What are all the viva questions expected in a case presentation topic of benign swelling from history to examination

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Here is a comprehensive list of expected viva questions for a benign swelling case presentation, organized from history to examination - the way an examiner would ask them:

Viva Questions: Benign Swelling Case Presentation

SECTION 1 - Opening / Introduction

Q1. What is a swelling? A swelling is any abnormal enlargement or protuberance in any part of the body. It may also be called a "lump" (breast) or "mass" (abdomen).

Q2. How do you classify swellings?

Based on tissue of origin: skin, subcutaneous, muscle, bone, nerve, vascular
Based on nature: benign vs. malignant
Based on content: solid, cystic, mixed
Based on behavior: inflammatory, neoplastic, traumatic, congenital

Q3. What are common benign swellings you can encounter in clinical surgery? Lipoma, sebaceous (epidermoid) cyst, dermoid cyst, ganglion, neurofibroma, fibroma, hemangioma, lymphangioma, pyogenic granuloma, epidermal inclusion cyst.

SECTION 2 - HISTORY Taking Questions

Chief Complaint

Q4. What are the cardinal features you ask about in the history of a swelling? Duration, onset (sudden vs. gradual), mode of onset (spontaneous vs. after trauma), progression (increasing, static, decreasing), associated symptoms.

Q5. Why is duration important? Long-standing slow-growing swellings suggest benignity (lipoma, sebaceous cyst). Rapid growth raises suspicion of malignancy.

Q6. Why do you ask about mode of onset? To determine if it started after trauma (haematoma, traumatic neuroma) or spontaneously (lipoma, cyst). Trauma is a key differentiating factor.

Q7. What do you mean by "rate of progress"?

Rapid: suggests malignancy or inflammatory swelling (abscess)
Slow and gradual: benign tumors (lipoma, dermoid)
Stationary: some benign lesions remain the same size for years

Pain

Q8. Why do you ask about pain? Benign swellings are classically painless. Pain suggests inflammation, infection, rapid expansion, nerve involvement, or malignancy.

Q9. Name benign swellings that can be painful.

Neurofibroma (along the nerve)
Glomus tumor (exquisite point tenderness)
Steatocystoma if infected
Ganglion (with activity/pressure)
Dermoid cyst (if infected)

Associated Features

Q10. What secondary changes do you ask about?

Change in size of the swelling
Ulceration of the overlying skin
Discharge (pus, sebum)
Discoloration
Functional impairment (limb movement, swallowing)
Numbness/tingling (nerve involvement)

Q11. Do you ask about loss of weight and appetite? Why? Yes - these are constitutional/systemic symptoms that suggest malignancy. Their absence supports a benign diagnosis.

Q12. What do you ask about fever? Nature, duration, and association with swelling. Fever with swelling suggests an abscess or inflammatory cause. Benign tumors are typically afebrile.

Q13. Do you ask about other swellings? Why? Yes - multiple swellings suggest:

Multiple lipomatosis
Neurofibromatosis (von Recklinghausen disease)
Multiple sebaceous cysts
Metastatic lymphadenopathy (though malignant)

Past History

Q14. What past surgical history is relevant?

Previous excision at the same or different site (risk of recurrence, e.g., lipoma)
Previous malignancy (metastasis)
Prior trauma (traumatic neuroma, haematoma)

Q15. What medical history is relevant?

Diabetes mellitus (risk of abscess formation, poor healing)
Tuberculosis (TB lymphadenitis)
Immunosuppression (unusual infections, Kaposi's sarcoma)

Personal and Family History

Q16. What personal habits are relevant? Smoking, alcohol, tobacco chewing - relevant if the swelling is in the oral cavity, neck, or skin (carcinoma risk). Also general health history.

Q17. When is family history important?

Familial multiple lipomatosis
Neurofibromatosis type 1 (autosomal dominant)
Gardner syndrome (multiple sebaceous cysts + colonic polyps)
Hereditary cylindromatosis

SECTION 3 - LOCAL EXAMINATION Questions

Inspection

Q18. What is the mnemonic for inspection of a swelling? "6 S" - Site, Size, Shape, Surface, Skin (overlying), Surroundings (surrounding structures)

Q19. What do you look for regarding the site? Exact anatomical location and relation to surface landmarks. For example:

Post-auricular swelling: dermoid cyst
Midline neck swelling: thyroglossal cyst
Over dorsum of wrist: ganglion
Subcutaneous anywhere: lipoma

Q20. How do you describe the shape of a swelling? Oval, globular, spherical, pear-shaped, lobulated, or irregular.

Q21. What skin changes over the swelling do you look for?

Color change (redness = inflammation)
Punctum (pathognomonic of sebaceous cyst)
Ulceration (malignancy or infected cyst)
Dilated veins (vascular tumor)
Scar from previous surgery
Normal skin color (lipoma)

Q22. What is a punctum? What does its presence tell you? A punctum is a small central dark opening (blocked duct opening) visible on the skin over a sebaceous cyst. It is pathognomonic for a sebaceous/epidermoid cyst and distinguishes it from a lipoma.

Q23. What do you observe about movements of the swelling?

Does it move with respiration? (suggests attachment to diaphragm or intra-abdominal origin)
Does it move with deglutition? (thyroid, thyroglossal cyst)
Does it move with tongue protrusion? (thyroglossal cyst specifically)
Is it pulsatile? (vascular swelling, aneurysm)

Palpation

Q24. What are the features you assess on palpation of a swelling? Temperature, tenderness, surface, edges, consistency, fluctuation, transillumination, compressibility, reducibility, pulsatility, bruit, slip sign, plane of the swelling, mobility, relation to surrounding structures.

Q25. How do you assess the temperature of a swelling? Using the dorsum of your hand, compare the swelling with the surrounding normal skin and the opposite side. Warmth suggests inflammation or vascularity.

Q26. How do you assess the surface and edges?

Surface: smooth (lipoma, cyst), lobulated (lipoma), irregular (malignancy)
Edges: well-defined and regular (benign), ill-defined and irregular (malignancy, infiltration)

Q27. What consistencies can a swelling have?

Soft: lipoma, abscess (fluctuant)
Firm: fibroma, ganglion
Hard/bony hard: osteoma, ossified fibroma
Cystic/fluctuant: sebaceous cyst, ganglion, abscess
Rubbery: lymphoma

Q28. How do you perform the fluctuation test? What does it indicate? Use two fingers of one hand to detect transmitted impulse when pressing with the opposite hand. Positive fluctuation = fluid-filled swelling (cyst, abscess). It must be tested in two planes at right angles.

Q29. How do you perform the transillumination test? What are the results? Shine a bright torch from one side of the swelling in a darkened room:

Brilliantly transilluminates: cystic swelling with clear fluid (hygroma, meningocele)
Does not transilluminate: solid swelling (lipoma, fibroma) - though lipoma may have faint transillumination
Faint glow: sebaceous cyst (turbid fluid)

Q30. What is the slip sign (slipping sign) of a lipoma? When you press the edge of a lipoma with one finger, the lobulated tumor slips away from under the finger due to its soft, encapsulated, lobulated nature. This is characteristic of lipoma.

Q31. How do you test for compressibility vs. reducibility?

Compressibility: swelling decreases in size on pressure but does NOT fully disappear and does NOT reappear on releasing pressure (e.g., cavernous hemangioma)
Reducibility: swelling fully disappears on pressure and reappears when pressure is released (e.g., hernia, varicocele)

Q32. How do you determine the plane of a swelling?

Skin-level: moves with pinching the skin (sebaceous cyst, dermoid)
Subcutaneous: moves freely in all directions below the skin but skin moves over it freely
Deep to fascia: limited mobility, skin moves freely over it
Muscle: moves when muscle contracts but not when muscle relaxes; limited mobility

Q33. How do you determine whether a swelling is in the muscle or deep to it? Ask the patient to contract the muscle. If the swelling becomes less palpable or disappears - it is deep to the muscle (under the muscle). If it becomes more prominent or fixed - it is within or superficial to the muscle.

Q34. What does good mobility suggest? Freely mobile swellings suggest benign origin (lipoma, sebaceous cyst). Fixity to surrounding structures suggests malignancy or deep infiltration.

Q35. How do you assess pulsatility of a swelling?

True pulsatility: expansile pulsation in two planes (at right angles) - arterial aneurysm
Transmitted pulsation: moves in one direction only, transmitted from adjacent artery - not an aneurysm

Q36. When would you auscultate a swelling? What do you look for? When you suspect a vascular swelling (pulsatile mass). A bruit suggests an arteriovenous malformation or vascular tumor. Absence of bruit does not exclude vascular origin.

Percussion

Q37. What does percussion of a swelling tell you?

Dull note: solid swelling or fluid-filled (lipoma, abscess, cyst)
Resonant note: air-filled swelling (pneumatocele, meningocele)
Useful in abdominal swellings to define extent

SECTION 4 - REGIONAL AND SYSTEMIC EXAMINATION

Q38. Why do you examine regional lymph nodes? To detect lymphadenopathy, which suggests:

Malignancy with regional spread
Inflammatory/infective cause (reactive lymphadenopathy)
Absence of lymphadenopathy supports benign diagnosis

Q39. What do you look for in the systemic examination for a case of benign swelling?

General examination: pallor, cachexia, jaundice (signs of malignancy or systemic disease)
Distant metastasis signs: hepatosplenomegaly, ascites
Other lumps elsewhere (neurofibromatosis, multiple lipomatosis)

SECTION 5 - SPECIFIC BENIGN SWELLINGS - Expected Viva Questions

Lipoma

Q40. Define lipoma. A lipoma is a benign tumor composed of mature fat cells (adipocytes), the most common benign soft tissue tumor.

Q41. What are the typical features of lipoma on examination?

Soft, non-tender, lobulated swelling
Well-defined edges
Slip sign positive
Freely mobile in subcutaneous plane
Skin moves freely over it (no punctum)
Fluctuation may be positive (pseudofluctuation)
Transillumination faintly positive or negative

Q42. What is pseudofluctuation? Lipomas may appear to fluctuate due to their soft, compressible nature, but they do NOT contain fluid. This is called pseudofluctuation. True fluctuation (fluid) is absent.

Q43. Where are lipomas most commonly found? Back, shoulders, posterior neck, axilla, arms, thighs. They are rare on the face, hands, and feet.

Q44. What is the treatment of a lipoma? Conservative if asymptomatic and small. Surgical excision (enucleation) if: large, cosmetically unacceptable, causing pressure symptoms, or doubtful nature.

Q45. When do you suspect liposarcoma (malignant transformation)? Rapid increase in size, hardening, fixity, large size (>5 cm), deep location, or onset in elderly. Always send specimen for histopathology.

Sebaceous Cyst

Q46. What is a sebaceous cyst? A retention cyst arising from blockage of the duct of a sebaceous gland, filled with keratin (not sebum - hence more correctly called an epidermoid/epidermal inclusion cyst).

Q47. What is the pathognomonic sign of a sebaceous cyst? The punctum - a small central blackish opening (blocked duct) visible on the skin surface.

Q48. What are the typical examination features of a sebaceous cyst?

Smooth, spherical, tense swelling
Attached to skin (skin cannot be moved over it) with punctum
Not attached to deep structures (freely mobile deep to it)
Fluctuation: usually negative (thick, cheesy content)
Transillumination: faint at best (turbid content)
Non-tender unless infected

Q49. What are the complications of a sebaceous cyst?

Infection and abscess formation
Ulceration (Cock's peculiar tumor - chronically infected, ulcerated sebaceous cyst on the scalp)
Calcification
Rarely: malignant transformation to squamous cell carcinoma

Q50. What is Cock's peculiar tumor? A chronically infected sebaceous cyst over the scalp that ulcerates, mimicking squamous cell carcinoma. It is benign.

Dermoid Cyst

Q51. What is a dermoid cyst? How does it differ from a sebaceous cyst? A dermoid cyst is a developmental cyst lined by stratified squamous epithelium containing skin appendages (hair, sweat glands, sebaceous glands). It differs from a sebaceous cyst in that it:

Has NO punctum
Contains hair, teeth, or other skin appendages
Is often found along embryological fusion lines
Is typically deeper and does not attach to skin

Q52. What are the common sites of dermoid cyst?

External angular dermoid: at the lateral end of the eyebrow (most common)
Post-auricular dermoid: behind the ear
Sublingual dermoid: floor of the mouth (midline)
Nasal dermoid
Implantation dermoid: palm, fingers (after penetrating trauma)

Q53. What is an implantation dermoid? A dermoid cyst formed by implantation of skin epithelium into subcutaneous tissue after a penetrating injury (e.g., finger-prick in a seamstress). It is tender and found on the hands/fingers.

Ganglion

Q54. What is a ganglion? A ganglion is a diverticulum of a joint capsule or tendon sheath containing synovial fluid. It is NOT a true cyst as it has no cellular lining.

Q55. What are the typical features of a ganglion?

Smooth, tense, cystic swelling
Common on dorsum of wrist
Transilluminates brilliantly
Fluctuation positive
Mobile transversely but restricted longitudinally along the tendon

Q56. What is the treatment of a ganglion?

Rupture by firm pressure (historically, a Bible was used - "Bible cyst")
Aspiration
Surgical excision (down to the neck of the stalk) - definitive but recurrence possible

SECTION 6 - INVESTIGATIONS Questions

Q57. What investigations would you order for a benign swelling?

Ultrasound: confirms cystic vs. solid nature, vascularity
FNAC (Fine Needle Aspiration Cytology): confirms benign nature, rules out malignancy
MRI: for deep-seated swellings, large lipomas (to rule out liposarcoma)
X-ray: if bony origin suspected
Routine bloods (CBC, blood sugar, LFTs): preoperative workup

Q58. What is the role of FNAC? FNAC provides cytological diagnosis - confirms benign nature and guides management. It is minimally invasive, quick, and accurate for most soft tissue swellings.

Q59. When do you request histopathology (biopsy) rather than FNAC? When FNAC is inconclusive, when malignancy is strongly suspected, or for definitive tissue diagnosis before planning treatment.

SECTION 7 - TREATMENT Questions

Q60. What are the indications for surgical excision of a benign swelling?

Increasing size
Cosmetic concern
Pressure symptoms (pain, nerve compression)
Diagnostic uncertainty (cannot exclude malignancy)
Infection or complications
Patient's request

Q61. What do you tell the patient about recurrence?

Lipoma: low recurrence if completely excised
Sebaceous cyst: higher recurrence if wall not completely removed (especially if ruptured during surgery)
Ganglion: recurrence rate 10-40% even after excision

Q62. Why do you always send excised tissue for histopathology? To confirm the benign diagnosis and exclude unexpected malignancy (e.g., liposarcoma within a suspected lipoma, squamous cell carcinoma within a sebaceous cyst).

SECTION 8 - DIFFERENTIALS AND FINALS

Q63. How do you differentiate lipoma from sebaceous cyst?

Feature	Lipoma	Sebaceous Cyst
Punctum	Absent	Present (pathognomonic)
Skin attachment	Skin moves freely over it	Attached to skin
Consistency	Soft, lobulated	Smooth, spherical
Slip sign	Present	Absent
Contents	Fat (solid)	Keratin (pasty/cheesy)
Transillumination	Faint/negative	Negative

Q64. How do you differentiate benign from malignant swelling?

Feature	Benign	Malignant
Duration	Long (years)	Short (weeks-months)
Growth	Slow	Rapid
Pain	Absent	May be present
Surface	Smooth, lobulated	Irregular, nodular
Edges	Well-defined	Ill-defined
Consistency	Soft/firm	Hard, stony
Mobility	Freely mobile	Fixed to skin/deep structures
Skin	Normal	Ulcerated, tethered
Lymph nodes	Not enlarged	Enlarged, hard, fixed
Constitutional sx	Absent	Weight loss, anorexia, fever

Q65. What is the significance of fixity of a swelling? Fixity to the overlying skin suggests malignancy or chronic infection (e.g., peau d'orange in breast carcinoma). Fixity to deep structures suggests deep tissue invasion. Benign swellings are generally mobile.

Q66. What is the first thing to determine about any lump? The plane in which the swelling lies - skin, subcutaneous, intramuscular, or deep to muscle/bone. This narrows the differential diagnosis immediately.

This covers the full spectrum of expected viva questions for a benign swelling case presentation, from the first patient greeting through final management discussion. Examiners typically progress from history principles to examination technique, then specific signs (punctum, slip sign, fluctuation, transillumination), then ask about specific tumors (lipoma, sebaceous cyst, dermoid, ganglion), and finally investigations and management.

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