Superficial Lesions

Question 1

Lipoma

Answer 1

Benign tumour of mature adipocytes Sarcomatous change probably doesn’t occur Liposarcomas arise denovo (older pts, deeper tissue of lower limbs) INSPECTION - anywhere fat can expand, not scalp or palms - including spermatic cord and submucosa Palpation - soft, subcutaneous, imprecise margin, fluctuant Mx - non-surgical, surgical excision

Question 2

Lipoma associated diseases

Answer 2

Dercum’s Disease / Adiposis dolorosa - Multiple, painful lipomas - Assoc. peripheral neuropathy - Obese postmen women Familial Multiple Lipomatosis Madelung’s Disease Bannayan-Zonana Syndrome - Multiple lipomas - Macrocephaly - Haemangiomas

Question 3

Sebaceous Cyst

Answer 3

Epithelial-lined cyst containing keratin histo subtypes 1. Epidermal Cyst - arise from hair follicle infundibulum 2. Trichilemmal cyst/wen - Arise from hair follicle epithelium - Often multiple - May be autosomal dominant Inspection - occur at sites of hair growth, not soles or palms - central punctum Palpation - firm, smooth, intradermal Mx - non-surgical Surgical Excision

Question 4

Sebaceous Cyst complications Cock’s peculiar tumour Gardener’s syndrome

Answer 4

Complications - 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

Question 5

Ganglion

Answer 5

Cystic swelling related to synovial lined structures - joint, tendon Myxoid degeneration of fibrous tissue Contain thick gelatinous material INSPECTION - can be found anywhere - 90% dorsum of hand or wrist Dorsumof ankle May be scar from recurrence Weakly transilluminable Palpation - soft, subcutaneous, may be tethered to tendon

Question 6

Ganglion DDx, Mx

Answer 6

DDx - bursae - cystic protrusion from synovial cavity or arthritic joint Non-surgical - aspiration followed by 3 weeks of immobilisation Surgical excision - recurrence can be 50% - neurovascular damage

Question 7

Seborrheic Keratosis

Answer 7

Benign hyperplasia of basal epithelial layer - hyperkeratosis: keratin layer thickening - acanthosis - prickle layer thickening Stuck on appearance dark brown greasy Non-surgical mx

Question 8

Neurofibroma

Answer 8

Benign nerve sheath tumour arising from schwann cells Inspection - solitary or multiple pedunculated nodules Palpation - fleshy consistency, pressure can > paraesthesia Remember - examine eyes, axilla, cranial nerves (esp CN8), BP Mx - surgical excision if malignant growth suspected Local regrowth common

Question 9

Neurofibromatosis 1 (Von Recklinghausen’s)

Answer 9

• AD, Chr 17 - Cafe-au-lait spots (>6) - Freckling - Neurofibromas - Lisch nodules (iris)

Question 10

Papilloma

Answer 10

Overgrowth of all layers of skin w a central vascular core Skin tag/fibroepithelial polyp Pedunculated, flesh coloured Mx - excision + diathermy to control bleeding

Question 11

Pyogenic Granuloma

Answer 11

Epidermal lined cyst deep to skin Congenital / Inclusion Cysts - Developmental inclusion of epidermis along lines of skin fusion - Midline of neck and nose - Medial and lateral ends of eyebrows Acquired / Implantation Cyst - Implantation of epidermis in dermis - Often 2ndary to trauma (e.g. piercing)

Question 12

Pyogenic Granuloma Inspection, palpation, Mx

Answer 12

Inspection Smooth spherical swelling Sites of embryological fusion Scar from recurrence Palpation Soft Non-tender Subcutaneous Mx Congenital - CT to establish extent - Surgical excision Acquired - Surgical excision

Question 13

Dermatofibroma

Answer 13

Benign neoplasm of dermal fibroblasts INSPECTION - can occur anywhere, mostly lower limbs of young to middle aged women - small brown pigmented nodule Palpation - firm, woody feel - characteristic intradermal, mobile over deep tissue Mx - excision + histology DDx - malignancy, melanoma, BCC

Question 14

Keratoma Acanthoma

Answer 14

Benign overgrowth of hair follicles Cytologically similar to well-differntiated SCCs Fast growing, dome shaped w keratin plug Intradermal Mx - regress w/i 6 weeks - excise to reduce scarring + obtain histology

Question 15

Malignant Melanoma Features RF

Answer 15

F>M Features

 Asymetry

 Boarder: irregular

 Colour: non-uniform

 Diameter >6mm

 Evolving / Elevation Risk Factors

 Sunlight: esp. intense exposure in early years.

 Fair skinned (low Fitzpatrick skin type)

 ↑ no. of common moles

 +ve FH

 ↑ age

 Immunosuppression

Question 16

Melanoma Classification

Answer 16

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 (w Hutchinson’s sign) Nodular Melanoma  All sites  Younger age, new lesion  Invade deeply and metastasis early = poor prog Amelanotic  Atypical appearance → delayed Dx

Question 17

Melanoma Staging + Prognosis

Answer 17

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: sc fat

Question 18

Melanoma Staging Mx, common mets sight

Answer 18

Mx 

Excision + 2O margin excision depending on Bres depth 

± lymphadenectomy 

± adjuvant chemo (may use isolated limb perfusion)

Question 19

Melanoma Mets, poor prognostic indicators

Answer 19

Mets - liver, eye

Poor Prognosis - male - ^mitosis - Satellite lesions (lymphatic spread)

Question 20

Squamous Cell Carcinoma

Answer 20

Ulcerated lesion w 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 Rx - excision + radiotherapy of affected nodes

Question 21

Actinic Keratoses

Answer 21

Irregular crusty warty lesions.  Pre-malignant (~1%/yr) Rx  Cautery  Cryo  5-FU  Imiquimod  Photodynamic phototherapy

Question 22

Bowen’s Disease

Answer 22

Red/brown scaly plaques typically on legs of older women SCC in situ Rx  Cautery  Cryo  5-FU  Imiquimod  Photodynamic phototherapy

Question 23

Basal Cell Carcinoma

Answer 23

Commonest ulcer Pearly nodule w rolled telangiectactic edge May ulcerate Typically on face in sun-exposed area - above line from tragus > angle of mouth  Low-grade malignancy → very rarely metastasise  Locally invasive Rx  Excision - Mohs: complete circumferential margin assessment using frozen section histology  Cryo/radio may be used.

Question 24

Neck Lumps Diagnosis

Answer 24

 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

Ix triple assessment - clinical assessment - imaging US - cyto/histo - aspiration/biopsy

Question 25

Anterior Triangle Neck Lumps

Answer 25

 Ant. margin of SCM  Midline  Ramus of the mandible  Roof: investing fascia  Floor: pre-vertebral fascia

Question 26

Anterior Triangle Neck Lumps Causes

Answer 26

Pulsatile

 Carotid artery aneurysm

 Tortuous carotid artery

 Carotid body tumour (chemodectoma) Non-pulsatile

 Branchial cysts

 Laryngocele

 Goitre

 Parotid tumour (lump in postero-superior area)

Question 27

Branchial Cyst

Answer 27

Embryological remnant 2nd branchial cleft Presentation  Age <20yrs  Ant. margin of SCM at junction of upper and middle 3rd  May become infected → abscess  May be assoc. c¯ branchial fistula Path - lined by squamous epithelium - contain glary fluid w cholesteral crystals

Question 28

Branchial Cysts Rx

Answer 28

Rx

Med  Abx for infection

 Sclerotherapy w OK-432 can be used

Surgical excision  Definitive Rx  May be difficult due to proximity of carotids

Question 29

Branchial Sinus or Fistula

Answer 29

 Small opening in lower 3rd of neck on ant. margin of SCM  Between tonsillar fossa and ant. border of SCM  May discharge mucus

Question 30

Carotid Body Tumour

Answer 30

Chemodectoma - Very rare - Carotid Bodies > located at carotid bifurcation > detect pO2, pCO2, H+ Present

 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

Question 31

Laryngocele

Answer 31

 Cystic dilatation of the laryngeal saccule  Congenital or acquired  Exacerbated by blowing

Question 32

Submandibular triangle

Answer 32

Mental process ramus of mandible line between two angles of mandible Causes of lumps  Salivary stone  Sialadenitis  Salivary tumour

Question 33

Posterior Triangle Neck lump

Answer 33

Post margin of SCM Ant Margin of trapezius Mid1/3 of clavicle Causes - LNs - Cervical Ribs - Pharyngeal pouch - Cystic hygromas - Pancoast’s tumour

Question 34

Cervical Ribs

Answer 34

Overdevelopment of transverse process of C7

Presentation  Mostly ASx

 Hard swelling

 ↓ radial pulse on abduction and external rotation of arm 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

Question 35

Pharyngeal Pouch - Zenker’s Diverticulum

Answer 35

Herniation of pharyngeal mucosa through its muscular coat at its weakest point.  Pulsion diverticulum Killian’s dehiscence - betw thyro and crico-pharyngeal muscles that form inferior constrictor

Question 36

Pharyngeal Pouch Presentation

Answer 36

 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

Question 37

Cystic Hygroma

Answer 37

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

Question 38

Midline Neck Lumps

Answer 38

<20yrs  Thyroglossal cyst  Dermoid cyst >20yrs  Thyroid isthmus mass  Ectopic thyroid tissue

Question 39

Dermoid Cyst

Answer 39

Developmental inclusion of epidermis along lines of skin fusion Presentation <20yrs Found at junctions of embryological fusion  Neck midline  Lateral angles of eyebrow  Under tongue Contains ectodermal elements  Hair follicles, sebaceous glands Rx - excision

Question 40

Thyroglossal cyst

Answer 40

Cyst formed from persistent thyroglossal duct  Path of thyroid descent from base of tongue Presentation Can be located anywhere between foramen caecum and the thyroid  Usually just inferior to the hyoid: subhyoid  Or, just above the hyoid: suprahyoid Fluctuant lump that moves up w tongue protrusion Can become infected → thyroglossal fistula Rx - Sistrunk’s Op - excision of cyst and thyroglossal duct

Question 41

Cervical Lymphadenopathy Features + examination

Answer 41

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

Question 42

Cervical LN+ Hx, Causes

Answer 42

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: LIST  Lymphoma and Leukaemia  Infection  Sarcoidosis  Tumours Infection >Bacterial  Tonsillitis, dental abscess  TB  Bartonella henselae (Cat scratch disease) >Viral  EBV  HIV > Protozoal  Toxoplasmosis

Question 43

Cervical LN+ Ix

Answer 43

Ix Blood  FBC, ESR, film (atypical lymphocytes)  TFTs, serum ACE  Monospot test, HIV test Radiological  US  CT scan Pathology  FNAC  Excision biopsy

Question 44

Hypertrophic + Keloid Scars

Answer 44

Scar more prominent than surrounding skin Wound Associations  Infection  Trauma  Burns  Tension  Certain body areas

Question 45

Hypertrophic Scar

Answer 45

 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

Question 46

Keloid Scars

Answer 46

 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

Question 47

Salivary Gland Enlargement Hx + Caues

Answer 47

History  Swelling/pain related to food: calculi  Malaise, fever, mumps  Dry eyes/mouth: Sjogrens (Sicca, Mickulicz) Causes Whole Gland  Parotitis  Sjogren’s / Sicca Syndrome  Sarcoid  Amyloid  ALL  Chronic liver disease  Anorexia or bulimia Localised > Tumours > Stones

Question 48

Acute Parotitis

Answer 48

Viral - Mumps, coxsackie A, HIV Bacterial - S aureus

Question 49

Calculi

Answer 49

Recurrent unilateral Swelling + pain worse on eating Red, tender, swollen gland (80% submandibular) Ix - plain XR or sialography Rx - gland excision

Question 50

Salivary gland neoplasms

Answer 50

80% in parotid 80% are pleomorphic adenomas Deflection of ear outwards - classic sign CNVII palsy - malignancy Classification Benign  1st: Pleiomorphic adenoma  2nd: Adenolymphoma (Warthin’s) Malignant (CN7 palsy + fast growing)  1st: Mucoepidermoid  2nd: Adenoid cystic Ix  ENT examination  US ± CT  FNAC

Question 51

Pleomorphic adenoma

Answer 51

commonest salivary gland neoplasm Presents - 90% occur in parotid > middle age F>M - benign slow growing Histo - different tissue types (pleomorphic) Rx - superficial parotidectomy

Question 52

Adenolymphoma (Warthin’s Tumour)

Answer 52

Benign soft cystic parotid tumour Older men Rx - enucleation

Question 53

Adenoid-cystic carcinoma

Answer 53

 One of the commonest malignant salivary tumours  Highly malignant and often incurable  Rapid growth  Hard fixed mass  Pain  Facial palsy

Question 54

Surgery Salivary gland swellings

Answer 54

 Superficial or radical parotidectomy  Facia lata face lift for facial palsy Complications -facial nerve palsy - salivary fistula frey’s syndrome

Question 55

Frey’s Syndrome

Answer 55

Gustatory sweating  Redness and sweating skin over parotid area  Occurs in relation to food (inc. thinking)  Auriculotemporal branch of CN V3 carries sympathetic fibres to sweat glands over parotid area and parasympathetic fibres to the parotid  Reinervation of divided sympathetic nerves by fibres from the secretomotor branch of auriculotemporal branch of CN V3