Superficial Lesions Flashcards
Lipoma
Benign tumour of mature adipocytes Sarcomatous change probably doesn’t occur Liposarcomas arise denovo (older pts, deeper tissue of lower limbs) INSPECTION - anywhere fat can expand, not scalp or palms - including spermatic cord and submucosa Palpation - soft, subcutaneous, imprecise margin, fluctuant Mx - non-surgical, surgical excision
Lipoma associated diseases
Dercum’s Disease / Adiposis dolorosa - Multiple, painful lipomas - Assoc. peripheral neuropathy - Obese postmen women Familial Multiple Lipomatosis Madelung’s Disease Bannayan-Zonana Syndrome - Multiple lipomas - Macrocephaly - Haemangiomas
Sebaceous Cyst
Epithelial-lined cyst containing keratin histo subtypes 1. Epidermal Cyst - arise from hair follicle infundibulum 2. Trichilemmal cyst/wen - Arise from hair follicle epithelium - Often multiple - May be autosomal dominant Inspection - occur at sites of hair growth, not soles or palms - central punctum Palpation - firm, smooth, intradermal Mx - non-surgical Surgical Excision
Sebaceous Cyst complications Cock’s peculiar tumour Gardener’s syndrome
Complications - Infection: pus discharge - Ulceration - Calcification Cock’s Peculiar Tumour - Large ulcerating trichilemmal cyst on the scalp - Resemble an SCC Gardener’s Syndrome: FAP + - Thyroid tumours - Osteomas - Dental abnormalities - Epidermal cysts
Ganglion
Cystic swelling related to synovial lined structures - joint, tendon Myxoid degeneration of fibrous tissue Contain thick gelatinous material INSPECTION - can be found anywhere - 90% dorsum of hand or wrist Dorsumof ankle May be scar from recurrence Weakly transilluminable Palpation - soft, subcutaneous, may be tethered to tendon
Ganglion DDx, Mx
DDx - bursae - cystic protrusion from synovial cavity or arthritic joint Non-surgical - aspiration followed by 3 weeks of immobilisation Surgical excision - recurrence can be 50% - neurovascular damage
Seborrheic Keratosis
Benign hyperplasia of basal epithelial layer - hyperkeratosis: keratin layer thickening - acanthosis - prickle layer thickening Stuck on appearance dark brown greasy Non-surgical mx
Neurofibroma
Benign nerve sheath tumour arising from schwann cells Inspection - solitary or multiple pedunculated nodules Palpation - fleshy consistency, pressure can > paraesthesia Remember - examine eyes, axilla, cranial nerves (esp CN8), BP Mx - surgical excision if malignant growth suspected Local regrowth common
Neurofibromatosis 1 (Von Recklinghausen’s)
- AD, Chr 17 - Cafe-au-lait spots (>6) - Freckling - Neurofibromas - Lisch nodules (iris)
Papilloma
Overgrowth of all layers of skin w a central vascular core Skin tag/fibroepithelial polyp Pedunculated, flesh coloured Mx - excision + diathermy to control bleeding
Pyogenic Granuloma
Epidermal lined cyst deep to skin Congenital / Inclusion Cysts - Developmental inclusion of epidermis along lines of skin fusion - Midline of neck and nose - Medial and lateral ends of eyebrows Acquired / Implantation Cyst - Implantation of epidermis in dermis - Often 2ndary to trauma (e.g. piercing)
Pyogenic Granuloma Inspection, palpation, Mx
Inspection Smooth spherical swelling Sites of embryological fusion Scar from recurrence Palpation Soft Non-tender Subcutaneous Mx Congenital - CT to establish extent - Surgical excision Acquired - Surgical excision
Dermatofibroma
Benign neoplasm of dermal fibroblasts INSPECTION - can occur anywhere, mostly lower limbs of young to middle aged women - small brown pigmented nodule Palpation - firm, woody feel - characteristic intradermal, mobile over deep tissue Mx - excision + histology DDx - malignancy, melanoma, BCC
Keratoma Acanthoma
Benign overgrowth of hair follicles Cytologically similar to well-differntiated SCCs Fast growing, dome shaped w keratin plug Intradermal Mx - regress w/i 6 weeks - excise to reduce scarring + obtain histology
Malignant Melanoma Features RF
F>M Features
Asymetry
Boarder: irregular
Colour: non-uniform
Diameter >6mm
Evolving / Elevation Risk Factors
Sunlight: esp. intense exposure in early years.
Fair skinned (low Fitzpatrick skin type)
↑ no. of common moles
+ve FH
↑ age
Immunosuppression
Melanoma Classification
Superficial Spreading: 80% Irregular boarders, colour variation Commonest in Caucasians Grow slowly, metastasise late = better prognosis Lentigo Maligna Melanoma Often elderly pts. Face or scalp Acral Lentiginous Asians/blacks Palms, soles, subungual (w Hutchinson’s sign) Nodular Melanoma All sites Younger age, new lesion Invade deeply and metastasis early = poor prog Amelanotic Atypical appearance → delayed Dx
Melanoma Staging + Prognosis
Breslow Depth Thickness of tumour to deepest point of dermal invasion
<1mm = >75% 5ys
>4mm = 50% 5ys Clark’s Staging
Stratifies depth by 5 anatomical levels
Stage 1: Epidermis
Stage 5: sc fat
Melanoma Staging Mx, common mets sight
Mx
Excision + 2O margin excision depending on Bres depth
± lymphadenectomy
± adjuvant chemo (may use isolated limb perfusion)
Melanoma Mets, poor prognostic indicators
Mets - liver, eye
Poor Prognosis - male - ^mitosis - Satellite lesions (lymphatic spread)
Squamous Cell Carcinoma
Ulcerated lesion w hard, raised everted edges Sun exposed areas
Causes - sun exposure, scalp face, ears, lower leg -
may arise in chronic ulcers - Marjolin’s ulcer -
xeroderma pigmentosa
Evolution Solar/actinic keratosis → Bowen’s → SCC Lymph node spread is rare Rx - excision + radiotherapy of affected nodes
Actinic Keratoses
Irregular crusty warty lesions. Pre-malignant (~1%/yr) Rx Cautery Cryo 5-FU Imiquimod Photodynamic phototherapy
Bowen’s Disease
Red/brown scaly plaques typically on legs of older women SCC in situ Rx Cautery Cryo 5-FU Imiquimod Photodynamic phototherapy
Basal Cell Carcinoma
Commonest ulcer Pearly nodule w rolled telangiectactic edge May ulcerate Typically on face in sun-exposed area - above line from tragus > angle of mouth Low-grade malignancy → very rarely metastasise Locally invasive Rx Excision - Mohs: complete circumferential margin assessment using frozen section histology Cryo/radio may be used.
Neck Lumps Diagnosis
85% of neck lumps are LNs: esp. if present < 3wks
Infection: EBV, tonsillitis, HIV
Ca: lymphoma or mets
8% are goitres
7% other: e.g. sebaceous cyst or lipoma
Ix triple assessment - clinical assessment - imaging US - cyto/histo - aspiration/biopsy
Anterior Triangle Neck Lumps
Ant. margin of SCM Midline Ramus of the mandible Roof: investing fascia Floor: pre-vertebral fascia
Anterior Triangle Neck Lumps Causes
Pulsatile
Carotid artery aneurysm
Tortuous carotid artery
Carotid body tumour (chemodectoma) Non-pulsatile
Branchial cysts
Laryngocele
Goitre
Parotid tumour (lump in postero-superior area)
Branchial Cyst
Embryological remnant 2nd branchial cleft Presentation Age <20yrs Ant. margin of SCM at junction of upper and middle 3rd May become infected → abscess May be assoc. c¯ branchial fistula Path - lined by squamous epithelium - contain glary fluid w cholesteral crystals
Branchial Cysts Rx
Rx
Med Abx for infection
Sclerotherapy w OK-432 can be used
Surgical excision Definitive Rx May be difficult due to proximity of carotids
Branchial Sinus or Fistula
Small opening in lower 3rd of neck on ant. margin of SCM Between tonsillar fossa and ant. border of SCM May discharge mucus
Carotid Body Tumour
Chemodectoma - Very rare - Carotid Bodies > located at carotid bifurcation > detect pO2, pCO2, H+ Present
Just anterior to upper 3rd of SCM.
Pulsatile
Move laterally but not vertically
May be bilateral
Pressure may → dizziness and syncope
Mostly benign (5% malignant)
Ix: Doppler or angio: splaying of bifurcation
Rx: extirpation by a vascular surgeon
Laryngocele
Cystic dilatation of the laryngeal saccule Congenital or acquired Exacerbated by blowing
Submandibular triangle
Mental process ramus of mandible line between two angles of mandible Causes of lumps Salivary stone Sialadenitis Salivary tumour
Posterior Triangle Neck lump
Post margin of SCM Ant Margin of trapezius Mid1/3 of clavicle Causes - LNs - Cervical Ribs - Pharyngeal pouch - Cystic hygromas - Pancoast’s tumour
Cervical Ribs
Overdevelopment of transverse process of C7
Presentation Mostly ASx
Hard swelling
↓ radial pulse on abduction and external rotation of arm Can → vascular symptoms
Compresses subclavian A
Raynaud’s Subclavian steal
↓ venous outflow → oedema Can → neurological symptoms Compresses lower trunk of brachial plexus, T1 nerve root or stellate ganglion.
Wasting of intrinsic hand muscles
Paraesthesia along medial border of arm
Pharyngeal Pouch - Zenker’s Diverticulum
Herniation of pharyngeal mucosa through its muscular coat at its weakest point. Pulsion diverticulum Killian’s dehiscence - betw thyro and crico-pharyngeal muscles that form inferior constrictor
Pharyngeal Pouch Presentation
Swelling on left side of neck Regurgitation and aspiration Halitosis Gurgling sounds Food debris → pouch expansion → oesophageal compression → dysphagia. Ix: barium swallow Rx Excision and cricopharyngeal myotomy Endoscopic stapling
Cystic Hygroma
Congenital multiloculated lymphangioma arising from the jugular lymph sac Presentation Infants Lower part of post. triangle but may extend to axilla. ↑ in size when child coughs/cries Transilluminates brilliantly Rx: excision or hypertonic saline sclerosant May recur
Midline Neck Lumps
<20yrs Thyroglossal cyst Dermoid cyst >20yrs Thyroid isthmus mass Ectopic thyroid tissue
Dermoid Cyst
Developmental inclusion of epidermis along lines of skin fusion Presentation <20yrs Found at junctions of embryological fusion Neck midline Lateral angles of eyebrow Under tongue Contains ectodermal elements Hair follicles, sebaceous glands Rx - excision
Thyroglossal cyst
Cyst formed from persistent thyroglossal duct Path of thyroid descent from base of tongue Presentation Can be located anywhere between foramen caecum and the thyroid Usually just inferior to the hyoid: subhyoid Or, just above the hyoid: suprahyoid Fluctuant lump that moves up w tongue protrusion Can become infected → thyroglossal fistula Rx - Sistrunk’s Op - excision of cyst and thyroglossal duct
Cervical Lymphadenopathy Features + examination
Key Features Consistency Number Fixation Symmetry Tenderness Additional Examination Face and scalp for infection or neoplasm Chest exam: infection or neoplasm Breast examination Formal full ENT examination Rest of reticuloendothelial system
Cervical LN+ Hx, Causes
History Symptoms from the lumps E.g. EtOH-induced pain General symptoms Fever, malaise, wt. loss Systemic disease PMH Previous operations Social history Ethnic origin HIV risk factors Causes: LIST Lymphoma and Leukaemia Infection Sarcoidosis Tumours Infection >Bacterial Tonsillitis, dental abscess TB Bartonella henselae (Cat scratch disease) >Viral EBV HIV > Protozoal Toxoplasmosis
Cervical LN+ Ix
Ix Blood FBC, ESR, film (atypical lymphocytes) TFTs, serum ACE Monospot test, HIV test Radiological US CT scan Pathology FNAC Excision biopsy
Hypertrophic + Keloid Scars
Scar more prominent than surrounding skin Wound Associations Infection Trauma Burns Tension Certain body areas
Hypertrophic Scar
Scar confined to wound margins Across flexor surfaces and skin creases Appear soon after injury and regress spontaneously Any age: commonly 8-20yrs M=F All races
Keloid Scars
Scar extends beyond wound margins Earlobes, chin, neck, shoulder, chest Appear months after injury and continue to grow Puberty to 30yrs F>M Black and Hispanic
Salivary Gland Enlargement Hx + Caues
History Swelling/pain related to food: calculi Malaise, fever, mumps Dry eyes/mouth: Sjogrens (Sicca, Mickulicz) Causes Whole Gland Parotitis Sjogren’s / Sicca Syndrome Sarcoid Amyloid ALL Chronic liver disease Anorexia or bulimia Localised > Tumours > Stones
Acute Parotitis
Viral - Mumps, coxsackie A, HIV Bacterial - S aureus
Calculi
Recurrent unilateral Swelling + pain worse on eating Red, tender, swollen gland (80% submandibular) Ix - plain XR or sialography Rx - gland excision
Salivary gland neoplasms
80% in parotid 80% are pleomorphic adenomas Deflection of ear outwards - classic sign CNVII palsy - malignancy Classification Benign 1st: Pleiomorphic adenoma 2nd: Adenolymphoma (Warthin’s) Malignant (CN7 palsy + fast growing) 1st: Mucoepidermoid 2nd: Adenoid cystic Ix ENT examination US ± CT FNAC
Pleomorphic adenoma
commonest salivary gland neoplasm Presents - 90% occur in parotid > middle age F>M - benign slow growing Histo - different tissue types (pleomorphic) Rx - superficial parotidectomy
Adenolymphoma (Warthin’s Tumour)
Benign soft cystic parotid tumour Older men Rx - enucleation
Adenoid-cystic carcinoma
One of the commonest malignant salivary tumours Highly malignant and often incurable Rapid growth Hard fixed mass Pain Facial palsy
Surgery Salivary gland swellings
Superficial or radical parotidectomy Facia lata face lift for facial palsy Complications -facial nerve palsy - salivary fistula frey’s syndrome
Frey’s Syndrome
Gustatory sweating Redness and sweating skin over parotid area Occurs in relation to food (inc. thinking) Auriculotemporal branch of CN V3 carries sympathetic fibres to sweat glands over parotid area and parasympathetic fibres to the parotid Reinervation of divided sympathetic nerves by fibres from the secretomotor branch of auriculotemporal branch of CN V3
