GeneralSwellings 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. 1 - With excessive vascular tissue. Bluish in color partially compressible. 4. Computerized By: Yahia Makkeyah General 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 Computerized By: Yahia Makkeyah 2 Diffuse lipomatosis (adiposa dolorosa or • in the females near menopause. Extradural • • It arise related to the spinal cord pressure symptoms never the cranium no fat 10.General 6. Retroperitoneal • behind posterior parietal peritoneum may reach huge size. Dercum’s disease) Dangerous types of lipoma • Submucus • Retroperitoneal • Extradural Complication of lipoma Dangerous types of lipoma (CB4) + 1.Inter & intra-muscular between or within muscle. • Some surgeons believes that in this site the lipoma may turn malignant others believes that it is a liposarcoma from the start. 8. Ulceration of the skin or mucous membrane above it. • usually painful (dolorosa = painful). • in the lower limb. NB: Pain: the cause of painful lipoma are Computerized By: Yahia Makkeyah 3 . 11. Infection (rare) 2.Subsynovial Beneath synovial membrane of the joints 7. 9.Intraglandular Inside the gland as parotid gland. B. not tender - te CB4 M ay extent to thumb or little finger C onsistency flactulant T B toxemia c onnected to extensor tendon when the tendon contract the cyst becomes less mobile from side to side.B. I mmobilization in plaster of paris. synovitis of synovial flexor sheaths of the fingers distended with T. granulation tissues. Infection. 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.General i) ii) iii) iv) Adipose dolorosa Lipoma pressing on a near by nerve. 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. TT T Complete excision under general anesthesia until its root S anatorial treatment A ntituberculous drugs. Malignancy. 4 Computerized By: Yahia Makkeyah . General C omplete excision may be tried. not red bluish patch raised above surface TTT -If shows spontaneous regression leave it alone. - 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. 5 Computerized By: Yahia Makkeyah . 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. -compressible & nonpulsating Complication -Thrombosis tender firm nodule or nodules inside the lesion. -consists of arteries & arteritized veins. bones or muscle blood spaces lined by endothelium Compositi on Diagnosis -at birth or shortly after birth -Ill-defined bluish swelling. -Infection Is rare & very dangerous. -congential arteriovenous fistula. -Hemorrhage (after trauma). -Plain X. Cavernous haemangioma Arterial haemangioma (Cirsoid aneurysm) -usually occurs in the scalp -especially temporal region (in relation to superficial temporal artery). -Machinary murmur is heard over the swelling. -but may occur in the deep viscera. Computerized By: Yahia Makkeyah 6 . face.ray skull Rarefied bone. as it may cause septicemia. -External carotid angiography diagnosis of intracranial affection of the dural vessels Site -subcutaneous & submucous tissues -common in the limbs.General -complicated cases Regional or systemic corticosteroid Laser photocoagulation by argon laser. Implantation dermoid cyst. 3. Tubulodermoid cyst ( thyroglossal cyst. testis. 4. general hypotensive anesthesia -external carotid is exposed & temporaly ligated Dermoid Cyst Cyst lined by sequamous epithelium Types of dermoid cyst: 1. Sequestration dermoid cyst. Computerized By: Yahia Makkeyah 7 . Teratomatous dermoid cyst of the ovary. branchial cyst). -Excision if tumor in the limbs where the control of bleeding is easy. DD with sebaceous cyst 2.General Cavernous haemangioma Arterial haemangioma (Cirsoid aneurysm) -Surgical excision under TTT -laser photocoagulation. epith. A slowly growing painless subcutaneous swelling -in characteristic site (CB4) -rounded well defined edge -smooth. -Contains sebaceous material . not translucent -painless -no signs of inflammation not tender.General 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). pre-auricular -Neck: in mid line sublingual inframyelohoid suprasternal . -on squeezing discharge 8 Computerized By: Yahia Makkeyah . cystic -not compressible.. -Ear: Post-auricular. 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. -Never in a limb (develop from buds no line of fusion ) -lined by stratified sq. -Trunk: In midline. not hot -attached to skin at point -not attached to skin or deep structures (punctum) back spot. (Implantation Dermoid Cyst ) Etiology 1. 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. Complications CB4 Treatment Excision . sebum -As any cyst Sequestration dermoid cyst -As any cyst -Cerebral compression: Very rare (doumble or hour glass dermoid ) . -Sebaceous horn dried sebum protrude from the punctum over the skin. -Cock’s peculiar tumor Very DD Invest. Computerized By: Yahia Makkeyah 9 . TTT rare ulceration simulating squamous cell carcinoma but base is not indurated. Pricking wound in the tip of finger . Dermoid cyst. 2.General Sebaceous cyst Compli c. -Infected cyst Incision & drainage followed by excision after subside of inflammation. 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) . rupture or incision of an abscess -Adenocarcinoma rere Compli c. -Fibrous cord passing between external & internal carotids connect cyst to pharynx (end above tonsil) -As any cyst -acquired branchial fistula. Computerized By: Yahia Makkeyah 10 . rupture or incision of an abscess -The cyst contain muciod substance rich in cholesterol -lined by squamous epithelium. 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) . due to incomplete excision. -lined by stratified sq. -Over thyroid cartilage (on one Although congenital. Pathol ogy -The cyst contains sebum. -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. epith.General 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. ClP Age Size Site childhood Usually small -Subhyoid commonest site. -moves with deglutition & with protrusion of tongue Complete excision through (Sistrunk’s operation). Discharge mucous but if infected it discharge pus Computerized By: Yahia Makkeyah 11 .General Thyroglossal Cyst Branchial cyst Mobility TTT -moved from sides to side not from above downward. Complete excision through (stepladder operation). The same as branchial cyst 1. Thyrogloss al fistula Etiolog y Pathol ogy Acquired never congenital track is tortuous & intimately related to the hyoid bone but not posterior. -Moves from side to side. Branchial fistula Acquired Congenital Branchial cyst with opening in the lower part of the cyst related to the anterior part of the sterno-mastoid. up in the neck ant. History of pre-existing cyst 3. 2. Fistula open in the midline of neck below hyoid bone Branchial fistula Acquired Congenital 2. Obstructed labour Recurrent infection. fistula open higher lower 1/3 of ant. Laryngocele to herniation of the m. Appears since birth 2. 1. Respiratory distress due to compression of trachea. fistula open at 3. 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. Complication Treatment Surgical excision as much as possible. 3.General Thyrogloss al fistula ClP 3.m through a weak point in the thyrohyoid membrane Pneumatocele herniation of the lung apex through weak Sibson’s 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 12 Plication of Sibson’s fascia Computerized By: Yahia Makkeyah . border of to the anterior sternomastiod border of sternomastiod Fistulogram Investi g. S. Cord & nerves herniate out in the bulging meninges. 3. neck. Mucous cyst..F. front of chest & abdomen.General Spina bifida Usually affect the sacral region. 2. Partial excision & marsupelization is better Keloid Definition A dense over growth of granulation tissues after wounds. 3. The affected scar becomes firm raised above the surface Early it is pink or reddish in color & later it become pale. 13 Clinical picture Computerized By: Yahia Makkeyah . Rarely weakness in LL may occur due to membrana reunies (fibrous tissue band between the skin & meninges) traction on the meninges. Ranula 2. Cysts in the floor of the mouth 1. Ranula − − It is a retention cyst which arises from the mucous glands in the floor of the mouth. It is especially common in the face. Negroes. Meningomyelocele The meninges bulges as a globular sac containing C. Spina bifida occulta Usually symptomless but overlying skin may show dimple. fibrofatty mass. Incidence 1. The cord is intact.F. Sublingual dermoid cyst. Tendency to develop keliod is inherited.S. Meningocele The meninges bulge as a globular sac containing C. but it occur in the midline. It stimulates semimembraneous buristis. consistency extension of knee. 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. 2. Stasis of saliva due to the upward direction of the duct. more tense on Excision cystic in on the medial side occur in adult age a painful or - Baker’s cyst herniation of synovial membrane of knee joint through the capsule. 14 Computerized By: Yahia Makkeyah .General Treatment In early cases Excision & local corticosteriod injection. Chronic infection. It secrets more viscid secretion. Semimembraneou s bursitis painless swelling of popliteal fossa. Predisposing factors 1. after lemon juice intake.Facial nerve injury. Duct obstruction. Computerized By: Yahia Makkeyah 15 . Treatment Stone inside the duct & felt through the floor of the mouth The duct is opened under local anesthesia & the stone is extracted. during meal or tasting food may refer to the ear or tooth or tongue Swelling The gland is enlarged firm & tender esp.Frey's postgustatory syndrome. 1 2 3 . a sinus forceps is introduced to drain it. 2. Postoperative complications: Salivary fistula It may be related to the gland substance or the gland duct. Plain X-ray It will show the stone in most of cases. Salivary fistula.Salivary Fistula. They are present either in the gland or in its duct. Stone inside gland submandibular sialoadenectomy. Sailoadenitis. 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). . Complications 1. . Sialodenitis The drainage is done by Blair’s incision & Helton technique. Pathology The stones are either single or multiple. Clinical Picture of submandibular gland stone: Pain Salivary colic esp.General 2. Computerized By: Yahia Makkeyah 16 . After drainage or spontaneous rupture of an abscess.General Causes 1. 2. Malignant tumour of the gland infiltrates the skin. Parotid fistula Fistula related to the gland: 1. Tumors may malignant behave as benign or 1. 1.General Clinical picture Watery discharge from abnormal opening in the skin over the related gland especially during smell or taste of the food. Adenocarcinoma. or meal. 2. 17 . if failed Superficial conservative parotidectomy. if fistula is masseteric Excision & end to end anastomosis over a tantalum wire 2. Probanthine 15mg/6 hrs for 1 week to ↓ salivary secretion. Adenolymphoma. Avulsion of auriculotemporal nerve to ↓ salivary secretion. Pleomorphic adenoma (mixed tumour). 2. Acinic cell tumour. Eczema of The skin around the fistula may excoriated especially with ductal fistula. Mucoepidermoid tumours. 2. Malignant = Carcinoma Computerized By: Yahia Makkeyah 1. Treatment Submandibular salivary gland fistula (ductal or glandular) submandibular sialoadenectomy. if fistula is premasseteric divide the duct and open it from inside. Neoplasm Classification Benign = Adenomas 1. spontaneous closure. Fistula related to the duct: 3. Adenoid cystic carcinoma. 2. Investigations Sialography To show whether the fistula is ductal or glandular. enucleation of the tumor risk of local recurrence. occur in the parotid - It might behaves as benign or malignant Histopathology cann’t detrmine its nature Adenoid cystic carcinoma Pathology It consists of Myoepithelial cells basophilic material.General 3. 4. lymphoid tissue C\P - Age & sex elderly ♂. Carcinoma in pleomorphic adenoma. Epidermoid carcinoma. presents as a slowly enlarging soft. It is usually symptomless. apart from the lump - Adenolympho ma (Warthin's Tumour) Unknown but it may be from the lymphoid tissue of the parotid. secreting cells. Pleomorphic Adenomas Origin Pathol ogy epithelial & myoepithelial cells capsule is incomplete the tumor forms buds. gland. Computerized By: Yahia Makkeyah 18 . 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. eosiophilic columar epithelium. Malignant tumors - Tumors of Nerves Computerized By: Yahia Makkeyah 19 . - Malignant Pleomorphic Adenoma years. In minor salivary gland incisional biopsy is performed. Treatment Parotid gland Benign tumors If the tumor in: - Superficial part Superficial conservative parotidectomy.General Duct epithelium eosinophilic material. Squamous-cell Carcinoma Some pathologists deny its existence. This gives a cribriform like appearance (swiss-chesse appearance) - C\P It tends to infilterate the facial nerve It tends to be both hard & fixed. 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. Total non conservative parotidectomy with graft of the facial nerve. Adenocarcinoma - Rare 3 basic histological patterns Tubular. considering it a high grade mucoepidermoid carcinomas Other possibility is that the tumor is metastasis from another head & neck site. papillary & undifferentiated. Deep part Total conservative parotidectomy. • 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 Computerized By: Yahia Makkeyah 20 .General Neurofibroma • It is a familial disease & is congenital. General Types 1. variable in size firm. Ch. • Treatment Excision of the complicated ones Type II On chromosome 22 Multiple schwannoma especially acoustic neuroma. tender mobile across but not along the nerve. Solitary neurofibroma Plexiform neuroma neurofibromatosis in relation to the cutaneous branches of the nerve network of beaded cords. 3. Computerized By: Yahia Makkeyah 21 . . • No sensory or motor Loss if present sarcomatous changes is suspected. By . • Multiple neurofibroma Ch.If arises in a spinal canal SC compression .lait patches especially on the back. - - May hangs down (pachy dermatocele) commonly it affects the face. • Pheochromocytoma may be present. 2.au.if arises from the intracranial nerve ↑ ICT. Generalized neurofibromatosis (Von Reckling Hausen’s disease) Type I • It is autosomal dominant on chromosome 17. • Cafe. C. 22 Computerized By: Yahia Makkeyah .General 4. Treatment - Solitary neurofibroma local excision Multiple neurofiberoma excision of the causing trouble. 5. tissue. hard in consistency nerve paralysis. Moluscum fibrosum When the cutaneous nerve endings are affected . Elephantiases neurofibromatosis Due to diffuse affection of the nerves of the skin & S. manifested by: pain rapid growth. Neurofibrosarcoma - It is either de novo or on top of neurofibroma. General - It may metastasize. Computerized By: Yahia Makkeyah 23 . Treatment Wide local excision or amputation.