Examination Of Swelling 5v5l

CONTENTS -Introduction -Classification Of Swelling in Head & Neck -Etiology of swelling -Pathophysiology Of Swelling -History to be taken from the patient -Examination Of a Swelling a) Inspection b) Palpation c) Percussion d) Ascultaion -Investigations For Swelling -Differential Diagnosis Of a Swelling -Surgical and Non-SurgicalManagement Of Swelling -Complications after Surgery

INTRODUCTION In medical parlance, swelling, turgescence or tumefaction is a transient abnormal enlargement of a body part or area not caused by proliferation of cells.[1] It is caused by accumulation of fluid in tissues.[2] It can occur throughout the body (generalized), or a specific part or organ can be affected (localized).[2] Swelling is usually not dangerous and is a common reaction to an inflammation or a bruise.

CLASSIFICATION OF SWELLINGS OF HEAD & NECK CLASSIFICATION OF CYSTS OF ORAL CAVITY INTRA-OSSEOUS CYSTS

SOFT TISSUE CYSTS

ODONTOGENIC ORIGIN 1) DEVELOPMENTAL DENTIGEROUS CYST CALCIFYING ODONTOGENIC CYST

ODONTOGENIC GINGIVAL CYSTS NON-ODONTOGENIC NASOLABIAL CYST RETENTION CYST MUCOCELE RANULA CONGENITAL CYSTS DERMOID CYST THYROGLOSSAL DUCT CYST PARASITIC CYSTS HYDATID CYST CYSTICERCOSIS

2) INFLAMMATORY RADICULAR CYST RESIDUAL CYST NON-ODONTOGENIC ORIGIN NASO-PALATINE DUCT CYST NON-EPITHELIAL CYST(Pseudocysts) TRAUMATIC CYST ANEURYSMAL BONE CYST

CLASSIFICATION OF NECK SWELLINGS CONGENITAL A) CYSTS -SEBACEOUS CYST -BRACHIAL CYST -DERMOID CYST B) VASCULAR -HAEMANGIOMA -LYMPHANGIOMA

ACQUIRED 1) INFLAMMATORY -ACUTE LYMPHADENITIS -TUBERCULOSIS -SALIVARY GLAND INFECTIONS 2) TRAUMATIC -HEMATOMA

NEOPLASTIC SWELLINGS BENIGN -SALIVARY GLAND ORIGIN -THYROID ORIGIN MALIGNANT -SALIVARY MALIGNANCIES -SARCOMA

VIRAL INFECTIONS MUMPS

BACTERIAL INFECTIONS CELLULITIS TUBERCULAR LYMPHADENITIS

ETIOLOGY OF SWELLING -INJURY -TRAUMA -INFLAMMATORY CONDIITONS -PATHOLOGICAL CONDITIONS –CYSTS,ABSCESS,TUMOURS

PATHOPHYSIOLOGY OF SWELLING

Pathophysiology of Swelling

Movement of Water and Salts between intravsacular and interstitial space (Maintained by Opposing effect of Vascular Hydrostatic Pressure) Outflow of fluid from the arteriolar end of the microcirculation into the interstitium is balanced by inflow at the venular end.

A small residual amount of fluid may be left in the interstitium and is drained by the lymphatic vessels, ultimately returning to the bloodstream.

Either Capillary pressure, or Colloid osmotic pressure or inadequate lymphatic drainage can result in an abnormally increased interstitial fluid

SWELLING/EDEMA

HISTORY TO BE TAKEN FROM THE PATIENT Duration of Swelling: -How long is the swelling present there? - When do you first noticed the swelling? a) If Congenital Swelling -(Brachial Cyst,Dermoid Cyst,etc) b) Swelling with short durartion (WITH PAIN)-Mostly Inflammatory Cause c) Swelling from long duration (WITHOUT PAIN) – Benign Neoplasia d) Swelling from long duration (WITH PAIN) – Chronic Inflammatory e) Swelling from short duration (PAINLESS) – Neoplastic/Mostly Malignant.

Mode Of Onset: -How did the Swelling start? a) May developed just after a Trauma? (Post Extraction Swelling,hematoma,etc) b) May developed suddenly and grow rapidly with Severe Pain? (Inflammatory) c) May noticed casually and gradually increased in size? (Neoplasm) d) May occur from Pre-existing Conditions.

Associated Symptoms:

-Pain is the only symptom which brings the patient to a doctor. -In addition to pain we have to ask about, a) Difficulty In respiration? Ex-Cellulitis Involving Trachea. b) Difficulty In Swallowing? Ex-Thyroid Goitre,Angioedema

Pain: -It is the most common complaint of traumatic and inflammatory swellings. -But pain may be absent in neoplastic (MALIGNANT) swelling. Nature: Throbbing- Inflammation leading to Suppuration. Stabbing/Lancinating- Pain is sudden,Sharp,Severe with Short Duration. Site: Sometimes Pain is referred to some other site than the affected one, (Ex- Pain of Impacted Third Molar leading to Pain in Temporal region.) Time Of Onset : a)Whether the pain preceeds the swelling? (Inflammatory Swelling) b)Swelling preceeds the pain? (Benign & Malignant Swellings).

Progression of the Swelling -Is there any change in the size of the swelling since it was first noticed? Benign Swellings-Grow Very slowly/Remain Static for a long time. Malignant Swellings- Grows Very Rapidly. Malignant Transformation of Benign Growths- Suddenly increases in size after remaining static for a longer time.

EXACT SITE: If Small Swelling-Easy to inspect the exact site. If Swelling is large-Exact site of the swelling can be identified by asking patient to show the exact site from where the swelling has originated at his/her first notice.

Fever: Is there any rise in body temperature?

Recurrence of Swelling: Recurrence even after the removal of cause indicates malignant change in benign growth. -Some Swelling’s recur commonly .Ex-Odontogenic Keratocyst -Cysts,if not completely enucleated it recurs.

Personal History: -Whether the Patient is having an Habit of Betal Nut,Slaked Lime/Tobacco should be asked. -Some of the growths in oral cavity are peculiar by the habits which patient is having,likeCHUTTA CANCER OF HARD PALATE: Seen commonly in women who smokes cigars with burning ends in the mouth. KHAINI CANCER : Lime addition to tobacco placed in Vestibular sulcus .

PHYSICAL EXAMINATION -General Physical Examination is considered if the swelling is INFLAMMATORY or NEOPLASTIC. -Check for the signs of malnutrition, Loss Of Body Weight Bleeding Gums Low Blood Pressure Low Heart Rate Minimal Body Fat -Increased Body Temperature -Increased Pulse Rate

Signs Of Inflammatory Swellings.

LOCAL EXAMINATION INSPECTION: A) Situation: Few swellings are peculiar in their positions, Ex-Dermoid Cyst- (Seen at the Midline of the body)

B) Colour: Colour gives a clue for diagnosis Ex- Black- Benign Nevus,Melanoma Red/Purple-Heamangioma. Blue- Ranula

C) Shape: -Ovoid/Pear shaped/Spherical/Irregular -Never mention as CIRCULAR as we don’t know deeper dimension of swelling,mention it as SPHERICAL.

D) Size: -Horizontal and vertical dimensions are noted in centimeters.(SIxAP)

E) Surface: -Difficult to diagnose by surface but few cases have peculiar surfaces like i) Cauliflower Surface-Squamous Cell Carcinoma. ii) Filliform Branched Surface-Papilloma

F) Edge: Clearly distinct from sorrounding tissue-termed as an EDGE of a Swelling.

i)Pedunculated-Which has distinct border and elevates from the adjacent tissue. Ex-Pulp Polyp

ii) Nodular-Which has distinct border and fixed to the underlying tissue.

G) Number: Single/Solitary-Eg-Cyst, Lipoma Multiple-Eg- Tubercular Lymphadenitis, Neurofibromatosis

I) Impulse On Cough: Swellings which are in continuity with Cranial Cavity, Spinal Cavity, Abdominal Cavity, Pleural Cavity will give Impulse on cough. In Children Crying can be considered to examine Impulse Eg-MENINGOCOELE

Examination: -Ask Patient to Cough and inspect swelling, If visible increase in size of the swelling gives Positive result. -Movement of the swelling without expansion or an increase in tension is not a cough impulse.

J) Movement On Deglutition: Swellings fixed to Larynx/Trachea moves on deglutition. Eg-Thyroid Swelling , Thyroglossal Duct Cyst . WHY THYROID SWELLINGS MOVES UP WITH DEGLUTITION?: Thyroid is enclosed in pretracheal fascia attaches to thyroid &cricoid cartilages(berry’s ligament) superior constrictor muscle contraction during deglutition these cartilages move up along with these thyroid moves up.,

K) MOVEMENT WITH TONGUE PROTRUSION: Movement with tongue protrusion in case of mid line neck swellings Eg-Thyroglossal cyst & Thyroglossal Fistula.

Why Swelling Moves with Tongue Protrusion? Because the swelling is Attached to Foramen Caecum of Posterior 2/3rds of the tongue

l) Skin Over The Swelling: If the skin over the swelling is,

Red & EdematousINFLAMMATORY Tense,Glossy with Venous Prominence- SARCOMA Black Punctum Over the Swelling- SEBACEOUS CYST Orange Peel Appearance- ULCERS

PALPATION: A) Temperature: Local Temperature will be raised due to increased Vascularity of swelling due to infection or Well Vascularised tumour(SARCOMA).

Temperature can be Examined by placing the BACK OF FINGERS over the swelling.

B) Tenderness: Pain on exerting pressure over the swelling is termed as TENDER.

Inflammatory Swellings are always TENDER. Neoplastic Swellings may or may not be TENDER. Place fingers over the swelling and gently apply pressure,and Observe patient’s Face to know wheather swelling is tender or not.

C) Pulsation: Swellings arising from arteries are pulsatile.E.g-ANEURYSMS -Pulsations due to presence of swelling just superficial to the artery, termed as TRANSMITTED PULSATIONS.it can be examined by placing fingers over the swelling In case your fingers will move outwards it is termed as Transmitted.

-Pulsations of Swellings arising from ARTERIAL WALLS areEXPANSILE PULSATIONS.It can be examined as similar to the above mentioned but if your fingers move upward it can be confirmed as Expansile Ex-ANEURSYMS

D) Size,Shape & Extent: -By Palpation,we can get the depth of invasion of swelling. -Vertical & Horizontal dimensions are confirmed by palpation.

E) Surface: -Surface of the swelling is palpated by the PALMAR SURFACES OF FINGERS. - If the surface is, Smooth- CYST Lobular with Smooth Bumps- LIPOMA Nodular- LYMPH NODES Irregular & Rough- CARCINOMA

F) Edge/Margin: Very Important aspect of Palpation,

-Neoplastic & Chronic Inflammatory Swellings -WELL-DIFINED MARGINS. -Benign - SMOOTH MARGINS -Malignant - IRREGULAR -Acute Inflammatory - ILL DEFINED PROCEDURE- By The Tips Of Fingers.

SLIP SIGN: Slip sign to differentiate between lipoma and cystic swelling(both have well defined ,regular borders) when edge of a swelling is palpated with a finger ,if it slips under the finger,. Then it is a lipoma,if it yields to finger is a cyst

G) Consistency : Very Soft to Stony Hard depending upon the contents of the swelling. Soft – Lipoma,Cysts &Chronic abscesses Firm –Fibroma SIGN OF MOULDING OR INDENTATION: Hard but yielding-Chondroma Soft &cystic swellings Bony hard-Osteoma Press a finger into swelling for 1-2 mts Stony hard- Carcinoma and release it, Variable consistency- Malignancy if swelling remains indented it indicates presence of pultaceous material(putty like) Eg-Sebacyous cyst,Dermoid cyst

How to assess consistency: Soft – ear lobule,alae of nose Firm- tip of nose,un contracted muscle Hard -bridge of nose,contracted muscle

H) Fluctuation : Fluctuation is POSTIVE if the swelling has liquid or gas. Procedure-

By one Finger of each hand Sudden Pressure applied on one border of swelling Pressure with in the swelling increases Transmits pressu re to right angles. Another finger is placed on the other border

Finger raises slowly b y itself due to increased pressure. FLUCTUAT ION-POSITIVE.

PSEUDO FLUCTUATION: Pseudo fluctuation a false sense of fluctuation felt in large soft swellings containing no fluid,fails to expand in other parts of a swelling like a true fluctuant swelling Ex- Lipoma,Fibroma,Vascular Sarcoma CROSS FLUCTUATION: Fluctuation between two separate cystic swellings communicating with each other. Ex-Plunging ranula,Mucocele

I) TRANSILLUMINATION: Transmission of light through a swelling Transillumination-POSITIVE in swellings containing clear fluid and thin transparent walls

Transillumination-NEGATIVE if wall is thick, or turbid fluid is present(blood,pus, lymph) -It has to be done in a dark room , with transilluminoscope.

J) Reducibility: -Reducibility indication same as for cough impulse,patient is asked to relax. -Swelling is compressed from all the sides uniformly -Reducible swellings decreases in size or completely disappear. REDUCIBLE SWELLINGS: Reducible Swellings,Eg-Meningocele

K) Compressibility: Compressibility when pressure is applied to a swelling,it decreases in size and when pressure is released,swelling regains its size itself with out any external factors like coughing Eg-Charectaristic sign of Vascular Haemangioma

l) FIXITY TO SKIN: Skin is pinched over different areas of the swelling

-Non Pinchable -if fixed to skin -Pinchable-Not fixed to skin. Ex: Sebaceous cyst,Papilloma.

M) REGIONAL LYMPH NODES: Regional draining lymph nodes examined -If involved next higher group examined -If the swelling itself is a lymph node examine Other lymph nodal groups

Percussion -Usually of little value in defining a mass with the exception of some abdominal swellings.

Auscultation -Vascular sounds may be detected. -For example, 'bruit' may be heard over large tumour, Vascular goiter and arterial aneurysms.

INVESTIGATIONS FOR SWELLING A) B) C) D) E) F) G) H) I)

X-RAYS Biopsy. FNAC/FNAB CBC ULTRASONOGRAPHY MRI CT SCAN 3D CT PET SCAN

X-RAYS -X-rays were discovered in 1895 by Wilhelm Conrad Roentgen, -Radiographs are the first investigatory approach that has to be advised for any variant of swelling. -There are two main types of dental X-rays: 1)Intraoral radiographs 2)Extra Oral radiographs

ULTRASONOGRAPHY Advised to know whether the Swelling is Solid or Cystic Mechanism: Uses Sound Waves (1 to 18 Megahetzes) to visualize muscles,tendons,ts,vessels,internal organs. Procedure: -This works by sending impulses of ultrasound into tissue using a probe. -The sound echoes reaches the tissue, and reflects varying degrees of sound. -These echoes are recorded and displayed as an image to the operator.

BIOPSY -An examination of tissue removed from a living body to discover the presence, cause, or extent of a disease. -It is the most important investigation of a swelling. -Done in suspected cases of malignant tumours.

Types of Biopsya) Needle Biopsy b) Drill Biopsy c) Brush Biopsy d) Punch Biopsy e) Open Biopsy i) Incisional Biopsy ii) Excisional Biopsy

B) FNAC: (Fine Needle Aspiration Cytology) In 1981, the first fine-needle aspiration biopsy in the United States was done at MAIMONIDES MEDICAL CENTER eliminating the need for surgery and hospitalization. ProcedureApparatus Required-Fine Needle (22/23 guage) with Syringe are used.

Syringe with a needle placed into the lesion and aspirated, Contents aspirated are taken onto a Slide, then dried & Fixed w ith Absolute Alcohol Stained examined under microscope.

COMPLETE BLOOD COUNT Inflammatory Swellings

Total Count Differntial Count Hemoglobin ESR FBS PPBS/RBS C-Reactive Protiens

Total Count-LEUCOCYTOSIS Number of PMNL CELLS Malignant & Chr.Inflammatory Swellings ESR Hb% Reccurent Abcess FBS/PPBS RBS

COMPUTERISED TOMOGRAPHY: -CT was invented in 1972 by British engineer Godfrey Hounsfield. -To be advised to know Size,Shape and Local Spread of a Lesion. -Detects mainly Hard tissue Lesions.

Mechanism: It makes use of computer-processed combinations of many X-ray images taken from different angles to produce cross-sectional (tomographic) images of specific areas of a scanned object. -It gives the detailed description of the lesion.

3D-CT SCAN: CT scan uses data from several X-ray images of structures inside the body and converts them into pictures. -The technique utilizes digital geometry processing to generate 3D images. -It helps in providing 3 dimensional view of the lesion. -It also deducts or resects the portion of a lesion to get the interior aspect of the lesion.

MAGNETIC RESONACE IMAGING: -Magnetic resonance imaging was invented by PAUL C.LAUTERBER in 1971. -It uses strong magnetic fields,radio waves to form images of the body.

MECHANISM: -Hydrogen Atoms are most-often used to generate a detectable radio-frequency signal and received by antennas in close proximity to the lesion being examined.

ANGIOGRAPHY: -It is advised for the swellings with blood vessel origin, like ANEURYSMAL SWELLINGS. -It differentiates a cyst from a tumour. -In Malignant tumour-Angiography exhibits “CONTRAST POOL” inside the tumour. ( Abnormal deposition of small arteries in and around the tumour.)

DIFFERENTIAL DIAGNOSIS OF SWELLING Midline Swellings of the neck:

Jaw Swellings:

-THYROID SWELLINGS -THYROGLOSSAL CYST -LUDWIG’S ANGINA -DERMOID CYST -LIPOMA

-DENTIGEROUS CYST -PERIAPICAL CYST -ALVEOLAR ABSCESS - OSTEOMYELITIS

Lateral Swellings of the Neck: -SUB MANDIBULAR SALIVARY GLAND SWELLING (UNILATERAL) -PLUNGING RANULA -ENLARGED LYMPH NODES (UNILATERAL) -BRACHIAL CYST -SJOGREN’S SYNDROME

SWELLINGS WHICH MAY OCCUR ANY WHERE IN NECK -Sebaceous cyst -Lymph node swellings -Thyroid enlargement -Brachial cyst -Lipoma

SALIVARY GLAND SWELLINGS

-SJOGREN’S SYNDROME -SIALOLITHIASIS -MUCUS RETENTION CYSTS -TUMORS OF SALIVARY GLANDS MUCO EPIDERMOID CARCINOMA ADENOID CYSTIC CARCINOMA PLEOMORPHIC ADENOMA WARTHINS TUMOR

THYROID SWELLINGS: -Age b/w 5-20 yrs -Enlargement is uniform and is soft. -This goitre may develop PHYSIOLOGICALLY at the time of puberty & in pregnancy when metabolic demands are high -This goitre may subsides by it self or with Iodine therapy. DIAGNOSTIC FEATURES: 1. Exopthalmus 2. Enlargement of Thyroid Gland 3. Loss of weight in spite of good appetite 4. Tachycardia 5. Tremors

THYROGLOSSAL DUCT CYST: -Typically present as Asymptomatic midline swelling that display vertical movement with tongue protrusion and swallowing. -Commonly seen below the Hyoid bone -Seen before patient reaches 20yrs of age.

LUDWIGS ANGINA Bilaterally involving tissue spaces of submandibular area: -Odontogenic in origin and rarely from trauma. DIAGNOSTIC FEATURE: - Swelling of the tongue - Elevated floor of the mouth - Hoarseness of the voice - Difficulty in swallowing and breathing - ODEMA GLOTTIS is the most is the most dangerous complication

SIALOLITHIASIS: -More common in sub- mandibular gland . -Pathognomic feature : Swelling of the gland during meals. -Bi digital palpation is done if stone is present in the duct.

MUCUS CYCT : Due to cystic degeneration of glands of Blandin & Nunh. Fluctuant ,Blue/amber colored and translucent mass

PLEOMORPHIC ADENOMA (MIXED TUMOR )– -Second decade of life and has female prediction DIAGNOSTIC FEATURE: -Lobulated painless swelling persisting over many months/years -Tumor is firm but variable consistency.

WARTHINS TUMOR -Seen in sixth and seventh decade of life. -Almost always occurs in the lower portion of the parotid overlying the angle of the mandible. -These are encapsulated lesions and do not undergo malignant

ADENOID CYSTIC CARCINOMA Malignancy of both major & minor salivary gland DIAGNOSTIC FEATURE: -Growth rate is slow but persistent -May cause facial paralysis when occurring in parotid region. -The characteristic feature is-“SWISS CHEESE” pattern.

SJOGRENS SYNDROME -Is a chronic autoimmune disease in which lymphocytes infiltrates and replace parenchyma of salivary glands. -Bilateral swelling of Parotid Gland. PRIMARY SJOGRENS: Dry eyes, Dry Mouth SECONDARY SJOGRENS: Dry eyes,Dry Mouth + Autoimmune disease (Rheumatic arthritis) DIAGNOSIS : -By SCHIRMER’S TEST-Decreased lacrimal secretion -Significant lab changes -Identification of auto antibodies SS-A & SS-B

SURGICAL MANAGEMENT Cysts of the oral cavity can be treated by : i) MARSUPIALIZATION ( DECOMPRESSION ) Partsch I • • Partsch II (Combined marsupialization and Enucleation)

ii) • • •

ENUCLEATION Enucleation and Packing Enucleation and Primary Closure Enucleation & Primary Closure with Reconstruction.

NEOPLASTIC SWELLINGS can be treated by : • Surgery • Cryosurgery • Laser Vapourization • Electrocoagulation

MARSUPIALIZATION: PARTSCH I OPERATION -The roof of the cyst is removed and the cavity is evacuated. -The cyst lining may be left intact at that movement but cystic contents are removed and the cyst is left open. -Edges or the border of the cyst are sutures with the normal outer epithelium. -This technique relives the intra cystic pressure and reduces size of the cyst and promotes healing. PACKING : By placing a guaze soaked in WHITE HEAD VARNISH or BISMUTH IODOFORM PARAFFIN PASTE (BIPP) into the cystic space for 7 to 14 days. -To prevent contamination of wound -To protect the wound margins.

PARTSCH II OPERATION -Also called as WALDRON’s Method.

-2 standard procedures, -First marsupialization is performed,in the later stages,when the cavity is smaller enucleation is performed and entire tissue is examined histopathologically.

INDICATIONS OF MARSUPIALIZATION: -When cyst cavity is so big that complete removal of cyst will result in excessive structure loss. -When cyst is in proximity with vital structure -When cyst have tendency of high recurrence. -Compromised cases which does not advocate for complete removal of the cyst.

ENUCLEATION: -Total removal of a cystic lesion with the epithelium and is covered by mucoperiosteal flap and the dead space gets filled with the blood clot and eventually transforms into normal bone. -Care should be taken to remove the entire cyst in a single piece without fragmentation of the epithelium which leads to recurrence. INDICATIONS: -Treatment of Odontogenic Keratocysts -Any cysts which have high recurrence rate.

PRIMARY CLOSURE -Wound closure immediately following the injury and prior to the formation of granulation tissue. -In general, closure by this way leads to faster healing and best cosmetic result.

NON SURGICAL MANAGEMENT OF SWELLING INFLAMMATORY SWELLINGS -ANTI MICROBIAL THERAPY - ANALGESICS & ANTI INFLAMMATORY DRUGS

VASCULAR SWELLINGS -INJECTION OF HYPERTONIC SALINE or SODIUM TETRADECYL SULPHATE (Sclerosing agent) makes the swelling fibrotic,less vascular thus surgical excision can be done. NEOPLASTIC SWELLINGS -RADIOTHERAPY -CHEMOTHERAPY

COMPLICATIONS AFTER SURGERY -POST OPERATIVE PAIN & EDEMA -RECURRENCE -SEPTICAEMIA due to improper handling of the tissues. -PARAESTHESIA if segmental resection of mandible is done for any malignant tumours. -SECONDARY INFECTIONS