General

Swellings
Lipoma
Definition
It is a benign tumor arising from the adipose tissue.

Macroscopic picture

True capsule of fibrous tissue. Outer false capsule formed by the surrounding structure. In between two capsules line of cleavage facilitates enucleation of tumor. Supplied by blood vessels enter the capsule at one part.

Microscopic picture
Aggregation of fat cells Separated by fibrous connective tissue stroma containing blood vessels arising from the pedicle.

Types of lipoma
1.

According to the structure

Pure lipoma mainly of adipose tissue. 2. Fibrolipoma With excessive fibrous tissue firm. 3. Haemangio or naevolipoma Neuro-lipoma.
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With excessive vascular tissue. Bluish in color partially compressible.

4.

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According to the site

1.

Subcutaneous lipoma
commonest type. common in back, shoulder, buttocks, forehead & limbs.

Clinically
-painless slowly growing swelling may attain a large size.

-soft & lobulated.

-Its capsule is attached to skin dimpling of the skin over

the tumor.
-It has a well defined slippery edge diagnostic sign

-It never to turn malignant except rare at back, shoulder, medial side of the tight.

2.

Subfacial lipoma
deep to the deep fascia. common at forehead. Lobulation is difficult to be detected.

3.

Submucous lipoma
Beneath the mucus membrane of
-larynx may cause respiratory obstruction -Intestine it may precipitate intussusception

4.

Subperiosteal
deep to periosteum of flat bones or long bones (as tibia).

5.Subserous beneath visceral or parietal peritoneum

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6.Subsynovial Beneath synovial membrane of the joints 7.Inter

& intra-muscular between or within muscle. 8.Intraglandular Inside the gland as parotid gland. 9. Extradural

It arise related to the spinal cord pressure symptoms never the cranium no fat

10. Retroperitoneal

behind posterior parietal peritoneum may reach huge size.

Some surgeons believes that in this site the lipoma may turn malignant others believes that it is a liposarcoma from the start.
11.

Diffuse lipomatosis (adiposa dolorosa or

in the females near menopause. in the lower limb. usually painful (dolorosa = painful).

Dercums disease)

Dangerous types of lipoma

Submucus Retroperitoneal Extradural

Complication of lipoma
Dangerous types of lipoma (CB4) +
1. Infection (rare) 2. Ulceration of the skin or mucous membrane above it. NB: Pain: the cause of painful lipoma are
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i) ii) iii) iv)

Adipose dolorosa Lipoma pressing on a near by nerve. Malignancy. Infection.

Treatment Surgical excision if complicated

Ganglion
Simple ganglion De f Sit e C/ P
chronic cyst containing mucoid material related to tendon (muciod degeneration) orsum of wrist ?? ound the ankle ?? d ar

Compound palmar ganglion

T.B. synovitis of synovial flexor sheaths of the fingers distended with T.B. granulation tissues. alm stal part of the forearm P Di

Cystic swelling
-

Cystic swelling
Si S C N
-

Si

te CB4
-

hape rounded
-

onsistency tense cystic

-

o Signs of inflammation painless not hot, not tender

-

te CB4 M ay extent to thumb or little finger C onsistency flactulant T B toxemia

onnected to extensor tendon when the tendon contract the cyst becomes less mobile from side to side.

TT T

Complete excision under general anesthesia until its root

S anatorial treatment A ntituberculous drugs. I mmobilization in plaster of paris.

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C omplete excision may be tried.

Haemangioma
Capillary haemangioma
Site Micro
skin & mucous membranes dilated capillaries & small amount of connective tissue in between

Diagno Strawberry sis haemangiom a

common in face & neck
-

Port wine haemangiom a

Salmon patch
over forehead or occipital region present at birth

appears shortly after birth enlarges in size till age of 1 year.

-

present at birth & grows as the child grows

regress & disappear at age of 10 years involuting haemangioma bright red localized swelling

does not disappear disappears after spontaneously non1 year involuting involuting haemangioma type blue pink in color, not red bluish patch raised above surface

TTT

-If shows spontaneous regression leave it alone. 5

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General

-complicated cases Regional or systemic corticosteroid

Laser photocoagulation by argon laser.

Cavernous haemangioma

Arterial haemangioma (Cirsoid aneurysm)

-usually occurs in the scalp -especially temporal region (in relation to superficial temporal artery). -congential arteriovenous fistula. -consists of arteries & arteritized veins. -Machinary murmur is heard over the swelling. -Plain X- ray skull Rarefied bone. -External carotid angiography diagnosis of intracranial affection of the dural vessels

Site

-subcutaneous & submucous tissues -common in the limbs, face, -but may occur in the deep viscera, bones or muscle blood spaces lined by endothelium

Compositi on Diagnosis

-at birth or shortly after birth -Ill-defined bluish swelling. -compressible & nonpulsating

Complication
-Thrombosis tender firm

nodule or nodules inside the lesion. -Infection Is rare & very dangerous, as it may cause septicemia. -Hemorrhage (after trauma).
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Cavernous haemangioma

Arterial haemangioma (Cirsoid aneurysm)

-Surgical excision under

TTT

-laser photocoagulation. -Excision if tumor in the limbs where the control of bleeding is easy.

general hypotensive anesthesia -external carotid is exposed & temporaly ligated

Dermoid Cyst
Cyst lined by sequamous epithelium

Types of dermoid cyst:

1. Sequestration dermoid cyst. DD with sebaceous cyst

2. Implantation dermoid cyst. 3. Tubulodermoid cyst ( thyroglossal cyst, branchial cyst). 4. Teratomatous dermoid cyst of the ovary, testis.

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Sebaceous cyst
Etiolog y Sites
-A retention cyst of a sebaceous gland -due to obstruction of the duct Any where in the skin except palms & sole (no sebaceous glands).

Sequestration dermoid cyst

-A congenital cyst from -sequestrated piece of skin at the line of fusion -but appears later on in life
-Face: External angular

Pathol ogy C/P

-lined by flat epithelium -contain sebum

internal angular. -Ear: Post-auricular. pre-auricular -Neck: in mid line sublingual inframyelohoid suprasternal . -Trunk: In midline. -Never in a limb (develop from buds no line of fusion ) -lined by stratified sq. epith. -Contains sebaceous material .

A slowly growing painless subcutaneous swelling -in characteristic site (CB4) -rounded well defined edge -smooth, cystic -not compressible, not translucent -painless -no signs of inflammation not tender, not hot -attached to skin at point -not attached to skin or deep structures (punctum) back spot.. -on squeezing discharge
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Sebaceous cyst
Compli c.
sebum -As any cyst

Sequestration dermoid cyst

-As any cyst -Cerebral compression: Very rare (doumble or hour glass dermoid ) .

-Cocks peculiar tumor Very

DD Invest. TTT

rare ulceration simulating squamous cell carcinoma but base is not indurated. -Sebaceous horn dried sebum protrude from the punctum over the skin. Dermoid cyst. Sebaceous cyst X-ray skull to exclude presence of bone defect if present wait till it closes -Uncomplicated Excision (best line of treatment)

-Uncomplicated Excision

through an elliptical incision to include the punctum. -Infected cyst Incision & drainage followed by excision after subside of inflammation.

(Implantation Dermoid Cyst ) Etiology

1. Pricking wound in the tip of finger . 2. The use of skin in hernioplasty .

Epidermoid Cyst

Pathology & C/P

As sequestration dermoid cyst in the tip of finger or related to scar (traumatic or surgical) .

Complications CB4 Treatment Excision .

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Thyroglossal Cyst
Etiolog y

Branchial cyst

-arise from unoblitrated portion of persistant cervical sinus ( 2-5 ) thyroglossal trunk -thyroglossal trunk develop from the foramen caecum & descend into the neck gives the thyroid isthmus & medial part of thyroid lobes.

Pathol ogy

-The cyst contains sebum. -lined by stratified sq. epith. -Fibrous cord connect the cyst to the hyoid bone (it can be followed to the foramen caecum at the base of tongue) -As any cyst -Thyroglossal fistula due to incomplete excision, rupture or incision of an abscess

-The cyst contain muciod substance rich in cholesterol -lined by squamous epithelium. -Fibrous cord passing between external & internal carotids connect cyst to pharynx (end above tonsil) -As any cyst -acquired branchial fistula. due to incomplete excision, rupture or incision of an abscess -Adenocarcinoma rere

Compli c.

ClP
Age Size Site
childhood Usually small
-Subhyoid commonest site. -Over thyroid cartilage (on one

Although congenital, it appear at the age of 20 years moderate in size -Upper part of the neck -partially superficial & partially deep to sternomastiod

side) -Suprahyoid (very rare) .

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General

Thyroglossal Cyst

Branchial cyst

Mobility

TTT

-moved from sides to side not from above downward. -moves with deglutition & with protrusion of tongue Complete excision through (Sistrunks operation).

-Moves from side to side.

Complete excision through (stepladder operation).

Thyrogloss al fistula
Etiolog y Pathol ogy
Acquired never congenital track is tortuous & intimately related to the hyoid bone but not posterior.

Branchial fistula
Acquired Congenital
Branchial cyst with opening in the lower part of the cyst related to the anterior part of the sterno-mastoid. The same as branchial cyst

1. Discharge mucous but if infected it discharge pus

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General

Thyrogloss al fistula
ClP
3. Fistula open in the midline of neck below hyoid bone

Branchial fistula
Acquired Congenital
2. Appears since birth

2. History of pre-existing cyst

3. fistula open at 3. fistula open higher lower 1/3 of ant. up in the neck ant. border of to the anterior sternomastiod border of sternomastiod Fistulogram

Investi g. TTT
Sistrunck operation

Step ladder operation

Cystic hygroma
Etiology Diffuse lymphangioma Clinical picture

lax cystic swelling partially compressible Superficial to sternomastiod & extends to posterior triangle. 1. 2. 3. Obstructed labour Recurrent infection. Respiratory distress due to compression of trachea.

Complication

Treatment Surgical excision as much as possible.

Laryngocele
to herniation of the m.m through a weak point in the thyrohyoid membrane

Pneumatocele
herniation of the lung apex through weak Sibsons fascia (supraplural membrane) Cystic swelling in the supracalvicular region

O/ E TT T

Cystic swelling in the neck

Which becomes prominent on straining Factor of straining should be corrected Excision

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Plication of Sibsons fascia

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Spina bifida
Usually affect the sacral region.

Meningocele
The meninges bulge as a globular sac containing C.S.F. The cord is intact.

Meningomyelocele
The meninges bulges as a globular sac containing C.S.F.. Cord & nerves herniate out in the bulging meninges.

Spina bifida occulta

Usually symptomless but overlying skin may show dimple, fibrofatty mass. Rarely weakness in LL may occur due to membrana reunies (fibrous tissue band between the skin & meninges) traction on the meninges.

Cysts in the floor of the mouth

1. Ranula 2. Sublingual dermoid cyst. 3. Mucous cyst.

Ranula
It is a retention cyst which arises from the mucous glands in the floor of the mouth. Partial excision & marsupelization is better

Keloid
Definition A dense over growth of granulation tissues after wounds. Incidence
1. It is especially common in the face, neck, front of chest & abdomen. 2. 3. Negroes. Tendency to develop keliod is inherited. The affected scar becomes firm raised above the surface Early it is pink or reddish in color & later it become pale.
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Clinical picture

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Treatment In early cases Excision & local corticosteriod injection.

Semimembraneou s bursitis
painless swelling of popliteal fossa. consistency extension of knee. more tense on Excision cystic in on the medial side occur in adult age a painful or -

Bakers cyst
herniation of synovial membrane of knee joint through the capsule. It stimulates semimembraneous buristis, but it occur in the midline.

TT T

Treatment of the cause

The Salivary Glands

Salivary stone
It is more common in the submandibular salivary gland than parotid (50:1) due to : 1. It secrets more viscid secretion. 2. Stasis of saliva due to the upward direction of the duct.

Predisposing factors
1. Chronic infection.
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2.

Duct obstruction.

Pathology
The stones are either single or multiple. They are present either in the gland or in its duct.

Clinical Picture of submandibular gland stone:

Pain Salivary colic esp. during meal or tasting food may refer to the ear or tooth or tongue Swelling The gland is enlarged firm & tender esp. after lemon juice intake. Plain X-ray It will show the stone in most of cases.

Complications
1. Sailoadenitis. 2. Salivary fistula.

Treatment

Stone inside the duct & felt through the floor of the mouth The duct is opened under local anesthesia & the stone is extracted. Stone inside gland submandibular sialoadenectomy.

Sialodenitis
The drainage is done by Blairs incision & Helton technique. Blair's incision for parotid decompression:

A vertical incision in the skin from front of lobule of ear to angle of mandible then a transverse incision in deep fascia over the gland (to avoid injury of the facial nerve branches). a sinus forceps is introduced to drain it.
1 2 3 - Salivary Fistula. - Facial nerve injury. - Frey's postgustatory syndrome.

Postoperative complications:

Salivary fistula
It may be related to the gland substance or the gland duct.
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General

Causes
1. After drainage or spontaneous rupture of an abscess. 2. Malignant tumour of the gland infiltrates the skin.

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Clinical picture

Watery discharge from abnormal opening in the skin over the related gland especially during smell or taste of the food, or meal. Eczema of The skin around the fistula may excoriated especially with ductal fistula.

Investigations
Sialography To show whether the fistula is ductal or glandular.

Treatment
Submandibular salivary gland fistula
(ductal or glandular) submandibular sialoadenectomy.

Parotid fistula
Fistula related to the gland: 1. Probanthine 15mg/6 hrs for 1 week to salivary secretion, spontaneous closure. 2. Avulsion of auriculotemporal nerve to salivary secretion. if failed Superficial conservative parotidectomy. Fistula related to the duct:
3. 1. if fistula is masseteric Excision & end to end

anastomosis over a tantalum wire

2. if fistula is premasseteric divide the duct and open it from

inside.

Neoplasm
Classification
Benign = Adenomas
1. Pleomorphic adenoma (mixed tumour). 2. Adenolymphoma.

Tumors may malignant

behave

as

benign

or

1. Mucoepidermoid tumours. 2. Acinic cell tumour.

Malignant = Carcinoma
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1. Adenoid cystic carcinoma. 2. Adenocarcinoma.

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General

3. Epidermoid carcinoma. 4. Carcinoma in pleomorphic adenoma.

Pleomorphic Adenomas
Origin Pathol ogy
epithelial & myoepithelial cells capsule is incomplete the tumor forms buds. enucleation of the tumor risk of local recurrence. It is usually symptomless, apart from the lump
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Adenolympho ma (Warthin's Tumour)

Unknown but it may be from the lymphoid tissue of the parotid. eosiophilic columar epithelium, lymphoid tissue

C\P

Age & sex elderly . presents as a slowly enlarging soft, bilaterally swelling

Pain & facial paralysis suspicion of malignancy

Muco-epidermoid Tumour
-

Acinic Cell Tumour

composed of

composed of sheets of epidermoid cells & mucous serous acini. secreting cells. gland.

occur in the parotid

It might behaves as benign or malignant Histopathology cannt detrmine its nature

Adenoid cystic carcinoma

Pathology
It consists of Myoepithelial cells basophilic material.
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General

Duct epithelium eosinophilic material. This gives a cribriform like appearance (swiss-chesse appearance)
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C\P
It tends to infilterate the facial nerve It tends to be both hard & fixed.

Adenocarcinoma
-

Rare 3 basic histological patterns Tubular, papillary & undifferentiated.

Squamous-cell Carcinoma
Some pathologists deny its existence, considering it a high grade mucoepidermoid carcinomas Other possibility is that the tumor is metastasis from another head & neck site. -

Malignant Pleomorphic Adenoma

years. What are S & S of malignant tansformation? The original mass will usually have been present for 10-15

Investigation
Biopsy
Superficial conservative parotidectomy for parotid tumor. In minor salivary gland incisional biopsy is performed.

Treatment
Parotid gland
Benign tumors If the tumor in:
-

Superficial part Superficial conservative parotidectomy. Deep part Total conservative parotidectomy. Total non conservative parotidectomy with graft of the facial nerve.

Malignant tumors
-

Tumors of Nerves
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Neurofibroma
It is a familial disease & is congenital. It arises from the neurolimmal & fibrous tissue elements of the nerves. Schwannoma arises from schwann cell of spinal roots, acoustic neuroma from 8TH cranial nerve

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General

Types
1. Generalized neurofibromatosis (Von Reckling Hausens disease)
Type I
It is autosomal dominant on chromosome 17. Multiple neurofibroma Ch. Ch. By - variable in size firm, tender mobile across but not along the nerve. - If arises in a spinal canal SC compression - if arises from the intracranial nerve ICT. Cafe- au- lait patches especially on the back. No sensory or motor Loss if present sarcomatous changes is suspected. Pheochromocytoma may be present. Treatment Excision of the complicated ones

Type II
On chromosome 22 Multiple schwannoma especially acoustic neuroma.

2. 3.

Solitary neurofibroma Plexiform neuroma

neurofibromatosis in relation to the cutaneous branches of the nerve network of beaded cords.
-

May hangs down (pachy dermatocele) commonly it affects the face.

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4.

Moluscum fibrosum
When the cutaneous nerve endings are affected .

5.

Elephantiases neurofibromatosis
Due to diffuse affection of the nerves of the skin & S.C. tissue.

Treatment
-

Solitary neurofibroma local excision Multiple neurofiberoma excision of the causing trouble.

Neurofibrosarcoma
-

It is either de novo or on top of neurofibroma. manifested by: pain rapid growth, hard in consistency nerve paralysis.
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It may metastasize.

Treatment Wide local excision or amputation.

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