PALPABLE MASSESTom Walker & Patrick Elder

Key areas to know: what’s your differential for lumps?

What is it important to consider when trying to work out the origin of a lump?

◦ Structure position & local anatomy

◦Weak regions in supporting tissues

◦ Embryology

◦Glands (endocrine & exocrine)

◦ Lymph drainage & glands

Which features of a lump do you need to determine and describe?◦ Size, Shape, Surface (i.e. smooth,

lobulated or regular?)◦ Position◦Attachments◦Consistency & Colour◦ Edge

◦ Thrills/pulsation/fluctuance◦ Inflammation◦ Transillumination

◦SPACETIT

What would you do after inspection and palpation?◦ Transillumination – what does it show?

◦ Fluid-filled

◦ Fluctuance – what does this mean?◦ Moveable and compressible◦ It means it’s fluid-filled

◦ Auscultation – why might you do this?◦ Listen for bruits◦ Listen for bowel sounds in the groin

What can the movement of a lump tell you?◦ Immobile

◦ Bone masses

◦Move, or have their movement limited, by muscle contraction◦ Muscle and tendon masses

◦ Left-to-right movement◦ Neural masses

◦ Pain/tingling/sensory loss◦ Neural masses

Lymphadenopathy – how might an enlarged lymph node appear on examination?

◦ Palpable, relatively non-mobile mass

◦Often unilateral (can be bilateral)

◦Malignancy◦ Hard and craggy◦ Normal temperature

◦ Infection / inflammation◦ Hot◦ Red ◦ Painful / sore

What do you need to consider when examining lumps in the groin region?◦ What do you need to consider?

◦ Can you get above the swelling?◦ Yes = not a hernia◦ No = most likely a hernia

◦ Reduce a hernia and test cough impulse

◦ Is it solid or fluid-filled?

◦ Where is the lump relative to the testicle?

◦ Where is the testicle?

◦ Does it look/feel like a ‘Bag of worms’?

◦ Testicular pain is torsion until proven otherwise!

What is your diagnosis?◦ Sudden onset extreme pain

◦Unilateral mass in scrotal sac

◦Does not transilluminate

◦ Thickened cord

◦Opposite testicle lies horizontal

◦ You can get your hand above it

◦ Testicular torsion◦ All testicular pain is torsion until proven otherwise

What is your diagnosis?◦ Fluctuant

◦ Transilluminates

◦Non-tender

◦Unilateral

◦ Sits around the testicle

◦ You can get your hand above it

◦ Testicle can’t be palpated

◦Hydrocele◦ Fluid in the tunica vaginalis

What is your diagnosis?◦ 10 year-old boy

◦ Fluctuant

◦ Transilluminates

◦ Non-tender

◦ Unilateral

◦ Sits around the testicle

◦ You can’t get your hand above it

◦ Not there in the morning but appears during the day

◦ Disappears when lying down

◦ Hydrocele with patent processus vaginalis◦ Fluid in the tunica vaginalis

What is your diagnosis?◦Non-tender, unilateral fleshy mass

◦On the left

◦ Feels like a bag of worms

◦Decreases in size with scrotal elevation

◦Does not transilluminate

◦ Varicocele◦ Dilated veins of the pampiniform plexus

◦ More common on the left◦ The left gonadal vein joins with the left renal

vein, whereas the right gonadal vein joins the IVC directly. This causes increased venous pressure on the left

What is your diagnosis?◦ Can be reduced

◦ You reduce it, put your finger on the deep inguinal ring and ask the patient to cough. You feel an impulse on your finger

◦ Origin is above and medial to the pubic tubercle

◦ You cannot get your hand above it

◦ Does not transilluminate

◦ On auscultation of the lump, you hear gurgling sounds

◦ Indirect inguinal hernia

What is your diagnosis?◦ Firm, non-tender lump adjacent to right

testis

◦ Painless

◦ Testicular tumour

What is your diagnosis?◦Non-tender, small nodules posterior

to the head of the epididymis

◦ Transilluminates

◦ You can get your hand above it

◦ Spermatocoele◦ Epididymal cysts present in a very

similar way; however the nodule is in the head of the epididymis rather than posterior to it.

Spermatocele/Epididymal cysts

What is your diagnosis?◦ 55 year-old woman

◦ Lump below and lateral to the pubic tubercle, points down the leg

◦ Irreducible

◦Does not transilluminate

◦ Femoral hernia

Femoral hernias◦More common in females

◦Occur in femoral canal, the fascial compartment for lymphatics in the femoral triangle

◦ Presents with a mass in the upper medial thigh or above the inguinal ligament

◦Often causes strangulation due to rigidity of femoral opening

Fascia does not bind to lymphatics (weak spot)

Femoral ring = opening to canal(Lacunar lig. Inguinal lig. Pectineal lig.)

High chance of hernial sac contents strangulation due to rigid borders of femoral ring

What is your diagnosis?◦ Lump in midline of the neck

◦Moves on tongue protrusion and swallowing

◦ Thyroglossal duct cyst

Form anywhere in the midline neck & move on swallowing and tongue protrusion

The thyroid gland tends to move during swallowing but not always with tongue protrusion

Thyroglossal duct cysts

What is your diagnosis?◦ Swelling in the neck on anterior

border of sternocleidomastoid

◦ Fluctuant

◦ Branchial cyst

Branchial sinus should obliterate. If it remains open it can form a branchial fistula that opens & discharges onto the lower neck

Branchial cysts often form on the anterior border of

sternocleidomastoid