INTRODUCTION

This introduction describes and discusses the case. In fact, there is no fundamental difference
different types of assessment of candidates in between the examination style required – it is
these examinations and describes the different only the assessment and marking schemes that
scenarios that might be presented. are different. Examining an inguinal hernia, or a
Before going any further – a note of caution. thyroid lump, or taking a history from a patient
It is often said that the OSCE is completely with abdominal pain, is the same in each.
different from the short case and therefore the However, because the OSCE is an ‘objective’
methods used for preparing for the clinical examination, the marking schedules are much
exam in surgery should be shredded and the more clearly defined, and deviation (on the part
process begun from scratch. This is not the of the examiner) from this is not allowed.

SHORT CASES
Format The pros of short cases are that they:
• Allow good candidates to progress rapidly to
At the beginning of the examination, candidates harder cases or more complex supplemental
wait in a specific central area to be collected by questions
the examiners, who work in pairs. One asks the • Give flexibility for examiners to choose
questions and the other listens and often makes different patients who are waiting in the bay,
notes. The examiners lead you round the which is less boring for both examiner and
patients, who are organized in clusters (or patients
‘bays’), and choose which patients you meet • Allow rapid assessment of clinical skills
and in which order. across areas, e.g. in superficial lesions,
It is possible to include the description of a cases vary from skin lesions to lumps and
prop, or an X-ray or another data-interpretation bumps to thyroid nodules, etc.
style question, but these are usually • Incorporate data interpretation questions,
supplemental to the major theme, which is the such as chest X-rays, as appropriate
physical examination of a particular part of a • Test clinical skills across a broad spectrum.
patient. The vast majority of the time will be The cons of short cases include that:
spent examining the patient and answering
questions on the background problem or • They allow little control of choice of patients
treatment options. an individual examiner picks (except the
presence of the co-examiner)
The examiners choose how many patients you
• They can emphasize ‘favourite’ clinical signs,
see per bay, which can vary between just one
which may not reflect clinical relevance
patient to six or seven. The only time limitation
is on the whole bay, which may be 10 or 15 • It is difficult to control the marking scheme
minutes. Within that time it is up to the to ensure transparency and fairness
examiner how many patients the candidates see • They are almost entirely subjective
and how deep (and difficult) the supplemental • It is difficult for the candidate to feel
questions become. In Final MB short cases confident about doing well (or badly) as the
there is usually only one bay, where all the questions tend to get increasingly difficult.
cases are examined, which might be part of a
ward or a day surgery unit.

OBJECTIVE STRUCTURED CLINICAL EXAMINATION (OSCE)

of the syllabus. The time spent at each station
Format is fixed (often 7–10 minutes) and is the same for
every candidate, irrespective of how well, or
The OSCE examination takes the form of a fair, badly, the candidate is performing at the
where candidates approach different examiners station. Often a bell rings between stations to
at different stations (or in different rooms let the examiners know to move on to the next
altogether), who test them on specific aspects candidate. Each OSCE would contain between
viii Introduction

10 and 20 stations. The whole examination to history taking and in particular, examination
therefore lasts at least 2 hours and can be of communication skills. Dummies and
much longer. mannequins (such as for trauma, breast
In general therefore, an OSCE takes much examination or scrotal examination cases) are
longer to complete and the time spent on each also being used much more commonly for the
case (or scenario) is often longer than in the clinical parts of examinations.
short case format. The marking sheet the The pros of using simulated patients are that
examiner has in front of him is pre-set and only they:
allows them to score on specific criteria that are • Allow accurate portrayal of ‘typical’ patients,
standard for every other examiner as well. e.g. response to grief, being given a
The pros of OSCEs are that: diagnosis or information on the treatment
• The marking scheme is explicit and therefore of a relative
seen as being ‘fairer’ • Are the most effective way of testing
• They reduce inter-examiner variability, and communication skills
usually mean assessment by a larger number • Contribute to discussion of each candidate’s
of examiners in total because each scenario performance and even the mark awarded
is examined by a different clinician The cons of using simulated patients are that:
• They allow the possibility of assessment by • They reduce the number of clinical scenarios,
other doctors (e.g. specialist registrars, and tend to increase history taking and
medical educators) or other healthcare communications stations
professionals • In the same way as practicing basic
• There tends to be much greater emphasis on resuscitation on a dummy, it is different in a
patient-centred examining, including real life situation
communication skills and rapport, i.e. tests • It can be difficult to believe if the same actor
greater range of skills (not just clinical is used for more than one scenario with the
examination) same candidate.
• They allow for much more extensive use of
simulated patients – see below.
The cons of OSCEs include that they: Range of testing
• Are repetitive for examiners and patients –
One conclusion about OSCEs is that they don’t
seen as being ‘boring’ and may lead to
just test clinical examination technique. In fact
error
the areas they test are classified into five
• Provide little or no scope for examiners to different headings:
push very strong candidates
1. Clinical examinations
• Make it easier to score an average mark, and
more difficult to pull out a clear fail or an 2. History taking
exceptional candidate 3. Data analysis
• May present patients as having a certain set 4. Communication skills technique
of characteristic symptoms or signs, which 5. Practical skills
may not mirror their personal clinical So how do you know which of these is being
situation tested in a given station?
• Usually under-represent unusual cases as
they focus on ‘common’ scenarios.
Clinical examinations
Simulated patients Who will be at the station (other than
examiners)?
Simulated patients are actors. There is a • A patient with an identifiable pathology
growing industry of simulated patients across (inguinal hernia, thyroid lump, etc.)
medical education. Actors were originally used
• Occasionally a mannequin
in teaching and assessment in general practice,
and the success of this has led to a huge What will be available to you?
expansion into other specialties over the last 5 • Anything required to adequately complete
years. Actors can, of course, be trained and will the examination, e.g. in a thyroid scenario, a
play a clinical scenario very effectively. Clearly glass of water is provided; in a vascular bay
there are drawbacks and their use is confined a hand-held Doppler probe is provided
 Introduction ix

How will the scenario begin? How will the scenario begin?
• Normally ‘examine …’, or ‘have a look at …’, • With an explicit instruction to comment on a
and you will be directed to the side of the prop or a set of data
patient’s examination couch, or to the area What kind of questions will be used?
where they are sitting
• Often very specific (and quite closed)
What kind of questions will be used? questioning will be used to ensure you
• These will often close in on the pathological understand the clinical significance of any
problem, especially if the candidate is getting abnormality you pick up
sidetracked with something which is not on What kind of supplemental questions should you
the marking sheet for the scenario expect?
What kind of supplemental questions should you • Usually these will relate to the clinical
expect? situation which has been diagnosed, and are
• Supplemental questions might be asked (as unlikely to relate specifically to history or
included in the chapters of this book) to examination technique.
ascertain background knowledge and
understanding of potential treatments.
Communication skills
History taking
Who will be at the station (other than examiners)?
Who will be at the station (other than • Simulated patient
examiners)? What will be available to you?
• A simulated patient or a real patient • Probably a sheet detailing the
What will be available to you? communications exercise (which is usually
• Possibly paper on which to make notes as given to you in advance to allow you to
you take the history prepare)
How will the scenario begin? What kind of questions will be used?
• You may be asked to gain some information • None, the scenario is a test of your rapport
about the symptoms a patient is describing and communication with the patient, not with
and to formulate a differential diagnosis the examiners
• Be aware of the time; you are not going to What kind of supplemental questions should you
be able to complete a whole history but expect?
should focus on answering the exact • None, for the same reason.
question posed, without going into a whole
stream of closed questioning
Practical skills
What kinds of questions will be used?
• During the scenario none, but if you are Who will be at the station (other than the
interrupted you should take from this that examiners)?
you may be getting side-tracked
• Nobody
What kind of supplemental questions should you
What will be available to you?
expect?
• A prop or mannequin
• Again supplemental questions may relate to
further parts of the assessment of the How will the scenario begin?
patient’s symptoms. • With an instruction to demonstrate a specific
technique, such as advanced trauma
Data analysis life-support, or suturing, or reduction of a
Colles’ fracture on the examiner’s arm
Who will be at the station (other than examiners)? What kind of questions will be used?
• Nobody • Usually you talk through as you are
What will be available to you? proceeding with the case; the only role the
examiners have is to ensure that you can
• Here a ‘prop’ will be used which might be
adequately perform the specific skill
arterial blood gases, blood laboratory results,
joint aspiration results, histopathology results What kind of supplemental questions should you
or possibly an X-ray, CT scan or barium expect?
series • Possibly none.
x Introduction

SCORING SYSTEMS
We set ourselves one objective in writing this understand under what basis you will be
book – to help you to pass any surgical assessed and how you will score marks.
examination – and the first stage is to

SCORING IN SHORT CASE ASSESSMENTS

As mentioned above, this is largely subjective, • Coming up with possible further
but marks here are awarded for: examinations or tests that could be done
• Introducing yourself to the patient and • Thinking of a list of differential diagnoses,
establishing rapport or a definite diagnosis, and a list of
• Taking care to appropriately expose the investigations that would tip you towards a
patient (as described in each individual particular cause
chapter) • Following the train of thought of the
• Examining the relevant parts of the body – examiner, picking up on suggestions and
including starting with the hands letting yourself be ‘taught’ technique at the
bedside.
• Accurately identifying the pathological
problems (if there are any)

SCORING IN OSCE ASSESSMENTS

This is an objective test, and there is a specific 9. Thanking patient and washing hands
marking sheet, which might look like this: It is possible to come up with a marking
Bay 1 Superficial lesions scheme for each case in this book by picking
Case 8 Thyroid examination out the detail of the examination and making a
list of the things you would need to do in order
Done well = 2, Done adequately = 1, Not done = 0
to demonstrate competence. In the same way
Elements being assessed:
as in the short cases, there comes a point
1. Introdution to patients where you should finish your examination and
2. Adequate exposure tell the examiner how you would proceed. This
3. Observing neck from front is clearly listed under each case in the book.
4. Observing swallow test and protrusion of The examiner indicates if you should continue,
tongue and this would imply there are more marks yet
to be awarded.
5. Palpating neck from behind
6. Checking for cervical lymphadenopathy At the end of each case your marks are allotted,
then totalled at the end of the entire
7. Percussion and auscultation from the front
examination to come up with a score which
8. Mentioning the need to check clinical thyroid
translates into a pass/fail.
status

FAILING THE CLINICAL EXAMINATION

Failing a clinical exam is most likely if you are and establish rapport, making them ‘like you’. It
not seen to show due concern for the patient, isn’t as simple as this, and at all levels you are
such as not introducing yourself, not exposing also expected to ask questions or examine
adequately, and not asking permission before intelligently and come up with the right answers
examining. The examiners may be trying very to most of the questions. You don’t fail the
hard to give a hint that you are heading in whole examination for failing one OSCE though,
completely the wrong direction. Ignoring these and one of the most important things to do is
hints, and not listening carefully enough to the brush yourself down after each station and
question, may also lead to a failed case. Gross get on with trying to pass the next. We all
lack of knowledge or understanding is the third naturally emphasize in our minds the things
possibility. that haven’t gone so well, and this will tend to
A common mistake in OSCEs is to assume that psychologically knock you down during OSCEs.
you pass if you show concern for the patient Work on ways of concentrating on what you
 Introduction xi

have done well at each station and move on to with the one he examines immediately before
the next, keeping your mind as fresh and alert or afterwards
as possible. • Inter-examiner variability – where different
In the OSCE, reducing as many variables as examiners have wildly different expectations
possible from the assessment reduces the of the appropriate amount of knowledge
chance that a candidate who should have required to pass
passed will actually fail (i.e. the false-negative • Testing one single modality – where,
rate). Variables that are reduced (or eliminated) instead of just being tested on clinical
in this format include the following: examination, a range of skills (as above) is
• Intra-examiner variability – where an examined.
examiner (by chance) chooses a ‘harder’ set A ‘pass’ mark for the OSCE may therefore be
of cases for a given candidate compared more fairly ascertained than in short cases.
 1 
SECTION

SUPERFICIAL LESIONS
1 Lumps and ulcers – history *** 3
2 Lumps and ulcers – examination *** 3
3 Lipoma *** 5
4 Sebaceous cyst *** 6
5 Ganglion *** 7
6 Neck examination – general *** 8
7 Cervical lymphadenopathy *** 12
8 Thyroid examination *** 14
9 Solitary thyroid nodule *** 19
10 Multinodular goitre *** 22
11 Diffuse thyroid enlargement *** 24
12 Thyroid history *** 25
13 Hypertrophic and keloid scars *** 26
14 Squamous cell carcinoma ** 28
15 Malignant melanoma ** 29
16 Basal cell carcinoma ** 32
17 Pressure sores ** 34
18 Grafts and flaps ** 35
19 Ptosis ** 36
20 Facial nerve palsy ** 38
21 Salivary gland swellings ** 40
22 Keratoacanthoma ** 43
23 Neurofibroma ** 44
24 Papilloma ** 45
25 Pyogenic granuloma ** 45
26 Seborrhoeic keratosis ** 46
27 Solar keratosis ** 47
28 Digital clubbing * 48
29 Branchial cyst * 49
30 Dermoid cyst * 50
31 Thyroglossal cyst * 51
32 Radiotherapy marks * 53
33 Dermatofibroma * 54
34 Hidradenitis suppurativa * 55
35 Kaposi’s sarcoma * 55
36 Pharyngeal pouch * 56
37 Cystic hygroma * 57
38 Chemodectoma * 58
39 Furuncles * 59
40 Pyoderma gangrenosum * 60
41 Vascular malformations * 61
 Case 2 Superficial lesions 3

CASE 1 LUMPS AND ULCERS – HISTORY  ***

INSTRUCTION Onset
‘Ask this gentleman a few questions about his
• When did you first notice it?
lump/ulcer.’
• What made you notice it?
• Were there any predisposing events
APPROACH (e.g. trauma, insect bite)?
It is common in cases and OSCEs at finals, and
the MRCS, to be asked to take a focused Continued symptoms
history from a patient presenting with relatively
common problems, such as a lump or ulcer. • How does it bother you, i.e. what symptoms
Listen carefully to the instruction. After does it cause? (Ask particularly about pain)
introducing yourself and establishing the • Has it changed since you first noticed it?
patient’s name and age, go straight to (colour, shape and size changes are
questions about the lump or ulcer. You may important in malignant melanoma)
continue on to further relevant surgical • Have you noticed any other lumps?
questions such as fitness for anaesthesia. The
• Has it ever disappeared or healed?
examiner will usually stop you once you have
extracted the necessary information. You may
not always be asked to continue to examine the Treatments and cause
patient.
• What treatments have you had in the past
for this?
TOP TIP • What do you think is the cause of the lump/
  If the examiner tells you the patient’s name, then do ulcer?
not embarrass yourself by asking his name again – this You will usually find that as you extract the
only shows that you have not been listening to the relevant information, the examiner will move you
examiner! onto the examination relatively quickly.

TOP TIP
  When asked to take a history, keep eye contact with
VITAL POINTS the patient throughout your questioning. Don’t stare at the
Ask the following questions about the lump/ lump!
ulcer:

CASE 2 LUMPS AND ULCERS – EXAMINATION  ***

give a diagnosis and to describe the specific

INSTRUCTION
features which have led you to this conclusion.
‘Examine this lump.’

VITAL POINTS
APPROACH
Inspect
Most clinical examinations in surgery include the
description of a lump. The examiners may even
• Site – most accurately measured with
expect an on-the-spot diagnosis. The description
respect to a fixed landmark, such as a bony
given here of the examination technique is
prominence
complete and exhaustive, but be prepared to
4 Superficial lesions Case 2

• Size – measure the dimension in centimetres of the lump and then flick one side of it,
(if the lump is large enough, be seen to use a feeling the other side for a percussion
measuring tape/ruler, but do not use a tape wave (most commonly performed in ascites,
on a small lump as it can appear awkward) Case 57)
• Shape • Fixation – decide which plane the lump is in
• Skin changes by determining which structures it is
• Symmetry attached to, e.g.:
• Scars • Skin – see if you can move the skin over
the lump
• Colour
• Muscle – move the lump in two planes
Ask the patient if the lump is tender before
perpendicular to each other, ask the
proceeding with palpation.
patient to then tense the relevant muscle
and reassess the motion in the two
Palpate planes.

• Surface – smooth/irregular Percuss

• Edge – well/poorly defined
• Consistency – soft/firm/hard • Dull/resonant (the latter indicating an air-filled
• Temperature – using the dorsal surface of mass).
the examining fingers or hand
• Tenderness Auscultate
• Transilluminability – using a pen torch on one
side of the lump and looking through an • Bruits or bowel sounds may be heard.
opaque tube, such as an empty Smarties
tube (this is difficult and cumbersome to
perform in a well-lit room and we therefore Finish your examination here
recommend not taking an empty Smarties
tube into the exam, especially if the lump is
a hydrocele!) Completion
• Pulsatility – place a finger on opposite sides
of the lump Say that you would like to:
• expansile pulsation = fingers pushed
• Examine the draining lymph nodes
apart
• Assess the neurovascular status of the
• transmitted pulsation = fingers pushed in
area/limb
the same direction (usually upwards)
• Look for similar lumps elsewhere
• Compressibility/reducibility – press firmly on
• Perform a general examination (as necessary).
the lump and release
• compressible = lump disappears on
pressure but reappears on release, TOP TIP
e.g. arteriovenous malformations
  When assessing consistency, imagine:
• reducible = lump disappears on pressure
but reappears only when another • Soft, comparable with the consistency of the flesh of
opposite force is applied, such as your nostrils (i.e. the ala)
coughing in hernia examination • Firm, comparable with your nasal septum
• Fluctuation (for small lumps) – rest two
• Hard, comparable with the bridge of your nose.
fingers of one hand on opposite sides of the
lump and press the middle of the lump with
the index finger of your other hand – if the
fingers are moved apart, the lump is
fluctuant. (Repeat the test at right angles to Mnemonic
the first in order to confirm your findings.)
This is also known as Paget’s sign (see We use the following mnemonic to remind us
Case 107) what to do with a lump. It is very useful as an
• Fluid thrill – for large lumps – ask the patient aide-memoire for completeness, but note that it
to place the edge of his hand on the centre does not provide you with the correct order for
examination:
 Case 3 Superficial lesions 5

Should The Children Ever Find Lumps Readily E – Edge/Expansility and pulsatility
S–S  ize/Site/Shape/Surface/Skin changes/ F – Fluctuation/Fluid thrill/Fixation
Symmetry/Scars L – Lymph nodes/Lumps elsewhere
T – Temperature/Tenderness/Transilluminability R – Resonance/Relations to surrounding
C – Colour/Consistency/Compressibility structures and their state, e.g.
neurovascular status

A note on ulcers
Ulcers should be examined in a similar way to a lump, • Undermined = pressure necrosis or tuberculosis
but important additional points to look for on • Rolled = basal cell carcinoma
examination can be remembered in the form of the
• Everted = squamous cell carcinoma
mnemonic BEDD:
Describe which structure is visualized at the base of
Base. Look for the presence of granulation tissue,
the ulcer, e.g. is the ulcer down to fascia, muscle
slough (i.e. dead tissue) or evidence of malignant
or bone?
change
Discharge. Is the discharge serous (clear),
Edge. Five types of edges to be aware of are:
sanguineous (blood-stained), serosanguineous
• Sloping = a healing ulcer (usually venous or (mixed) or purulent (infected)?
traumatic)
Individual ulcers, e.g. arterial, venous, neuropathic,
• Punched-out = ischaemic or neuropathic (rarely
are considered in the appropriate sections.
syphilis)

CASE 3 LIPOMA  ***

INSTRUCTION Palpate
No specific instruction.
• Lobulated surface
• May be soft or firm depending on the nature
APPROACH of the fat within the lipoma and the
temperature at which it liquefies
Examine as for any lump (see Case 1).
• If soft and large in size, may show fluctuation
• ‘Slip sign’ – describes the manner in which
VITAL POINTS a lipoma tends to slip away from the
examining finger on gentle pressure
Lipomas can occur anywhere in the body where
• Skin freely mobile over the lipoma (compared
there are fat cells, although they most
with a sebaceous cyst)
commonly occur in the subcutaneous layer of
• Try and elicit which layer the lipoma is in,
the skin, particularly in the neck and trunk.
e.g. whether subcutaneous or intramuscular
(in the latter case, the lipoma disappears on
Inspect contraction of the relevant muscle).

• Discoid or hemispherical swelling Completion

• May appear lobulated
• Look carefully for scars (may be a recurrent Say that you would like to ask the patient:
lipoma).
• How the lipoma affects their lives, e.g.
cosmetic symptoms, pain
• Whether they have noticed similar lumps
elsewhere.
6 Superficial lesions Case 4

• Hibernomas, which consist of brown fat cells

QUESTIONS similar to those seen in hibernating animals
(a) What is a lipoma? • Bannayan–Zonana syndrome – rare
autosomal dominant hamartomatous
A lipoma is a benign tumour consisting of disorder, characterized by multiple lipomas,
mature fat cells. Multiple, painful lipomas are macrocephaly and haemangiomas.
known as adiposis dolorosa or Dercum’s
disease, and are associated with peripheral (b) How are liposarcomas classified?
neuropathy. • Liposarcomas can be classified
pathologically into three main groups:
(b) Do lipomas undergo malignant change?
1. Well-differentiated
• It is thought that malignant change in a 2. Myxoid and round cell (poorly-
lipoma does not occur differentiated myxoid) liposarcoma
• Liposarcomas arise de novo and usually 3. Pleomorphic liposarcoma.
occur in an older age-group in deeper
tissues of the lower limbs.

(c) How would you treat a lipoma? Francis X. Dercum (1856–1931). North American
neurologist, born in Philadelphia.
• Non-surgical: reassure and ‘watch and wait’
• Surgical: if the patient wants it removed, e.g.
pain, cosmesis. Some surgeons remove
lipomas using suction lipolysis via a small, FURTHER READING
remote incision. Usually this is performed Dalal KM, Antonescu CR, Singer S: Diagnosis
under local anaesthetic. However, ‘nuchal’ and management of lipomatous tumors. J Surg
lipomas have extremely fibrous septae and Oncol 97(4):298–313, 2008.
are difficult to excise, and any lipoma close Dei Tos AP: Liposarcoma: new entities and
to a joint may communicate with the joint evolving concepts. Ann Diagn Pathol 4(4):252–
and it may not be possible to excise it under 266, 2000.
local anaesthetic.
www.cancerhelp.org.uk/help/default.
asp?page=18503 – information for patients on
ADVANCED QUESTIONS lipoma removal.

(a) Do you know of any variants of lipomas or

syndromes associated with lipomas?
• Angiolipomas, which have a prominent
vascular component

CASE 4 SEBACEOUS CYST  ***

INSTRUCTION • Usually solitary

• Found most commonly on the face, trunk,
No specific instruction. neck and scalp
• Punctum present at apex of cyst in 50%.
APPROACH
Examine as for any lump (see Case 1). Palpate

• Smooth surface
VITAL POINTS • Firm to soft on palpation
Inspect • Punctum may exhibit plastic deformation on
palpation
• Smooth hemispherical swelling
 Case 5 Superficial lesions 7

• All sebaceous cysts are attached to the skin, • Epidermal cyst (EC) – thought to arise from
therefore the cyst does not move the infundibular portions of hair follicles
independently from the skin. • Trichilemmal cysts (TC) – thought to arise
from hair follicle epithelium and so are most
Completion common on the scalp, and are frequently
multiple; these cysts have an autosomal
dominant mode of inheritance.
Say that you would like to ask the patient:
• How the cyst affects their lives, e.g. (b) What is a Cock’s peculiar tumour?
cosmetic symptoms Proliferating trichilemmal cysts are usually
• Whether they have noticed similar lumps solitary, occur on the scalp in 90% of cases,
elsewhere. and can grow to a large size and ulcerate.
Clinically and histologically, they may resemble
a squamous cell carcinoma, in which case it is
QUESTIONS known as a Cock’s peculiar tumour. Very rarely,
(a) What are the complications of a malignant transformation can occur.
sebaceous cyst?
(c) What is Gardner’s syndrome?
• Infection – frequent complication, there may Multiple epidermal cysts may be part of
be an associated discharge Gardner’s syndrome, which is also associated
• Ulceration with:
• Calcification (trichilemmal cysts, see • Adenomatous polyposis of the large bowel
below) – this may cause the cyst to feel • Multiple osteomata of the skull
hard on palpation
• Desmoid tumours.
• Sebaceous horn formation (hardening of
Note that Gardner’s syndrome is now part of
a slow discharge of sebum from a wide
the spectrum of familial polyposis coli
punctum)
syndromes, which includes familial
• Malignant change. adenomatous polyposis.
(b) How would you treat a sebaceous cyst?
• Non-surgical: may be left alone if small and Edward Cock (1805–1892). English surgeon at Guy’s
asymptomatic Hospital, who was the nephew of Sir Astley Cooper
and performed the first pharyngectomy in England.
• Surgical: to prevent recurrence, complete
excision of cyst and its contents is required Eldon J. Gardner (1909–1989). American geneticist
which requires removal of an elliptical portion and Professor of Zoology, Utah State University.
of skin containing the punctum.
FURTHER READING
ADVANCED QUESTIONS Dastgeer GM: Sebaceous cyst excision with
minimal surgery. Am Fam Physician 43(6):1956–
(a) What are the different histological 1960, 1991.
subtypes of sebaceous cysts?
www.intelihealth.com/IH/ihtIH/WSIHW000/
Two types of cysts are recognized according to 9339/9779.html – information for patients on
their histological features: sebaceous cysts.

CASE 5 GANGLION  ***

INSTRUCTION APPROACH
‘Examine this gentleman’s hand.’ Expose to elbows and ask the patient to
place his hands palm upwards on a pillow
(if available).
8 Superficial lesions Case 6

sheath. The origin of ganglia is controversial –

VITAL POINTS
they are seen as a pocket of synovium
Ganglia can occur anywhere in the body, communicating with the joint or tendon sheath,
although they are commonly found around the or as a myxomatous degeneration of fibrous
wrist, on the dorsum of the hand and on the tissue.
dorsum of the ankle. In fact, the most common
soft-tissue mass found in the hand is a (b) What is the differential diagnosis?
ganglion. • Bursae
• Cystic protrusions from the synovial cavity of
Inspect arthritic joints
• Benign giant cell tumours of the flexor
• Usually single sheath (indistinguishable from flexor sheath
• Hemispherical swelling ganglia)
• Look carefully for scars (may be recurrent). • Rarely, malignant swellings, e.g. synovial
sarcoma.

Palpate (c) How would you treat a ganglion?

• Non-surgical: ‘watch and wait’, or aspiration
• Smooth surface followed by 3 weeks of immobilization
• May be multiloculated (successful in 30–50% of patients). (The old
• May be soft and fluctuant (especially if large) method of striking the ganglion with the
or firm (if small with tense, viscous contents) family Bible is now out of favour!)
• Associated with a synovial lined structure • Surgical: complete excision to include the
such as a tendon or joint neck of the ganglion at its site of origin.
• Weakly transilluminable due to its viscous
fluid contents.
(d) What complications are associated with
surgical treatment of a ganglion?
• Wound complications, e.g. scar, haematoma,
Completion
infection
• Recurrence – can be as high as 50% but
Say that you would like to ask the patient:
can be lower if care is taken to completely
• How the ganglion affects their lives, excise the neck
e.g. cosmetic symptoms • Damage to adjacent neurovascular
• Whether they have noticed similar lumps structures.
elsewhere
• Which hand is dominant (considering
treatment options) FURTHER READING
• Their occupation (also to consider treatment Thornburg LE: Ganglions of the hand and wrist.
options). J Am Acad Orthop Surg 7(4):231–238, 1999.
www.med.und.nodak.edu/users/jwhiting/ganglia.
QUESTIONS html – information for patients.

(a) What is a ganglion?

A ganglion is a cystic swelling related to a
synovial lined cavity, either a joint or a tendon

CASE 6 NECK EXAMINATION – GENERAL  ***

INSTRUCTION APPROACH TO THE NECK

‘Examine this gentleman’s neck.’ • Note that the patient is usually sitting in a chair
and may have a glass of water next to him
 Case 6 Superficial lesions 9

• If there is a glass of water, be prepared to examination of a thyroglossal cyst

examine the thyroid gland in full (see Case 31)
• Expose the whole neck down to both • A thyroid lump does not move on protrusion
clavicles – this may necessitate undoing the of the tongue.
top buttons of a shirt or even taking off a
polo neck jumper
Swallowing
• Ask the patient to remove any jewellery
present.
• Place the glass of water in the patient’s
hands
TOP TIP • Ask him to take a sip of water, hold it in his
mouth and swallow when you ask him to
  The examiners may try to catch you out by placing
the patient on a chair with its back against the wall. Your • As he swallows, inspect the lump – if it
first move is to ask the patient to stand up and move the moves on swallowing, it is likely to originate
chair away from the wall, allowing you to access and from the thyroid gland.
examine the patient’s neck from behind.
Palpate (from the back)

• The neck is best (and first) palpated from

behind the patient
VITAL POINTS • Be as gentle as possible, as you are unable
to watch the patient’s face for pain
Inspect (from the front)
• Use the fingertips of both hands to elicit the
• Site of the lump, e.g. midline, supraclavicular physical signs
fossa • Begin by showing the examiner that you
• Other features on inspection of the lump, know the borders of the two main triangles
e.g. size, skin changes, scars (see Case 1). of the neck and tell him which triangle the
lump is in (Fig. 1)
• The anterior triangle of the neck is
Protrusion of the tongue bordered by the anterior border of
sternocleidomastoid, the midline and the
• Ask the patient to open his mouth and stick ramus of the mandible
his tongue out as far as possible • The posterior triangle of the neck is
• If the lump moves on protrusion of the bordered by the anterior border of
tongue, it is likely to be a thyroglossal cyst trapezius, the clavicle and the posterior
(this is because the cyst is usually related to border of sternocleidomastoid
the base of the tongue by a patent or fibrous • Next, determine whether the lump is solid or
track, which runs through the central portion cystic. You should now be ready to consider
of the hyoid bone) – proceed with the differential diagnosis (Table 1 and Fig. 2).

Mandible

Posterior border of Midline

Borders of Borders of
sternocleidomastoid
posterior anterior
triangle Anterior Anterior border of triangle
of the border of sternocleidomastoid of the
neck trapezius neck

Clavicle
Figure 1  Posterior and anterior triangles of the neck.
10 Superficial lesions Case 6

Table 1  Differential diagnosis of neck lumps

Position Solid Cystic
Midline Thyroid swelling (Case 8) Thyroglossal cyst (Case 31)
Anterior triangle Lymphadenopathy (Case 7) Branchial cyst (Case 29)
Chemodectoma (Case 38) Cold abscess (secondary to tuberculosis)
Posterior triangle Lymphadenopathy Pharyngeal pouch (Case 36)
Cystic hygroma (Case 37)
Within sternocleidomastoid Sternocleidomastoid tumour

Submental gland, dermoid Submandibular

or thyroglossal cyst gland

Parotid gland
Carotid
chemodectoma
Branchial cyst

Thyroid nodule Thyroglossal

cyst

Cystic hygroma

Tip of Thyroid
cervical rib nodule
Figure 2  Locations of the most common swellings in the neck.

TOP TIP Examination of cervical lymph nodes

  Multiple lumps palpable within the neck are invariably
The cervical lymph nodes (Fig. 4) are best
lymph nodes.
examined using the ‘up-and-down’ technique:
• Use gentle rotating movements of the
fingertips – this allows you to palpate even
the smallest nodes
Continuing the examination
• If the patient tries to help you by raising their
chin, ask him to drop his chin – this makes
If at this stage you think that the lump is thyroid
the examination easier by relaxing the
in origin you should proceed to examine the
anterior neck muscles
thyroid gland in full (Fig. 3 and see Case 8).
• Begin by moving from the chin backwards,
If you have attempted a differential diagnosis palpating the submental, submandibular and
you should be prepared to offer additional parotid glands and pre-auricular nodes
‘evidence’ for your suggestions – see individual
• Move your fingers behind the ears and feel
cases.
the mastoid (post-auricular) nodes
If you have not found a lump at this stage you • Go down the anterior border of the
should examine the neck thoroughly using the sternocleidomastoids, feeling the anterior
up-and-down technique as in Table 2.
 Case 6 Superficial lesions 11

General approach

Inspect
Protrusion of tongue
Swallowing

Palpate from the back

Define triangle of neck

If you know the

differential diagnosis If lump is
state this and move NECK midline continue
on to discuss each DECISION with thyroid
individual diagnosis CIRCLE examination
(see individual
cases)

If you haven't found a

lump proceed with up-and
-down technique

Figure 3  ‘Neck decision circle’ approach to examination of the neck.

Table 2  The up-and-down technique • Move up the posterior border of the

Stage Procedure sternocleidomastoids, feeling the posterior
triangular nodes
1 Palpate from the chin backwards to below
• Finish by palpating the occipital nodes at the
the ears
back of the neck.
2 Move your hands behind the ears and
palpate DOWN the anterior border of
sternocleidomastoid to the clavicle Palpate (from the front)
3 Move laterally along the clavide and then • Confirm your findings if necessary by feeling
UP the posterior border of the lump from the front, watching the
sternocleidomastoid patient’s face carefully for signs of
4 Finish by palpating the back of the scalp discomfort.
for occipital nodes
Percussion and auscultation
triangular nodes, including the jugulodigastric
(tonsillar) node See individual cases.
• Move laterally along the clavicular region,
feeling for both supraclavicular and
infraclavicular nodes