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Medicine Finals - Imperial & Quick Medical Revision > Superficial Lesions Surgery > Flashcards

Superficial Lesions Surgery Flashcards

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USMLE® Step 1 flashcards
1
Q

What is a lipoma?

A

Benign tumour of mature adipocytes
Sarcomatous change probably does’nt occur.

Liposarcomas arise de novo

  • Older patients
  • Deeper tissues of the lower limb.

On inspection - Anywhere fat can expand (not on scalp or palms).

May be a scarfrom recurrence.

Palpation
- Soft, subcutaneous, imprecise margin, fluctuant.

Management - Non-surgical/surgical excision.

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2
Q

What are the syndromes associated with Lipomas?

A

Dercum’s Disease (painful lipomas, associated with peripheral neuropathy, obese postmenopausal women)

Familial Multiple Lipomatosis

Madelung’s disease

Bannayan-Zonana Syndrome

  • Multiple lipomas
  • MAcrocephaly
  • Haemangiomas
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3
Q

What is a sebaceous cyst?

A

Epithelial lined cyst containing keratin

Two histological subtypes
- 1) Epidermal cyst (arise from hair follicle infundibulum)

-2) Trichilemmal cyst (arise from hair follicle epithelium, often multiple)

Inspection

  • Occurs at site of hair growth
  • Scalp, face, neck, chest, back.
  • Not soles or palms
  • Central punctum.

Palpation
- Firm, smooth, intradermal.

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4
Q

What are the complications of a sebaceous cyst ?

A

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.

Manage with non-surgical or surgical excision .

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5
Q

What is a ganglion?

A

Cystic swelling related to a synovial lined structure: joint, tendon

Myxoid degeneration of fibrous tissue

Contain thick, gelantinous material.

Inspection

  • Can be found anywhere
  • 90% on dorsum of hand or wrist
  • Dorsum of ankle
  • May be a scar from recurrence
  • Weakly transilluminal
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6
Q

Differentials for a ganglion?

A

Bursea
- Cystic protrusion form synovial cavity of arthritic joint

Non-surgical
- Aspiration followed by 3 weeks of immobilisation

Surgical excision

  • recurrence can be 50%
  • Neurovascular damage
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7
Q

Seborrheic keratosis?

A

Benign hyperplasia of basal epithelial layer

  • Hyperkeratosis: keratin layer thickening
  • Acanthosis: prickle layer thickening

Stuck on appearance. Dark brown. Greasy.

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8
Q

What is a neurofibroma?

A

Benign nerve sheath tumour arising from schwann cells.

Inspection: Solitary or multiple pedunculated nodules.

Palpation: Fleshy consistency, pressure can –> Paraesthesia

Extra - Examine eyes, axilla, cranial nerves, BP.

NF1 = AD, Chr 17, cafe-au-lait spots (>6), Freckling, neurofibromas, lisch nodules.

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9
Q

What is a Papilloma?

A

Overgrowth of all layers of the skin with a central vascular core.

Skin tag/fibroepithelial polyp.
Peduncuated, flesh coloured.

Manage = Excision + diathermy to control bleeding.

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10
Q

Pyogenic granuloma - what is it?

A

Rapidly growing capillary haemangioma

Neither pyogenic, nor a granuloma.

Inspection = Most commonly on hands, face, gums, lips. Bright red hemispherical nodules. May have serious/purulent discharge.

palpation: - soft, bleed very easily.

Possible assoc with previous trauma. Common in pregnancy.

  • Surgery = curettage with diathermy of the bases.
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11
Q

Dermoid cyst - what is it?

A

Epidermal-lined cyst deep in the skin.

Congenital (developmental inclusion of epidermis along lines of skin fusion. Midline of neck and nose. Medial and lateral ends of the eyebrows.

Acquired

  • Impantation of epidermis in dermis
  • Often 2ndry to trauma (piercing)

Inspection

  • Smooth spherical swelling
  • Sites of embroyological fusion
  • Scar from recurrence

Palpation
- Soft, non-tender, subcutaneous.

Child/young adult: congenital
Adult: congeital - ask re.trauma.

Congenital = CT To establish extent , surgical excision.

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12
Q

Dermatofibroma?

A

Benign neoplasm of dermal fibroblasts

  • Can occur anywhere, mostly on the lower limbs of young to middle-aged women.
  • Small, brown pigmented nodule.

Palpation: Firm, woody feel: characteristic.
Intradermal: mobile over deep tissue.

Differential
- Malignancy: melanoma, BCC.

Excision + histology

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13
Q

Kerato-acanthoma?

A

Benign overgrowth of hair follicle cells.
Cytologically similar to well-differentiated SCCs

Fast-growing dome-shaped with a keratin plug.
INtradermal.

Regress within 6 weeks. Excise to reduce scarring and obtain histology.

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14
Q

Diagnosis of neck lumps generally? - Top causes

A

85% of neck lumps are LNs: esp if present <3 weeks.

Infection: EBV, tonsillitis, HIV

Ca: Lymphoma or mets.

8% are goitres

7% other: Sebaceous cyst or lipoma

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15
Q

What investigations are required for Neck lumps?

A

Triple assessment

  • Clinical assessment
  • Imaging: US
  • Cyto/Histo: aspiration or biopsy
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16
Q

What is the anterior triangle?

A

Ant margin or SCM
Midline
Ramus of the mandible

Roof: investing fascia
Floor: pre-vertebral fascia.

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17
Q

What are the causes of a pulsatile anterior triangle mass?

A

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

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18
Q

What are the causes of a non-pulsatile anterior triangle mass?

A

Branchial cyst
Laryngocele
Goitre
Parotid tumour (lump in postero-superior area)

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19
Q

What is the submandibular triangle?

A

Mental process
Ramus of the mandible
Line between two angles of the mandible

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20
Q

Causes of masses in submandibular triangle?

A

Salivary stone
Sialadenitis
Salivary tumour

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21
Q

What is the posterior triangle?

A

Posterior margin of SCM
Anterior margin of trapezium
Mid 1/3 clavicle.

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22
Q

Causes of masses in the posterior triangle?

A 
LNs
Cervical Ribs 
Pharyngeal pouch
Cystic Hydromas 
Pancoast tumour
23
Q

What could a midline lump in <20yr old mean?

A

Thyroglossal cyst

Dermoid cyst

24
Q

What could a midline lump in >20yr old mean?

A

Thyroid isthmus mass

Ectopic thyroid tissue

25
Q

What is a branchial cyst?

A

Embryological remnant 2nd branchial cleft.

Presentation

  • Age <20yrs
  • Anterior margin of SCM at junction of upper and middle 3rd.
  • May become infected –> Abscess
  • May be associated with branchial fistula.

May contain glary fluid with cholesterol crystals.

DOES NOT TRANSILLUMINATE

26
Q

Management of branchial cyst?

A

Abx for infection
Sclerotherapy with OK-432 can be used.

Surgical excision

  • Definitive Management
  • May be difficult due to proximity of carotids.
27
Q

Branchial sinus or fistula - what is it?

A
  • Small opening in lower 3rd of neck on anterior margin of SCM
  • Between tonsillar fossa and anterior border of SCM
  • May discharge mucus.
28
Q

What is a carotid body tumour: chemodectoma

A

Very rare
Carotid bodies are located at the carotid bifurcation. Detect pO2, pCO2, H+.

Presentation

  • Just anterior to upper 3rd of SCM
  • Pulsatile
  • Move laterally but not vertically
  • May be bilateral
  • Pressure may - dizziness + syncope
  • Mostly benign

Ix: Doppler or angio = splaying of bifurcation

management: Extirpation by a vascular surgeon.

29
Q

Laryngocele - what is it?

A
  • Cystic dilatation of the laryngeal saccule
  • Congenital or acquired
  • Exacerbated by blowing.
30
Q

What are the midline neck lumps?

A

Thyroglossal cyst

Dermoid cyst

31
Q

What is a dermoid cyst

A

Developmental inclusion of epidermis along lines of skin fusion.

Presentation

  • common <20yrs
  • Found at junction of embryological fusion
  • neck midline
  • lateral angles of eyebrow
  • under tongue

Contains ectodermal elements
- hair follicles, sebaceous glands

Excise it

32
Q

What is a thyroglossal cyst

A

Cyst formed from peristent thyroglossal duct
- Path of thyroid descent from base of tongue.

Presentation

  • Can be located anywhere between foramen caecum and thyroid.
  • Inferior to hyoid.
  • Or just above the hyoid.

Fluctuant lump that moves up with tongue protrusion
Can become infected –> thyroglossal fistula. persistent infection etc.

Management = Sistrunk’s OP: excision of the cyst and thyroglossal duct.

33
Q

What are the posterior triangle lumps?

A

Cervical rib
Pharygeal Pouch
Cystic Hygroma

34
Q

What is a cervical rib?

A

Overdevelopment of transverse process of C7
Occurs in 1;150

Presentation 
- mostly asymptomatic 
- Hard swelling 
- Decreased radial pulse on abduction and external rotation of arm 
- Can --> vascular symptoms 
Compression subclavian A
Raynaud's 
Subclavian steal 
Decreased venous outflow --> oedema.

Can –> neurological symptoms
Compression lower trunk of brachial plexus, T1 nerve. root.
- Wasting of intrinsic hand muscles
- paraesthesia along medial border of arm.

35
Q

What is a pharyngeal pouch?

A

Herniation of pharygeal mucosa through its muscular coat.
- Between thyro and crico-pharygeal muscle that forms the inferior constrictor.

presents

  • Swelling on left side of neck Regurg + aspiration.
  • Halitosis
  • Gurgling sounds
  • Food debris –> pouch expansion –> oesophageal compression –> Dysphagia.

Ix: barium swallow

Management: Excision and cricipharyngeal myotomy
- Endoscopic stapling.

36
Q

What is a cystic hygroma?

A

Congenital multiloculated lymphangioma arising from the jugular lymph sac.

Found in birth.

Presents

  • Infants
  • Lower part of post. triangle but may extend to axilla
  • Increased in size when child coughs/cries.
  • transilluminates brilliantly

Rx: Excision or hypertonic saline sclerosant
- May recur.

37
Q

What is the history from a salivary gland issues?

A
  • Swelling/pain related to food: calculi
  • Malaise fever, mump
  • Dry eyes/mouth: Sjorgrens (Sicca).
38
Q

Causes of salivary gland enlargement?

A

Whole gland

  • Parotitis
  • Sjorgren’s/Sicca Syndrome
  • Sarcoid
  • Amyloid
  • ALL
  • Chronic liver disease
  • Anorexia or bulimia

Localised

  • Tumour
  • Stones
39
Q

Acute Parotitis?

A

Viral: mumps, coxsackies A< HIV

Bacterial: S.aureus associated wtih calculi and poor oral hygiene.

40
Q

Calculi in salivary glands?

A

Recurrent unilateral swelling and pain

Worse on eating
Red, tender swollen gland (80% submanidular)

Ix: plain x-ray or sialography

Management: gland excision.

41
Q

What are the salivary gland neoplasms?

A

80% are in parotid
80% are pleiomorphic adenoma
Deflection of ear outwards is classic sign.

CN VII Palsy = malignancy

42
Q

Classification of salivary gland tumours?

A

Benign

  • 1st: pleiomorphic adenoma
  • 2nd: Adenolymphoma (Warthin’s)

Malignant (CN7 palsy + fast growing)

  • 1st: mucoepidermoid
  • 2nd: adenoid cystic (most common)
43
Q

Investigations for salivary gland neoplasm?

A
  • ENT Examination
  • Sialogrpahy = delineate ductal anatomy.
    US ± CT
    FNAC
44
Q

What is a pleiomorphic adenoma.

A 
Commonest salivary gland neoplasm 
Presentation 
- 90% in parotid 
- Occur in middle age
- F>M 
- Benign and slow growing

Histo: different tissues types
Management: superficial parotidectomy

45
Q

Adenolymphoma (Warthin’s tumour)?

A

old men remember the warthins.

Benign soft cystic tumour in older men.
Most common bilateral benign neoplasm of the parotid.
Occurs in 6-7th decade of life.

Also consider
- Haemangioma. Parotid mass in child.

46
Q

Malignant parotid tumours?

A

1) Mucoepidermoid carcinoma = low potential for local invasiveness.

2) Adenocystic carcinoma Most common malignant salivary tumours
- Highly malignant and often incurable
- Rapid growth
- Hard fixed mass
- Pain
- Facial palsy

3) Mixed tumours - malignancy occuring in a previously benign parotid lesion.

4) Acinic cell carcinoma
- Intermediate grade malignnacy
- May show perineural involvement
- Low potential for distance mets.

5) Adenocarcinoma
- develops from secretory portion of gland. Risk of regional nodal and distant mets.

47
Q

Management of neoplasms of the salivary gland?

A

Superficial or radical parotidectomy

Facia lata face lift for facial palsy

48
Q

Complications of parotid/salivary gland tumour?

A

Facial Palsy
Salivary Fistula
Frey’s syndrome
- Redness + Sweating skin over parotid area
- Occurs in relation to food
- Auriculotemporal branch of CNV3 carries sympathetic fibres to sweat glands over parotid area.
- reinnervation of divided sympathetic nerve by fibres from the secretomotor branch of auriculotemporal branch of CN V3.

49
Q

HIV parotid disordder?

A

Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid
Typically presents as bilateral, multicystic, symmetrical swelling
Risk of malignant transformation is low and management usually conservative

50
Q

Sjorgen’s syndrome?

A

Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca

90% of cases occur in females postmenopausally

Second most common connective tissue disorder
Bilateral, non tender enlargement of the gland is usual
Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma
Treatment is supportive
There is an increased risk of subsequent lymphoma

51
Q

Sarcoid parotid?

A

Parotid involvement occurs in 6% of patients with sarcoid

Bilaterally in 70% of cases. Facial nerve involvement is recognised.

Steroids help with facial nerve palsy.

Bilateral in most cases
Gland is not tender
Xerostomia may occur
Management of isolated parotid disease is usually conservative

52
Q

Reactive lymphadenopathy?

A

Most common cause of neck swelling. There may be a history of local infection or a generalised viral illness.

Viral mumps with pancreatitis and parotid swelling.

53
Q

Sialolithiasis?

A

80% of all salivary gland calculi occur in the submandibular gland.

70% of these calculi are radio-opaque.
Stones are usually composed of calcium phosphate or calcium carbonate.

Colicky pain and post prandial swelling of gland.

Investigations = sialography to demonstrate site of obstruction and associated other stones.

Stones impacted in the distal aspect of Wharton’s duct may be removed orally. May require gland excision.

Medicine Finals - Imperial & Quick Medical Revision (29 decks)

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