Superficial swellings By Dr Khaled Ahmad, MD, FACS, FASMBS

Objectives At the end of this presentation students will be able to : Name the common causes of superficial swellings Describe clinical presentation, treatment, examination, management of most common superficial swellings

Superficial swellings Swelling denotes enlargement or protuberance in any part of the body Can be called ‘’mass’’ or ‘’lump’’

History Duration Mode of onset & progress (trauma or spontaneous; rate of progression) Pain Fever Other lumps or swellings Other features (movements, secondary changes loss of weight or appetite)

Inspection of a superficial swelling Site Size Shape Surface (smooth : epidermoid cyst, lobular or irregular) Skin (tense, glossy with prominent veins) Surrounding area (changes, pigmentation/edema, wasting, discoloration) Others (number, colour, edges, extent, movements)

Superficial swellings : Most common causes Swellings or lumps which are superficial to the underlying muscle and fascia are commonly caused by: Sebaceous cysts (epidermoid cysts) Lipoma Neurofibroma Carbuncle

1- Sebaceous cysts Also called Epidermoid cysts Most common cutaneous cysts Can occur anywhere on the body and typically present as a skin-colored dermal nodules, often with a clinically visible central punctum. Epidermoid cysts unusual in number and location (on extremities rather then face, base of ears and trunk) may be seen in the setting of Gardner syndrome, a rare inherited condition characterized by familial adenomatous polyposis of the colon associated with a number of extracolonic abnormalities.

1- Epidermoid cyst : skin-colored subcutaneous nodule Central punctum corresponding to the follicular opening

1- Epidermoid cyst : Diagnosis Diagnosis usually clinical, based upon the clinical appearance of a discrete nodule or cyst, often with a central punctum freely movable on palpation. Cyst wall consists of squamous epithelium similar to skin surface. Cavity filled with laminated layers of keratinous material.

1- Epidermoid cysts: Differential diagnosis 1- Pilar cysts 2- Lipoma 5- Abscess 3- Pilomatricoma 4- Ganglion cyst

1- Epidermoid cyst : examination https://www.youtube.com/watch?v=R0_EGlmNuuo

1- Epidermoid cyst :Treatment Inflamed uninfected epidermoid cysts may resolve spontaneously without therapy, although they tend to recur. Treatment not necessary unless desired by patient. Injection of Kenalog® into the inflamed lesion can hasten the resolution of inflammation in uninfected epidermoid cysts.

2- Lipoma Superficial subcutaneous lipomas are the most common benign soft-tissue neoplasms. Consist of mature fat cells enclosed by thin fibrous capsules Can occur on any part of the body Develop superficially in the subcutaneous tissue Rarely, they may involve fascia or deeper muscular planes

2- Lipoma : presentaiton Soft, painless subcutaneous nodules ranging in size from 1 to > 10 cm Occur on the trunk and upper extremities and can be round, oval or multi-lobulated Patients may have more than one lipoma, occasionally patients can have genetic condition : development of multiple lipomas in several family members Malignant transformation of a lipoma into a liposarcoma is rare

2- Lipoma : Diagnosis Made clinically If suspected lipoma causes symptoms (pain or restriction of movement), if it is rapidly enlarging , or is firm, then a biopsy is indicated

2- Lipoma : examination https://www.youtube.com/watch?v=KJ1j4ylfOKM

2- Lipoma : Treatment Treatment indicated if pain or for cosmetic purposes or concerns over diagnosis Surgical removal of the fat cells and fibrous capsule Recurrence of an excised lipoma is not common Side effects of surgery includes : scarring, seroma, and hematoma formation. Surgical technique with segmental extraction and minimal surface incision may limit the scar size.

3- Neurofibroma Cutaneous neurofibromas are benign nerve tumors composed of cells of neuromesenchymal origin. Cutaneous neurofibromas occur as sporadic, solitary lesions in healthy adults. Asymptomatic, soft, flesh-colored or hyperpigmented papules or nodules that are <2 cm in diameter. Multiple cutaneous neurofibromas and their variants (plexiform, dermal) may occur in the setting of neurofibromatosis.

3- Cutaneous neurofibroma Soft, flesh-colored papules or nodules. Applying direct pressure to some neurofibromas may make them seem to retract into the skin, a finding that has been described as the ‘’button-hole’’ sign.

3- Neurofibroma : Differential diagnosis Melanocytic Nevi (intradermal nevus) Acrochorda

3- Neurofibroma : treatment Treatment is not necessary for solitary cutaneous neurofibromas. Surgical excision can be used to remove lesions when the diagnosis is in question or when removal is desired due to discomfort or cosmetic concerns.

4- Carbuncle Coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles Series of abscesses in the subcutaneous tissue that drain via hair follicles.