Examination of a Lump

Introduction

The examination of a lump (or swelling) is one of the most fundamental and commonly tested surgical OSCE stations. The same systematic approach can be applied to any lump, regardless of its location on the body. A rigorous, methodical examination not only demonstrates clinical competence but also allows you to generate a meaningful differential diagnosis and present your findings confidently. Always consider the possibility of malignancy — this should run as an undercurrent through every lump examination.

This guide is equally applicable to the surgical OSCE (MRCS, finals) and to ENT examinations involving neck lumps, thyroid swellings, and salivary gland masses.

Before You Begin — Introduction and Consent

Always introduce yourself, confirm the patient's identity, and ask for consent before examining.

An example opening statement:

"Is there any pain at all? And would it be alright if, while I am examining you, I speak to the examiner about what I find?"

Remember to wait for the patient's response. In the anxiety of an OSCE, candidates frequently rehearse the examination so many times that they forget to pause for answers — this is noticed by examiners and scores marks for communication.

Expose the area as widely as possible, ideally exposing the regional draining lymph nodes as well.

Inspection

Stand back and inspect before touching the patient. A useful framework for inspection uses the following features (remembered with the "6 Ss"):

• Site — where exactly is the lump? Describe anatomically (e.g., "on the dorsal aspect of the right wrist" or "in the anterior triangle of the neck").
• Size — estimate visually in centimetres in two dimensions.
• Shape — spherical, hemispherical, irregular, pedunculated.
• Skin — examine the overlying skin for: colour change (erythema = inflammation), skin tethering or dimpling (suggests malignant invasion), ulceration, punctum (sebaceous cyst), skin thickening, dilated veins, or scarring from previous surgery.
• Surface — smooth or irregular (visible on inspection, confirmed on palpation).
• Surroundings — are there other similar lumps nearby? Any lymphadenopathy visible?

An example inspection presentation:

"On the dorsal aspect of the right hand there is a 2 × 2 cm hemispherical lump which has a smooth surface and a well-defined margin. The overlying skin is of normal colour, and I cannot see any scars or other similar lumps nearby."

Palpation

Always ask whether the lump is tender before palpating, and watch the patient's face throughout. Palpation yields the following information:

Surface

Describe the surface on palpation as either smooth, nodular, or craggy. A smooth surface is reassuring; a craggy, irregular surface is more suspicious of malignancy.

Edge

Is the edge well-defined (sharp, clearly demarcated from surrounding tissue — as in a cyst or lipoma) or ill-defined (blending imperceptibly into surrounding tissue — more suspicious of malignancy or an infiltrative process)?

Temperature

Use the back of your hand to assess temperature compared with the surrounding skin. Increased warmth suggests an inflammatory or infective process (abscess, cellulitis, rapidly enlarging tumour).

Tenderness

Note whether the lump is tender on palpation and whether tenderness is localised or diffuse. Tenderness suggests inflammation or infection; however, some malignant lumps can be tender, and some benign lumps (e.g., lipomas) are painless.

Consistency

A useful clinical scale is the "nose scale":

• Soft — like the tip of your nostril (lipoma, fluctuant cyst)
• Firm — like the tip of your nose (normal lymph node, fibroma)
• Hard — like the bridge of your nose (bone, calcification, scirrhous carcinoma)

Fluctuance

Fluctuance demonstrates that a lump contains fluid. It is tested by placing two fingers of one hand on either side of the lump while pressing in the centre with a finger of the other hand — a fluid impulse transmitted in two planes at right angles indicates fluctuance. Fluctuant lumps include cysts and abscesses.

Compressibility

A compressible lump can be fully compressed flat and will re-expand when released — this is characteristic of a vein or a venous malformation. It differs from reducibility in that a compressible lump remains empty until released (it does not require pressure to stay compressed).

Reducibility

A reducible lump can be pushed back into the body cavity from which it has emerged — the classic example is a hernia. A hernia should also have a cough impulse — a palpable expansion of the lump on coughing.

Pulsatility

Determine whether the lump is pulsatile. Distinguish between:

• Transmitted pulsation — the lump transmits a vascular pulse from an adjacent artery but does not expand. This is not pathological (e.g., a lymph node overlying the carotid artery).
• Expansile pulsation — the lump expands outwards in all directions with each pulse. This indicates the lump itself contains blood under arterial pressure (aneurysm, arteriovenous malformation).

Tethering (Fixation)

Assess fixation in two planes:

• Tethering to the overlying skin — ask the patient to relax the underlying muscle, then try to move the skin freely over the lump. Inability to do so indicates skin tethering (suggests infiltration of the skin — a sign of malignancy in breast lumps or elsewhere).
• Fixation to underlying tissues — contract the underlying muscle (e.g., ask the patient to tighten the pectoralis by pressing their hands together at the chest for a breast lump) and reassess mobility of the lump. A lump that becomes fixed on muscle contraction is tethered to the underlying deep fascia or muscle — another sign of malignancy.

A freely mobile lump in two planes is reassuring (e.g., lipoma, benign lymph node).

An example palpation presentation:

"The findings on inspection are confirmed on palpation. There is a 2 × 2 cm lump with a smooth surface and a well-defined edge. The temperature is similar to the surrounding skin and the consistency is firm. There is no fluctuance, nor is it compressible or reducible. There is no detectable pulse and the lump is not tethered to the overlying skin nor fixed to the underlying tissues in two planes."

Percussion

Percuss the lump to determine whether it is dull (solid or fluid-filled) or resonant (gas-containing — relevant for hernias containing bowel).

Auscultation

Listen over the lump for:

• Bruits — a vascular hum suggesting an arteriovenous malformation or vascular tumour.
• Bowel sounds — present over a hernia containing bowel.

Transillumination

In a darkened room, apply a pen-torch to one side of the lump. A lump that transmits light and glows is said to transilluminate, indicating that it contains clear fluid (e.g., a cyst or a hydrocoele). A branchial cyst and a thyroglossal cyst may transilluminate. Solid lumps and those containing blood or turbid fluid do not transilluminate.

Completion

Always finish with a standard completion statement:

"I would then continue to examine the regional draining lymph nodes, assess the neurovascular status of the surrounding area, and complete my examination with a general assessment of the patient including relevant systemic examination."

Examination of the Regional Lymph Nodes

After examining the lump itself, always examine the regional lymph nodes that drain the area. Lymphadenopathy may indicate malignant spread (hard, matted, fixed nodes) or a reactive process (soft, tender, mobile nodes). The key node groups to remember:

• Head and neck — cervical chains (anterior, posterior, deep cervical), submandibular, submental, pre-auricular, post-auricular, supraclavicular (particularly Virchow's node on the left — enlarged due to intra-abdominal malignancy).
• Upper limb — axillary (five groups), epitrochlear (medial elbow — enlarged in lymphoma, sarcoid, secondary syphilis).
• Lower limb — inguinal (superficial and deep), popliteal.
• Breast — axillary, supraclavicular, infraclavicular.

Site-Specific Considerations

Neck Lumps

The neck is the most commonly tested site for lump examination. The differential diagnosis can be organised by anatomical triangle:

Anterior triangle (between the midline, the anterior border of sternocleidomastoid, and the mandible):

• Thyroid or thyroglossal cyst — moves upward on swallowing and on tongue protrusion (thyroglossal cysts only). Ask the patient to swallow and to protrude their tongue during examination.
• Lymph node — commonest cause of a neck lump overall. Consider reactive (infective, inflammatory), lymphoma, or metastatic malignancy.
• Submandibular salivary gland — palpate bimanually (one finger inside the floor of the mouth, one externally).
• Branchial cyst — emerges from the anterior border of the sternocleidomastoid at the junction of its upper third and lower two-thirds. Classically in young adults. May transilluminate.
• Carotid body tumour — at the carotid bifurcation (level of the thyroid cartilage). Expansile pulsation, bruit, and the lump moves horizontally but not vertically (Fontaine's sign).

Posterior triangle (between the posterior border of sternocleidomastoid, the anterior border of trapezius, and the clavicle):

• Lymph node — cervical chain, particularly related to ENT pathology or lymphoma.
• Cystic hygroma (lymphatic malformation) — in children; brilliantly transilluminable.
• Subclavian artery aneurysm — pulsatile.

Midline neck lumps: Thyroglossal cyst, dermoid cyst, enlarged lymph node, thyroid isthmus goitre.

Breast Lumps

Breast lump examination demands particular attention to:

• Skin changes — peau d'orange (skin oedema resembling orange peel, indicating dermal lymphatic invasion by carcinoma), nipple inversion or retraction, nipple discharge, skin dimpling.
• Tethering to skin and to pectoral muscle (assessed with arm raised and with muscle contracted as described above).
• Axillary lymphadenopathy — always examine the axilla thoroughly (anterior, posterior, medial walls, and the apex).
• Common diagnoses: fibroadenoma (smooth, firm, very mobile — "breast mouse"), breast cyst (fluctuant, may be tender), fibrocystic change (diffuse nodularity), carcinoma (hard, irregular, often tethered).

Limb Lumps

On the limbs, consider:

• Lipoma — soft, lobulated, non-tender, mobile subcutaneous lump. Occurs wherever there is subcutaneous fat. Does not transilluminate. Note that a very large lipoma on the trunk or proximal limb should raise the possibility of a well-differentiated liposarcoma — size, depth, and rapidity of growth are relevant.
• Ganglion — firm (not always fluctuant, contrary to popular belief), non-tender, arising from a joint capsule or tendon sheath. Commonest site is the dorsum of the wrist. Transilluminates if fluid content is sufficient.
• Sarcoma considerations — any soft tissue mass that is >5 cm, deep to the deep fascia, increasing in size, or recurrent after previous excision must be regarded as potentially malignant until proven otherwise, and should be referred to a regional sarcoma unit for assessment before biopsy. An inappropriate excision biopsy of a sarcoma outside a specialist centre can compromise subsequent surgical margins.
• Neurofibroma — along the course of a peripheral nerve; may cause paraesthesia on palpation (Tinel's sign). Multiple neurofibromas suggest neurofibromatosis type 1 (von Recklinghausen's disease).

Examination of an Ulcer

If you are presented with an ulcer rather than a lump, use the following structured approach, keeping to your usual examination framework as much as possible.

Site, Size, Shape, and Number

Describe the location, dimensions, shape (round, irregular, serpiginous), and whether there are multiple ulcers.

Base

How deep is the ulcer? Does it extend down to fascia, muscle, tendon, or bone? Look for:

• Granulation tissue (pink, moist — healing)
• Slough (yellow, necrotic — infected or ischaemic)
• Malignant change (irregular, raised, friable tissue)

Edge

The edge is the most diagnostically informative feature of an ulcer:

• Sloping edge — healing ulcer (venous or traumatic). The edge slopes gradually from normal skin to the ulcer floor.
• Punched-out edge — the edge appears as though it has been stamped out with a cookie-cutter. Characteristic of ischaemic ulcers (arterial) and neuropathic ulcers (e.g., diabetic foot). Historically also seen in tertiary syphilis (gumma).
• Undermined edge — the edge overhangs the ulcer floor. Seen in pressure ulcers and tuberculosis.
• Rolled (pearly) edge — a rolled, beaded, translucent edge. Characteristic of basal cell carcinoma (BCC).
• Everted edge — the edge is heaped up and turned outward. Characteristic of squamous cell carcinoma (SCC).

Discharge

Note the nature of any discharge:

• Serous (clear) — inflammatory
• Blood-stained — malignancy or trauma
• Purulent — infection

Surrounding Skin

Look for lipodermatosclerosis and haemosiderin deposition (brown staining — venous ulcers), loss of hair, atrophie blanche (white scarring — venous), or peripheral oedema.