10 Care of the Acutely Injured
BENIGN TUMORS Adenoma
It arises from secretory glands, e.g. thyroid, parathyroid, breast. If an adenoma contains large amount of fibrous tissue, it is called fibroadenoma (commonly seen in breast).
If an adenoma has multiple cystic spaces, it is called as cystadenoma (seen in parotid, thyroid, pancreas, ovaries).
If an adenoma arises from secretory glands of mucous membrane, it is likely to be pedunculated (rectal polyp).
Fibroma
It is a benign tumor arising from fibrous connective tissue. A pure fibroma is rare and is mostly combined with other mesodermal tissues, e.g.
Nerve sheath - Neurofibroma Glandular tissue - Fibroadenoma
Fat - Fibrolipoma
Muscles - Fibromyoma
A fibroma can be soft or hard depending upon proportion of fibrous tissue with other cellular tissue.
Papilloma
It is a benign tumor arising from epithelial surface (skin or mucous membrane). It consists of a central core of connective tissue containing lymphatics and blood vessels that is covered with epithelium. The surface may be rough or made of finger like projections. Depending upon its location, the surface epithelium can be:
• Squamous cell (skin, tongue, lip, cheek)
• Columnar cell (small and large intestine)
• Transitional cell (urinary bladder) A papilloma of skin is of two types:
Squamous Cell Papilloma It has four varieties:
a. Congenital papilloma: It is present since birth and is seen as brownish warty growth.
b. Soft papilloma: It is often seen on eyelids, neck and face of elderly people. It forms pedunculated, soft, fleshy skin tags.
c. Keratin horn: It is also seen in old people and is due to excess keratin formation .
d. Infective papilloma: It is due to viral infection caused by Verruca vulgaris. It is common in children and RK Karwasra, Sanjay Marwah
young adults. It is usually seen at sites that are prone to trauma, e.g. beard area, hand, feet and genitals.
It appears as small, pigmented nodules that unite to form frond-like surface. Most of the warts may disappear spontaneously.
Basal Cell Papilloma
(Senile warts, Seborrheic keratosis)
It is a benign tumor due to overgrowth of basal layer of epidermis. They appear as raised, brownish warts over face, neck and shoulders in elderly people. They gradually increase in size but not in thickness. They may fall off spontaneously.
Treatment
Papillomas usually need surgical excision due to cosmetic reasons.
Lipoma
It is the most common benign tumor arising from fat cells of adult type (Box 11.1B).
It can occur anywhere in the body where fat is present, hence named universal tumor.
The most common sites are nape of neck, abdominal wall and thighs.
There are three types of lipoma:
Encapsulated Lipoma
Commonest variety present in subcutaneous tissue. The patient presents with painless slow growing swelling of long duration (Fig. 11.1).
• On examination, there is a soft smooth and lobulated swelling.
• Slipping sign: If edge of the swelling is pressed, it slips under the finger. It is pathognomonic sign of lipoma and differentiates it from a cyst.
• Pseudo-fluctuation: A sense of fluctuation may be obtained since fat at body temperature behaves like fluid.
• Pseudo-transillumination: The swelling may trans-illuminate due to presence of clear fat.
• The swelling is free from overlying skin and freely mobile over underlying structures.
• Sometimes the swelling may become pedunculated.
Diffuse Lipoma (Fig. 11.2)
It is a rare variety and does not have characteristic features of lipoma hence called as ‘pseudolipoma’. It is overgrowth of fat and does not have a capsule. It usually presents as a diffuse swelling at nape of the neck.
Multiple Lipomas
Sometimes subcutaneous lipomas are multiple and painful due to presence of nerve tissue (neurolipomas).
Fig. 11.2: Diffuse lipoma at back of thigh Fig. 11.1: Encapsulated lipoma at nape of the neck
Box 11.1B: Lipoma
• Benign tumor arising from fat cells
• Universal tumor (except cranial cavity)
• Commonest site—nape of neck, abdominal wall
• Soft, smooth, lobular swelling
• Slipping sign present
• Pseudofluctuation present
• Pseudotransillumination present
• Treatment—surgical excision
• Lipoma in thigh or retroperitoneum may undergo malignant change
The condition is known as adiposis dolorosa or Dercum’s disease.
Lipomas are also classified according to their anatomical plane:
i. Subcutaneous: Commonest variety with charac-teristic features described above.
ii. Subfascial: It is difficult to diagnose because overlying fascia masks the lobulations and negates the slipping sign. Long standing subfascial lipoma deep to epicranial aponeurosis can erode the underlying bone.
iii. Intermuscular: Commonly seen in thigh and becomes fixed on muscle contraction.
iv. Submucous: Occurring under mucous membrane, e.g. in the tongue (causes macroglossia), in the larynx (causes respiratory obstruction).
v. Subserous: Occurring beneath pleura or in retroperitoneum. It may attain enormous size without causing any symptoms due to presence of potential space.
vi. Extradural: It is a rare spinal tumor presenting with cord compression. Intracranial lipomas do not occur due to absence of fat in the cranial cavity.
vii. Intraglandular: Lipoma occurring within the glands, e.g. breast, pancreas, beneath renal capsule.
viii. Lipomas in relation to bones and joints, e.g.
Subperiosteal
Subsynovial
Intra-articular Complications
Long standing lipomas may undergo:
• Myxomatous degeneration
• Saponification
• Calcification
Large sized lipoma in thigh or retroperitoneum may undergo malignant transformation into liposarcoma.
The swelling starts growing rapidly in size and becomes painful. Overlying veins become dilated and surface becomes warm due to increased vascularity. If untreated, overlying skin may ulcerate and fungate due to rapidly growing tumor.
Treatment
Lipoma is treated by surgical excision. Aim of surgery is to take care of cosmetic disfigurement and to prevent complications.
Neuroma
Benign tumor of nerve is called neuroma. Based on site of origin, they are of two types:
True Neuromas
They are very rare and arise from sympathetic nervous system. They develop from neural crest and their distribution is shown in Box 11.2.
False Neuromas
They are benign tumors arising from nerve sheath. This group includes:
i. Neurilemmoma ii. Stump neuroma iii. Neurofibroma
i. Neurilemmoma (Schwannoma): It is a benign tumor arising from Schwann cells. Commonest site of involvement is acoustic nerve. It produces a soft, whitish, lobulated mass that displaces the nerve from which it arises. It can be safely removed without damaging the nerve of origin.
ii. Stump neuroma: After limb amputation, the end of a divided nerve forms a fusiform swelling due to proliferation of nerve fibers. It is also called as
‘Amputation neuroma’. It can cause numbness, tingling and severe neuralgic pain due to pressure by prosthesis or nerve entrapment in the scar.
Treatment is excision of neuroma. However, it can be prevented if nerve is divided at a higher level than the site of amputation. Other causes of neuralgic pain due to nerve compression are shown in Box 11.3.
iii. Neurofibroma: It arises from the connective tissue of nerve sheath (endoneurium). It can appear at any age but usually presents in adult life. As nerve fibers pass through the tumor, so tumor cannot be removed without damaging the nerve (c/f neurilemmoma). It has following types:
Localized Neurofibroma
• It is usually seen in subcutaneous tissue.
• It mostly involves peripheral nerves (ulnar or median nerve) or cranial nerves (acoustic neuroma).
• It produces a fusiform swelling in direction of nerve.
• Mostly asymptomatic, but patient may complain of paresthesia, numbness and pain in distribution of the nerve.
Box 11.2: True neuromas
Box 11.3: Causes of nerve compression
• Stump neuroma
• Cervical rib syndrome
• Carpel tunnel syndrome
• Elbow tunnel syndrome
• Tarsal tunnel syndrome
• Morton’s metatarsalgia
• On examination, there is ‘tender subcutaneous nodule’ that is firm, smooth and circumscribed.
• The swelling typically moves at right angle to the direction of nerve and fixed in the direction of nerve.
• The area of distribution of affected nerve should be examined for sensory and motor weakness.
• Complications: Box 11.4.
• Differential diagnosis: Box 11.5A.
• Treatment: Asymptomatic neurofibroma should be left as such since excision will always lead to the damage of involved nerve. Indications of excision are:
Cosmetic deformity.
Symptomatic; causing severe pain and par-esthesia.
Rapidly growing (? Sarcomatous change).
Box 11.4: Complications of neurofibroma
• Sensory and motor weakness
• Deafness (Acoustic neuroma)
• Paraplegia (Dumb-bell tumor pressing spinal cord)
• Cystic degeneration
• Sarcomatous change
Box 11.5A: Differential diagnosis of neurofibroma
• Lymph node (in neck, multiple)
• Dermoid cyst (in midline)
• Sebaceous cyst (skin adherent)
• Lipoma (slipping sign)
• Hemangioma (skin discoloration, compressible)
• Ganglion (see Box 11.5B)
The swelling should be completely excised to prevent the risk of recurrence.
Generalized Neurofibromatosis (von Recklinghausen’s disease)
• Multiple neurofibromas are seen involving various parts of the body (face, neck, trunk and limbs) (Fig. 11.3).
• It is an autosomal dominant disease and runs in the families.
• It may involve peripheral, spinal and cranial nerves.
• There may be associated pigmentation of skin called Cafe-au-lait spots. It is so named because its appearance resembles color of coffee diluted with milk (Fig. 11.4).
• One or more neurofibromas may undergo sarco-matous change.
• Treatment: Treatment is ‘wait and watch’ policy since excision of so many swellings is not possible.
Sometimes, one or more swellings may need excision if there is:
neurological deficit (e.g. pressure on spinal cord).
Severe pain.
Suspicion of malignant change.
• von Recklinghausen’s disease of bone is a separate entity (Box 11.6).
Box 11.6: von Recklinghausen’s disease A. Generalized neurofibromatosis
Multiple neurofibromas
Cafe-au-lait spots
B. von Recklinghausen’s disease of bone
Osteitis fibrosa cystica
Parathyroid adenoma causing hyperparathyroidism
Pathological fractures and renal stones Plexiform Neurofibromatosis
• There is ‘myxofibromatous degeneration’ of endo-neurium so that affected nerve becomes enormously thickened (Fig. 11.5).
• It usually involves branches of 5th cranial nerve (Trigeminal nerve) in area of face and scalp.
• The affected skin of face becomes thick, edematous, pigmented and adherent causing severe cosmetic deformity.
Box 11.5B: Ganglion
• Cause—myxomatous degeneration of tendon sheath or synovial lining of joint space.
• Site—commonly on wrist (dorsum of hand).
• Presentation—painless, smooth, tense cystic swelling containing gelatinous fluid.
• Mobile side to side (at right angle to tendon)
• Mobility gets restricted on contraction of the tendon
• Treatment
No treatment for asymptomatic ganglion.
Spontaneous rupture may cure it.
Needle aspiration and intra-lesional injection of hylase and kanacort (steroid).
Surgical excision should be avoided due to risk of recurrence.
Fig. 11.4: Cafe-au-lait spots
Fig. 11.3: Generalized neurofibromatosis
Fig. 11.5: Plexiform neurofibromatosis
• As it grows in size, the involved skin starts hanging down in pendulous folds (Pachydermatocele).
• The hanging skin folds can obstruct the vision.
• As a rule, the skin is covered with hair unless repeated friction causes skin ulceration and scarring.
• Treatment is staged excision. However, it is difficult and should be performed by a plastic surgeon.
Elephantiasis Neuromatosa
• It is advanced and severe form of plexiform neurofibromatosis.
• It usually affects lower limbs.
• The skin is coarse, dry and thickened. The subcutaneous tissue is also greatly thickened and fat is replaced by fibrous tissue.
• The appearance resembles elephant’s hide and the patient finds walking very difficult.
• Differential diagnosis: Filarial elephantiasis (involves lymphatics).
Hemangioma: See Chapter 12—Cysts and Neck Swellings.
Lymphangioma: See Chapter 12—Cysts and Neck Swellings.
Hamartoma: See Chapter 12—Cysts and Neck Swellings.
Benign melanoma (Pigmented nevus):
• These are benign tumors arising from melanocytes (Figs 11.6 and 11.7).
• Melanocytes are derived from neural crest and are present in basal layer of epidermis.
• Proliferation of melanocytes produces pigmented nevus. It has following types:
i. Lentigo: It is present only in basal layer of epidermis.
ii. Junctional nevus: It is localized aggregation of melanocytes projecting into dermis. It appears as a brownish black, localized and slightly raised lesion anywhere on the body. It can undergo malignant change.
iii. Dermal nevus: It is present entirely in the dermis.
It is mostly seen on face as ‘hairy mole’. It is a pigmented, dome shaped, soft, smooth lesion. It never undergoes malignant change.
iv. Compound nevus: It is combination of both junctional and dermal nevus. It is usually seen in adults as a pigmented, rounded and elevated
lesion. Its junctional component is prone to malignant change.
v. Blue nevus: It is seen on face, dorsum of hand and foot in babies. It is darkly pigmented and due to presence of overlying thin normal epidermis, it looks shiny and blue in color. Very rarely, it may undergo malignant change.
vi. Congenital nevus:
A. Hairy mole: Common variety and does not change to malignancy.
B. Giant lesion: It may cover 25% or more of body surface area as irregular pigmentation.
It can undergo malignant change (Fig. 11.8).
vii. Hutchinson’s melanotic freckles: These are seen as dark pigmented, smooth and flat lesions in elderly persons on sun exposed areas (face and neck).
These have high incidence of malignant change (Fig. 11.9).
Fig. 11.6: Pigmented nevus infra-orbital region
Fig. 11.7: Pigmented nevus forehead
Treatment of Pigmented Nevus Surgical excision. Indications are:
• Cosmetic reasons.
• Nevus exposed to repeated trauma, e.g. cuts during shaving, rubbing by clothes (belts, brassier, etc.).
• Suspicion of malignant change.
The excision should involve 2 mm of healthy skin margin and the specimen should always be sent for histopathological examination to rule out malig-nancy.
Other Benign Tumors in Head and Neck Region Turban Tumor (Cylindroma)
• It arises from apocrine glands and is benign in nature.
• It forms a slow growing extensive swelling that covers the scalp and looks like a turban.
• Surface ulceration is uncommon.
• Treatment is cryotherapy.
Potato Nose (Rhinophyma)
The skin of distal nose becomes thickened and bluish red in color. The openings of sebaceous follicles become prominent. Rarely, it may be associated with basal cell carcinoma. Treatment is surgical excision of excess tissue (Fig. 11.10).
Keratoacanthoma (Molluscum Sebaceum)
• It is a benign tumor arising from hair follicle.
• It is mostly seen on face and neck in young adults.
• It forms a small, solitary, hard tumor in subcutaneous tissue, attached to overlying skin.
• Clinically, it resembles sebaceous cyst.
• There is central dark brown area that separates spontaneously in 2-4 weeks time and it heals with scarring.