Clinical- Swelling Discussion (Qs and Answers)


What is the most imp. Q. to be answered in swelling examination?
Is it benign or malignant by
1-    Attachments to skin & muscles
2-    L.N.s
3-    Neurovascular status of limb (distal pulsation. is it felt?)

What is rhinophyma? Hypertrophy of nasal sebaceous gls with aging


What is lipoma? Benign tumor of fat cells

What are common sites? Back, Shoulder, Thigh, Trunk, Neck, forearm

What are types of lipoma?
1-Subcutaneous (superficial to ms →  more prominent on contraction)
2- Intramuscular & Subfascial (deep to ms → less prominent on contraction)
3- retroperitoneal
4- extradural
5- Submucous(intest.)

What are diagnostic signs by examination?
Lobulated surface (SC)
Slippery edge (more with SC)

What is Adiposa Delerosa (Dercum disease)? Multiple painful lipomas (usually in back)

Can Lipoma be painful? Yes as above

Can lipoma turn malignant? Never, liposarcoma arise de nevo

D.D. lipoma?
1- sebaceous cyst
2- dermoid cyst
3- Benign muscle tumor
4- aneurysm (pulsatile)

What is diagnosis of Lipoma? Example (Lipoma of thigh)
soft mass in thigh, 7X5 cm,
Slippery edge, lobulated surface, soft consistency
not fluctuant, not attached to skin or muscles (knee extensors or hip adductors),
inguinal L.N.s not felt (vertical or horizontal group),
distal pulse felt (post. tibial , bec. D.pedis may be absent)
→ Lipoma of Rt thigh,

Ask pt. one Q? how long do you have this swelling: if long=benign

What is ttt of lipoma? Ask pt. how it is affecting his life
1-    conservative
2-    surgery: excision via incision smaller than lipoma because it can be squeezed, along bl.vs or with cosmetic lines (e.g, lipoma of thigh excised by smaller incision longitudinal to avoid inj. femoral vessels)
      LA (usually) or GA (if communic. with joint)
3- Liposuction (new)

How to test relation to muscles in lipoma of back? By inspection & palpation
Latissmus dorsi: elbow backward
Serratus ant.: push the wall
 → if mass ↑= superficial to ms (SC)
 → if mass ↓= deep to ms (intramuscular or subfascial)

What is ccc of liposarcoma by inspection? Dilated veins over it

OSCE advanced Qs
What are types of liposarcoma?
1- well diff
2- poorly diff
3- pleomorphic(mixed)

What are Syndromes associated with lipoma?
Angiolipoma= lipoma with vascular element
Hibernoma= brown fat
Cowden dis.= lipoma + vitelligo + palmar keratosis
Bannayan- Zonana synd.= Lipoma+ macrocephaly + hemangioma

Dermoid cyst

What is dermoid cyst? Cyst lined by skin but lies under skin

What are common sites? According to type see next Q

What are types of dermoid cyst?
1- Congenital (Sequestration) dermoid cyst: at lines of fusion (int.angular, ext.angular, preauricular, postauricular) & in midline of neck, trunk & back (never in limbs).
2- Acquired (implantation) dermoid cyst: at site prev. oper or Tr due to implanted skin
3- Tubodermoid dermoid cyst (in int. organs): thyroglossal cyst & branchial
4- Teratomatous dermoid cyst: Ovarian & testicular 

What are diagnostic signs by examination?
Paget test +ve
Transillumination +ve in 10%

Is dermoid cyst always translucent? NO. only in 10% of cases

What is diagnosis of dermoid cyst? Example
Soft Mass above Lt eyebrow,
1X1 cm, scar in overlying skin 2cm healed by 1ry intention
fluctuant, translucent (transimmunable)
not attached to skin or ms (occiptofrontalis)
L.N.s (preauricular) not felt (if felt → examine rest of neck L.N.s)
Implantation Dermoid cyst

What is D.D. of dermoid cyst?
1- sebaceous cyst
2- Lipoma
3- Benign muscle tumor
4- aneurysm (pulsatile)

How to surly diagnose dermoid cyst? Excisional biopsy

What is ttt dermoid cyst? Ask pt. how it is affecting his life
1-    conservative
2-    surgery: excision (if cosmetic or pain)
- cong. dermoid cyst in head: X-ray or CT for intracranial extension → surgery under GA by senior surgeon.
If intracranial extension may need bone graft (synthetic or iliac crest)

Sebaceous cyst

What is dermoid cyst? Retention of sebum in sebaceous gl.

What is the origin of sebaceous cyst? Structures around hair follicle (Cuticle)

What are common sites? Hairy area (not in palm or sole) (common in scrotum)

What are types of sebaceous cyst?
Epidermal cyst (SC): from infandibulum of hair follicle
Trichelemmal cyst (TC): from epithelium of hair follicle

What is the consistency of sebaceous cyst? Soft or Firm (thick sebum) (common)

What is a cyst? Cavity lined by epithelium

What are diagnostic signs by examination?
Punctum = point of attachment of sebaceous cyst to skin (may be multiple) (need to tract skin aside to find punctum) (found in 50% of cases)

How to diagnose Sebaceous cyst? Example
Swelling above Rt eyebrow, 1X1 cm, well defined edge, smooth surface, soft consistency, attached to skin at punctum, not attached to underlying ms (occipto-fr)
→ Sebaceous cyst of forhead

What are complications of sebaceous cyst?
Inf., hemorrhage, calcification, sebaceous horn, malignancy (rare)

How to treat sebaceous cyst?
Excision (for fear complic.) by elliptical incision including punctum

OSCE advanced Qs
What is cock‘s peculiar tumor? TC that grows rapidly and ulcerates (D.D. with SCC)
What is gardner syndrome? Seb.cyst+ L.I. polyps+ skull osteoma+ desmoid tumor


What is ganglion? Myxomatous  (cystic) degeneration of fibrous tissue of tendon or joint synovium (may be communicating with joint or non-communicating)

What are common sites? Near tendon or joint (esp, dorsum hand or foot or ventral wrist)

What are diagnostic signs by examination?
Paget test +ve
Transillumination +ve in 10%
Along tendons (esp, dorsum hand at wrist)
Mobility in single plain & become limited by tendon contraction

How to treat ganglion? Ask pt. how it is affecting his life
1- Conservative
2- Excision under GA or regional (because a tourniquet is needed for bloodless field (painful if LA)  (20% recurrence, ↓ to 5% if neck excised)
3- Aspiration & 3 weeks immobilization (30 – 50% recurrence + risk of inf.)

What are complic. of ganglion excision?
1- wound: inf., scar, hematoma
2- injury to nerves & vessels
3- recurrence (20% & ↓ to 5% if neck excised

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