Examination of Lumps and Bumps

Professor Doug
 Generic Lumps

• Lipoma
• Sebaceous Cyst
• Lymph Node
• Skin Lesion
Lipomas
Lipoma Pathology
 Gardener Syndrome

• Gardner syndrome consists of

adenomatous polyps of the
gastrointestinal tract, desmoid
tumours, osteomas,
epidermoid cysts, lipomas,
dental abnormalities and
periampullary carcinomas. The
incidence of the syndrome is
1:14,025 with an equal sex
distribution. It is determined
by the autosomal dominant
familial polyposis coli gene on
chromosome 5
 Dercum’s Disease

• Adiposis dolorosa, also known as

Dercum's disease or Anders disease,
is a rare condition characterized by
generalized obesity and fatty tumours
in the adipose tissue. The tumours are
normally painful and found in
multiples. The cause and mechanism
of Dercum's disease remains
unknown. Possible causes include
nervous system dysfunction,
mechanical pressure on nerves,
adipose tissue dysfunction, and
trauma
 Treatment of Lipomas

• Lipomas don't usually need to be removed unless they're

causing problems, such as pain, or if there's uncertainty about
whether it's a lipoma.
• You may want your lipoma removed if it's large or in an obvious
place and it's affecting your self-esteem.
• Surgery
• If small….local anaesthetic
• If large…..general anaesthetic
Sebaceous Cysts
 Sebaceous (Epidermoid) Cysts

• A sebaceous cyst is a term commonly used

to refer to either:
Epidermoid cysts
Pilar cysts
• Both of the above types of cyst contain
keratin, not sebum, and neither originates
from sebaceous glands. Epidermoid cysts
originate in the epidermis and pilar cysts
originate from hair follicles. Therefore,
technically speaking they are not
sebaceous cysts. "True" sebaceous cysts,
cysts which originate from sebaceous
glands and which contain sebum, are
relatively rare and are known as
steatocystoma simplex.
• It has been suggested that the term
sebaceous cyst be avoided since it can be
misleading
 Treatment of Sebaceous Cysts

• Leave alone if small and not bothering patient

• Excise (LA) if catching on clothes, unsightly location and to
avoid infection
 Lumps in Specific Locations

• Joints
• Groin
• Neck
• Abdomen
 Joints - Ganglia
Out-pouching or distention of a
weakened portion of a joint capsule or
tendon sheath.
The microscopic anatomy of the cyst
resembles that of the tenosynovial
tissue, the fluid is similar in composion
to synovial fluid.
Occur around the dorsum of
the wrist and on the fingers but can
occur in the foot.
A common site of occurrence is along
the extensor carpi radialis brevis as it
passes over the dorsum of the wrist
joint.
 Treatment of Ganglia

• Leave the cyst in place

• Aspirate the ganglion (50% recurrence)
• Surgical Excision (25% recurrence)
• One common traditional method of treatment for a ganglion
cyst was to strike the lump with a large heavy book, causing the
cyst to rupture and drain into the surrounding tissues.
Historically, a Bible was the largest or only book in any given
household, and was often employed for this treatment. This led
to the former nickname of "Bible bumps”
 Hernia
Groin Lumps e

Generic Specific
• Lipoma • Hernia
• Sebaceous Cyst - Inguinal
• Lymph Node - Direct
• Skin Lesions - Indirect
- Femoral
• Maldescended Testis
• Varicocoele
• Sapheno varix
• Femoral artery
aneurysm
• Psoas abscess
 Groin Lumps

‘Undescended Testes’
 Groin Lumps

Varicocoele
Groin • A saphena varix, or a saphenous varix is a dilation
of the great saphenous vein at its junction with the
femoral vein in the groin
Lumps • Saphena varix is a common surgical problem.
Patient can present with a groin swelling due to
saphena varix.
Saphena • Cough impulse and may be mistaken for a femoral
hernia
Varix • Bluish tinge and disappears on lying down
• On auscultation a venous hum may be heard
 Groin Lumps • False aneurysms, also known as a
pseudoaneurysm, is when there is
a breach in the vessel wall which
Femoral artery aneurysm allows blood to leak through the
wall but is contained by the
adventitia or surrounding
perivascular soft tissue.
 Groin Lumps

Psoas abscess
 Neck Lumps

Generic Specific
• Lipoma • Thyroid Swellings
• Sebaceous Cyst - Goitre
• Lymph Node • Salivary glands
• Skin Lesions - Submandibular
- Parotid
• Carotid swellings
• Branchial cyst
• Thyroglossal cyst
 Neck Lumps
• Single thyroid nodule (solitary nodule)
Solitary nodules are most commonly benign and very often
Thyroid swellings can be left untreated. If a cancer cannot be excluded by
investigations, surgery is usually recommended.
• Multiple thyroid nodules (multinodular goitre)
A multinodular goitre is common and usually does not need
an operation unless there are problems with swallowing
and/or breathing or if the goitre is unsightly. It is rare to
find cancer in a multinodular goitre.
• Diffuse goitre
This is often caused by autoimmune thyroid conditions such
as Hashimoto’s thyroiditis and Graves’ disease and can be
associated with an over- or an under-active thyroid.
• Retrosternal goitre
A multinodular thyroid can enlarge distally behind the
sternum.
 Neck Lumps Salivary gland swellings may be due
to infection, inflammation,
Saliary gland obstruction or tumour
swellings Parotid
• Viral parotitis - mumps.
• Stone in salivary duct.
• Benign and malignant tumours
• Sjögren's syndrome
Submandibular
• Stone in salivary duct.
• Benign and malignant tumours.
• Sjögren's syndrome (less common).
Sublingual
• Benign and malignant tumours
 Neck Lumps

Carotid body tumour

• Rare
• Paragangliomas.
• The carotid body,
which originates in the
neural crest, is
important in the body's
acute adaptation to
fluctuating
concentrations of
oxygen, carbon dioxide,
and pH.
 Neck Lumps • branchial cyst is a congenital
epithelial cyst that arises on
the lateral part of the neck
due to failure of obliteration
Branchial cyst of the second branchial cleft
in embryonic development.
• Asymptomatic unless they
become infected
Neck Lumps
 Preparation

• Wash your hands

• Introduce yourself, Identify patient (confirm)
• Permission (consent and explain
examination) Pain?, Privacy
• Exposure
 Site

• Anatomical location
• Usually expressed in terms of distance from a bony prominence (e.g.
2cm superior to the angle of the right mandible) or a well-demarcated
site (e.g. left antecubital fossa)
• Relationship to surrounding structures
• It may be possible to determine the anatomical plane from information
given in the history or on examination (e.g. a subcutaneous lump lying
superficial to a muscle will become more prominent when the
underlying muscle is contracted, an intramuscular or submuscular lump
will become less visible)
 Size

• Size can be estimated but ideally should be measured using a

tape measure or ruler
• This ensures accuracy and allows objective assessment of any
change in size
• Size should be stated in at least two dimensions (and three
where possible)
• For example “I palpated a 3 by 5 by 5cm mass…”
 Shape

• The lump should be considered in three dimensions when

describing its shape
• Descriptions should be made in geometrical terms where
possible (e.g. spherical, oval, round etc.)
 Surface (appearance and colour)

• Appearance
• Is it smooth or rough; flat or raised; regular or irregular?
• Is there any evidence of ulceration (skin breakdown) or necrosis
(blackened, usually secondary to ischaemia)?
• Normal skin often overlies deep lumps, while superficial swellings are more
likely to result in a change in the overlying skin
• Colour
• The lump may be the colour of the overlying skin or may appear red
and inflamed
• Certain lumps are abnormally pigmented (e.g. melanoma)
 Consistency
• This clinical feature describes a
spectrum between hard and soft
and can be considered under three
categories: hard, firm (rubbery or
spongy) or soft
• Hard lumps suggest the possibility of
cancer
• Fluid-filled lumps may be tense (and
thus quite hard), rubbery or spongy
• Soft lumps are more likely to be benign
(e.g. lipoma)
• In terms of comparisons: hard is like
your chin, firm is like your nose, soft
is like your ear-lobe
 Pulsatility

• Note whether the lump is

pulsatile, suggesting a vascular
origin
• Try to determine whether the
pulsation originates from the
lump itself or whether it is
transmitted from a nearby vessel
• Intrinsic pulsation is indicated by
a swelling that is pulsatile and
expansile (e.g. an abdominal
aortic aneurysm)
 Compressibility and Reducibility

• Compressibility
• Lumps that can be emptied by pressure but reappear spontaneously on
release of pressure are compressible (e.g. saphena varix or varicose
veins)
• Reducibility
• Lumps which disappear with pressure and do not return spontaneously
(e.g. inguinal hernias) are reducible
• Before attempting to compress or reduce a lump be sure to ask
the patient if the area is tender
• It is often helpful to ask the patient to demonstrate reducibility
themselves (particularly true of hernias)
 Fluctuation

• To test for fluctuation put your

fingers on either side of the lump,
opposite each other. Press with
one finger and feel whether the
lump bounces against your other
finger
• This indicates a fluid- or fat-filled
lump
• If the lump is thought to contain
fluid, this can sometimes be
confirmed by eliciting a ‘fluid thrill’
• Tapping a large fluid-filled swelling
causes a pressure wave which can be
felt on the other side of the lump
 Mobility

• Observe first whether the lump moves spontaneously, on

respiration or with muscular contraction
• Certain lumps have a characteristic mobility (e.g. fibroadenoma). The
mobility of other swellings may vary depending on anatomic site and other
factors
• Lesions that lie superficial to a muscle group should be tested for
mobility with the underlying muscles both relaxed and contracted
• If a previously mobile lump becomes fixed on contraction of the underlying
muscles it is likely that the lesion has infiltrated the muscle layer
• Mobility can also be reduced by ‘skin tethering’, which reflects an
inflammatory or neoplastic process (e.g. in breast cancer)
• Tethering can be demonstrated by gently moving the lump in two planes,
looking carefully for wrinkling or pulling of the skin
 Transillumination

• Using a pen torch, shine a

light across the lump –
ideally in a dark room
• A swelling containing clear
fluid will glow when this test
is performed, such as in:
• Simple cyst
• Hydrocele
• It is important to note,
however, that lipomas (fat-
filled lumps) will also
transilluminate
 Percussion

• Percussion is of limited value in

assessing most lumps but may
still provide important
information
• Gas-filled swellings (such as any
involving the bowel) are
resonant to percussion, while
dullness to percussion is a
feature of fluid-filled lesions
and solid structures (e.g.
retrosternal thyroid mass)
Auscultation (bruits, murmurs & bowel sounds)

• Auscultation may confirm findings in the preceding examination.

Typical findings include bruits/murmurs over vascular lesions or
areas with an abnormally increased blood supply (e.g. enlarged
thyroid) and bowel sounds heard over an inguinal hernia
 Extra points

• Examination should be completed with a specific examination of

the lymph nodes which drain the site of the lump, followed by a
general assessment of the patient, with particular attention
being paid to eliciting signs of systemic infection or malignancy
• Temperature, weight loss and lymphadenopathy are particularly
relevant in this respect
 Complete the examination

• Thank the patient after finishing the examination

• Make sure they are comfortable and happy getting dressed
• Clean your hands with alcohol gel
• When presenting or in an exam hold your stethoscope behind
your back, then turn to the examiner to present your findings…
…..and go and have a coffee !