Plastics/orbit lesions Flashcards
benign/malignant lymphoid conjunctival lesion
Type of lymphoma - characterized by cell surface markers and flow cytometry. Specimen has to be fresh/ unpreserved for these tests.
90% are non-Hodgkins B-cell lymphoma.
Primary intraocular lymphoma is also B-cell derived.
Bowen’s disease
squamous cell caricnoma in situ (SCCIS)
actinic keratoses (AK)
Premalignant (22% becomes SCC) Thick, scaly, crusty lesion Usu. elderly white men Linked to sun exposure Parakeratosis Tx: excision, cryotherapy, topical 5-FU
Lentigo (solar, maligna, simplex)
Solar lentigo occurs in older patients that are sun exposed. (Resemble freckles but are larger in size and occur in old age.)
Lentigo simplex resembles freckles but are larger and are not related to sun exposure nor age.
Lentigo maligna lesions appear similar to solar lentigo except that they have irregular pigmentation. 30-50% of these lesions progress to melanoma.
freckle vs nevus
Freckle 2/2 melanocytes producing TOO MUCH pigment (and not from an over-abundance of melanosomes).
Nevus is derived from UNDIFFERENTIATED MELANOCYTES found at the epidermal/dermal border.
-Nests of dermal melanocytes (Derived from neural crest cells). Increased in pigment & size with puberty
BCC
MC eyelid malignancy
More common on? Lower lid (50-60%) > medial canthus (25-30%) > upper lid (15%) > lateral canthus (5%)
Pathology?
Basal cell nests
Peripheral palisades
1) MC = nodular - firm, raised, pearly nodule sometimes with telangiectasia.
Histologically, nodular BCC has “peripheral palisading” of basal cells. When the center ulcerates it has the classic “rodent ulcer” type of appearance.
2) Morpheaform = Much more aggressive
Firm, flat with indistinct borders
Slender tendrils. pagetoid spread
3) Other BCC types: ulcerative, pigmented and sclerosing
Treatment?
Excision w/ Mohs’ surgery
Rarely metastasize
Medial canthal basal cell carcinomas are particularly prone to infiltrate deeper tissues.
what to worry about after a face lift
In a patient having had a face-lift procedure, the surgeon is most worried about post-operative hematoma, which can–if untreated–lead to necrosis of the flap. This is an emergency and the hematoma should be drained immediately.
The typical time course of a hematoma is within the first twelve hours after surgery, and they are more common in men.
Untreated hematomas can lead to skin necrosis of the flap.
Nerve injuries are uncommon after facelift, occuring about 1-2% of the time.
Infections occur less than 1% of the time, and most patients are routinely covered with oral antibiotics perioperatively.
trichofolliculoma
A trichofolliculoma presents as a solitary and sometimes umbilicated lesion.
Trichoepithelioma
Firm flesh-colored nodule w/ telangiectasia, resembles BCC
Usu. on forehead, eyelids, usu. In females
Basaloid cells surrounding keratin center
Pilomatrixoma appearance/path. Systemic assoc?
Solitary firm deep nodule
reddish-purple subcutaneous mass attached to the overlying skin.
Affects young adults
Pathology?
Islands of epithelial cells surrounded by basophilic cells with shadow cells
Purple blends into pink
Association?
Myotonic dystrophy
Gardner’s syndrome
Treatment? Excision
trichilemmoma. Systemic assoc?
Small crusty, ulcerated, resembles verruca
Usu. on face
Glycogen-rich clear cells of outer hair sheath
Cowden’s disease?
multiple facial tricholemmomas
marker for breast or thyroid CA
MC site for orbital lymphoma to occur?
50% of orbital lymphoproliferative lesions are located in the LACRIMAL FOSSA (the one in the frontal bone and not the one housing the lacrimal sac).
90% of orbital lymphomas are non-Hodgkin B-cell lymphoma, 40%-60% of which are of the MALT variety. Fresh biopsies not in fixative should be sent to pathology.
MC epitheloid lacrimal gland
Lacrimal fossa lesions are generally of three types: inflammations (pseudotumor), lymphoproliferative lesions (lymphoma), and tumors of the lacrimal gland itself. One characteristic finding with lacrimal gland tumors is that they can impinge on the globe and cause inferior displacement of the globe. Lymphoproliferative lesions generally mold around the bone. Pleomorphic adenoma is the most common epithelial lacrimal gland tumor. The thing to remember about this lesion is that it should be removed in total. Violation of the pseudocapsule and leaving remnants behind is thought to increase recurrence. It should not be biopsied. Adenoid cystic is the most common malignant lacrimal gland tumor. These tumors are associated with a lot of pain and have a Swiss-cheese pattern on pathology.
Rhabdo location
Rhabdomyosarcomas = derived from undifferentiated pluripotential MESENCHYMAL cells and not from muscle. -typically occur in patients 8-10 years old.
MC type is embryonal (80% of cases) SUPERONASAL quadrant.
-good survival rate (94%)
Alveolar = awful (10-year survival rate of 10%)
-lower orbit location
Rx: XRT & chemotherapy (mainstays for all types)
Surgical removal of the lesion is not indicated unless the lesion is small and encapsulated.
Mnemonic for the types of rhabdo: Everyone gets Embryonal (most common, 80%); Alveolar is Awful (most lethal, survival <10%); Pleomorphic Please (best survival rate, 97%, so if someone gets rhabdo please let it be this type)
hemifacial spasm
MCC: The facial nerve may be compressed as it exits the brainstem by an ectactic vertebral artery or anterior inferior cerebellar artery (AICA).
In a patient presenting with hemifacial spasm, it is recommended to obtain an MRI/MRA of the head and neck to evaluate for mass lesions that may be compressing the 7th nerve.
DDx: stroke to this region, multiple sclerosis, or trauma
Rx: neuromodulatory injections such as botulinum toxin or neurosurgery (the Jannetta procedure) in which a sponge is placed in between the nerve and ectatic vessel to distract it away from compressing the nerve. This procedure has a high success rate in hemifacial spasm caused by vascular compression.
Seborrheic keratosis
Benign basaloid neoplasm
Smooth, greasy, stuck-on
Acanthosis, hyperkeratosis, horn or pseudohorn cysts
MC start to appear in middle age
Leser-Trelat sign?
Sudden appearance of multiple SK associated with internal malignancy (GI adenocarcinoma).
Nevus (early in life to late in life)
Nevi start out at the junctional level between the epidermis and dermis. Then, they extend into the epidermis and dermis where they are referred to as compound. Loss of the epidermal portion comes next, leaving just the dermal portion. They are then referred to as dermal.
Dacryocystitis in adults
Dacryocystitis in adults is almost always secondary to obstruction of the nasolacrimal duct. Probing and irrigation will not relieve strictures in adults. (Only indicated in children where there is a suspicion of a non patent valve of Hasner).
Topical antibiotics are not indicated because they do not penetrate into the skin.
Most adults with a history of dacryocystitis secondary to total NLDO will need a dacryocystorhinostomy (DCR).
Sebaceoucs carcinoma etiology of papillary conj
Pagetoid spread (PS) is responsible for its appearance as a papillary palpebral conjunctivitis. PS occurs intraepidermally, whereby cells proliferate singly or in nests at all levels of the epidermis. This finding is most commonly seen in association with neoplasms (most of which are malignant).
When sebaceous gland carcinoma involves the conjunctival epithelium and spreads (pagetoid spread), it can spread very rapidly. Excision of the lesion is indicated with sentinel lymph node biopsy
XRT - NOT effective.
Lacrimal gland fistula
- occurs when a ductule from the lacrimal gland goes to the external skin
- generally an overlying extra few eyelashes near the fistula. It is treated by excising the ductules.
dacryocystocele
=lacrimal sac distension 2/2 a nasolacrimal sac distension and is filled with amniotic fluid or mucus
-If infection is present, IV antibiotics in children or oral antibiotics in adults may be indicated to clear the infection.
Conservative treatment is indicated first which includes lacrimal sac massage. Because of the high rate of infection, topical antibiotics should be considered. Lacrimal system probing is indicated if this fails to clear the obstruction in 1-2 weeks.
NLDO in adult with bloody tears
Epiphora = defined as an overflow of tears. +/-mucus discharge and mattering of the eyelids. Dry eye may be a concomitant complaint although often dry eye and tearing suggests a reactive hypersecretion.
Presence of bloody tears = possibility of a malignancy in the lacrimal drainage apparatus.
MC malignancy of the lacrimal sac = squamous cell carcinoma (risks: smoking)
DDx (specific for lacrimal sac): Lymphoma, inverted papilloma (a benign lesion that may progress to SCC), and other malignancies
If you plan to perform a DCR and the patient complains of bloody tears, it is important to get a biopsy of the lacrimal sac at the time of surgery in order to diagnose an occult malignancy.
ON meningioma
Most arise from arachnoid villi
Si/Sx: typically present as painless loss of vision with an APD and sometimes with proptosis.
Optic nerve disc optociliary shunt vessels should raise suspicion.
Bilateral cases are associated with neurofibromatosis.
Rx: similar to optic nerve gliomas =observation unless intracranial or chiasmal extension is noted. In these cases, resection of the entire nerve may be indicated as well as possible radiation.
MCC of optociliary shunt vessels
A: ON meningioma
Optociliary shunt vessels (aka retinochoroidal collaterals) are a dilation of the naturally-occurring veins that drain from the peripapillary retinal circulation into the choroidal circulation.
- Similar to hemorrhoids or esophageal varices,
- optociliary shunt vessels evolve 2/2 chronically-poor drainage of the central retinal vein.
DDx:
- sphenoid wing meningioma (30% of patients)
- optic nerve sheath meningioma
- low-grade optic nerve glioma
- chronic papilledema
- chronic glaucoma
- old central retinal vein occlusion
