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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 5 General examination physical signs
102
Lump in the face (non-parotid lesion)
Swelling is anterior to border of the masseter muscle (teeth clenched).
Some differential diagnoses and typical outline evidence
Preauricular
lymph node
inflammation
Suggested by: tender nodular swelling in front of ear
Confirmed by: above clinical features
Preauricular
lymphoma
Suggested by: non-tender nodular swelling in front of ea
r
Confirmed by: biopsy with or without or excision
Basal cell
carcinoma
Suggested by: painless ulcer with rolled edge
Confirmed by: biopsy
Sebaceous cyst Suggested by: fluctuant swelling with central punctum
Confirmed by: incision
Subcutaneous
abscess
Suggested by: tender, fluctuant swelling
Confirmed by: incision when pointing
Dental abscess Suggested by: tenderness of underlying tooth
(tap gently)
Confirmed by: dental exploration
Skin melanoma Suggested by: painless swelling with pigment and
red edge
Confirmed by: wide excision biopsy
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Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 5 General examination physical signs
104
Submandibular lump—not moving
with tongue or on swallowing
This occurs below the mandible and above the digastric muscle.
Some differential diagnoses and typical outline evidence
Parotitis Suggested by: acute, painful swelling of whole gland(s),
contact with others cases
Confirmed by: bilateral swelling or associated pancreati
t
is
or orchitis (rising mumps titer if doubt)
Nonsuppurative
sialitis from
ascending
infection along
duct
Suggested by: unilateral swelling, oral sepsis, or poor
general condition
Confirmed by: discharge from duct orifice. Resolution
with antibiotics
Suppurative
salivary
infection
Suggested by: hot, tender, fluctuant swelling with high
fever. No discharge from duct orifice
Confirmed by: ultrasound scan, response to drainage
± antibiotics
Salivary duct
obstruction
(usually due to
stone)
Suggested by: intermittent infection or no discharge
from duct
Confirmed by: ultrasound scan response to
stomaplasty
Salivary
Sjögren’s
syndrome
Suggested by: dry mouth and eyes with no tears
Confirmed by: rheumatoid factor positive, anti-Ro(SSA)
and anti-La(SSB) positive
Salivary
sarcoidosis
Suggested by: dry cough, enlarged lacrimal glands, and
erythema nodosum
Confirmed by: CXR appearances (e.g., bilateral lympha-
denopathy) and tissue biopsy showing noncaseating
granuloma
Salivary tumor
due to adeno-
carcinoma,
squamous cell
tumor, etc.
Suggested by: no obvious features of alternative
nonmalignant or infective condition
Confirmed by: urgent surgical referral for biopsy or
exploration
SUBMANDIBULAR LUMP1
105
Submandibular
lymph node
inflammation
Suggested by: tender, solid, nodular swelling between
the mandibular branches, especially at age <20 years
Confirmed by: above clinical features or ultrasound scan
Submandibular
lymph node
malignancy
Suggested by: non-tender solid nodular swelling
between the mandibular branches, especially at age
>20 years
Confirmed by: ultrasound scan, biopsy ± excision
Ranula Suggested by: transilluminable cyst lateral to midline,
with domed, bluish discoloration in floor of mouth
lateral to frenulum
Confirmed by: clinical appearance, ultrasound scan, and
histology after excision
Submental
dermoid
Suggested by: midline cyst and age <20 years
Confirmed by: histology after excision
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CHAPTER 5 General examination physical signs
106
Anterior neck lump—moving with
tongue and swallowing
This suggests extrathyroid tissue.
Some differential diagnoses and typical outline evidence
Thyroglossal
cyst
Suggested by: fluctuant cystic lump in midline or just to
the left
Confirmed by: ultrasound scan, radioisotope scan (cyst
is cold), CT scan, histology of excised tissue
Ectopic thyroid
tissue
Suggested by: solid lump in midline or just laterally
Confirmed by: ultrasound scan, radioisotope scan (nod-
ule may take up iodine), CT scan, histology of excised
tissue
Neck lump—moving with swallowing
but not with tongue
This suggests a goiter (or attached to thyroid gland). The following are
preliminary diagnoses (see also pp. 107, 108).
Some differential diagnoses and typical outline evidence
Thyrotoxic
goiter
Suggested by: sweating, fine tremor, tachycardia, weight
loss, lid lag
Confirmed by: iFT4, ± iFT3 and ddTSH. Ultrasound
scan, isotope scan
Hypothyroid
goiter
Suggested by: cold intolerance, tiredness, constipation,
bradycardia
Confirmed by: iTSH, dFT4. Ultrasound scan ± thyroid
antibodies positive
Euthyroid
goiter
Suggested by: no sweating, no fine tremor, no weight
change, no cold intolerance, no tiredness, no lid lag,
normal bowel habit, normal pulse rate
Confirmed by: normal FT4, and normal TSH
BILATERAL NECK MASS1
107
Neck lump
Bilateral neck mass
Bilateral neck mass—moving with
swallowing but not with tongue
This is a central mass crossing the midline.
Some differential diagnoses and typical outline evidence
Graves’ disease Suggested by: clinical thyrotoxicosis, exophthalmos,
pretibial myxedema. No nodules
Confirmed by: iFT4 or iFT3 and ddTSH and TSH
receptor antibody positive. Diffuse increased uptake
on thyroid isotope scan
Hashimoto’s
thyroiditis
Suggested by: clinically euthyroid or hypothyroid
(or rarely transient thyrotoxicosis). Multiple nodules in
large gland
Confirmed by: FT4i transiently then dFT4 and iTSH,
thyroid antibodies titer ii. Diffuse poor uptake on
thyroid isotope scan
“Simple” goiter Suggested by: clinically euthyroid. Not nodular
Confirmed by: normal FT4 or FT3 and normal TSH and
negative thyroid antibodies
Toxic
multinodular
goiter
Suggested by: multiple nodules and clinically
thyrotoxic
Confirmed by: iFT4 or iFT3, and dTSH and nodules
on ultrasound scan or thyroid isotope scan
Nontoxic
multinodular
goiter
Suggested by: multiple nodules and clinically euthyroid
Confirmed by: normal FT4 or FT3 and normal
TSH. Nodules on ultrasound scan or thyroid
isotope scan
Thyroid
enzyme
deficiency (rare)
Suggested by: presentation in childhood, clinically
hypothyroid or euthyroid. Not nodular
Confirmed by: dFT4 or dFT3 and iTSH but with
abnormal (high or low) radio-iodine uptake
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CHAPTER 5 General examination physical signs
108
Solitary thyroid nodule
Some differential diagnoses and typical outline evidence
Autonomous
toxic thyroid
nodule
Suggested by: single nodule and clinically thyrotoxic
(weight loss, frequent bowel movement, i pulse rate,
sweats, tremor)
Confirmed by: iFT4 or FT3, dTSH and single hot nodule
thyroid isotope (iodine or technetium) scan.
Thyroid
carcinoma:
papillary 60%
follicular 25%
medullary 5%
lymphoma 5%
anaplastic <1%
Suggested by: single nodule and clinically euthyroid.
Confirmed by: normal FT4 or FT3, normal TSH and
single cold nodule thyroid isotope (iodine or techne-
tium) scan. Solid on ultrasound scan. Malignant cells on
needle aspiration or removal.
Thyroid
adenoma
Suggested by: single nodule and clinically euthyroid
Confirmed by: normal FT4 or FT3, normal TSH and
single cold nodule thyroid isotope (iodine or
technetium) scan. Solid on ultrasound scan. No
malignant cells on needle aspiration or removal
Thyroid cyst Suggested by: single nodule and clinically euthyroid
Confirmed by: normal FT4 or FT3, normal TSH and
single cold nodule thyroid isotope (iodine or
technetium) scan. Cystic on ultrasound scan.
Disappears on needle aspiration and no malignant cells
then or if removed
LUMP IN ANTERIOR TRIANGLE OF NECK1
109
Lump in anterior triangle of neck
This is below the digastric and in front of the sternocleidomastoid
muscles.
Some differential diagnoses and typical outline evidence
Lymph node
inflammation
Suggested by: tender, solid nodular swelling, especially
at <20 years of age
Confirmed by: above clinical features, CT scan
Acute abscess Suggested by: hot, tender, fluctuant swelling with high fever
Confirmed by: clinical features and discharge of pus
after incision, ultrasound scan, CT scan
Tuberculous
(“cold”)
abscess
Suggested by: fluctuant swelling with low-grade or no fever
Confirmed by: acid-fast bacillus (AFB),
culture and sensi-
tivity of aspirate
Branchial cyst Suggested by: fluctuant swelling at anterior border of
sternocleidomastoid muscle, patient <20 years of age
Confirmed by: ultrasound scan, CT scan, surgical
anatomy, appearance and histology on excision
Cystic hygroma Suggested by: fluctuant swelling that transilluminates
well, patient <20 years of age
Confirmed by: ultrasound scan, CT scan, surgical
anatomy, appearance and histology on excision or
regression with sclerosing agent
Pharyngeal
pouch
Suggested by: intermittent, fluctuant swelling (usually on
left) and dysphagia
Confirmed by: barium swallow fills pouch
Carotid body
tumor (chemo-
dectoma)
Suggested by: mobile arising from carotid bifurcation
soft (upper third of sternocleidomastoid) and gently
pulsatile
Confirmed by: ultrasound scan, CT scan, surgical anatomy,
appearance and histology on excision
Hodgkin’s or
non-Hodgkin’s
Iymphoma
Suggested by: non-tender solid nodular swelling
between the mandibular branches, especially at >20
years of age, fever, weight loss. Chest pain with alcohol
in Hodgkin’s lymphoma
Confirmed by: ultrasound scan, CT scan, biopsy with or
without or excision
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CHAPTER 5 General examination physical signs
110
Lump in posterior triangle of neck
This is behind the sternocleidomastoid and in front of trapezius muscles.
Some differential diagnoses and typical outline evidence
Acute abscess Suggested by: hot, tender, fluctuant swelling with high
fever
Confirmed by: clinical features and discharge of pus
after incision, ultrasound scan, CT scan
Cystic hygroma Suggested by: fluctuant swelling that transilluminates
well, patient <20 years of age
Confirmed by: ultrasound scan, CT scan, surgical
anatomy, appearance and histology on excision or
regression with sclerosing agent
Lymph node
inflammation
Suggested by: tender, solid nodular swelling, especially
at <20 years of age
Confirmed by: clinical features, ultrasound scan, CT scan
Hodgkin’s or
non-Hodgkin’s
Iymphoma
Suggested by: non-tender, solid nodular swelling. Chest
pain with alcohol in Hodgkin’s
Confirmed by: ultrasound scan, CT scan, biopsy with or
without or excision
Metastasis in
lymph node
Suggested by: non-tender, solid nodular swelling
Confirmed by: ultrasound scan, CT scan, biopsy
± excision
Tuberculous
(“cold”) abscess
Suggested by: non-tender, cystic swelling, especially at
>50 years of age
Confirmed by: ultrasound scan, CT scan, aspiration
biopsy or excision, culture of AFB
SUPRACLAVICULAR LUMP(S)1
111
Supraclavicular lump(s)
Some differential diagnoses and typical outline evidence
Lymph node
inflammation
Suggested by: tender, solid nodular swelling, especially
at <20 years of age
Confirmed by: clinical features
Lymphoma Suggested by: rubbery, matted nodes
Confirmed by: lymph node biopsy
Lymph node
secondary to
gastric or lung
carcinoma
Suggested by: rock-hard, fixed nodes, Virchow’s node in
left supraclavicular fossa (Troisier’s sign)
Confirmed by: lymph node biopsy, gastroscopy,
bronchoscopy
Aneurysm of
subclavian
artery
Suggested by: pulsatile cyst
Confirmed by: ultrasound scan and MRI scan or
angiography
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