how to access skin swellling?

1. Benign skin swellings
How to examine?
Various types of benign skin
swellings

2. Classification
 According to orgin:
• Skin
• Subcutaneous tissue
• Muscle
• Nerves
• Blood vessels
• Bone

4. • According to consistency:
• Solid swellings: soft, firm, hard
• Cystic swelling

5. CLINICAL EXAMINATION
OF SWELLING

6. History
Size
Site
Onset:
 Accidental : breast swellings
 Acute onset: cute inflammation.
 Gradual onset (weeks or months) :chronic
inflammation or neoplastic swellings

7. Course
 Progressive: neoplastic swellings.
 Stationary: chronic inflammation.
 Regressive: inflammatory conditions.
 Fluctuating : chronic inflammation with
acute exacerbation

8. Duration
 Short: (days or weeks) inflammatory.
 Long: (months or years) neoplastic.
 Since birth : congenital

9. Other swellings
 Multiple: lipoma, Neurofibroma.
 Lymph nodes : in inflammatory
conditions
 Metastasis in malignancy.

10.  Effect on the general condition:
 Toxic symptoms: Fever
 Malignant symptoms: cachexia.

11. Examination
 Inspection
 Palpation
 Percussion
 Auscultation

12. INSPECTION
 SITE-
 EXACTANATOMICAL LOCATION:
IMPORTANT AS SOME SWELLINGS OCCUR
IN ATYPICAL POSITIONWHICH IS
DIAGNOSTIC
 EXAMPLES
 EXTERNALANGULAR DERMOID –LATERAL END
OF EYE BROW
 MENINGOCELE- OVERTHE BACK IN MIDLINE

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EXTERNAL ANGULAR DERMOID

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EXTERNAL ANGULAR DERMOID

15. *Image by 48276084@N00 via Flickr

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INTERNAL ANGULAR DERMOID – MEDIAL END OF EYE BROW

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MENINGOCELE

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MENINGOCELE

19. 2.NUMBER
 SINGLE OR MULTIPLE
 MULTIPLE EXAMPLES
 MULTIPLE NEUROFIBROMATOSIS)
 MULTIPLE LIPAMATOSIS (DERCUMS DISEASE)

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MULTIPLE LIPAMATOSIS

23. 3.SHAPE
 SPHERICAL
 OVOID
 KIDNEY /BEAN SHAPED/RENIFORM
 IRREGULAR

25. 4.SIZE
 LONGITUDINAL &TRANSVERSE ON
INSPECTION
 DEPTH BETTER JUDJED ON PALPATION
 USUALLY NOTED IN CENTIMETRES

26. 5.SURFACE
 COLOUR
 OVERLYING SKIN

27. A)COLOUR
 ARTERIAL HAEMANGIOMA – BRIGHT RED
 VENOUS HAEMANGIOMA— PURPLE
 MALIGNANT MELANOMA- BLACK
 BENIGN NAEVUS – BLACK
 RANULA –BLUE

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CAPILLARY HAEMANGIOMA OVER FORE HEAD

29. BENIGN NEVUS

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BENIGN NEVUS

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MALIGNANT MELANOMA

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MALIGNANT MELANOMA OF FOOT

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RANULA

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37. c)Skin over lying swelling
 RED &EDEMATOUS – INFLAMMATORY
 BLACK PUNCTUM – SEBACEOUSCYST
 PIGMENTATION-MOLES , NAEVI
 SCAR
 ULCERS

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ABSCESS

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ABDOMINAL WALL ABSCESS

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INFECTED SEBACEOUS CYST WITH PUNCTUM

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POSTTHYROIDECTOMY SURGICAL SCAR

42. 6.VISIBLE PULSATIONS
 PULSATION
 A MOVEMENT OR INCREASE IN SIZE
SYNCHRONOUSWITH EACH HEART BEAT
 2TYPES
 EXPANSILE PULSATIONS – SWELLINGS
ARISING FROM ARTERIES EX: AORTIC
ANEURYSM , CAROTID BODYTUMOUR
 TRANSIMITTED PULSATIONS – SWELLINGS
CLOSETO ARTERIES
 REMEMBER NOTTOTOUCHTHE PATIENT
DURING INSPECTION

43. 7.VISIBLECOUGH IMPULSE
 PERFORMEDWHEN SWELLING IS OVER
ABDOMEN,CHEST,SPINALCANAL OR
CRANIUM
 COUGH IMPULSE
 VISIBLE INCREASE INTHE SIZE OF SWELLING
SYNCHRONOUSWITH COUGH
 POSITIVE IN SWELLINGS COMMUNICATING
WITH ABDOMEN,THORACICCAVITY,SPINAL
CANAL OR CRANIAL CAVITY

44. POSITIVECOUGHIMPULSE
 HERNIA
 MENINGOCELE
 VARICOCELE
 SAPHENAVARIX
 IN CHILDRENCRYING ACTS AS COUGHING

45. 10.Movementwith deglutition
 IN CASE OF NECK SWELLINGS
 SWELLINGS MOVINGWITH DEGLUTITION
 THYROID SWELLING
 THYROGLOSSAL CYST
 THYROGLOSSAL FISTULA
 SUBHYOID BURSA
 PRE/PARA TRACHEAL LYMPH NODES
 EXTRINSIC CARCINOMA OF LARYNX

46. WHYTHYROIDMOVESUPWITHDEGLUTITION?
 THYROID IS ENCLOSED IN PRETRACHEAL
FASCIA
 PTF ATTACHES TO THYROID &CRICOID
CARTILAGES(BERRY’S LIGAMENT)
 SUPERIOR CONSTRICTOR MUSCLE
CONTRACTION DURING DEGLUTITION
 THESE CARTILAGES MOVE UP
 ALONGWITHTHESETHYROID MOVES UP

47. 11)MOVEMENTWITHTONGUEPROTRUSION
 IN CASE OF MID LINE NECK SWELLINGS
 EG:THYROGLOSSALCYST &FISTULA
 WHY?
 ATTACHEDTO FORAMEN CAECUM OFTONGUE

48. 12)PRESSURE EFFECTS
 WHEN SWELLING IS PRESENT ON LIMBS
 AN AXILLARY SWELLING WITH LIMB EDEMA –
LYMPH NODAL SWELLING
 PARESIS – PRESSURE ON NERVES
 SWELLING IN NECK WITHVENOUS
ENGORGEMENT(RETROSTERNAL EXTENSION)

49. PALPATION
 DEFINITE CLUE FOR DIAGNOSIS
 METHODICAL,FOLLOW DEFINITE ORDER
 BE GENTLE
 SHOULD NOT HURTTHE PT.

50. 1.TEMPERATURE
 BEST FELT BY BACK OFTHE HAND-WHY?
 INCREASED IN
 INFLAMMATORY SWELLING
 WELLVASCULARISEDTUMOURS- SARCOMA

51. 2.TENDERNESS
 PAIN DUETO PRESSURE EXERTED OVER
THE SWELLING ISTENDERNESS
 PALPATE GENTLY OVER ALLTHE AREA
 IT IS A FEATURE OF
 INFLAMMATORY SWELLINGS
 SWELLING RELATEDTO NERVES -
NEUROFIBROMA

52. 3.SIZE&SHAPE
 CONFIRMVERTICAL & HORIZONTAL
DIMENSIONS
 NOTETHETHIRD DIMENSION DEPTH
WHICH COULD NOT BE EXACTLY
DETERMINED BY INSPECTION

53. 4.SURFACE
 WITH PALMAR SURFACE
 SMOOTH –CYSTIC SWELLINGS
 LOBULAR -LIPOMA
 NODULAR –MULTI NODULAR GOITRE
 MATTED: LYMPH NODES
 IRREGULAR - CARCINOMA

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SMOOTH SURFACE OF A SEBACEOUS CYST

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56. 5.EDGE
 1)WELL DEFINED & REGULAR – BENIGN
NEOPLASMS
 2)WELL DEFINED & IRREGULAR –
MALIGNANT NEOPLASM
 3)ILLDEFINED &DIFFUSE –INFLAMMATORY
SWELLINGS

57. *Image by 9085776@N08 via Flickr
ABSCESS WITH ILL DEFINED MARGINS

58. *Image by 72310117@N07 via Flickr
LIPOMAWOTHWELL DEFINED MARGINS

59. *Image by 78523246@N00 via Flickr
LARGE LIPOMAWITH WELL DEFINED MARGINS

60. *Image by 78523246@N00 via Flickr

61. 6.CONSISTENCY
 SOFT – LIPOMA
 CYSTIC- CYSTS &CHRONIC ABSCESSES
 FIRM –FIBROMA
 BONY HARD-OSTEOMA
 VARIABLE CONSISTENCY- MALIGNANCY

62. HOW TO ASSESS CONSISTENCY
 SOFT – EAR LOBULE,ALAEOF NOSE
 FIRM-TIP OF NOSE
 HARD -BRIDGE OF NOSE, FORHEAD

63. PAGET’S TEST
 DONE FOR SMALL SWELLINGSTO KNOW
THE CONSISTENCY(CYSTIC/SOLID)
 THE CENTREAND PERIPHERIESARE
PALPATEDWITH INDEX FINGER
 CYSTIC SWELLING FEELS SOFTER AT CENTRE
THAN PERIPHERY
 SOLID SWELLING FEELS FIRMER AT CENTRE
THAN PERIPHERY

64. SPECIAL TESTS
 DONE IN CASE OF SOFT/CYSTIC SWELLING
 7.FLUCTUATION
 8.TRANSILLUMINATION
 9.COUGH IMPULSE
 10.REDUCIBILITY
 11.COMPRESSIBILITY
 IN SOLID SWELLINGS DIRECTLY PROCEED
TOTEST FOR RELATIONTO OTHER
STRUCTURES

65. 7.FLUCTUATION
 TRANSMISSION OF IMPULSE INTWO
DIRECTIONS AT RIGHT ANGLESTO EACH
OTHER
 IMPLIES PRSENCE OF FLUID INTHE
SWELLING

66. HOW TO ELICIT FLUCTUATION?
 IFTHE SWELLING IS MOBILE FIRST FIX IT OR
ASKTHE ASST.TO HOLD IT
 KEEP 2 INDEX FINGERS ON OPPOSITE POLES
 WHEN ONE FINGER IS PRESSEDTHE FINGER
AT OPPOSITE END FEELSTHE IMPULSE &
PASSIVELY LIFTED UP
 REPEAT THE MANUVERE IN A PLANE AT
RIGHT ANGLES TO THE 1ST ONE
 IF IMPULSE IS FELT IN BOTH PLANES IT IS A
POSITIVE FLUCTUATIONTEST

67. LAW BEHIND FLUCTUATION!
 PASCAL’S LAW
 PRESSURE EXERTEDTO A FLUID ISTRANSMITTED
EQUALLY IN ALLTHE DIRECTIONS
*Image via Bing

68. PRINCIPLES WHILE DOING FLUCTUATION TEST
 ALWAYS PERFORM IN 2 DIRECTIONS AT
RIGHT ANGLESTO EACH OTHER
 TWO FINGERS SHOULD BE KEPT AS FAR
APARTAS POSSIBLE
 FREELY MOBILE SWELLINGS SHOULD BE
FIXED FIRST(AS IN HYDROCELE)
 SMALL SWELLINGS –WATCHING FINGER &
DISPLACING FINGER
 VERY LARGE SWELLINGS MORETHAN ONE
FINGFR SHOLD BE USED

70. PSEUDO FLUCTUATION
 A FALSE SENSE OF FLUCTUATION FELT IN
LARGE SOFT SWELLINGS CONTAINING NO
FLUID
 SEEN IN
 LARGE LIPOMA

71. CROSS FLUCTUATION
 FLUCTUATION BETWEENTWO SEPARATE
CYSTIC SWELLINGS COMMUNICATING
WITH EACH OTHER
 SEEN IN
 COMPOUND PALMAR GANGLION
 PSOASABSCESS

72. 8.TRANSILLUMINATION
 DEMONSTRATIONOFTRANSMISSION OF
LIGHTTHROUGHA SWELLING
 POSITIVE IN SWELLINGS CONTAINING
CLEAR FLUID ANDTHINTRANSPARENT
WALLS
 NOTRANSILLUMINATION IFWALL ISTHICK,
ORTURBID FLUID IS PRESENT(BLOOD,PUS,
LYMPH)
 DARK ROOM ,TRANSILLUMINOSCOPE

73. TRANSILLUMINANT SWELLINGS
 2.EPIDIDYMAL CYST
 3.MENINGOCELEWITHTHIN SKIN
 4.RANULA
 5.CONGENITAL HYDROCELE

74. 11.COMPRESSIBILITY
 WHEN PRESSURE IS APPLIEDTOA
SWELLING IT DECREASES IN SIZE AND
WHEN PRESSURE IS RELEASED SWELLING
REGAINS ITS SIZE ITSELF
 CHARECTARISTIC SIGN OFVASCULAR
HAEMANGIOMA

75. 12.PULSATILITY
 WHEN FINGER IS PLACED OVERA
PULSATILE SWELLING IT RAISESWITH
EACH BEAT
 TOTYPES OF PULSATIONS
 TRANSMITTED PULSATIONS- SEEN IN
SWELLINGS PRESENT NEAR AN ARTERY
 EXPANSILE PULSATIONS-SEEN IN SWELLINGS
ARISING FROM ARTERIES
 EX:AORTIC ANEURYSM

76. HOW TO DIFFERENTIATE?
 TWO FINGERS ARE PLACED OVERTHE
SWELLING AND FINGER MOVEMENTSARE
NOTED
 TRANSMITTED PULSATIONS – FINGERS
ARE SIMPLY LIFTED UP
 EXPANSILE PULSATIONS- FINGERS ARE
LIFTED UP AND MOVEAPART

77. 13.FIXITYTOSKIN
 SKIN PINCHED OVER DIFFERENT PARTS OF
THE SWELLING -CANNOT BE PINCHED IF
FIXEDTO SKIN
 SKIN IS MADETO MOVE OVERTHE
SWELLING-THE SKINWILL NOT MOVE IF IT
IS FIXEDTO SKIN
 SWELLINGS ARISING FROM SKIN ARE FIXED
TO SKIN EX:SEBACEOUS CYST , PAPILLOMA
, EPITHELIOMA

78. 14.RELATIONTOSURROUNDINGSTRUCTURES
 1)SUBCUTANEOUSTISSUE
 SWELLINGS IN SUB CUTANEOUSTISSUE ARE
NOTADHERENTTO SKIN OR UNDERLYING
MUSCLE
 LIPOMA-PUSHED SIDEWAYS PUCKERING IS
SEEN IN SOME PLACES – DUE PRESENCE OF
FIBROUS SEPTA
 2)DEEP FASCIA
 SWELLINGARISING FROM DEEP FASCIAWILL
NOT BE AS MOBILEAS SUBCUTANEOUS
SWELLINGS

79. 3)RELATIONTO MUSCLE
 RELATION SHIPTO MUSCLE IS KNOWN BY
THROWINGTHE CONCERNED MUSCLE
INTO CONTRACTION
 TUMOURS IN SUB CUTANEOUSTISSUE-
BECOME MORE PROMINENT &REMAIN MOBILE
 TUMOURS ARISING FROM MUSCLE
INCORPORATED IN MUSCLE- FIXED&IMMOBILE
 TUMORS DEEPTO MUSCLE –LESS PROMINENT,
OR DISAPPEARS,DIFFICULTTO PALPATE

80. 4)SWELLING IN RELATION TO TENDON
 MOVESALONGWITHTENDON&BECOMES
FIXEDWHEN MUSCLE CONTRACTS
 5)IN CONNECTIONWITHVESSELS
&NERVES
 DO NOT MOVEALONGVESSELS OR
NERVES BUT MOVETO A LITTLE EXTENT AT
RIGHT ANGLESTOTHEIRAXES
 6)IN CONNECTIONWITH BONE
 IS ABSOLUTELY FIXED IRRESPECTIVE OF
MUSCLE CONTRACTION

81. PERCUSSION
 LIMITEDVALUE IN SWELLINGS

82. AUSCULTATION
 BRUIT OVER PULSATILE &VASCULAR
SWELLINGS
 BRUIT
 SHORT,MEDIUM PITCHED MURMUR HEARD
OVERTHE SWELLING WITH EACH PULSE
WAVE
 EX:ANEURYSM
 THYROTOXIC GOITRE

83. REGIONAL LYMPH NODES
 DRAINING LYMPH NODES EXAMINED IF
INVOLVED NEXT HIGHER GROUP EXAMINED
 IFTHE SWELLING ITSELF IS ALYMPH NODE
EXAMINE
 1.OTHER LYMPH NODAL GROUPS
 2.SPLEEN
 3.LIVER
 TO EXCLUDE SYSTEMIC CAUSE
 EXAMINE DRAINAGE AREATO EXCLUDE INFECTION

84. PRESSURE EFFECTS
 1.OVER BONE – FEEL FOR BONY EROSION
 AS IN DERMOID CYST
 2.IN LIMBS
 DISTAL PULSES- PRESSURE OVER ARTERIES
 EDEMA &DILATEDVEINS – PRESSURE OVER
VEINS
 PARESIS& MUSCLEWASTING – PRESSURE OVER
NERVES
 MOVEMENTS OF JOINTS

85. *Image via Bing
WASTING OFTHENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE

86. Benign skin swellings

88. Dermoid cyst
 Types
 Sequestration dermoid cyst
 Implantaion drmoid
 Tubuldermoid:
Thyroglossal cyst
Branchial cyst
 Teratomatous dermoid

89. Sequestration dermoid
 True cyst
 Cause :sequestration of piece of epithelium in
subcutaneous tissue
 Occurs at lines of fusion as
Face: external angular (most common)
internal angular
Ear: pre and post auricular
Neck: sublingual, midline , suprasternal

90. Diagnosis
 Painless round subcutaneous
 Slowly growing
 At fusion site
 Soft and cystic
 Free from skin and deep structures N.B.
There may be communication with dura
matter so CT is mandatory to exclude
communication before excision

96.  Differentiation from lipoma:
it yields with the pressure of finger not slips
away
TTT:
Not infected: Excision
Infected : incision and drainage followed by
excision when swelling subsides

98. Implanation dermoid
 Acquired not conginital
 Due to pricking wound
 Common in manual worker and sewer
 Overlying skin is sometimes scaring

101. Thyroglossal cyst
 From unobliterated portion of thyroglossal
cyst
 Painless cystic mass in the midline of front of
neck
 Moves up and down with deglutation and
protrusion of tongue

104. Inflammatory swellings

107. Traumatic swelling

109. Sebacous cyst (Epidemoid cust)
 Acquired cyst
 Cause : obstruction of the sebaceous gland
duct ------retention of secretion
 Site: hairy skin never palm and sole

110. Diagnosis
 Smooth painless slowly growing round
swelling
 Cystic , yields to palpating finger
 Attached to skin at a point (Punctum)
 Single or multiple
 Fluctuation positive

116. Lipoma
 Commonest benign tumor of
subcutaneous tissue
 Slowly growing painless
 Soft and lobulated solid swelling
 At any age
 Freely mobile over deep structure
 Solitary or multiple
 Slippery edge
 Pseudofluctuant
 Skin can be piched up

117. Other types of lipoma
Subfascial :
 Firm
 Common in forehead
 No slippery edge
 Not attached to skin

118. SUBmucous lipoma:
 Dangerous in larynx it cause respiratory
obstruction or intussception
Extradural only spinal cord
rETROPERIONEAL
Intermuscular

119. DANGEROUS TYPES
 SUBMUCOUS
 Retroperitoneal
 Extradural
 TTT excision

127. Dercum disease
 Rare disease of unknown etiologyy
 Characterized by:
generalized obesity
fatty tumors in adipose tissue
painful (unknown- pressure on nearby
nerves
TTT: no specific ttt, analgesic, removal of
lesions near joints, liposuction, psychotherapy

129. NEUROFIBROMA
Tumor contains both neural and fibrous
element.
Types
 Generalized
multiple
firm
café au lait patches
familial
tender
mobile across not along the nerve

135.  Solitary
firm
tender
acrosss nerve
café au lait

137.  Plexiform
cystic
common in face causing deformity.
occurs in connection with branches of
trigeminal nerve.
Sensation of bag of worms