaceous cyst. Punctum is usually absent
in sebaceous cysts of the scrotum (Fig. 3.57) (Fordyce’s
disease is heterotopic sebaceous glands in mucosa
of lip and oral cavity).
Lipoma
It is a benign tumour arising from yellow fat (Tumour
arising from brown fat is called as hibernoma). It is
called as universal tumour/ubiquitous tumour as it can
B
Figs 3.56A and B: Cock’s peculiar tumour over scalp and
ear. It is a misnomer. It is not a tumour. It mimics epithelioma.
occur anywhere in the body (except in brain). It is the
commonest benign tumour. It can be diffuse or
localised. Diffuse lipomas are not encapsulated, not
well localised. They are common in palm, sole, head
and neck region, difficult to be removed. Diffuse type
is often called as pseudolipoma. It is usually harmless
except with some cosmetic problem. Lipoma can be
single or multiple. Multiple lipomas (5%) are often
associated with many syndromes like MEN Syndrome
(multiple endocrine neoplasia syndrome). Types -
Painful lipomas are called as neurolipomas. Dercum’ s
disease is tender deposition of fat especially on the
trunk, is also called as adiposis dolorosa. It is common
in females. It is basically multiple neurolipomatosis.
Fibrolipoma; naevolipoma; lipoma arborigens
(pedunculated lipoma); neurolipoma are different
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Fig. 3.57: Multiple sebaceous cysts in the scrotum.
Punctum is usually absent in scrotal sebaceous cysts.
SRB’s Clinical Surgery
variants of lipoma. Localised lipoma is the commonest
type. It is encapsulated type. It can occur anywhere but
more commonly observed in nape of the neck, back,
neck and shoulder. It is most common in subcutaneous
plane. It also can be intermuscular; subfascial;
intramuscular; parosteal; subserosal; submucosal;
extradural; subdural (not intracerebral); subserosal;
intraarticular or subsynovial. Lipomas attain large size
in thigh, shoulder, retroperitoneum, back which may
often turn into sarcoma (Figs 3.58A and B).
A
Clinical features: Localised painless swelling, which
is lobular, nontender, semifluctuant (in normal body
temperature fat is in semiliquid state and so often slight
fluctuation may be elicited), freely mobile, with edge
slipping between the palpating fingers (slip sign),
with free skin. Using index finger edge of the lipoma
when pushed will slip under the palpating finger.
Naevolipoma shows dilated veins over the surface and
so called as lipoma telangiectasis. Fibrolipoma con-
tains more fibrous tissue and so it is firm. Neurolipoma
also contains nerve tissue also and so is painful. At
times lipomas may be pedunculated (Figs 3.59A to
C). Lipoma is not transilluminant.
Differential diagnoses: Neurofibroma and other
cystic swellings.
B
Figs 3.58A and B: Typical lipoma. Note the well defined,
lobulated surface.
Complications: Sarcomatous change—liposarcoma;
myxomatous change; saponification; calcification;
submucosal lipoma in intestine can cause intussusception and so intestinal obstruction. Repeated
trauma may cause ulceration over the summit which
is more often seen in pedunculated lipoma.
Glomus Tumour
It is also called as glomangioma.It arises from the
cutaneous glomus composed of a tortuous arteriole
which communicates directly into the venule and these
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