Superficial Lesions Flashcards
lipoma
occurs anywhere fat can expand
Soft
Subcutaneous
Imprecise margin
Fluctuant
benign
saracomatous change v unlikley, if occurs likely old pt + in deeper tissues
sebaceous cyst
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
ganglion
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
seborrhoeic keratosis
Benign hyperplasia of basal epithelial layer
- Hyperkeratosis: keratin layer thickening
- Acanthosis: stratum spinosum thickening
stuck on look, dark brown, greasy
neurofibroma
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
papilloma
skin tag
excision and diathermy if needed
bleed a lot as core is vascular
‘pyogenic granuloma’
rapidly growing fleshy red growth
remove trigger and excision / diathermy
dermoid cyst of skin
acquired or congenital
Smooth spherical swelling
Sites of embryological fusion
Soft
Non-tender
Subcutaneous
dermatofibroma
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
keratoacanthoma
regress within six weeks
mild form of SCC
dome-shaped
remove
assessment malignant melanoma
Asymmetry • Boarder: irregular • Colour: non-uniform • Diameter >6mm • Evolving / Elevation
risk factors malignant melanoma
- Sunlight: esp. intense exposure in early years.
- Fair skinned (low Fitzpatrick skin type)
- ↑ no. of common moles
- +ve FH
- ↑ age
- Immunosuppression
5 types of malignant melanoma and some info for each
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
staging melanoma
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
management melanoma
excision incl secondary margin
+/- LN removal
+/- adjuvant chemotherapy
summarise SCC
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
actinic keratosis
• 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 the legs of older women
- SCC in situ
treat as actinic keratosis
basal cell carcinoma
• 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
general info on neck lumps
• 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
assessment of neck lumps in anterior triangle and DDx
Pulsatile
§ Carotid artery aneurysm
§ Tortuous carotid artery
§ Carotid body tumour (chemodectoma)
• Non-pulsatile § Branchial cysts § Laryngocele § Goitre § Parotid
triple asssess
exam, USS, FNA
neck lumps in submandibular area and DDx
Salivary stone
• Sialadenitis - inf
• Salivary tumour
causes of posterior triangle lumps
LNs • Cervical ribs • Pharyngeal pouch • Cystic hygromas • Pancoast’s tumour
cause of midline neck lumps
• <20yrs § Thyroglossal cyst § Dermoid cyst • >20yrs § Thyroid isthmus mass § Ectopic thyroid tissue
presentation and treatment branchial cysts
• 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
carotid body tumour - v rare, just FYI
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
laryngocoele
- Cystic dilatation of the laryngeal saccule
- Congenital or acquired
- Exacerbated by blowing
may be seen in wind instrument players (rare)
define posterior and anterior triangle of the neck
divided by sternocleidomastoid
QED
dermoid cyst
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
thyroglossal cyst
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
cervical ribs general info
Overdevelopment of transverse process of C7
• Occur in 1:150
Presentation
• Mostly asymptomatic
• Hard swelling
• ↓ radial pulse on abduction and external rotation of arm
cervical ribs complications
• 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
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
full assessment of cervical lymphadenopathy
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
causes of cervical LNs raised
• Lymphoma and Leukaemia • Infection • Sarcoidosis • Tumours Infection • Bacterial § Tonsillitis, dental abscess § TB § Bartonella henselae (Cat-scratch disease) • Viral § EBV § HIV • Protozoal § Toxoplasmosis
investigations if concerned about cervical LNs
Blood
• FBC, ESR, film (atypical lymphocytes)
• TFTs, serum ACE
• Monospot test, HIV test
Radiological
• US
• CT scan
Pathology
• FNAC
• Excision biopsy
define hypertrophic vs keloid scars
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
managing keloid or hypertrophic scars
Non-surgical
• Mechanical-pressure therapy
• Topical silicone gel sheets
• Intralesional steroid and LA injections
Surgical
• Revision of scar ¯c closure by direct suturing
summarise DDx structure for a goitre
diffuse
multinodular
solitary lump
diffuse goitre DDx
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)
multinodular goitre DDx
Multinodular
• Multinodular colloid goitre (commonest)
• Multiple cysts
• Multiple adenomas
solitary thyroid nodule DDx
Solitary nodule • Dominant nodule in multinodular goitre • Adenoma (hot or cold) • Cyst • Malignancy
investigating thyroid lumps
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
simple goitre
diffuse painless goitre Mass effects: - dysphagia - stridor - SVC obstruction Usually euthyroid
cause =
iodine deficiency
goitrogens - sulphonylureas
give thyroxine or remove if pressure symptoms
multinodular goitre
evolves from long term simple goitre
treat as for that - thyroxine and remove if probs
toxic multinodular goitre
Multinodular goitre
Thyrotoxicosis
Uneven iodine uptake with hot nodule
treat with carbimazole
radioiodine
or removal
Grave’s
Diffuse goitre ¯c bruit Ophthalmopathy Dermopathy Thyrotoxicosis Assoc. ¯c other AI disease (T1DM, PA) ↑ uptake on radionucleotide scan
anti TSHr
Propanolol
Carbimazole
Radioiodine
Thyroidectomy
Hashimoto’s thyroiditis
diffuse painless goitre
thyrotoxic phase followed by hypothyroid
may have viral trigger?
anti TPO
thyroxine
DeQuervain’s thyroiditis
painful! diffuse goitre
viral trigger esp URTI
Cocksackie common trigger too
start toxic then go hypo then resolve themselves
supportive
subacute lymphocytic thyroiditis
Diffuse painless goitre
May occur post-partum
Thyrotoxicosis → hypo → eu
resolves
follicular thyroid adenoma
Single thyroid nodule
± thyrotoxicosis (majority are cold)
May get pressure symptoms
remove half thyroid
thyroid cysts
s Solitary thyroid nodule
Asympto or pressure symptoms
Can → localised pain due to cyst bleed
sort cyst
Riedel’s thyroiditis
rare btw, just FYI
Firm, fixed, irregular thyroid mass
Mass effects
Assoc. ¯c retroperitoneal fibrosis
malignant thyroid disease
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
5 reasons for thyroid surgery
- Mechanical obstruction
- Malignancy
- cosmetic
- Medical Rx failure: thyrotoxicosis
- Mediastinal extension: can’t monitor changes
thyroid pre op prep
• 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
thyroid surgery complications
early - reactive bleed, laryngeal oedema, recurrent laryngeal nerve palsy (hoarse), hypocalcaemia, hyperthyroidism
late - low thyroid, recurrent high thyroid, scarring
dealing with hypocalcaemia
pt is tingling + has wheeze, Chvostek (zygoma tap) + Trousseau (BP cuff) signs
give 10ml 10% cal gluconate
salivary gland enlargement
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
- Assoc. ¯c calculi and poor oral hygiene
salivary calculi
- Recurrent unilateral swelling and pain
- Worse on eating
- Red, tender, swollen gland (80% submandibular)
- Ix: plain x-ray or sialography
- Rx: gland excision
salivary gland malignancies
- 80% are in the parotid (80% are superficial)
- 80% are pleiomorphic adenomas
- Deflection of ear outwards is classic sign
- CN VII palsy = malignancy
