SWELLING
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
Lipoma
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
Ganglion
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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