EXAMINATION OF A SURFACE SWELLING

INTRODUCTION
 A lump can be present in any part of the body. It may be:
 External—Visible to exterior.
 Internal—May or may not be visible. Detected due to its effects on the organ of
origin.
COMPLAINT AND DURATION
Complains of swelling in front of the right thigh— 2 years
o Pain in the swelling—1 month
HISTORY OF PRESENT COMPLAINT :
(NOTE THE FOLLOWING)
1. How it started?
o Spontaneously
o Following trauma
o If there is any pre-existing lesion like :
i. Keloid or
ii. Pigmented mole—Melanoma
2. Where it started?
o Exact site of beginning in case of very large swelling
3. Duration
o Short duration
i. Inflammatory (days to weeks only) not more than 1 or 2 months
ii. Traumatic (hours to days only) not more than 72 hours
o Long duration
i. Neoplastic
a. Benign years (More than 1 year)
b. Malignant (3-6 months)
o Since birth
i. Congenital
Some congenital swellings may present after some years, as time is
required for accumulation of secretions in the cyst. Eg.Dermoid cyst,
Branchial cyst, Thyroglossal cyst
4. Mode of progress of the swelling.
o Slowly growing—Benign swellings
 o Rapidly growing - Malignancy
o Recent history of rapidity of growth – Benign tumour turn into malignancy
o Sudden increases in size of the swelling – Haemorrhage into the swelling.
(Rapidly growing, short duration—Malignant tumour)
(Slowly growing and longer duration – Benign tumour)
o Regression in the size of the swelling
o Inflammatory (In the early stages of inflammation a swelling occurs in a wide area.
But once inflammation subsides the swelling is reduced to a small localized area –
abscess formation
(Patient noticed a small swelling of Pea-nut size in front of the left thigh which is
growing very slowly and attain the present size. No history of trauma. No history
of recent rapidity of growth. No history of decrease in the size of the swelling)
Associated symptoms
o Pain – Enquire about whether pain is continuous or intermittent
Character of pain – Throbbing type of pain – inflammation
Burning type of pain – Nerve irritation
Pins and needles type of pain – Peripheral neuritis
Colic type of pain - Exaggerated peristaltic activity of a
tubular structure like intestine, ureter, CBD, Fallopian tube.
Squeezing type of pain (Compressing) – Irritation of spinal
nerves.
Radiation of pain–
o Aggravating factors
o Relieving factors
(Patient noticed pain since 1 month which is intermittent, throbbing in nature,
pain is aggravated on walking and relieved on rest. No radiation)
(Pain First, swelling later - Inflammatory)
(Swelling First, Pain later – may be due to
- Haemorrhage
- Malignancy
- Pressure effects
- Secondary infection
5. Any history loss of appetite and weight
6. Any history of fever
 7. Enquire about bowels and micturation
Bowels – Constipation or diarrhea
Micturation – Burning pain, frequency, hesitancy, normal stream or thin stream
(No history of loss of appetite or weight. No history of fever. Bows and micturation
are normal)
Past history
Any history of hospitalization either medically or surgically must be enquired and
mentioned.
Any treatment underwent for chronic illness like tuberculous or leprosy
(Patient had not suffered with any medical or surgical illness which require medical
attention)
Personal history
o Patient married or unmarried, living with family or not, number of children, male
and female, age of last child, if wife or husband died how many years back and what
is the cause of death.
o Patient is habituated to smoking or not
o Addicted to alcohol or not
o If smoker, how many cigars, chuttas per day since how many years.
o If alcoholic, enquire how frequently and quantity of alcohol - used to take
o Whether patients is known diabetic or hypertensive.
o Whether he is suffering with any chronic illness like tuberculous or leprosy.
(Patient is married living with wife & two children. All are healthy. Patient is
habituated to smoking 2 cigars per day since 10 years. Patient is used to drink
alcohol about 120 ml. twice a week. Patient is not known diabetic or hypertensive
and is not suffering with any chronic illness)
Family history
o Any member of the family suffered with similar complaint.
o Any member of the family are known diabetic or hypertensive.
o Any member suffered with chronic illness like TB or leprosy.
(All members of the family are healthy. No history of diabetes, hypertension or
any chronic illness in the family)
Drug history
o Patient is not allergic to any known drugs.
 PHYSICAL EXAMINATION
- Patient moderately built and moderately nourished
- Not anaemic, No jaundice,
- Oral cavity – Mucous membrane is pink and moist.
- Tongue – Moist, pink and healthy, all teeth are present, gums are healthy
- No generalized lymphadenopathy
- No pedal edema.
Pulse –
75/min, regular in rhythem, volume and tension - normal
Vessel wall is not thickened (below 40 years)
Vessel wall is thickened (above 40 years)
Blood Pressure – 120/80mm of Hg (below 40 years)
130/90mm of Hg (above 40 years)
Temperature – 98.40 F
Respiratory rate - 18/min. regular (Thoraco abdominal – female)
(Abdomino thoracic – male)
 SYSTEMATIC EXAMINATION
Cardio Vascular System – Apex beat is palpable at 5th intercostals space on left side at
midclavicular line.
1st and 2nd heart sounds are heard normally. No murmurs are heard.
JVP – Normal. No pedal edema.
Respiratory System - Chest is moving equally with respiration on both sides.
On oscultation bilateral vesicular breath sounds are heard. No
rhyonchi or crepitations.
Central Nervous System - Patient conscious, coherent, answering questions
Pupils are normal in size and normally reacting to light.
There is no neurological deficit.
Gait normal.
Gastrointestinal System - Abdomen is scapoid in shape, moving equally with respiration, soft
on palpation, no free fluid, no mass palpable. No
hepatospleenomegaly. Intestinal sounds are normal
 LOCAL EXAMINATION OF SWELLING
Inspection -
1. Number - Single
2. Shape - Hemioval
3. Size – Horizontally 10 cms, vertically 6 cms
4. Site – Front of the left thigh
5. Extent – Extending 10 cms below the inguinal ligament and 6 cms above the knee joint.
6. Surface – Uneven (Lobulated)
7. Skin over the swelling - Healthy
8. Colour of the swelling - Normal
9. Borders – Well defined, round and regular
10. Surround area - Healthy
11. Visible pulsations – No visible pulsations
Summary of Inspection :
There is a single any oval swelling measuring 10 cms horizontally, 6 cms vertically present
on the front of left thigh extending 10 cms below the inguinal ligament 6cms above the knee joint.
Surface is uneven, borders are well defined, skin over the swelling is healthy, colour of the
swelling is normal, surrounding area is normal, no visible pulsations.
12. Visible cough impulse (can be noted in case of swellings present over the head and neck
chest and abdomen only)
(Six ‘S’ in examination of the swelling are
1. Site
2. Shape
3. Size
4. Surface
5. Surrounding area
6. Skin over the swelling.)
Palpation
1. Local raise temperature – No local raise of temperature
2. Tenderness – Not tender
(Tenderness means - Pain on touch) (Pain is symptom whereas tenderness is
a sign).
3. Site – Front of left thigh
4. Shape - Oval
 5. Size – Horizontal 10 cms, vertically 6 cms.
6. Extent – Extending 10 cms below the inguinal ligament & 8 cms above the knee joint.
7. Surface - Lobulated
8. Borders – Well defined, round and regular
Slip sign is positive
9. Surrounding area – Healthy, no other swelling is palpable in the surround area.
10. Consistency –Soft in consistency. Fluctuation is negative.
(Soft or firm or hard, stoney hard)
(If soft in consistency, verify whether the contents are semisolid material
(Sebaceous cyst or Dermoid cyst) or liquid by doing fluctuation test.
If the fluctuation test is positive indicates, the swelling contain fluid.
To know the nature of fluid i.e., clear fluid (serous fluid or lymph) or
turbid fluid (pus, blood, chyle) transillumination test is performed (when light rays
from pen torch is passed through the swelling, if the swelling contain clear fluid, the
swelling appears as red glow – Transillumination test is positive.
If the swelling contain turbid fluid, there is no red glow – Transillumination Test is
negative
11. Mobility – Swelling is mobile freely in both vertical and horizontal directions.
(Mobility of the swelling is tested in both horizontal and vertical directions.
Swellings arising from linear structures like tendon, nerve, blood vessel move at right
angles to that structure only but not along the course of the structure).
12 (Expansile pulsations) –
If visible pulsations are present on inspection, confirm whether they are expansile or
transmitted pulsations.
Expansile pulsations – swelling will enlarge in all directions, present in case of swellings
arising from the artery (dilatation of the artery known as aneurysm)
In this case when blood is pumped into the vascular swelling during systole the whole
swelling enlarges as the volume of contents (blood) increased uniformly.
This is confirmed by keeping two fingers over the swelling. If it is expansile pulsations,
the fingers will be elevated and separated.
Further confirmed by two tests (A) Distal occlusion test (B) Proximal occlusion test.
(A) Distal occlusion test – The artery distal to the swelling is compressed by finger, so that,
blood is not leaving the swelling. The swelling increase in size with more prominent
pulsations.
(B) Proximal occlusion test – The artery proximal to the swelling is occluded by finger, so that
blood is not allowed to enter the swelling. The swelling becomes decrease in size and
pulsations are absent.
13. Expensile cough impulse (When the swelling have communication with the body cavities like
cranial cavity, thoracic cavity and abdominal cavity, whenever pressure is increased in the cavity,
the same pressure is transmitted to the swelling leading to expansion of swelling in all directions.
This is confirmed by holding the swelling with fingers and ask the patient to cough, so that to
raise pressure in the body cavity. If this swelling has communication with the cavity, the size of
the swelling increases in all directions, indicated by elevation and separation of fingers. Eg.
Meningocele, encephalocele, hernia.
14. Plain of the swelling -
Skin is pinchble. On contraction of underlying muscle the swelling becomes more prominent
with well defined borders and mobility is not restricted.
On palpation - No local raise of temperature and not tender.
Summary of palpation, percussion and auscultation -
(A single oval swelling present in front of the left thigh measuring horizontally 10 cms
vertically 8 cms, extending 10 cms below the inguinal ligament and 8 cms above the knee joint.
Surface is lobulated bordersare well defined, round and regular. Slip sign positive. Consistency
is soft. No fluctuation present.
Skin is pinchble, all over the swelling and on contraction of the underlying muscle, a swelling
becomes more prominent with well defined borders and mobility is not restricted. Dull on
percussion and auscultation no bruit is heard).
(Anatomical part from which the swelling arises) Eg. Skin or subcutaneous tissue or muscle or
nerve or tendon or artery or vein or bone.
(A) Swellings arising from the skin – Skin is not pinchble from the swelling and the swelling
moves along with the skin.
(B) Swellings arising from the subcutaneous tissue – Skin is pinchble
On contraction of the underlying muscle, the swelling becomes more prominent and mobility is
not restricted.
(C) Swelling arising from the upper part of the muscle – Skin is pinchble
On contraction of the underlying muscle, the swelling becomes more prominent and mobility is
restricted.
(D) Swelling arising from the middle of the muscle – Skin is pinchble
 On contraction of the underlying muscle, the swelling becomes less prominent and mobility
is restricted.
(E) Swelling arising from the posterior part of the muscle - Skin is pinchble
On contraction of the underlying muscle, the swelling disappears and mobility is restricted.
(F) Swelling arising below the muscles (intermuscular) – Skin is pinchble
On contraction of the underlying muscle, the swelling disappears and mobility is not
restricted.
(G) Swellings arising from the bone – Skin is pinchble but no mobility (it move along with the
bone).
Purcussion – Dull on percussion
(Solid and fluid filled swellings are dull on percussion.
Air filled swellings like hernia which contain air filled intestine, resonant on percussion).
Auscultation – No bruit is heard
(Bruit is heard in vascular malformations and A-V fistula (Continuous sound on auscultation)
 REGIONAL EXAMINATION
o Examine regional lymph nodes
o Examine peripheral pulsations
o Peripheral neurological examination
o Function of joints above and below
o Examination of spine and other corresponding systems
THERE IS NO REGIONAL LYMPHADENOPATHY. ALL PERIPHERAL PULSATIONS ARE
FELT NORMALLY.
THERE IS NO NEUROLOCAL DEFICIT.
FUNCTIONS OF JOINT BELOW AND ABOVE THE SWELLING ARE NORMAL.)
Summary (Salient clinical findings regarding the swelling which conclude the diagnosis)
Swelling in front of the thigh present since 2 years, slowly growing. Since 1 month intermittent
pain present during walking.
Swelling is in oval in shape with lobulated surface, well defined round and regular borders, slip
sign positive, consistency soft, no fluctuation – Lipoma.
Skin over the swelling is pinchble and on contraction of the underlying muscles, the swelling
becomes more prominent with well defined borders and mobility is not restricted – Plain of the
swelling is subcutaneous.
Provisional diagnosis – Subcutaneous lipoma over the front of left thigh
(Include anatomical and pathological diagnosis. Anatomical diagnosis includes plane of the swelling
and site of body part).
Eg. Subcutaneous lipoma over the front of left thigh.
Subcutaneous (anatomical) front of the left thigh (site of body part) lipoma (pathological)
Differential diagnosis (Mention the other possible swellings)
Fibroma, lymphangioma, haemengioma, dermitofibroma, sebaceous cyst
Investigations
a) For confirmation of diagnosis - FNAC
b) For surgery and anaesthetic purpose – Hb,TC, DC,
Blood sugar & Blood urea
Serum creatitine
X-ray chest & ECG if patient is above 40 years.
Treatment - Under local anaesthesia, the swelling is excised through a linear incision along
Langerhan’s lines. The incision is deepened through skin and subcutaneous tissue and false
capsule. Then with the help of index finger or artery forceps, the swelling is separated from the
false capsule cutting all the fibrous bands that pass from the swelling through the surrounding
area. The swelling is completely excised and removed. Haemostasis secured using diathermic
cautery or ligation of blood vessels using 2.0 plain catget. Then wound is closed without dead
space using 2.0 plain catget. Skin is closed with non-absorbable material (Nylon). If the swelling is
very large to avoid collection of fluid and later prevention of abscess formation a corrugated drain
is kept in the wound.
(This swelling is small and no complications reassure the patient for observation.
If the swelling is large and producing symptoms surgical excision is performed).
Explanation
- Shape – May be
 Round
 Oval
 Irregular
 Piriform
- Surface – May be
 Smooth
 Uneven
 Lobulated
 Nodular
- Skin over the swelling may be
 Normal or
 Features of inflammation (erythmatous, edematous)
 Pigmentation
- Hypopigmentation
- Hyperpigmentation
 Presence of any “Punctum”. (Bluish spot indicates occluded mouth of the
sebaceous gland)
 Scar - whether it is liener with suture marks (Previous surgery) or puckered
scar (previous abscess formation, ruptured and healed with irregular scar)
 Any dilated veins.
- Surrounding area – Look for
 Features of inflammation
 Prominent veins
 Wasting
  Oedema
 Any other swellings
 Any dilated veins
 Any scars
Palpation
- Local rise of temperature
Tested with dorsal aspect of fingers —most sensitive area to appreciate temperature variation
Comparison Chart
Hard - Feel like bone or metal object
Firm - Feel like contracted muscle or tip of nose
Soft - Cheek, lip; relaxed muscle; cotton wool
Cystic - Balloon filled with water
Edge or border
 Smooth and rounded—Cyst or benign swellings like lipoma
 Sharp and irregular - Malignancy
 Slipping—under the finger—Lipoma
Slip sign —The edge slips beneath the examining finger when try to define the border
It is not slippery edge—finger slips over the edge only.
Mobility
 Freely mobile
 Restricted mobility
 Fixed (not mobile)
Sign of Compressibility
 When pressure is applied over the swelling, it reduces in size but not disappear.
Eg. Vascular tumours like haemengioma, lymphangioma which contain fluid and vascular
tissue, when pressure is applied, the fluid is displaced leaving solid vascular tissue which
appears smaller than the original size of the swelling. (For reappearance of the original
size of the swelling, opposite force is not required, as the fluid will fill the swelling slowly
from the communicating vessels either veins or lymphatics).
Sign of reducibility – If the swelling have communication with the body cavity as in hernia or
meningocele, when pressure is applied over the swelling, all the contents of the swelling are
displaced into the body cavity with complete disappearance of the swelling. (For reappearance of
the swelling, opposite force is required in the form of coughing (to raise the intra cavity pressure).
Local bruit on auscultation – When a vascular tumour with an arterial communication is present, a
continuous sound is hard on auscultation.
 POSSIBLE COURSE OF DISCUSSION
1. What is your anatomical diagnosis?
A soft swellings in the middle of anterior part of the thigh.
2. What is the plane of swelling?
a) Subcutaneous tissue

3. What are the reasons to say?

a) Skin is pinchable
b) Swelling is freely mobile
c) On contraction of muscle, the swelling becomes more prominent and mobility is not
restricted.
 PLANE OF THE SWELLING
1. What are the features of cutaneous (skin) swelling?
a) Skin is not pinchable.
b) Freely mobile in all directions along with the skin
c) On contraction of the underlying muscle, the swelling becomes more prominent and
mobility is not restricted.
2. What are the features of subcutaneous swelling?
1) Skin is pinchable
2) Freely mobile in all directions
3) On contraction of the underlying muscle, the swelling become more prominent and
movement is not restricted with well defined borders.
3. What are the features of a swelling arising from or attached to deep fascia or anterior sheath of
muscle?
a) Skin is pinchable
b) Mobile in all directions, more of side to side than in vertical direction
c) On contraction of the underlying muscle:
 Swelling becomes more prominent with restricted mobility.
 Borders are well defined
4. What are the features of a swelling arising from the muscle?
a) Skin is pinchable
b) Mobile in all directions, more of side to side mobility than in vertical direction
c) When muscle is contracted:
 Swelling becomes less prominent
 Borders become diffuse
 Movements become restricted
5. What are the features of a swelling arising from posterior surface of muscle or posterior fascia of
the muscle?
a) Skin is pinchable
b) Mobile in all directions.
c) When muscle is contracted:
 Swelling disappears with diffuse borders and mobility is restricted
6. What are the features of a swelling arising from the bone or periosteum?
a) Skin is pinchable
b) No movement – Fixed swelling
 c) Moves along with the bone when the bone is moved
d) When muscle is contracted, the swelling disappears
7. What are the features of a swelling arising from a linear structure like, tendon, nerve, vessel etc.?
a) Swelling is mobile side-to-side only at right angles to the structure from which it arises , but
not vertically
b) If it arises from artery, pulsations are present
8. What are the features of a swelling fixed to the skin due to infiltration from below?
a) Skin is not pinchable
b) Local puckering of the skin
c) Oedema of the skin with Orange peel appearance (Peud-O’orange)
9. What is slipping edge or slip test?
a) When the edge of a swelling is palpated if it slips beneath the finger it is called as a slipping
edge or a positive slip sign.
b) It is commonly seen with lipoma.
c) One should not say “edge is slippery,” which gives a different meaning.
10. What type pulsations are seen or felt in a swelling?
It can be :
a) Transmitted
b) Expansible
11. What are transmitted pulsations?
a) If the swellings is situated in front of a pulsating artery, the pulsations can be transmitted to
the swelling and the swelling appears pulsatile and is known as transmitted pulsations.
b) Disappears when the swelling falls away from the artery, by changing the position of body
part.
c) When two fingers are placed over the swelling, the fingers are elevated but separated
Transmitted impulse.
12. What are expansible pulsations?
a) Swelling arises from the artery (aneurysm) due to dilatation artery, the entire artery is
pulsating and the pulsations spread in all directions.
b) When two fingers are placed over the swelling they are elevated and separated as the
whole swelling enlarges with filling of blood - Expansible impulse.
13. What is a thrill and a bruit?
a) When a swelling has increased vascularity, the flow of blood may give a feeling of thrill on
palpation.
 b) The same when it is heard on auscultation, it is known as bruit.
c) Sometimes, if fluid is present in a swelling, tapping over it may produce a thrill and is called
as “fluid thrill” and is appreciated by palpation.
14. What is your pathological diagnosis?
a) Question yourself: Is it ‘Congenital’ or ‘Acquired’?
If it is an acquired swelling, is it:
o Traumatic or
o Inflammatory or
o Neoplastic or
o Degenerative
b) If by the presentation and examination, the swelling appears to be neoplastic. It could be a:
o Benign swelling – Eg.
- Lipoma
- Neurofibroma
- Haemangioma
- Dermoid cyst, sebaceous cyst - etc.,
o Malignant swelling
- Epithelioma (squamous cell carcinoma)
- Malignant melanoma
- Basal cell carcinoma (Rodent ulcer)
- Soft tissue sarcoma
15. How the swellings are differentiated depending on the nature of behavior and outcome?
They are grouped into two types:
a) Benign
b) Malignant
16. What are the features of benign swelling?
a. Slow growing
b. Does not produce any ill effects on the host
c. It produces pressure symptoms, if it is large
d. Long duration
e. No loss of weight
f. No local infiltration (freely mobile)
g. No enlargement of regional glands (Secondaries)
h. No distant secondaries may present
 i. No recurrence following surgery
j. Good postoperative survival
17. What are the features of malignant swelling?
a. Rapidly growing
b. Ill effects on the host
c. Short duration
d. Loss of weight
e. Local infiltration give rise to fixidity (no mobility)
f. Regional lymph nodes are involved by secondaries
g. Distant secondaries
h. May recur following surgery
i. Bad prognosis
18. What are the clinical features of a cystic swelling?
a) Smooth surface + Rounded regular and well defined borders = cyst
b) Presentation as
o Asymptomatic or
o Symptomatic -
- Due to pressure
- Due to growth
- Due to complications
c) Examination
o Smooth surface + Rounded borders
o Soft in consistency
o Fluctuation (+)
- Transillumination (+/-), depending on cyst wall and Nature of content
- Cyst call was thickened or calcified transillumination is negative even though it
contain clear fluid
- Transillumination is positive if the swelling contains clear fluid like water (exudates
as in hydrocele or lymph cyst)
- Transillumiantion is negative if it contain turbid fluid like pus, blood and chyle.
19. What is fluctuation?
a) It is a clinical test to demonstrate the presence of fluid in a swelling.
b) It is demonstrated by fixed the swelling with thumb and middle, ring and little fingers of the
both hands.
 The index fingers are placed over the swelling with a gap of more than one inch. One finger
is pressed over the swelling, the other fingers is elevated indicating fluid is shifted from one
pole to other pole.
c) This displacement is demonstrated in both directions.
20. How will you investigate the case?
a) To confirm the diagnosis
o FNAC or
o BIOPSY depending on the condition
b) Ancillary
Radiology of the part
o CT Scan
o MRI Scan
o Chest x-ray
c) Lab Studies
o CBP
o Blood Sugar
d) Tumour markers
21. What are the modalities of treatment?
a) Benign
o Enucleation
o Excision
a) Malignant
o Wide excision or Radical excision followed by
o Chemotherapy
o Radio therapy
o Hormone therapy
 LIPOMA (Case Sheet)
Complaint and duration - Swelling over the back of the right side of chest – 3 years
duration.
Pain – 1 month
History of present complaint - 3 Years back patient noticed a lemon sized (3 cm diameter)
swelling on the back of the right side of chest which is slowly growing and attain the present size.
There is no H/o trauma,
No h/o decrease in size of the swelling
No h/o recent rapidity of growth
No h/o sudden increase in the size of the swelling
Since 1 month, patient is having mild, dull aching, pain in the swelling which is
intermittent, more on exercise. Pain is relieved on rest, pain aggregates on lying over the
swelling. No history of radiation. Pain localized to the swelling only.
No history of fever
No history of loss of weight or appetite
Bowels and mixturation normal
Past history :
Personal history :
Family history :
Drug History :
Physical examination :
Systematic examination :
Cardiovascular system
Respiratory system
Central Nervous System
Gastrointestinal system

Local Examination
Inspection – A single horizontally placed hemi-oval shaped swelling, measuring horizontally 12cm,
vertically 8 cm, present over the back of right chest over scapular region, extending 3 cm, lateral to
midline (vertebral column) 4 cm below the spine of the scapula.
Surface is lobulated, borders are well defined, skin over swelling is healthy, colour of the skin is
normal, surrounding area is healthy.
No visible pulsations
No visible cough impulse (Seen in case of swelling present over the head, neck, chest and abdomen
only)
Palpation – There is no local raise of temperature.
Mild tenderness present
Inspectory findings like Number, shape, size, site and extent are confirmed.
Surface is lobulated
Borders are well defined, round and regular.
Slip sign positive.
Consistency is soft, fluctuation negative.
Swelling is freely mobile in both vertical and horizontal direction.
Plane of the swelling : Skin is pinchable
On contraction of underlying muscles, the swelling becomes more prominent with well defined
borders and mobility is not restricted.
Summary : History – Long duration, slowly growing tumour.
On examination – Surface lobulated with well defined round and regular borders,
consistency is soft. Fluctuation absent. Slip sign positive.
Skin is pinchable.
On contraction of the underlying muscles, swelling become more prominent and mobility is not
restricted (subcutaneous plane)
Regional examination –
No regional lymphadenopathy
No dilated veins
All peripheral pulsations are present
Provisional Diagnosis : Subcutaneous lipoma over the back of right side of chest (Scapular region).
Differential Diagnosis :
Fibroma
Sebaceous cyst
Lymphangioma
Haemengioma.
Investigations : For confirmation of diagnosis – FNAC
Treatment: Excision or Enucleation
Anaesthesia : Local/General depending upon the size and site of the tumour.
Incision given along the Langerhan’s lines
The incision is deepened through skin, subcutaneous tissue and false capsule.
With the help of index finger or curved haemostat, the tumour is separated from the false capsule
cutting all the fibrous bands that pass between the tumour and surrounding tissue.
The tumour is excised from the surrounding tissue and removed.
Haemostasis secured by cauterizing or ligation of bleeding vessels with plain catget.
The cavity is obliterated without dead space by suturing with 2.0 plain catgut (Vicryl rapid)
If the swelling is very large a corrugated drain is kept to prevent seroma formation which later will
develop into an abscess.

FNAC – shows large oval shaped clear cells with excentric nucleus.
Straining for lipoma (Fat globules) is with Sudan blue.
Excision is removal of the tumour along its capsule and surround normal tissue.
Enuclearion is removal of tumour along its true capsule from the false capsule.
 LIPOMA
• A lipoma is the commonest benign tumour.
• It is arises from adult fat cell.
• It can occur anywhere in the body, that is why it is often called ‘universl tumour’ or
‘ubiquitous tumour’.
• But the common sites are the subcutaneous tissue of (i) the trunk (ii) the nape of the neck
(iii) the limbs.
• Lipoma never occurs in brain tissue as there is no fat in the drain but it can occur in the
meninges.
Clinical classificationof lipoma :
Three varieties – (1) Encapsulated lipoma (2) Diffuse lipoma (3) Multiple lipomas.
(1) Encapsulated lipoma is the commonest benign tumour.
(2) Diffuse lipoma – This is a rare variety and does not possess capsule and typical features of lipoma,
hence it is often called ‘pseudolipoma’.
It is seen in the subcutaneous and intermuscular tissues of nape of the neck, back of chest,
retroperitoneum and gluteal region.
It is not a typical tumour but an overgrowth of the fat in this region.
It does not possess the capsule which is typical of a lipoma.
It gives rise to a disfigurating swelling on the neck.
It is often found in persons taking excessive alcohol.
Treatment is excision of the excess of fat if it is required by the patient due to cosmetic reason.
3. Multiple lipomas –
It is often called lipomatosis.
The tumours remain small or moderate in size (1-5 cms) and the sometimes painful as these
often contain nerve tissue.
These are mostly seen in the limbs and in the trunk.
Lipoma of different sizes and shapes may be seen.
Macroscopically and microscopically these are not different from solitary lipoma.
Multiple painful lipometa over the trunk is known as Dercum’s disease (adiposis dolorosa).
PATHOLOGICAL CLASSIFICATION :
(i) Pure lipoma – contains fat tissue only.
(ii) Fibrolipoma – A combinationof fat and fibrous tissue.
(iii) Naevolipoma – when a lipoma contains blood vessels with telangiectasis of the overlying
skin.
(iii) Neurolipoma – when a lipoma contains nerve tissue.
It is often painful.
 ANATOMICAL CLASSIFICATION
Clinically a lipoma can occur in different anatomical situations.
According to this a lipoma can be classified into –
(i) Subcutaneous type – This is the commonest variety.
a. Although any part of the body can be affected, yet it shows particular tendency to occur
in the back, nape of the neck and on the shoulders.
Subcutaneous lipoma is usually sessile, but occasionally may become pedunculated.
(ii) Subfascial lipoma – Lipoma may occur under the palmar or plantar fascia and is often mistaken
as tuberculous tenosynovitis.
Lipomas may also occur in the areolar layer under the epicranial aponeurosis in the scalp.
Such Subfascial lipoma can be confused with a dermoid cyst, but there is no underlying bony
indentation. (In dermoid cyst bony indentation is present)
(iii) Intramuscular lipoma – Lipoma present within the muscle.
It gives rise to mechanical interference with the action of the muscles.
(iv) Intermuscular lipoma – Presents within a group of muscles.
Commonly seen in the thigh or around the shoulder.
(v) Subserous lipoma – Found beneath the pleura or peritoneum or beneath the serosa of the
intestine.
(vi) Retroperitoneal lipoma - often misdiagnosed as hydronephrosis, pancreatic cyst or
teratomatous cyst.
A retroperitoneal lipoma may attain a big size and malignant transformation (Lipoma sarcoma) is
common.
This is a condensation of extraperitoneal fat rather than a typical lipoma (Diffuse lipoma)

(vii) Submucous lipoma -

It may occur below the mucous membrane of respiratory or elementary tract.
It is also seen in the tongue.
In the respiratory tract it may cause respiratory obstruction.
(viii) Intra-articular - in side the joint
(ix) Subsynovial lipoma – Such lipoma occurs under the synovial membrane of a joint or tendon
sheath.
If it is seen in the knee joint can be differentiated from Bakers cyst or a bursitis.
(x) Parosteal lipoma – Occurs under the periosteum of a bone
(xi) Extradual lipoma – Occurs from the dural layers of spinal cord or brain.
 Spinal cord lipomas may be dumbel shaped with intraspinal and extraspinal masses with
communication through vertebral foramina.
Lipoma does not occur within the brain tissue because of absence of fat in the brain matter, but
lipomas can occur in the meninges (Intracranial extramedullary).
(xii) Intraglandular lipoma – Lipoma may be seen – the breast, pancreas, under the renal capsule
and salivary glands
Lipoma arborescens – A pedunctulated subcutaneous lipoma is called lipoma arborescens.
Commonly seen in the thigh, because of strong muscular contractions the lipoma is pushed outside
with cutaneous pedicle.
Intraspinal lipomas may present as nerve compression.
Dangerous lipoma – Submucous lipoma in subglotic region produces narrowing of the respiratory
passage and cause death.
Subserous lipoma of intestine may lead to intussusception.
Complications –
(i) Myxomatous degeneration.
(ii) Saponification.
(iii) Calcification.
(iv) Malignant transformation to liposarcoma
Commonly seen in retroperitoneal and gluteal regions.
 SUBCUTANEOUS LIPOMA
Duration – Long, more than 1 year
Shape – Spherical or over swelling
Surface – Lobulated
Borders – Well defined, regular and round
Slip sign – Positive
Consistency – Soft
Fluctuation negative
Skin – Pinchable
Mobility – Freely mobile with dimpling of skin.
On contraction of the underlying muscle, the swelling becomes more prominent and mobility is not
restricted.
 Sebaceous cyst (Case Sheet)
Complaint and duration : Swelling over the face/chest/scalp – 2 years duration
Pain – since 1 month
History of present complaint: 2 years back, patient noticed a swelling of 1 cm diameter which is
slowly growing and attain the present size.
No history of trauma
No history of decrease in the size of the swelling
No history of sudden increase in the size of the swelling
No history of recent rapidity of growth.
Patient complains of pain since 1 month which is continuous, throbbing in nature, relieved on
standing position but aggravated on lying down position.
No history of radiation of pain.
No history of fever
No history of loss of weight or appetite
Bowels and mixturation normal
Past history -
Personal history -
Family history -
Drug history -
PHYSICAL EXAMINATION -
SYSTEMATIC EXAMINATION -
Cardiovascular system
Respiratory system
Central Nervous System
Gastrointestinal system

Local examination
Inspection – A single spherical swelling measuring 5cm in diameter present on the left side of
occipital region of the scalp extending 2 cm away from the midline, 3 cm above the superior nuchel
line.
Surface is smooth, borders are well defined, round and regular.
Skin over the swelling is healthy.
A bluish spot - punctum present over the centre of the swelling.
Colour of the swelling is bluish in colour.
Surrounding area is normal.
No visible pulsations
No visible cough impulse.
Palpation –
Mild raise of temperate present over the swelling.
Mild tenderness present over the swelling.
Inspectory findings – Number, Size, Shape, Site, extent are confirmed.
Surface is smooth, borders are well defined round and regular.
Consistency is soft.
Paget’s test : positive (If it is positive indicate fluid is present in the swelling, then transillumination
test is performed)
Transillumination test – Negative (Indicate swelling contain turbid fluid)
Paget’s test- Negative (Indicate semisolid material {Sebum} present in the swelling)
Sign of moulding is positive (Indicate swelling contain semisolid material).
Mobility – The swelling is mobile in both horizontal and vertical directions along with the skin.
Plane of the swelling – Skin is not pinchable in the centre of the swelling at the site of punctum, but
pinchable in the periphery of the swelling.
On contraction of the underlying muscle, the swelling becomes more prominent and mobility is not
restricted.
Summary:
History – Long duration, slowly growing swelling.
On examination – Spherical swelling. Surface is smooth with well defined round and regular borders,
punctum is present. Consistency is soft and cystic. Paget’s test is positive. Transillumination is
negative
Skin is not pinchable in the centre of the swelling but pinchable in the periphery.
On contraction of the underlying muscle, the swelling becomes more prominent and mobility is not
restricted.
Provisional diagnosis :
Sebaceous cyst over the scalp with secondary infection
Differential diagnosis
Lipoma, Dermoid cyst,Haemnngioma, Papilloma, Dematofibroma.
Investigations for confirmation of diagnosis.
FNAC
X-ray scalp – (To know any intracranial extension (Dermoid Cyst).
Treatment – 1. Excision
Local anaesthesia with 1% zylocaine
An elliptical incision given around the punctum.
The skin is separated from the cyst wall by blunt and sharp dissection using haemostat or curved
dissecting scissor.
The cyst is removed.
Haemostasis secured, the wound closed in layers.
Subcutaneous tissue with No.2.0 plain catgut (Vicryl rapid)
Skin - 2.0 nylon (Polyamide)
2. Incision and evulsion – Under local anaesthesia an elliptical incision is given around the punctum
opening the cyst wall. The contents of the cyst are expressed. The cyst wall is held with tissue
forceps and evulsed completely from the surrounding tissue. Haemostasis secured and wound
closed in layers.
3. Incision and drainage – If the cyst is infected and abscess formed, the cyst wall is incised to drain
the pus. Under antibiotic cover, once infection subside, the cyst wall is excised from the surrounding
tissue.
If infection of the cyst is present without abscess formation, a course of antibiotic for a period of 5-7
days is given. Once infection is controlled the cyst can be excised.
 SEBACEOUS CYST
• Sebaceous glands are present in the skin.
• These glands secrete sebum which keeps the skin soft and oily.
• The duct of the sebaceous gland mainly opens into the hair follicle and rarely may open
directly on to the skin.
• If the duct or the mouth of the sebaceous gland becomes blocked, the gland becomes
enlarged due to retention of its own secretion and forms a sebaceous cyst. So, it is an
example of retention cyst
• Other retention cysts are – Mucous cyst of oral cavity, Bartholain Cyst of labia majora
• It also called ‘epidermoid cyst’ because it is present above the dermis.
• It arises from the basal layers of epidermis.
• It is also called as WEN, when it occurs as multiple cysts on the scrotum
Pathology -
• Cyst is lined by squamous epithelium and contains sebum which is yellowish pultaceous
material with unpleasant smell.
• Sebum contains fat and desquamated epithelial cells.
• At the central point of swelling, it is adherent to the epidermis. In the centre of the swelling,
at a black spot is present, which is keratin-filled punctum.
• Common sites –
• Sebaceous cyst occurs anywhere in the body except palm and sole as there is no sebaceous
glands present in palm and sole of feet.
• Most commonly seen in those parts where there are plenty of sebaceous glands like (i) The
scalp (ii) Face (iii) Neck (iv) Shoulders (v) Chest (vi) Scrotum
• The characteristic feature of sebaceous cyst in scrotum is –the cysts are multiple, elevated
above the dermis covered by thin layer of epidermis and solid, known as WEN.
• C/F : Occur at any age from young to old, but rare in childhood.
• Typical cystic swelling which is spherical in shape. Its size varies from a few milli metres to
about 5 cm in diameter.
• The surface is smooth and there is a blackish spot or punctum which indicates the blocked
opening of the duct.
• Cyst is always fixed to the skin, so the overlying skin cannot be pinchable. (In case of
dermoid cyst skin is pinchable)
 Consistency is cystic.
Due to presence of sebum (semisolid material) there may be indentation on pressure
with finger tip. (Sign of indentation or sign of moulding)
If the sebum degenerates and liquefies, fluctuation test may be positive, but sign of
indentation is negative.
Transillumiantion test is always negative, as the contents are turbid fluid.
The swelling is not tender usually, but if it infected it is tender.
The cysts is free from underlying structures and move along with the skin.
Treatment –
Total excision of the cyst is the treatment of choice.
If the cyst is infected, preliminary antibiotic treatment should be given and the excision is only
possible when the infection has subsided.
If the cyst is a small one it can be excised under local anaesthesia.
Three kinds of procedure may be adopted –
(a) Dissection method – An elliptical incision is made on the skin including the punctum.
The cyst is gradually dissected from the surrounding skin till the entire cyst can be removed
intact.
It must be remembered that the whole of the cyst wall must be removed, otherwise
recurrence is inevitable.
(b) Incision-avulsion technique – Under local anaesthesia an incision is made through the skin into
the cyst.
Contents of the cyst are squeezed out.
The cyst wall is then held with a pair of dissecting forceps and the cyst is carefully avulsed
out from the surround tissue.
(c) If the cyst infected and abscess formed, incision and drainage of the pus was performed under
antibiotic cover. Later when the infection is subsided the cyst wall is excised.
Complications –
(i) Infection – Infection is treated with antibiotics and analgesics until infections subsides.
If the infection subsides, excision of the cyst should be carried out.
If infection does not subside, abscess formed, it should be incised and drain the pus.
(ii) Ulceration (Cock’s peculiar tumour) – This complication arises when an infected cyst ruptures by
itself and discharges its contents.
The floor of ulcer is covered by granulation tissue with fungation.
It may look like on epithelioma.
When the sebaceous cyst of the scalp ulcerates, excessive granulation tissue forms
resembling fungating epithelioma.
This is called the Cock’s peculiar tumour.
(iii) Sebaceous horn – Slow discharge of sebum from the punctum which hardens step by
step leads to formation of sebaceous horn.
(iv) Calcification – Commonly seen in sebaceous cysts of scrotum.
(v) Malignancy – Basal cell carcinoma may develop in a sebaceous cyst.
Salient points of sebaceous cyst :
1. Punctum is a block spot which is present on the summit of the swelling due to blockage of
the mouth of the duct.
2. Spherical swelling with well defined round borders.
3. Consistency – soft. Fluctuation (Paget’s test) is positive if it contain liquid
If it contains semisolid material, sign of indentation or sign of moulding is present.
4. Swelling is freely mobile along with the skin over the underlying structures
5. Skin over the swelling is not pinchable
Demodex follicularum – A parasite, found in the wall of the cyst.
Multiple sebaceous cyst in the scrotum is known as WEN
Fordyce’s disease – Presence of ectopic sebaceous glands in lips and oral mucosa. WEN
DERMOID CYST :
Dermoid cyst is a which lies deep to the skin and is lined by skin (squamous epithelium)
Because it is below the skin, it is known as epidermal cyst.
Cyst contains pultaceous or tooth paste like material a mixture of sebum, desquamated epithelial
cells, air and salts N.& Cl).
Dermoid cysts are two types: (I) Congenital – 3 types (II) Acquired – Implantation dermoid
Congenital - 3 types :
i) Sequestration dermoid
ii) Tubulo-dermoid cyst
iii) Teratomatous dermoid
i. Sequestration dermoid –It is congenital dermoid cyst, formed by inclusion of epithelium buried at
the lines of embryonic fusion.
Found along the lines of fusion of the two embryonic segments (Front of midline of body and in
between union of skull bones).
Pathology- Cyst is lined by stratified squamous epithelium with hair, hair follicles, sepabaceous
glands and sweat glands.
Origin – At the line of embryonic fusion, a few ectodermal cells are sequestrated into the deeper
layer.
These cells proliferate to form a sequestration dermoid cyst.
The dermoid cyst lies near the mesoderm from which the bones will develop, that is why indentation
is often found in the underlying bone.
Prolongation of the cyst through the bones give rise to cyst in the intracranial region.
Common sites are –
i. Midline of the body particularly in the neck.
ii. External angular dermoid – above the outer canthus of the eye – the line of fusion of frontonasal,
orbital and maxillary processes.
iii. Post auricular – behind the ear – at the site of fusion of the mesodermal hillocks.
iv. On the skull- Line of fusion of the skull bones.
v. Midline of the face at the root of the nose (Gabella) joining of nasal bones and frontal bone –
Clinical features
Painless and slowly growing cystic swelling
Site must be at the embryonic fusion
Size and shape – May not be more than 5 cms in diameter and Ovoid or spherical in shape.
Surface – is smooth
Punctum - No punctum
Consistency is soft and sign of indentation is present if the material is semisolid.
Fluctuation (Paget’s test) is positive.
Transillumination is negative if the contents are liquefied due to degeneration.
No impulses on coughing
No compressibility or reducibility
Bony indentation is present deep to the cyst which can be palpated by moving the base of the cyst
with a finger.
X-ray – Shows a depression in the bone underlying the cyst or a defect in the bone (perforation) in
the bone indicates intracranial extension of the cyst.
Complications
1. Infection
2. Suppuration
3. Ulceration
4. Pressure symptoms
Treatment :
Complete excision of the cyst is the treatment of the choice under local anaesthesia or GE
The cyst is dissected from the sensitive pericranium
Preliminary x-ray shows a gap in the underlying bone, neurosurgical assistance may be taken.
ii. Tubulo dermoid
An epidermal cyst which develops from an unobliterated portion of a congenital ectodermal duct or
tube.
Pathology-
Cyst is formed by accumulation of the secretions of the lining ectodermal cells of the unobliterated
portion of an embryonic duct.
Eg. 1. Thyroglossal cyst – It develops from the thyroglossal duct
2. Vitello –intestinal cyst – developed form vitello intestinal duct
3. Urecheal cyst – Developed from uracheas.
4. Post-anal dermoid cyst develops from remnant of neurrenteric canal (Post-anal gut).
5. Ependymal cyst of brain – Sequestration of cells derived from infolding neuroectoderm.
iii. Teratomatous dermoid –
A systemic swelling develops from the totipotent cells with ectodermal predominance with
mesodermalelements like bone, cartilage.
Hairs are almost always present
Usual contents are bone, cartilage, tooth, hair and cheesy material.
Common sites are –
(i) Ovary – Ovarian cyst
(ii) Mediastinum – Mediastinal cyst.
(iii) Retroperitoneum – Retroperitoneal cyst
(iv) Testis – Teratoma.
Acquired type – Implantation dermoid
It is a acquired dermoid arises from indriven epithelium beneath the skin due to pucture injury
Eg. Needle prick or thron prick.
Common sites
(i) Palm of the hand
(ii) Any part of the finger
(iii) Tip of the finger
(iv) Sole

They are commonly seen in gardners, tailors and women

Pathology – Cyst is lined by stratified squamous epithelium without hair follicle, sweat and
sebaceous glands.
Contain cheesy material made up of desquamated epithelial cells.
Clinical features – History of pin or thorn prick
On examination a tense cystic swelling found in the finger or palm or sole.
Consistency is firm and cystic.
Page’s test is negative if it contain semi-solid material.
Complications – Infection, suppuration and bursting
Treatment – Under local anaesthesia, excision of cyst.

THYROGLOSSAL CYST
H/o swelling in the midline of the neck in a young patient (15-30)
Onset, progress, pain and any discharge must be asked.
On inspection, location of swelling in relation to hyoid bone
Size, shape, surface, movement with deglutation and on protrusion of tongue.
On palpation temperature and tenderness
Consistency – Soft, cystic, fluctuation - Positive
Transillumination - Negative
Swelling moves horizontally but not vertically
Swellings move with protrusion of tongue - Thyroglossal cyst only
Swellings move with deglutition –
1. Thyroid swelling.
2. Cyst in relation to the isthmus of the thyroid gland.
3. Ectopic thyroid.
4. Thyroglossalcyst.
5. Subhyoidbursal cyst.
6. Enlarged pretracheal glands.
7. Laryngocele.
Cystic swelling developed in the remnant of thyroglossal duct or tract.
Present in any part of thyroglossal tract from foramen caecum to isthumus of thyroid gland.
Common sites in order of frequency are – Subhyoid or over the thyroid cartilage or suprahyoid or in
the floor of mouth.

Midline swelling slightly towards left

Lined by psedostratified columnar epithelium with
lymphoid tissue
Complications –
Infection and abscess formation
Thyroglossal sinus after rupture of the abscess
Papillary carcinoma
MANAGEMENT :
I will do radio active iodine nuclear scan to exclude any ectopic thyroid tissue in the swelling and also
to know the position of normal thyroid gland, because, this is the only thyroid tissue that may be
present in ectopic position. If normal thyroid is present in its original position, I will do FNAC
to confirmation diagnosis.
After investigating for fitness to surgery, under general anaesthesia, Sistrunk operation is performed
– Ellliplical incision made around the cyst. The cyst is separated from the surround tissue along the
tract. The tract is dissected upto the foramina caecum of tongue with excision of the body of the
hyoid bone.
Thyroglossal fistula
Aetiology
1. Infection with abscess formation give rise to thyroglossal fistula
2. Latrogenic (Thinking it as an abscess and performed drainage.
3. Incomplete removal of the tract.
Treatment : Sistrunk operation

BRANCHIAL CYST
Cystic swelling arises from persistent cervical sinus which is formed due to fusion of second branchial
arch with 6th branchial arch. (5th arch disappears)
Clinical features : Age of presentation between 22-25 years even though it is congenital.
Location – Anterior triangle of neck at junction of upper 1/3rd and lower 2/3rds of sternomastoid
muscle along its anterior border.

Lining epithelium - squamous epithelium

Shape - Oval or spherical in shape with smooth surface.
Well defined round and regular borders
Consistency soft as it contains pulsatious material.
Fluctuation is positive, if the material is liquid. Transillumination is negative.
If the material is semi-solid, sign of indentation is present.
Mobility - Freely mobile,
skin is pinchable
On contraction of the sternocledomastoid muscle the swelling becomes more prominent and
mobility is not restricted.
Complications :
Recurrent infection due to presence of lymphoid tissue in the wall.
Cyst may rupture or due to inadvertent incision may give rise to branchial sinus.
Squamous cell carcinoma may occur.
Treatment :
Excision under general anaesthesia
Hypoglossall nerve, glossal pharyngeal nerve, spinal accessory nerve lie deep to the cyst and are at
danger during surgery.
Branchial Sinus : Incomplete fusion of second branchial arch with sixth arch in its distal part results
in branchial sinus.
Internal opening is not found.
Types :
Congenital – Due to incomplete closure of cervical sinus in its distal part.
Acquired - Due to infection or incomplete excision of branchial cyst.
External opening – Congenital – Typically located at the junction of upper 2/3rd and lower 1/3rd of
anterior border of stenomastoid muscle.
Acquired - Typically located at the site of br. Cyst (Jn. Of Upper 1/3rd & Middle 1/3rd of
sternomastoid muscle).
There is no internal opening as it is a sinus.
Treatment : Excision of sinus tract.

BRANCHIAL FISTULA
Congenital branchial fistula develops from failure of fusion between the second and fifth branchial
arches.
Acquired branchial fistula may be due to (1) Infection of the branchial cyst and rupture (2) Due to
inadvertent incision of the infected branchial cyst.
Site – Congenital – External opening at the junction of upper 2/3rds and lower 1/3rd of anterial
border of SCM muscle
Acquired – External opening is at the junction of upper1/3rd and lower 2/3rds of anterior border of
SCM muscle.
Internal opening on the posterior pillar of fauces behind the tonsil.
Course of the sinus tract – The tract pierces the deep facia at the level of upper border of thyroid
cartilage passes through the fork of common carotid artery. Ascends upwards and pierces the
superior constrictor muscle of the pharynx and open just behind the tonsil.
Treatment – Sinogram is performed by injecting radio-opaque dye to know the upper limit of the
fistula.
Under general anaestesia the whole tract is excised taking care not to injuring caratid vessels as the
tract passes between the internal and external caratid arteries.

CYST
Cyst is a collection of fluid in a sac lined by epithelium or endothelium. (Cyst means bladder)
Cysts are classified as true cysts and false cysts.
True cyst : In true cyst, the Cyst wall is lined by either epithelium or endothelium
If infection occurs, the lining epithelium or endothelium is replaced by granulation tissue.
The cyst contain fluid, usually serous or mucoid derived from the secretion of the lining.
False cyst : Cyst does not have epithelial or endothelial lining, but the fluid is collected in between
the fascial sheaths, muscles or walled off by intestine or omentum as in case of TB abdomen.
Fluid collection occurs as a result of exudation Eg. Pseudocyst of pancreas or degeneration Eg.
Cystic degeneration of tumour.
Apoplectic cyst formed in brain as a result of ischaemia with collection of fluid.
Classification of cysts : (a) Congenital (b) Acquired
a. Congenital cyst –
(1) Sequestration dermoid
(2) Tubulo dermoids – Thyroglossal cyst, urachal cyst, vitallo-intestinal duct.
(3) Teratomatous dermoid – Cystic swelling develops from the totipotent cellswith ectodermal
predominance.
It also contain mesodermal elements like bone, cartilage, tooth and cheese material
Common sites are –
(1) Ovary – Ovarian cyst, (2) Testis – Teratoma, (3) Mediastinum – Mediastinal cyst,
(4) Retroperitoneum –Retroperitoneal cyst (5) Post-anal dermoid
Hairs almost always present.
(4) Cysts of embronic reminants – Cysts from paramesonephric duct and mesonephric duct.
b. Acquired–
(1) Implantation Dermoid – Acquired dermoid cyst arising from indriven epithelium beneath the skin
due to a pucture injury Eg.Needle prick or thorn prick
Common sites are – Palm or tip of the fingers of the hand and sole of the feet.
Common in gardeners, tailors and women.
Cyst is lined by stratified squamous epithelim with no air follicles, sweat and sebaceous glands.
Contain white cheesy material formed by desquamated epithelim cells and sebum.
On examination tense cystic swelling found in the fingers or palm
Consistency is firm
Paget’s test is positive, transillumination is negative.
The swelling is small tense and cystic.
Complications, infection, suppuration and bursting
Treatment – Excision of cyst under local anaesthesia.
2. Retention cysts – Accumulation of secretion of a gland due to obstruction of the duct
Eg. Sebaceous cyst, Bartholin’s cyst, cysts of parotid, breast and epididymis.
2. Distention cyst – Lymph cyst, colloid goiter, follicular cyst of ovary.
3. Exudation cyst – Bursa, hydrocele, pseudopancreatic cyst
4. Cystic tumours - Dermoid cyst of ovary, cystadenomas
5. Traumatic cysts – Due to trauma, haematoma occurs usually in thigh, loin.
Lined by muscular sheaths or fascial sheaths containing brown coloured fluid with
cholesteral crystals
6. Degenerative cyst –
Due to cystic degeneration of a solid tumour (Necrosis of tumour)
7. Parasitic cyst – Hydatid cyst, trichiniasis, cysticerosis
Clinical features :
Hemispherical swelling with smooth surface well defined borders, soft consistency fluctuation
positive (Paget’s test) transillumination negative.
Complications of a cyst –
Compress of the surround structures (CBD-Choledochal cyst)
Infection
Abscess formation
Sinus formation
Calcification (Hydatid cyst)
Cachexia –In malignant
Haemorrhage
Torsion Eg. Ovarian cyst
Swellings with brilliantly transilluminant :
Ranula
Meningocele
Cystic hygroma and lymph cyst
Hydrocele
Epidymal cyst (Chinese-Lantern pattern)

Sequestration dermoid Sebaceous cyst

* Occurs in the line of fusion * Occurs anywhere except palm and sole
* Skin is not adherent (free) * Skin is adherent over the summit
(Around punctum)

* Extends often into deeper plane or * Subcutaneous plane-do not extend to

cavities through suture line deeper plane

* Punctum is absent * Punctum is present – 70% cases

* Bone resorption and indentation is * No bone resorption(identation)

common

* Restricted mobility * Freely mobile along with skin

* Needs proper evaluation with X-ray/CT No CT or x-ray required

scan for intracranial extension

Excision is done under general * Excision is done under local anaesthesia

anaesthesia

EXAMINATION OF AN ULCER
MODE OF PRESENTATION
 Ulcer following trauma cause or
 - Swelling or oedema, later developed in to an ulcer
- May occur spontaneously or
- May follow after application of counter irritant.
Ulcer may develop
 On burns scar
 In association with peripheral vascular disease due to ischaemia of tissue (tropic
ulcer)
 In varicose veins due to venous hypertension.
 On genitalia following sexual exposure (chancres due to syphilis and chrancoid (soft
sore due to haemophylis Ducrey).
IMPORTANT POINTS IN HISTORY
8. H/o injury
9. Initially swelling and then ulcerated as in
o Lymph nodal masses
o Tumours
10. H/o venous disorders
o Varicose veins
o Deep vein thrombosis
4. H/o any scars
o Post burns
o Post irradiation
5. H/o Peripheral vascular disease
6. H/o of any neurological disorders
o Spinal lesion
o Peripheral neuropathy
o Leprosy
7. H/o diabetes or/and hypertension
8. H/o exposure to STD
o Syphilis
- Primary chancre on genitalia
- Gumma over the bones
9. H/o tuberculosis
NATURAL H/O THE ULCER
o Site of occurrence
 o Duration
o Discharge
- Serous
- Sero sanguinous
- Bloody
- Purulent
o Any complications
- Bleeding
- Deformity
- Malignant transformation
o Pain
- Type
- Site
- Radiation
- Relieving factors
- Aggravating factors
- Disturbance to sleep
- Claudication pain
11. Nutritional status of the patient
o Anaemia
o Hypoproteinaemia
o Avitaminosis
o Obesity
o Hyperlipaedemic state
12. Any chronic illnesses -
o Diabetes
o Hydertension
o Nephritis
o Rheumatoid arthritis

EXAMINATION
General Examination
III. Past history
 Any history of hospitalization either medically or surgically must be enquired and
mentioned.
Any treatment underwent for chronic illness like tuberculous or leprosy
IV. Personal history
o Patient married or unmarried, living with family or not, number of children, male
and female, age of last child, if wife or husband died how many years back and what
is the cause of death.
o Patient is habituated to smoking or not
o Addicted to alcohol or not
o If smoker, how many cigars, chuttas per day since how many years.
o If alcoholic, enquire how frequently and quantity of alcohol - used to take
o Whether patients is known diabetic or hypertensive.
o Whether he is suffering with any chronic illness like tuberculous or leprosy.
V. Family history
o Any member of the family suffered with similar complaint.
o Any member of the family are known diabetic or hypertensive.
o Any member suffered with chronic illness like TB or leprosy.
VI. Drug history
o Patient is not allergic to any known drugs.
VII. Physical examination
- Patient moderately built moderately nourished
- Not anaemic
- No jaundice
- Oral cavity – Mucous membrane is pink and moist.
- Tongue – Moist, pink and healthy
- All teeth are present
- Gums are healthy
- No generalized lymphadenopathy
- No pedal edema.
Pulse –
75/min, regular in rhythem, volume and tension - normal
Vessel wall is not thickened (below 40 years)
Vessel wall is thickened (above 40 years)
Blood Pressure – 120/80mm of Hg (below 40 years)
 130/90mm of Hg (above 40 years)
Temperature – 98.40 F
Respiratory rate - 18/min. regular (Thoraco abdominal – female)
(Abdomino thoracic – male)
VIII. Systematic Examination
A. Cardio Vascular System – Apex beat is palpable at 5th intercostals space on left side at
midclavicular line. 1st and 2nd heart sounds are heard normally. No murmurs are heard.
JVP – Normal. No pedal edema.
B. Respiratory System - Chest is moving equally with respiration on both sides.
On oscultation bilateral vesicular breath sounds are heard. No rhyonchi or
crepitations.
C. Central Nervous System - Patient conscious, coherent, answering questions
Pupils are normal in size and normally reacting to light.
There is no neurological deficit.
Gait normal.
D. Gastrointestinal System - Shape of abdomen is scapoid, moving equally with
respiration, soft on palpation, no free fluid, no mass palpable. No hepatospleenomegaly.
Intestinal sounds are normal
o Built and nourishment
Local examination
o Inspection
Number- Single or Multiple
- Shape - Rounded or Oval or Irregular
- Size – Vertical and horizontal measurements
- Site – Note where the ulcer is present
- Margin – Pale or inflammed
- Edge – Whether if it is
 Sloping or Punched out or Undermined or Raised and everted or raised and rolled out
 Sloping edge – Non-specific ulcer
 Punched out edge – Neurogenic ulcer, syphilis
 Undermined edge – Tuberculous
 Raised and everted – Squamous cell carcinoma or Malignant melanoma
 Raised and rolled out with beaded appearance – Basal cell carcinoma
- Floor
  Healthy granulations—Pink
 Unhealthy granulation—Pale
 Wash leather slough—Syphilis
 Blackish pigmentation—Melanoma
 Slough—Infected ulcer
- Discharge
 Serous discharge – Healing ulcer
 Purulent discharge – Non-healing ulcer (spreading ulcer)
 Serosanguineous discharge – Malignant ulcer or Healing ulcer (Blood stained serous
fluid)
 Greenish discharge – Infection with pseudomonas
 Bloody discharge –Malignant ulcer
- Surrounding area – Note any
 Pigmentation
 Signs of ischaemia (Pale and Cold, loss of hair, loss of subcutaneous tissue as evident
by prominent intermetatarsal groove, absence of veins, brittle nails with transverse
ridges and minor ulceration in between the toes.
 Presence of varicose veins
 Scar tissue
 Deformity
- Talipes equino varus—Varicose ulcer
- Local gigantism—Congenital AV fistula
Palpation
- Tenderness – present or not
- Local raise of temperature - present or not
- Induration of margin edge and base – present or not
- Mobility
- Mobile in both horizontal and vertical directions – Subcutaneous
- Reduced mobility – may be fixed to the underlying structures
- No mobility – fixed to bone or periosteum or infiltration to surrounding
tissue as in case of malignancy.
- Bleeding on touch – present or not – Bleeding on touch present in healthy
granulation tissue of healing ulcer and in malignant ulcer.
3. Regional examination
 o Examination of Iymph nodes
o Examination for vascular insufficiency—Peripheral pulses
o Examination for nerve lesion—Local anaesthesia, paraesthesia, movement of joints (Test for
touch, temperature and joint position).
o Deformity
o Venous system; if any varicose veins
POSSIBLE COURSE OF DISCUSSION
1. What is an ulcer?
Ulcer is a discontinuity in the surface epithelium or mucous membrane with molecular death of
tissue.
Gangrene is macroscopic death of tissue.
2. What is the margin of an ulcer?
Margin of the ulcer denotes the junction between the normal and the ulcerated area. It
gives the shape of the ulcer as:
 Round
 Oval
 Irregular
Floor
3. What is the floor of an ulcer?
 The exposed part of the ulcer seen on inspection is called floor.
 The floor may be covered :
- Red granulation tissue – Healing ulcer.
- Unhealthy granulation tissue --- non-healing ulcer
- Slough – infected
- Wash leather – syphilis
- Apple jelly granulation - tuberculosis
Zones of an healing ulcer – Floor is divided into three zones, from periphery to centre
- White zone - Outer zone - Indicates fibrous tissue
- Blue zone – Middle zone - Indicates granulation tissue covered by 3 to 4 layers of
epithelial cells
- Pink zone – Inner zone - Indicates granulation tissue covered by single layer of epithelial
cells.
More of red zone and less of white zone=Healing ulcer.
More of white zone and less of red zone=Non healing, chronic ulcer.
4. What is the edge of an ulcer?
 The part of the ulcer between the floor and the margin.
 It denotes the nature of the ulcer- Eg. Sloping edge in case of non-specific ulcer.
5. What are the types of edges?
An edge can be :
 Sloping—Non-specific
 Undermined—Tuberculous
 Punched out—Penetrating ulcer (Tropic ulcers due to lack of sensation and nutrition) syphilis
 Raised and everted—Malignant ulcer
 Raised and Rolled out with beaded appearance —Rodent ulcer (Basal cell carcinoma)
6. What is undermined edge?
a. Floor is more than the roof
b. The margin of the ulcer overhangs upon the floor
c. A small probe can be passed beneath the margin
7. What is a punched out edge?
a. The margin and the floor are of same size
b. The sides are clear cut—punched (900)
c. The floor can be deeply placed formed by bone in some cases
d. Seen typically with trophic ulcers (Neuropathic ulcers)
8. What is raised and everted edge?
a. Edge is raised above the surface and everted
b. A probe can be passed between normal skin and edge
9. What are raised and rolled out edges?
 Edge is raised above the surface but not everted with beaded appearance
 Eg. Basal cell carcinoma
10. What is the base of an ulcer?
 Base is the structure on which the ulcer lies.
 It is a palpatory finding.
 Induration is seen in case of chronic ulcer
 Marked induration is a feature of malignancy.
Discharge
11. What is discharge in an ulcer?
Discharge is secretions from the raw area of the ulcer.
Mostly due to infection.
12. What are different types of discharges?
Types:
 Serous—Healing ulcer
 Purulant —Infected ulcer
 Blood—Neoplastic, vascular
 Serosanguinous—Infected or malignancy
 Greenish—Pseudomonas
 Purulent with foul smelling—Gram –ve bacteria, anaerobes and bacteroids
CLASSIFICATION OF ULCERS :
Clinical classification -
 Healing ulcer
 Non-healing ulcer
 Chronic or callous ulcer
Pathological classification
 Nonspecific ulcers – Eg. Infective, traumatic, burns, acids, alkalis, sun-burns
 Specific ulcers – Eg. Tuberculous, syphilis,
 Malignant ulcers – Eg. Squamous cell carcinoma (epithelioma), basal cell carcinoma,
malignant melanoma.
13. What are the stages in an ulcer development and healing?
An ulcer passes through three stages:
a) Stage of extension
 It is the stage of spreading
 Floor is covered by slough without any evidence of granulation tissue; the discharge is
profuse, purulent with foul smelling.
 The edges and surrounding tissue are inflamed and oedematous
b) Stage of transition
 Preparatory stage for healing
 Separation of slough
 Discharge is decreased, may be serous or seropurulent
 Appearance of granulation tissue
 Base is less indurated
 Signs of inflammation are minimal
c) Stage of healing
 Whole floor of the ulcer is covered with red, healthy granulation tissue.
  Spread of epithelium from margin across the ulcer
 Formation of scar tissue
 Minimal serous discharge without smell
 No signs of inflammation
14. What are the zones of healing ulcer?
a) White zone—Outer zone, white in colour due to fibrous tissue reaction.
b) Bluish zone—Middle zone, granulation tissue covered by 3-4 layers of epithelial cells.
c) Red zone—Inner zone – Granulation tissue covered by single layer of epithelium
15. What is a callous ulcer?
a) History – Long duration more than 6 months
b) Floor is covered by unhealthy, pale granulation tissue with areas of slough
c) Base is indurated
d) Discharge is seropurulent, smell can be present
e) Marked induration of base edge and surround tissue with pigmentation
16. What are non-specific ulcers?
a) No specific aetiological factors
b) No special clinical features
c) Etiology of non-specific ulcers:
 Traumatic
- Mechanical
- Physical
- Chemical
- Radiation
 Arterial
- Atherosclerosis
- TAO
- Raynaud’s disease
 Venous
- Varicose ulcer
- Post Deep Vein Thrombosis
 Trophic
- Bed sore
- Perforating
- Neurological conditions Eg. Parapleasia, quadriplegia, syringomyelia
 - Hansen’s disease (Leprosy)
 With associated diseases
- Anaemia
- Nephritis
- Rheumatic arthritis
- Diabetes
 Miscellaneous
- Bazini’s ulcer
- Morterelli’s ulcer
- Meleney’s ulcer
17. What are specific ulcers?
a) Caused by specific aetiological factors
b) Produces typical clinical features for that aetiology
c) Types.
 Tuberculous
 Syphilis
 Actinomycosis
18. What are malignant ulcers?
a) Epithelioma
b) Rodent ulcer
c) Malignant melanoma
19. How will you investigate a case of an ulcer?
a) Laboratory investigations:
 CBP/ESR
 Urine routine for blood sugar and proteins
 Blood urea/creatinine
 Blood sugar
b) Discharge from the ulcer for culture and sensitivity
c) Staining of the discharge – AFB & gram stain
d) Tests for tuberculosis
 Mantoux test
 Staining for AFB
e) Genital ulcer
 VDRL
 f) Diagnostic
 Wedge biopsy
 Biopsy of the regional node
20. What is wedge biopsy?
a) A triangular bit of ulcer along with normal skin is taken for biopsy is called wedge biopsy.
b) It is advantageous as the pathology can be properly studied with comparison to normal
tissue.
21. What is edge biopsy?
a) A bit of tissue taken from edge of an ulcer without including normal tissue
b) Not ideal as normal tissue is not present for comparison and infiltration cannot be seen in
case of malignancy.
If biopsy taken from the centre of the ulcer it may be a nectrotic tissue only due to ischaemia, not
useful for pathological diagnosis. So biopsy can never be taken from centre of the ulcer
22. How you manage the ulcer?
a) Conservative
 Rest to the part
 Avoid local irritation
 Improve the nutrition through -
- Protein supplementation
- Vitamin supplementation
 Blood transfusion if patient is anaemic
 Proper antibiotics after c/s
 Treat the cause
b) Tuberculous ulcers
 Non-dependent aspiration of cold abscess.
 Excision of the underlying lymph node/sinus, etc.
 Antituberculous treatment for a period of 6-9 months following any procedure
c) Venous ulcer
 Elevation
 Compression stockings
 Treat DVT
 Treat varicose veins
d) Genital ulcer
 Treat with antibiotics—Penicillin group of drugs
 e) Malignant ulcer
 Wide excision
 Radiotherapy/chemotherapy
 Amputation
f) Chronic and callous ulcer
 Local care
 Infrared radiation
 Short wave therapy
 Ultraviolet therapy
 VAC therapy
g) Trophic ulcer
 Protection and soft padding
 Amputation/disarticulation of the involved bone
h) Diabetic ulcer
 Control the blood sugar levels
 Perform c/s
 Debridement
 Antibiotics
 If gangrene - Local amputation/disarticulation
i) Role of amputation
 Penetrating ulcers with osteomylitis
 Malignant ulcers not fit for local therapy
j) Presence of excessive granulation tissue can be managed by -
 Excision of excessive granulation tissue or
 Currettage or
 Application of copper sulfate crystals—Cuatery effect
k) Antibiotic after c/s
l) Improve the nutrition
 Protein supplementation
 Vitamin supplementation
23. Separation of the slough can be achieved by
 Hypochlorite solution – EUSOL (Edenburg University Solution)
 0.5% Silver nitrate
 1% Zinc sulfate
  Normal saline soaks
24. Local coverage of the ulcer with -
 Amnion
 Silver foil
 Boiled potato peels
 Split skin grafting
 Gauze impregnated with antibiotic-Sofra tulle
25. What are the surgical methods that may be used?
a) Excision of the ulcer + grafting
b) Covering the area with split skin grafting
c) Rarely amputation—Penetrating and malignant ulcers
26. When amputation is indicated?
a) Penetrating ulcers – Fixed to bone with osteomylitis
b) Malignant ulcers – Not fit for local therapy
27. What are the different types of amputations?
1. Ray’s amputation – Amputation through heads of metatarsal
2. Transmetatarsal (Gillies) amputation is done proximal to the neck of the metatarsals, distal to
the base.
3. Tarsometatarsal (Lisfranc’s) amputation – Disarticulation of tarsometatarsal joint with long
volar flap.
4. Mid tarsal (Chopart’s) amputation - Here talo navicular joint and calcaneo-cuboid joints are
disarticulated.
5. Tibialis anterior muscle is suture to talus bone by drilling with long volar flap.
6. Syme’s amputation – Removal of the with calcaneum and cutting of tibia and fibula just above
the ankle joint with retaining heal flap (Dividing both malleoli).
Heal flap is separated by medial and lateral calcaneal vessels branches of posterior tibial artery.
Many patients can walk well without difficulty.
Elephant boot is used after amputation for walking.
7. Below-knee (Burgess) amputation - Long posterior flap with scar placed over anterior aspect
is used. Prosthesis placement is better with greater range of movement without limp and
without support. Fibula is divided first higher than the proposed site of cut of tibia. Posterior
muscles are sutured across the bone and to the periosteum in front. The length of stump is 14-
17 cms. from the knee joined. But a minimum of 8 cms. is required for prosthesis.
 8. Transcondylar – Gritti-strokes amputation – With long posterior flap the femur is divided just
above the articular surface and petalla is anchored to the divided femur (No longer performed).
9. Above-knee-amputation – Equal anterior and posterior flaps are used.
Lower third and middle third level amputation is done.
Idle length stump is 25 cms from the tip of the trochanter.
Less than 10 cms stump is not possible to fit prosthesis so, hip disarticulation is advised.
28. What are the complications of ulcer?
 Infection
 Haemorrhage
 Malignant transformation
 Local deformity
Points to Remember
 Ulcer is a discontinuity in skin or mucous membrane with superadded infection.
 Margin of the ulcer is the junction between the normal and the beginning of the ulcer.
 Edge of an ulcer is the junction between the margin and the floor.
 The floor is what we see and is an inspectory finding.
 Base of the ulcer is the one on which the ulcer sits. It is a palpatory finding.
 Induration is a hard thickening of margin, edge and the base of the ulcer.
Present in case of chronic ulcers and malignant ulcers due to fibrous tissue infiltration or
malignant cells infiltration
 Sloping edge denotes healing ulcer.
 Undermined edge is seen with tuberculosis.
 Punched out edge is seen with penetrating ulcers.
 Raised and everted edges are seen with malignant ulcers.
 Raised and rolled out edges seen rodent ulcer.
 Ulcers can be specific, nonspecific or malignant.
 They can be healing, non-healing or callous ulcers.
 Wedge biopsy of the ulcer is diagnostic for malignant ulcers.
 Infection, haemorrhage, deformity and malignant transformation are the common
complications.
 Specific ulcers are managed by treating the cause.
 Nonspecific ulcers require excision of slough, dressings and proper antibiotics.
 Chronic and non healing ulcers may require VAC therapy.
 Malignant ulcers are managed by surgery, RT and chemotherapy.
NON-SPECIFIC ULCERS
Ischaemic Ulcers
1. What are the features of ischaemic ulcers?
 Due to vascular insufficiency.
 Develop over limbs
 Over pressure areas
 Starts as superficial ulcer, later become deep ulcer
 Can be multiple
 Painful
 Mostly toward lateral aspect of foot and leg
 Limb is cold and pale with absent or diminished pulsations
2. What are the features of trophic ulcer?
a. They are also called as penetrating ulcers.
b. They are usually seen in:
 Neurological cases due to loss of sensation (Hansen’s disease, paraplegia)
 Constant pressure - Decubitus ulcer (bed sores)
 Diabetes
c. Common sites are:
- Heel
- Ball of the toes
- Sacrococcoygeal region
d. Features:
 Deep ulcers
 Base may be formed by underlying bone
 Punched out edges
 Bone may be visible in the floor
 Foul smelling slough
 Surrounding insensitivity area
e. They are called trophic because of lack of nutrition to the part. For proper nutrition
nerve supply and blood supply are necessary.

1. What are tropical ulcers?

a) These ulcers are seen in tropical countries.
Eg. Delhi boil, Baghdad sore.
 b) They were thought to be due to Vincent’s organisms, but now it is established due to a
protzoal parasite Lieshmania tropica.
c) It starts as a indurated papule on exposed surface commonly on the face,
leads to formation of an indolent ulcer,
Leaving black, ugly and pigmented scar.
1. What are the features of tuberculous ulcer?
a) It results as secondary to cold abscess of caseous lymph nodes.
b) The edge of the ulcer are thin, pale and bluish discolouration with undermined edges.
A probe can be passed beneath the edge.
Size of the floor is more than the roof
c) Discharge is thin and watery .
d) Floor—Pale gtranulation tissue (Apple jelly granulation tissue)
e) Commonly over the neck and face in lymphnodal areas
2. What is lupus vulgaris?
a) It is a type of cutaneous tuberculosis.
b) Sites:
 Face
 Hands
 Common in children and adults
c) The ulcer is active at the periphery with areas of healing in the centre.
d) Lupus literally means a ‘wolf’.
3. What is a gummatous ulcer?
a) Seen in tertiary stage of syphilis
b) Sites:
 Subcutaneous bones
 Tibia
 Sternum
 Skull
 Ulna
 Testis
 Upper part of leg
c) Features:
 Punched out edges
 Washed leather-like slough in the floor
  Healed with tissue paper type of scar tissue
4. What is a chancre (Hard chancre)?
a) It is seen on ext. genitalia following exposure to syphilis caused by treponema Pallidum
b) Incubation Period: 3—4 Weeks following contact
c) Painless ulcer
d) Indurated base
e) Associated with painless, firm, shoty, hard inguinal lymph nodes
5. What is a soft Sore (Chancroid)
a. It is caused by Ducrey bacillus—Haemophllus Ducrie
b. Sexually transmitted disease seen on external genitalia
c. Incubation Period is - 3-4 days
d. Multiple, painful ulcers over genitalia
f. May bleed
g. Base is not indurated
h. Painful, enlarged inguinal lymph nodes
i. Suppuration take place in lymph nodes and leads to the formation of a “bubo” – is a
Fluctuant unilocular abscess
6. What is a Meleney’s ulcer?
a) Seen in Post Operative wounds of abdominal surgery contaminated with intestinal
contents.
b) Due to symbiotic action of microaerphillic organisms.
c) It is a spreading ulcer seen over anterior abdominal wall.
d) Associated with features of toxaemia with extensive sloughing of the abdominal wall.
7. What is Marjolin’s ulcer?
 Slow growing squamous cell carcinoma developing on chronic ulcer or Longstanding scar
tissue of burns.
 Orginally described for ulcer developing in a scar tissue
 It locally malignant squamous cell carcinoma without secondaries either in lymph nodes or
by blood spread as there is no lymphatic or blood vessels in the scar tissue
 It behaves as locally malignant tumour as long as it confined to the scar tissue or ulcer, but if
it encroaches onto normal tissue it behaves like normal squamous cell carcinoma with
secondaries.
 Base is indurated with raised and everted edges
 It is radio insensitive, treated by wide excision or amputation.
How it differs from squamous cell carcinoma?
a) Regional lymph nodes are not involved due to lack of lymphatics in scar tissue
b) Lymph nodes may be involved once the ulcer encroach to normal tissue and behavious like
squamous cell carcinoma.
c) Response to radiotherapy is poor due to scar tissue
d) Prognosis is good

How squamous cell cancinoma can develop in a scar tissue, which is made up of fibrous tissue?
It develops from islands of remnant of squamous epithelium in the scar tissue.
Who was Marjolin?
Rene Marjolin (1812-1895), Surgeon, Hospital Sainte, Eugenic-Paris, originally described a
carcinomatous ulcer occurring in a post burn scar.
MARTORELL’S ULCER :
 Effects elderly over the age of 50 years, hypertensive hence –
 Hypertensive ulcers.
 Atherosclerosis is precipitating factor even though all peripheral pulses are usually present.
 It occurs due to sudden obliteration of arterioles of skin on back (or) out side of calf region.
 Severe pain, ischaemic patch of skin which results later in to deep, non healing ulcers.
 Healing is delayed due to vascular in sufficiency.
BAZIN’S ULCER :
 The ulcer exclusively occur in young females and in the lower third of leg and ankle region.
 Usually seen in obese with thick ankles and abnormal amount of subcutaneous fat.
 It begins with erythematous purplish nodules (Erytherocyanosis frigida) on the calves which
rupture resulting non healing ulcer.
 Etiology of these ulcer is not clear, suppose to be ischaemia due to spasm of branches of
post tibial and peroneal arteries.
 These vessels are abnormally sensitive to hot and cold weather similar to Raynaud’s disease.
 In some cases tubercle bacilli isolated which respond to anti T.B. Drugs.
 Sympathectomy may be helpful in patients hypersensitive to weather changes.
 Diabetic ulcer –
Due to three causes – 1. Diabetic neuropathy, vasculopathy and superadded infection.
BURULI ULCER –
Deep ulcer caused by mycobacterial ulcerans with dermal necrosis.
BAIRNSDILE ULCER –
Superficial ulcer caused by the same organism.
CURLING ULCER –
Stress ulcers occur in stomach of burned patients.
CUSHING ULCER :
Ulcers present in patients suffering from cushing syndrome due to excessive corticosteroids.
It is also seen in people who are taking steroids for long time.
FOOTBALLER’S ULCER :
Ulcers seen around the ankle in football players due to repeated trauma.
What are traumatic ulcers?
Ulcer developed following trauma
Present on exposed parts of body.
Usually heal with treatment
Diabetic Ulcer
It is a nonspecific ulcer due to ischaemia, neuropathy and infection (Wet gangrene)
Commonly occurs in foot – over the heads of metatarsals.
Foul smelling discharge with slough
Loss of sensation.
Normal peripheral pulsations.
Managed by debridement, antibiotics and controlling the blood sugar levels.
VAC therapy is helpful following wide debridement
Signs of diabetic neuropathy
- Loss of sensation
- Loss of sweating
- Loss of muscle strength
- Loss of curvature of foot
-Loss of normal joint position
- Loss of elasticity of skin
Sequence of events in diabetic ulcer foot
- Following injury or infection ulcer develops with oedema and swelling of foot – Stages of
cellulitis.
- Infection takes virulent course, spreads to deeper fascial planes – Stage of spreding cellulitis.
- Secondary infection caused by mixed organisms along with anaerobes and non-clostridial gas
forming organisms produce multiple abscess – Stage of abscess.
 - Tense oedema along with vascular compression produce ischaemia and gangrenous patches of
skin, toes etc., - Stage of gangrene or untreated cases may develop gangrene of the limb with
septicaemia and diabetic keto acidosis –Stage of septicaemia.
- In cases with chronic ulcer, infection involves the bone results in osteomylitis – Stage of
osteomylitis.
Investigations :
CBP
Blood and urine sugar estimation
Pus for c/s
X-ray foot to rule out osteomylitis
LFT, ECG, X-ray chest, Blood urea and serum creatinine
Treatment :
1. Control of diabetes with plane insulin given 3 to 4 times per day depending upon requirement.
2. Control of infection after c/s commonly gram positive, gram negative and anerobic infection.
Triple antibiotics may be given for long time.
3. Local treatment of diabetic ulcer – It is a non-healing ulcer. Initial treatment is
debridement/dressings with iodine solution until the ulcer is converted into a healing ulcer with pink
granulation tissue.
4. Later the ulcer is covered with split thickness skin graft.
Care of the patient : Treat for nutritional deficiencies, preventive care for development of bed
source, chest infection and water and electrolyte depletion.
5. Revascularisation of foot in diabetic patients –
- If angiography shows short stenotic lesion, balloon angioplasty with or without stent placement is
the treatment of the choice.
- Infrainguinal bypass surgery – If there is block present in the posterior tibial or anterior tibial
arteries present, a bypass surgery using long sephenous vein between poplital to tibial or pedal
artery can be performed.
- Even after successful surgery amputation rate is 35% and two year patency rate is around 70%.
Public education to protect the diabetic foot (Remember ‘BEARFOOT’
Bearing foot waling should be avoided. Use microcellular rubber shoes. Keep the foot dry after
proper cleaning. Paring of the nails and trimming should be done carefully. If infection occurs
consult physician at the earliest.
Avoid herbal/local ointment application
Regular and Rigorous control of diabetes with diet
Exercises
Foot care – dry, frequent cleaning and corn care
Oxygenation to toes/foot, proper shoes (MCR)
Trimming of nail should be done carefully
Cause of death in diabetic ulcer
 Ketoacidosis with septicaemia.
 Severe electrolyte abnormalities.
 Silent myocardial infarction.
Treatment of Spreading ulcer :
After obtaining pus culture/sensitivity report, appropriate antibiotics are given. Many solutions are
available to treat the slough, such as hydrogen peroxide and Eusol.
 Hydrogen peroxide (diluted) when poured over the wound, liberates nascent oxygen which
bubbles out and helps in separating the slough. Eusol1 also separates the slough.
There are reports that H2O2 and Eusol can cause more damage. Hence, they are no longer
used.
 Partially separated slough needs to be removed by excision daily or on alternate days, in
the wards.
 Excessive granulation tissue or pouting granulation tissue (pround flesh) needs to be
decapitated by excision or by application of copper sulphate or silver nitrate solution.
By repeated dressings, slough gets separated and discharge becomes minimal, resulting in a
healing ulcer with healthy red granulation tissue.
 Once, the floor is completely covered with red granual tissue, a swab is taken for c/s.
If the discharge is negative for streptococcal infection, a split thickness skin grafting is
applied for rapid healing.
Treatment of healing ulcer :
 I will do daily dressings with antiseptic solutions such as betadine or silver sulphadiazine
ointment.
 A swab is taken to rule out the presence of Streptococcus haemolyticus.
 If the swab is negative for Strepotococcus haemolyticus infection,
o If the ulcer is small, it healed by itself with epithelialisation from the margin of the
ulcer.
o If the ulcer is large, split skin graft is applied for rapid healing.
o If the discharge is positive for strepotococcus, I will treat the infection with
antibiotics (Penicillin or capholosporins) for a period of 5-7 days.
 o Then I will take swab for c/s, if it is negative, then I will apply split thickness skin
graft.
Advantages of Split thickness skin graft:
 Wound healing occurs fast
 Secondary infection is avoided because early skin cover
 It prevents contractures
 Pain is lessened
 It prevents Marjolin’s ulcer
Treatment of chronic ulcers
 These ulcers results from chronic ischaemia - to improve blood supply to the area I will treat
the ulcer with infrared radiation or short-wave therapy or ultraviolet rays.
 To accelerate epithelisation, I will cover the wound with amnion.
 To decrease the size of the ulcer, I will apply VAC (Vacuum Assisted Closure) therapy.

EXAMINATION OF AN ULCER
Definition
An ulcer is a break in the continuity of the covering epithelium – skin or mucous membrane.
It may either follow molecular death of the surface epithelium or its traumatic removal.
Name: __________________________ Age________________ Sex__________________
Occupation :_________________________Address_______________________________

Complaint and duration:

Ulcer over the left foot – 15 days duration
Pain :15 days
History of present complaint:
15 days back patient sustained injury by thorn prick (trauma)
Later patient developed swelling of the foot for which he went to a local doctor who gave some
medicines.
But the swelling increases in size and extended to the leg with development of blackish spots over
the dorsum of the left foot. Then he came and joined in this hospital for which a underwent surgery
leaving this ulcer.
Patient complaints of continuous throbbing type of pain which radiate along the leg relieved on
elevation of the foot and aggravated on elevation of the limb.
Patient is a known diabetic and hypertensive (enquire about diabeties and hypertension)
No history of fever.
Bowels and mixturation normal.
Appitate good
Past history
Patient is known diabetic taking treatment (Enquire about any previous illness that require
admission or treatment in hospital)
Personal history:
Patient married living with wife and children.
All are healthy.
Patient habituated for smoking, 2 cigars per day since 5 years.
Patient is used to take alcohol once in a week about 100 cc per day since10 years.
(For female patients – Note menstrual history) – Periods are regular, flow moderate, last for 3 days,
no clots, no pain)
Family history :
All family members are alive.
No members of the family suffered with diabetes, hypertension or chronic diseases
Drug history :
Patient is not allergic to any known drugs.
 PHYSICAL EXAMINATION
Patient is moderately built, moderately nourished, no anaemic, no jaundice
Oral cavity – Tongue - moist and pink
Oral mucosa – Moist, pink and healthy
All teeth are present, gums are healthy
Pulse : 70/min. Regular, volume, tension, normal vessel wall not thickened (if patient is less than 40
years. Vessel wall is thickened if patient is more than 40 years)
BP : 130/90mm of Hg (If patient is more than 40 years)
120/80 (if patient is less than 40 years)
Respiratory rate : 18/min Regular (Thoraco abdominal in case of females).
(Abdomo thoracic in case of males).
SYSTEMIC EXAMINATION
Cardiovascular system : Apex beat is palpable at 5th intercostals space on left side lateral to mid
clavicular line.
1st and 2nd heart sounds are normal.
No murmus are heard.
Respiratory system :
Chest is moving equally with respiration.
Bilateral vesicular breath sounds are heard.
No advantious sounds are heard.
Central Nerve System :
Patient is conscious and coherent.
Pupils are normal in size and shape, normally re-acting to light.
No neurological deficit.
Gait is normal.
Gastrointestinal system :
Abdomen is full moving with respiration.
No mass, peristalsis, pulsations are visible.
On palpation abdomen is soft.
No mass is palpable.
No hepato-splenomegaly.
LOCAL EXAMINATION
Inspection :
Number – Single
Shape and size – Irregularly oval in shape, measuring horizontally 15 cms. vertically 10 cms.
Site and extent – Present over the dorsum of Left foot extending 2 cms. above the toe line and 3
cms. below the ankle joint.
Margin – Margin is red in colour.
Floor – Floor is covered by red granulation tissue.
Surrounding area – Healthy and pigmented
Palpation : On palpation, there is no local raise of temperature.
Tenderness – Present.
Inspective findings like number, shape, size, site, extent are confirmed.
Edge is sloping
Margin, edge and base are not indurated.
Mobility - The ulcer is slightly mobile over the underlying structures.
Discharge – Slight serous discharge present.
The ulcer bleeds on touch.
Examination of arterial system – Femoral artery, poplitial artery, posterior tibial artery, anterior
tibial artery and dorsalis pedis artery are palpable.
Examination of venous system –There is no varicose veins.
Examination of lymphatic system – There is no lymph nodes are palpable in inguinal region.
(If lymph nodes are palpable, note – Number, size, tenderness and mobility)
Examination of nervous system – Movements of joints are normal.
Touch and temperature sensation are normal.
Pin-prick sensation is normal
Joint sensation is normal
Provisional diagnosis – Non-specific – Healing ulcer over the dorsum of left foot due to diabetes.
Investigations – Blood – Fasting and postprondial blood sugar levels.
Blood urea and serum creatinine.
HB, TC, DC
X-ray chest PA view
X-ray left foot AP and lateral views to know regarding osteomylitis of bones.
ECG
Culture & sensivity of secretions from the ulcer.
Management- I will control blood sugar by plain insulin.
I will do daily dressings with normal saline to keep hydration of the granulation tissue.
If the culture swab is negative for streptococcal infection, as the ulcer is very large and take long
duration for healing so, I apply partial thickness (Therish graft) skin graft to cover the wound.
If the culture is positive for streptococcal infection, I will treat the infection with sensitive antibiotics
for a period of 5-7 days. Then once again I will take c/s if the wound is negative for streptococci,
then I will apply skin grafting.
(Streptococci produces streptolysins which will destroy the graft. So, presence of streptococcal
infection is a contraindication for skin grafting.