EXAMINATION OF A LUMP OR A SWELLING.pptx

EXAMINATION OF A LUMP

1. EXAMINATION OF A LUMP OR A SWELLING

2. Definition A ‘Lump’ is a vague mass of body tissue. A ‘Swelling’ is a vague term which denotes any enlargement or protuberance in the body due to any cause. A ‘ Tumour ’ or ‘Neoplasm’ is a growth of new cells which proliferate independent of the need of the body.

3. HISTORY Duration: shorter duration and pain - inflammatory (acute). longer duration and without pain - possibly neoplastic (benign). longer duration and with slight pain - chronic inflammatory swellings swellings with shorter duration - neoplastic, mostly malignant. Mode of onset: 'How did the swelling start’? – spontaneous ,trauma, scar or benign naevus.

4. HISTORY cont … Pain: nature of pain site Time of onset Progress of the swelling: 'Has the lump changed its size since it was first noticed’? Increased or decreased in size.

5. HISTORY cont … Exact site Fever Presence of other lumps Secondary changes Impairment of function Recurrence Loss of body weight Past history Personal history Family history

6. PHYSICAL EXAMINATION General survey: Cachexia or malnutrition, abnormal attitude of limb, raised temperature and pulse (inflammatory swelling). LOCAL EXAMINATION Inspection Palpation Regional lymph nodes Percussion Auscultation Measurements Movements

7. Inspection Situation Colour Size Shape Edge Surface Number Pulsation Peristalsis Movement with respiration Movement with deglutition Movement with protrusion of tongue Impulse on coughing Skin over the swelling Any pressure effects

8. Palpation Temperature Tenderness Size, shape, extent Surface Edge Consistency Fluctuation Fluid thrill Translucency Impulse on coughing Reducibility Compressibility Pulsatility Fixity to the overlying skin. Relations to surrounding structures

9. Percussion The importance of this examination is not much in case of a swelling. Its sole place is to find out the presence of a gaseous content within the swelling e.g. resonant note over a hernia; or to elicit slight tenderness e.g. Brodie's abscess.

10. AUSCULTATION: All pulsatile swellings should be auscultated to exclude presence of any bruits or murmurs. 'Machinery murmur' is heard in an aneurysmal varix.

11. MEASUREMENTS: This is important not only to find out increase in swelling at definite intervals, but also to find out if there is any wasting distal to the swelling. MOVEMENTS: In case of a swelling, the students must not forget to examine the movements of the nearby joint to exclude any impairment. This should be noted in the history and is of particular importance to find out if the swelling has involved the joint or not.

12. EXAMINATION FOR PRESSURE EFFECT: Swellings will inevitably exert pressure on the surrounding structures. Its effect must be noted by the following examinations : ( i ) The arterial pulse distal to the swelling is felt. Sometimes the swelling may press on the main artery of the limb and causes weak pulse distally. (ii) The nerves may be affected by the pressure of the swelling. This will cause wasting, paresis or paralysis of the muscles supplied by the nerve with or without sensory disturbances. (iii) The swelling may even exert its pressure on the subjacent bone by eroding it. This is sometimes seen in aneurysm and dermoid cyst on the skull.

13. GENERAL EXAMINATION: It is very much tempting while examining a swelling to do all with the swelling and forget about the rest of the body. This will lead to innumerable misdiagnoses. So one must examine the patient as a whole.

14. SPECIAL INVESTIGATIONS BLOOD: t otal count (T.C.), differential count (D.C.), haemoglobin (Hb%), erythrocyte sedimentation rate (E.S.R.) and sugar. In urine, estimation of sugar is very important in case of recurrent abscesses and carbuncles to find out if the patient is suffering from diabetes. Aspiration and examination of the aspirated material physically, chemically, microscopically and bacteriologically are very important in case of chronic cystic swellings.

15. Fine Needle Aspiration Biopsy (FNAB) or Fine Needle Aspiration Cytology (FNAC). X-ray examination is indispensable in case of bony swellings and to find out if the subjacent bone has been eroded by an aneurysm or a dermoid cyst. Chest X-ray should be taken when pulmonary metastasis is to be excluded in case of a malignant growth. Skin test.— (a) Tuberculin test — if positive in infants and young children suggests tuberculous lesion. If this test is negative in adult, it can straightway exclude possibility of tuberculous origin of the swelling. (b) Casoni's test becomes positive in case of a hydatid cyst; but a negative result cannot exclude hydatid cyst.

16. Ultrasonography: It is particularly used to determine whether a mass is solid or cystic. Computed Tomography (CT Scan): - This technique provides unique two-dimensional representation of differing radiographic densities throughout a cross-sectional volume of tissue. - It provides more accuracy than that of ultrasonography in assessment of any growth e.g. its size, shape, local spread and general dissemination. It helps in exact anatomical localization of deep seated masses even in obese individuals.

17. Three Dimensional CT Scan (3D CT Scan) — is now available which provides 3 dimensional picture of the structure or organ of the body. MRI Angiography Biopsy Biopsy is by far the most important investigation of a swelling

18. Types of biopsy a) NEEDLE BIOPSY: In this method a hollow needle is introduced into the swelling and a core of tissue is taken out for histological examination. (b) DRILL BIOPSY — is performed by an apparatus consisting of a small sharp cannula within which is attached a high speed compressor air drill. This is claimed to be better than needle biopsy and has been mostly used in case of breast lumps. The core of tissue obtained by this method is now examined for histopathological report. (c) PUNCH BIOPSY.— This method is more often used in case of tumour for hollow viscera or solid viscera. With punch biopsy forceps pieces of tissue are taken from the margin of the tumour along with surrounding normal tissue or from the base of the tumour . (d) OPEN BIOPSY.— This is performed by operation. After getting access to the tumour a slice of tissue (Incisional biopsy) or the whole of the tumour (excisional biopsy) is excised and then histopathological examination of the tumour is performed. Incisional biopsy — has the theoretical disadvantage of spreading the tumour to the adjoining tissues. Excisional biopsy — is safe and better. It is done by excising the tumour with a margin of healthy surrounding tissue in case of malignant growth.

19. DIAGNOSIS OF A SWELLING While diagnosing a swelling, the clinician should first find out, whether the particular swelling is originating from — the skin, the subcutaneous tissue, the muscles, the vessel, the nerve or bone and secondly, the cause of the swelling — whether it is: congenital, traumatic, inflammatory, neoplastic or otherwise.

20. Characteristics of benign and malignant growths BENIGN Symptoms: Occurs at younger age. 1. Duration.— Slow growth. 2. Pain.— Usually absent. 3. Loss of weight.— Never seen. 4. Loss of function.— Usually not seen. MALIGNANT Seen usually above 40 years of age, but may occur at younger age. 1. Rapid growth. 2. May be painful at late stage, barring osteosarcoma which is painful from the beginning. 3.A feature of malignant growth. 4.Seen quite early.

21. Characteristics of benign and malignant growths Signs: 1. Cachexia, anaemia and loss of weight.— Usually absent. 2. Mobility.— Freely mobile. 3. Surface.— Usually smooth. 4. Margin.— Definite and smooth. 5. Consistency.— Usually firm6. Pressure Effects.— Usually absent. 7. Regional lymph nodes.— Not enlarged. 8. Distant metastasis.— Almost never seen9. Secondary changes.— Not seen. 10. Recurrence.— Never recurs after excision. 1. Usually present. 2. Fixed early due to infiltration. 3. Usually irregular. 4. Not definite and irregular. 5. Either hard or of varying consistency. 6. Often present. 7. Early involved and enlarged. 8. A feature of malignant growth — a late feature. 9. Often come across. 10. Often recurs after excision.

22. Histology: 1. Cell differentiation.— A feature of benign 2. Polarity.— Cells are arranged as parent tissue. 3. Capsule.— Always encapsulated. 4. Anaplasia.— Not seen. 5. Nuclear structure.— Same as the parent tissue without mitosis.. 1. Cells are usually undifferentiated. growth. 2. Polarity is lost 3. No capsule formation as local infiltration is the rule. 4. A feature of malignant growth. 5. Nucleus becomes larger, hyperchromatic with mitosis Characteristics of benign and malignant growths

23. Differential diagnosis CONGENITAL DERMOID CYST - this cyst may appear anywhere in the midline of the body as also in places where the two embryonic processes meet each other e.g. at the outer angle of the behind the pinna (Fig. 3.9) (Post auricular dermoid), just below the tongue in the midline (Sub-lingual dermoid) etc. 2. HEMANGIOMA These are vascular malformations or hamartomas and may arise from the capillary or the vein or the artery and accordingly called a capillary haemangioma or cavernous haemangioma or a plexiform ( cirsoid ) haemangioma respectively