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AS Surg RT > Superficial Lesions > Flashcards

Superficial Lesions Flashcards

1
Q

lipoma

A

occurs anywhere fat can expand

Soft
Subcutaneous
Imprecise margin
Fluctuant

benign
saracomatous change v unlikley, if occurs likely old pt + in deeper tissues

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2
Q

sebaceous cyst

A

2 types - epidermal (from hair follicle infundibulum), trichilemmal (from hair follicle epithelium)

occurs anywhere hair grows
central punctum seen
Firm
Smooth
Intradermal

can get infected, calcified or ulcerate

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3
Q

ganglion

A

Cystic swelling related to a synovium lined structure e.g. joint, tendon
Contain thick, gelatinous material

90% on dorsum of hand or wrist
weakly transilluminable

Soft
Subcutaneous
May be tethered to tendon

DDx - consider bursae, arthritis sequelae

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4
Q

seborrhoeic keratosis

A

Benign hyperplasia of basal epithelial layer

  • Hyperkeratosis: keratin layer thickening
  • Acanthosis: stratum spinosum thickening

stuck on look, dark brown, greasy

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5
Q

neurofibroma

A

Benign nerve sheath tumour arising
from Schwann cells.

pedunculated, fleshy
pressure - pins/needles

must examine eyes / axilla / CNs if identified

may also see freckling, Lisch nodules in iris, cafe au lait spots

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6
Q

papilloma

A

skin tag

excision and diathermy if needed
bleed a lot as core is vascular

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7
Q

‘pyogenic granuloma’

A

rapidly growing fleshy red growth

remove trigger and excision / diathermy

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8
Q

dermoid cyst of skin

A

acquired or congenital

Smooth spherical swelling
Sites of embryological fusion

Soft
Non-tender
Subcutaneous

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9
Q

dermatofibroma

A 
Can occur anywhere
Mostly on the lower limbs of young to
middle-aged women
Small, brown pigmented nodule
Firm, woody feel: characteristic
Intradermal: mobile over deep tissue

need biopsy as often unclear - exclude mal

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10
Q

keratoacanthoma

A

regress within six weeks
mild form of SCC
dome-shaped
remove

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11
Q

assessment malignant melanoma

A 
Asymmetry
• Boarder: irregular
• Colour: non-uniform
• Diameter >6mm
• Evolving / Elevation
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12
Q

risk factors malignant melanoma

A
  • Sunlight: esp. intense exposure in early years.
  • Fair skinned (low Fitzpatrick skin type)
  • ↑ no. of common moles
  • +ve FH
  • ↑ age
  • Immunosuppression
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13
Q

5 types of malignant melanoma and some info for each

A 
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 (Hutchinson’s sign)

• Nodular Melanoma
§ All sites
§ Younger age, new lesion
§ Invade deeply, metastasis early = poor prog

• Amelanotic
§ Atypical appearance → delayed Dx

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14
Q

staging melanoma

A 
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: s/c fat

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15
Q

management melanoma

A

excision incl secondary margin
+/- LN removal
+/- adjuvant chemotherapy

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16
Q

summarise SCC

A

Ulcerated lesion with 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

excise and radiotherapy locally if progressed

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17
Q

actinic keratosis

A 
• Irregular, crusty warty lesions.
• Pre-malignant (~1%/yr)
Rx
• Cautery
• Cryo
• 5-FU
• Imiquimod
• Photodynamic phototherapy
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18
Q

Bowen’s disease

A
  • Red/brown scaly plaques
  • Typically on the legs of older women
  • SCC in situ

treat as actinic keratosis

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19
Q

basal cell carcinoma

A

• Commonest skin cancer
• Pearly nodule with rolled telangiectactic edge
• May ulcerate
• Typically on face in sun-exposed area
§ Above line from tragus → angle of mouth
Behaviour
• Low-grade malignancy → very rarely metastasise
• Locally invasive

treat with Mohs excision and cryotherapy

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20
Q

general info on neck lumps

A

• 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

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21
Q

assessment of neck lumps in anterior triangle and DDx

A

Pulsatile
§ Carotid artery aneurysm
§ Tortuous carotid artery
§ Carotid body tumour (chemodectoma)

• Non-pulsatile
§ Branchial cysts
§ Laryngocele
§ Goitre
§ Parotid

triple asssess
exam, USS, FNA

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22
Q

neck lumps in submandibular area and DDx

A

Salivary stone
• Sialadenitis - inf
• Salivary tumour

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23
Q

causes of posterior triangle lumps

A 
LNs
• Cervical ribs
• Pharyngeal pouch
• Cystic hygromas
• Pancoast’s tumour
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24
Q

cause of midline neck lumps

A 
• <20yrs
§ Thyroglossal cyst
§ Dermoid cyst
• >20yrs
§ Thyroid isthmus mass
§ Ectopic thyroid tissue
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25
Q

presentation and treatment branchial cysts

A

• Embryological remnant 2nd branchial cleft

Presentation
• Age <20yrs
• Ant. margin of SCM at junction of upper and middle 3rd
• May become infected → abscess

abx if infected
excise

may form fistula

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26
Q

carotid body tumour - v rare, just FYI

A 
Carotid Body Tumour: Chemodectoma
• Very rare
• Carotid bodies
§ Located @ carotid bifurcation
§ Detect pO2, pCO2 and H+
Presentation
• 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
27
Q

laryngocoele

A
  • Cystic dilatation of the laryngeal saccule
  • Congenital or acquired
  • Exacerbated by blowing

may be seen in wind instrument players (rare)

28
Q

define posterior and anterior triangle of the neck

A

divided by sternocleidomastoid

QED

29
Q

dermoid cyst

A 
Developmental inclusion of epidermis along lines of
skin fusion.
Presentation
• Common <20yrs
• Found at junctions of embryological fusion
§ Neck midline
§ Lateral angles of eyebrow
§ Under tongue
• Contains ectodermal elements
§ Hair follicles, sebaceous glands
treat with excision
30
Q

thyroglossal cyst

A

Cyst formed from persistent thyroglossal duct
§ Path of thyroid descent from base of tongue

§ Usually just inferior to the hyoid: subhyoid
§ Or, just above the hyoid: suprahyoid
• Fluctuant lump that moves up on tongue protrusion
• Can become infected → thyroglossal fistula

treatment=
• Sistrunk’s Op: excision of cyst and thyroglossal
duct with segment of hyoid bone

31
Q

cervical ribs general info

A

Overdevelopment of transverse process of C7
• Occur in 1:150
Presentation
• Mostly asymptomatic
• Hard swelling
• ↓ radial pulse on abduction and external rotation of arm

32
Q

cervical ribs complications

A 
• 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

33
Q

pharyngeal pouch

A 
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
34
Q

cystic hygroma

A

• 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

35
Q

full assessment of cervical lymphadenopathy

A 
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
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
36
Q

causes of cervical LNs raised

A 
• Lymphoma and Leukaemia
• Infection
• Sarcoidosis
• Tumours
Infection
• Bacterial
§ Tonsillitis, dental abscess
§ TB
§ Bartonella henselae (Cat-scratch disease)
• Viral
§ EBV
§ HIV
• Protozoal
§ Toxoplasmosis
37
Q

investigations if concerned about cervical LNs

A

Blood
• FBC, ESR, film (atypical lymphocytes)
• TFTs, serum ACE
• Monospot test, HIV test

Radiological
• US
• CT scan

Pathology
• FNAC
• Excision biopsy

38
Q

define hypertrophic vs keloid scars

A

Hypertrophic
• 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
• 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
39
Q

managing keloid or hypertrophic scars

A

Non-surgical
• Mechanical-pressure therapy
• Topical silicone gel sheets
• Intralesional steroid and LA injections
Surgical
• Revision of scar ¯c closure by direct suturing

40
Q

summarise DDx structure for a goitre

A

diffuse
multinodular
solitary lump

41
Q

diffuse goitre DDx

A 
Diffuse
• Simple colloid goitre
§ Endemic: iodine deficiency
§ Sporadic: autoimmune, hereditary,
goitrogens (e.g. sulphonylureas)
• Graves’
• Thyroiditis
§ Hashimoto’s
§ De Quervain’s
§ Subacute lymphocytic (e.g. post-partum)
• (multinodular goitre ¯c nodules too small to palpate)
42
Q

multinodular goitre DDx

A

Multinodular
• Multinodular colloid goitre (commonest)
• Multiple cysts
• Multiple adenomas

43
Q

solitary thyroid nodule DDx

A 
Solitary nodule
• Dominant nodule in multinodular goitre
• Adenoma (hot or cold)
• Cyst
• Malignancy
44
Q

investigating thyroid lumps

A 
Bloods
• TFTs: TSH, fT3, fT4
• Other: FBC, Ca2+, LFTs, ESR
• Antibodies: anti-TPO, TSH
Imaging
• CXR: goitres and mets
• High resolution US
• CT
• Radionucleotide (Tc or I) scan (hot vs. cold)
Histology or cytology
• FNAC (can’t distinguish adenoma vs. follicular Ca)
• Biopsy
Laryngoscopy
• Pre-operative assessment of vocal cords
45
Q

simple goitre

A 
diffuse painless goitre 
Mass effects:
 - dysphagia
 - stridor
 - SVC obstruction
Usually euthyroid

cause =
iodine deficiency
goitrogens - sulphonylureas

give thyroxine or remove if pressure symptoms

46
Q

multinodular goitre

A

evolves from long term simple goitre

treat as for that - thyroxine and remove if probs

47
Q

toxic multinodular goitre

A

Multinodular goitre
Thyrotoxicosis
Uneven iodine uptake with hot nodule

treat with carbimazole
radioiodine
or removal

48
Q

Grave’s

A 
Diffuse goitre ¯c bruit
Ophthalmopathy
Dermopathy
Thyrotoxicosis
Assoc. ¯c other AI disease (T1DM, PA)
↑ uptake on radionucleotide scan

anti TSHr

Propanolol
Carbimazole
Radioiodine
Thyroidectomy

49
Q

Hashimoto’s thyroiditis

A

diffuse painless goitre
thyrotoxic phase followed by hypothyroid
may have viral trigger?
anti TPO

thyroxine

50
Q

DeQuervain’s thyroiditis

A

painful! diffuse goitre
viral trigger esp URTI
Cocksackie common trigger too

start toxic then go hypo then resolve themselves

supportive

51
Q

subacute lymphocytic thyroiditis

A

Diffuse painless goitre
May occur post-partum
Thyrotoxicosis → hypo → eu
resolves

52
Q

follicular thyroid adenoma

A

Single thyroid nodule
± thyrotoxicosis (majority are cold)
May get pressure symptoms

remove half thyroid

53
Q

thyroid cysts

A

s Solitary thyroid nodule
Asympto or pressure symptoms
Can → localised pain due to cyst bleed

sort cyst

54
Q

Riedel’s thyroiditis

A

rare btw, just FYI

Firm, fixed, irregular thyroid mass
Mass effects
Assoc. ¯c retroperitoneal fibrosis

55
Q

malignant thyroid disease

A

papillary 80% Thyroglob marker

follicular 10% thyroglob marker

medullary - parafollicular C cells, calcitonin + CEA markers (screen phaeo pre op)

lymphoma - MALToma in Hashimoto’s

anaplastic <1%

for ALL -> remove nodes + thyroid, give radioiodine

56
Q

5 reasons for thyroid surgery

A
  • Mechanical obstruction
  • Malignancy
  • cosmetic
  • Medical Rx failure: thyrotoxicosis
  • Mediastinal extension: can’t monitor changes
57
Q

thyroid pre op prep

A

• Render euthyroid pre-op ¯c antithyroid drugs
§ Stop 10 days prior to surgery (they ↑
vascularity)
§ Alternatively just give propronalol
• Check for phaeo pre-op in medullary carcinoma
• Laryngoscopy: check vocal cords pre- and post-op

58
Q

thyroid surgery complications

A

early - reactive bleed, laryngeal oedema, recurrent laryngeal nerve palsy (hoarse), hypocalcaemia, hyperthyroidism

late - low thyroid, recurrent high thyroid, scarring

59
Q

dealing with hypocalcaemia

A

pt is tingling + has wheeze, Chvostek (zygoma tap) + Trousseau (BP cuff) signs

give 10ml 10% cal gluconate

60
Q

salivary gland enlargement

A 
Whole gland
§ Parotitis
§ Sjogren’s / Sicca Syndrome
§ Sarcoid
§ Amyloid
§ ALL
§ Chronic liver disease
§ Anorexia or bulimia
• Localised
§ Tumours
§ Stones
61
Q

acute parotitis

A

Viral: mumps, coxsackie A, HIV
• Bacterial: S. aureus
- Assoc. ¯c calculi and poor oral hygiene

62
Q

salivary calculi

A
  • Recurrent unilateral swelling and pain
  • Worse on eating
  • Red, tender, swollen gland (80% submandibular)
  • Ix: plain x-ray or sialography
  • Rx: gland excision
63
Q

salivary gland malignancies

A
  • 80% are in the parotid (80% are superficial)
  • 80% are pleiomorphic adenomas
  • Deflection of ear outwards is classic sign
  • CN VII palsy = malignancy

AS Surg RT (15 decks)

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