Swellings

By: Dr Vikram Singh Mujalde

(M.S.,Mch Pediatric surgery)
 LIPOMA
• It is a benign tumour arising from yellow fat.
• • Tumour arising from brown fat is called as hibernoma
(reddish brown).
• It is called as universal tumour (ubiquitous tumour)
as it can occur anywhere in the body (except in brain).
• It is the commonest benign tumour (Karyotype 12q
change).
• It can be diffused or localised.
• Diffuse lipomas are not encapsulated, not well localised.
Common in palm, sole, head and neck region, difficult to
be removed. It is seen in subcutaneous and intermuscular
tissues.
• It can be single or multiple (5%). Multiple lipomas often
associated with many syndromes like MEN syndrome
(Multiple endocrine neoplasia syndrome)
Types-
• Painful lipomas are called as neurolipomas.
• Dercum’s disease is tender deposition of fat
especially on the trunk, is also called as adiposis
dolorosa. It is basically multiple neurolipomatosis.
• Fibrolipoma–Lipoma with fibrous component.
• Naevolipoma–Lipoma with telangiectasis.
• Lipoma arborigens is pedunculated lipoma.
• Lipomas attain large size in thigh, shoulder,
retroperitoneum, back and often may turn into
sarcoma.
Sites-
1.Subcutaneous. 2.
Subfascial.
3. Intramuscular.
4. Intermuscular in anterior abdominal wall.
5. Parosteal.
6. Subserosal.
7. Submucosal (GI tract).
8. Extradural (not intradural).
9. Intra-articular.
10. Subsynovial.
11. Superiosteal.
Clinical Features-
1. Localised swelling, which is lobular,
nontender.Semifluctuant (because fat in body
Types-
• Painful lipomas are called as neurolipomas.
• Dercum’s disease is tender deposition of fat
especially on the trunk, is also called as adiposis
dolorosa. It is basically multiple neurolipomatosis.
• Fibrolipoma–Lipoma with fibrous component.
• Naevolipoma–Lipoma with telangiectasis.
• Lipoma arborigens is pedunculated lipoma.
• Lipomas attain large size in thigh, shoulder,
retroperitoneum, back and often may turn into
sarcoma.
2.Mobile, with edges slipping between the palpating fingers
(‘slip sign’).
3. Skin is free.
4.Lipomas may be pedunculated at times.
Differential Diagnosis-
• Neurofibroma.
• Cystic swellings.
Complications-
• Sarcomatous changes—liposarcoma .
• Myxomatous changes.
• Saponification.
• Calcification.
• Submucosal lipoma can cause intussusception and
so intestinal obstruction.
Treatment-
• Excision.
• Small lipoma is excised under local anaesthesia and larger
one under general anaesthesia.
• If it is liposarcoma, CT chest should be done to see
secondaries in lungs. Later wide excision is done along with
adjuvant chemotherapy and radiotherapy.
CYSTS-
• Cyst is a collection of fluid in a sac lined by epithelium or endothelium.
Word meaning of cyst is “bladder”.
True Cyst
• Cyst wall is lined by epithelium or endothelium.
If infection occurs cyst wall will be lined by granulation tissue.
• Fluid is usually serous or mucoid derived from the secretion of the
lining.
False Cyst
• It does not have epithelial lining.
• Fluid collection
Example:
1. Pseudocyst of pancreas.
2. Wall of cystic swelling in tuberculous peritonitis.
3. Cystic degeneration of tumour.
4. After haemorrhage, in a haematoma, RBC’s are lysed, gets absorbed
and fluid remains as a false cyst.
Classification-
a. Congenital cyst-
• Dermoids: Sequestration dermoid.
• Tubulodermoids: Thyroglossal cyst, postanal dermoid, ependymal cyst,
urachal cyst.
• Cysts of embryonic remnants: Cysts from paramesonephric duct and
mesonephric duct,
cysts of urachus and vitellointestinal duct.
b. Acquired cysts-
• Retention cysts: They are accumulation of secretions of a gland due to
obstruction of the duct, e.g. sebaceous cyst, Bartholin’s cyst, cyst of parotid,
breast, epididymis.
• Distention cyst: Lymph cyst, ovarian cyst, colloid goiter.
• Exudation cyst: Bursa, hydrocele.
c. Cystic tumours: Dermoid cyst of ovary, cystadenomas.
d. Traumatic cyst: Due to trauma, haematoma occurs usually in thigh, loin,
shin. It eventually gets lined by endothelium containing brown coloured fluid
with cholesterol crystals.
e. Degenerative cyst: Due to cystic degeneration of a solid
tumour (due to necrosis of tumour).
f. Parasitic cyst: Hydatid cyst, trichiniasis, cysticercosis.
Clinical Features of a Cyst-
• Hemispherical swelling which is smooth,
fluctuant,nontender, well-localised. Some cysts are
transilluminant. Presentation varies depending on it
anatomical location.
Effects of a Cyst-
• Compression of adjacent structures: Choledochal
cyst compressing over the CBD.
• Infection.
• Sinus formation.
• Haemorrhage.
• Torsion, e.g. ovarian cyst.
• Calcification.
 DERMOIDS
Types-
1. Sequestration Dermoids-
• It occurs at the line of embryonic
fusion, due to inclusion of epithelium
beneath the surface which later gets
sequestered forming a cystic swelling in
the deeper plane.
Common sites are:
1. Forehead, neck, post auricular dermoid.
2. External angular dermoid.
3. Root of nose.
4. Sublingual dermoid.
5. Anywhere in midline or in the line of
fusion
• Dermoid cyst contains putty like desquamated material, hair follicle,
sebaceous and sweat glands. It is lined by both dermal and epidermal
components.
Types of angular dermoid-
a. External angular dermoid: It is a sequestration dermoid situated over
the external angular process of the frontal bone. Outer extremity of the
eyebrow extends over some part of the swelling. This typical feature
differentiates it from the swelling arising from the lacrimal gland.
b. Internal angular dermoid: It is a sequestration dermoid cyst in central
position near the root of the nose. It occurs in fronto nasal suture line. It is
rare.
Clinical features--
• Painless swelling in the line of embryonic fusion.
• Presents in the second or third decade onwards.
• Smooth, soft, nontender, fluctuant (Paget’s test positive
i.e. swelling is fixed with two fingers and summit is indented
to get yielding sensation due to fluid).
• Nontransilluminating.
• Free skin, often adherent into the deeper plane.
• There will be resorption and indentation of the bone
beneath.
• Impulse on coughing may be present only if there is
intracranial extension.
Differential diagnosis-
• Sebaceous cyst.
• Lipoma.
Investigations-
• X-ray—skull or part.
• CT scan head or part
Complication of sequestration dermoid-
• Infection
• Haemorrhage, rupture
• Surface ulceration
• Pressure effects if there is intracavitary extension like into
cranial cavity or thoracic cavity, etc
• Calcification
Treatment-
• Excision is done under general anaesthesia. Often formal
neurosurgical approach is required by raising cranial
osteocutaneous flaps.
2. Tubulodermoids-
• It arises from the embryonic tubular
structures.
• Examples include-
• Thyroglossal cyst.
• Ependymal cyst.
• Postanal dermoid.
3. Implantation Dermoid-
• Due to minor pricks or trauma,
epidermis gets buried into the deeper
subcutaneous tissue which causes
reaction and cyst formation (Trauma is
forgotten often). It is an acquired cyst.
• It is common in fingers (common in
tailors,
gardeners), toes and feet.
Differential diagnosis-
• Lipoma.
• Bursa.
Treatment-
• Excision.
4. Teratomatous Dermoid
• It arises from all germinal layers ecto, meso and
endoderms.
• It occurs in ovary, testis, retroperitoneum,
mediastinum.
• It contains hair, teeth, cartilage and muscle.
• It can be benign or malignant.
SEBACEOUS CYST (WEN, EPIDERMOID CYST)-
• It is a retention cyst. It is due to blockage of the
duct of sebaceous gland, causing a cystic swelling
Sebaceous glands are situated in dermis which
secretes sebum through sebaceous duct which
opens either directly to skin surface or in to a hair
follicle.
• It is common in face, scalp, scrotum.
• It is not seen in palms and soles as there are no
sebaceous glands.
• Sebaceous cyst contains yellowish white cheesy
material with fat and epithelium. It has putty like
consistency, with a parasite in the wall of the
sebaceous cyst—demodex folliculorum. It is lined
by only epidermal layer of squamous epithelium.
Clinical Features-
1.Painless swelling which is smooth, soft, nontender, freely
mobile, adherent to skin especially over the summit,
fluctuant (positive Paget’s test), nontransilluminating with
punctum over the summit.
2.It moulds on finger indentation.
3.Punctum is present over the summit in 70% of cases
because here sebaceous duct opens directly into the skin
which gets blocked. Punctum is depressed black coloured
spot over the summit of the sebaceous cyst. Because of the
denuded squamous epithelium (keratin) it is black in
colour. In 30% cases sebaceous duct opens into the
hair follicle and so punctum is not seen.
4.(Fordyce’s disease is heterotopic sebaceous glands
in mucosa of the lip and oral cavity).
5.Hair loss over the surface is common due to
constant pressure over the roots of the hair follicles.
Complications-
• Infection and abscess formation.
• Surface gets ulcerated leading to formation of a painful, fungating mass
with discharge called
as—Cock’s peculiar tumour—often resembles epithelioma. It is a
misnomer as it is not a tumour. It is a chronic granuloma on an ulcerated
surface of a sebaceous cyst.
• Sebaceous horn results from hardening of slowly discharged sebum
through the punctum.
• Multiple sebaceous cysts may be associated with syndromes like
Gardner’s syndrome.
Treatment-
• •Excision including skin adjacent to punctum.
• Incision and avulsion.
• • If abscess is formed, then drainage initially and
later excision is done.
• If capsule is not removed properly the cyst will
recur.
NEUROFIBROMA-
• It is tumour arising from connective tissue of the
nerve.
• It can be single or multiple. Neurofibromas may be
associated with pheochromocytomas, hypertension
and few syndromes.
Sites-
• Cranial.
• Spinal. Neurofibroma is the commonest intradural
extramedullary spinal tumour.
• Peripheral.
Types-
1.Nodular neurofibroma presents as single smooth, firm,
tender (often) swelling which moves horizontally or
perpendicular to the direction of the nerve, not in the
direction of the nerve. There is pain and hyperaesthesia in the
2.Plexiform neurofibroma commonly occurs along the distribution of 5th
cranial nerve in the skin of face. It often occurs in the cutaneous
distribution of the peripheral nerve.
3. Generalised neurofibromatosis (von Recklinghausen’s disease)
• It is an inherited autosomal dominant disease wherein there will be
multiple neurofibromas in the body—chromosome 17.
• It may be cranial, spinal or peripheral.
• It is associated with pigmented spots (coffee coloured) in the skin,
commonly seen on the back, abdomen, thigh (café au lait spots). More
than 5 in number, with each 1.5 cm or more in size is significant. Café au
lait signifies common neuroectodermal origin of nerve sheath cells and
melanocytes.
• Axillary/groin freckles and Lisch nodules may be present.
• Neurological disturbance is uncommon.
4.Elephantiatic neurofibromatosis: It is of congenital origin. It involves
limbs.
Complications-
1. Sarcomatous changes.
2. Cystic degeneration
3.Haemorrhage into the tissues.
4.spinal and cranial neurofibroma can cause neurological defeicit.
5. Erosion into deeper planes, bone, orbit.
6. Muscle atrophy.
7. Spinal dumbbell tumour can cause compression of
spinal cord and paralysis of the limb.
Treatment-
• Excision.
Indications
• Symptomatic neurofibroma—Pain and pressure symptoms
• Cosmetically problematic lesion
• Recent increase in size
• Malignant transformation 5% .
 GANGLION
• It is a cystic swelling occurring in relation to tendon sheath
or synovial sheath or joint capsule. It contains clear gel like
fluid.
Common sites-
1. Dorsum of wrist (Near scaphoid-lunate articulation)
2. Flexor aspect of wrist .
3. Around ankle joint—occasionally
Pathogenesis-
• Cystic degeneration of the tendon sheath.
• Leakage of synovial fluid through joint capsule.
• There are small islets of microspaces in synovial
sheath which often fuse together or one of them gets
enlarged to form ganglion.
Clinical Features-
• Well localised swelling which is smooth, soft, cystic, or
tensely cystic, (Paget’s test is +ve), nontender,
transilluminant. It is mobile but mobility is restricted when
tendon is contracted against resistance.
• Occasionally it is communicating with joint capsule.
• Often pain, tenderness and restricted joint movement may
be the presentation (but rare).
Differential Diagnosis-
• Lipoma.
• Lymph cyst.
• Sebaceous cyst.
• Small ganglion often mistaken for sesamoid bone or
exostoses.
• Bursa.
Treatment-
• Asymptomatic ganglion is better left alone because
of high recurrence rate.
• Excision. Usually done under local anaesthesia
(lignocaine plain 2%). Patient should be explained of
high recurrence rate (30%). After excision always it
should be sent for histopathology. Firm crepe
bandage application for 4 weeks is better in these
patients.
• Aspiration and sclerosant injection may be useful.
• (In olden days people used to rupture the ganglion
using bible book).