o Hyperchloraemic acidosis
EPIDIDYMAL CYST
R: reducability, relationship to each other
11. DERMOID CYST Inspection
Usually single Ovoid / spherical Site: o Congenital, 1-2 cm usually
Along lines of fusion of ophthalmic & maxillary facial processes Inner & outer ends of upper eyebrow
o Acquired, 0.5-1 cm usually
Beneath skin likely to be injured e.g. fingers Scars often present
Palpation
Not warm, maybe tender if infected Smooth surface, Well-defined margins Consistency
o Congenital: Soft (not tense / hard)
o Acquired: Hard & tense (sometimes stony hard) Fluctuant (if large)
Mobile over deeper tissues
o Deep to skin, in subcutaneous tissue
i. Congenital: Not attached to skin or underlying structures ii. Acquired: may be tethered to scar
Background Information
A dermoid cyst is a cyst deep to the skin, lined by skin 2 different methods of formation:
o Congenital: Accident during antenatal development
o Acquired: Implantation of skin into subcutaneous tissue by injury
Clinical features
Congenital (suspect if in child, young adult)
o Formed intra-utero, when skin dermatomes fuse
o Occur at any point in mid-line, common in neck / face / nose
Particularly along lines of fusion of ophthalmic & maxillary facial processes Also: inner & outer ends of upper eyebrow
o May be seen at birth
o Distends a few years later, becomes obvious; few symptoms other than cosmetic problems o Rarely infected
Acquired – Implantation dermoid (suspect if in adult – Browse pg 60)
o Develop when piece of skin survives after being forcibly implanted into subcutaneous tissue Often by injury: cut, stab, etc.
o Symptoms
Small, tense lump
Painful and tender (in areas subjected to repeated trauma) Local effects (e.g. problems with grip / touch if on finger) Also rarely infected
o Differentials
Sebaceous cyst (look for old injury, presence of scar near cyst: more likely dermoid)
Treatment
Congenital
o Surgical treatment; complete excision
o Full extent should first be established with X-ray / CT
Midline cysts may communicate with CSF; must exclude bony defect Acquired
o Complete excision of cyst “Ms. X is a young Chinese girl…”
“On inspection, there is a single ovoid lump just above the lateral edge of the left eyebrow” “It measures 3 by 2 cm”
“There are no scars, ulceration, or discharge seen, nor any overlying or surrounding skin changes)” “On palpation, the overlying skin is not warm. It is non-tender.”
“The surface is smooth, with clearly-defined margins” “The consistency is firm, and it is fluctuant”
“The lump is not attached to the overlying skin nor underlying tissues.” “It is fully mobile in all directions.”
“My provisional diagnosis is a congenital dermoid cyst” “My differentials are: sebaceous cyst, lipoma”
12.
SEBORRHOEIC KERATOSIS
(Senile wart / seborrhoeic wart / verruca senilis / basal cell papilloma)Inspection
Often multiple
Any part of skin; most found on back & face Round / oval
Light brown → black
“stuck on appearance”;; appears warty Varying size; Few mm to 2-3 cm Distinct margins
Palpation
No warmth, no tenderness
Rough surface (sometimes papilliferous) More firm than surrounding skin
Attached to skin Special tests
o May be picked off gently – reveals patch of pale-pink skin, 1-2 surface capillaries (bleed slightly) (DON’T DO THIS IN EXAM)
Request to look for similar lesions elsewhere
Background Information
Benign outgrowth of basal layer of epidermis
o Raised above the level of normal epidermis Microscopy:
o Hyperkeratosis (thickening of keratin layer) o Acanthosis (thickening of prickle cell layer) o Hyperplasia of variably pigmented basaloid cells
Clinical features
Occur in both sexes
More common in elderly people Begin as a patch,
o increases in area, size over months / years o May not increase in thickeness
o May suddenly fall off: leave pale-pink patch of skin Complications:
o May become disfiguring, catch on clothes
o May get infected (may imitate SCC, pyogenic granuloma) o Seldom bleeds (may cause it to change colour to brown)
Leser-Trelat sign: Sudden onset of multiple seborrhoeic keratoses may imply visceral malignancy
Treatment
Non-surgical
o Can be left alone as it is benign Surgical – for cosmetic reasons, etc.
o Superficial shaving (lies above level of normal epidermis) o Cautery
“Mr. X is an elderly Chinese gentleman…”
“On inspection, there is a single ovoid lesion lump on the back” “It measures 1 by 2 cm”
“The margins are well-defined, and it appears to be slightly raised above the skin” “There are no scars, ulceration, or discharge seen, nor any surrounding skin changes” “On palpation, the overlying skin is not warm. It is non-tender”
“The surface is rough and greasy; the consistency is firm” “The lump arises from the skin”
“My provisional diagnosis is seborrhoeic keratosis” “My differential diagnosis is: pigmented naevus, melanoma” “I would like to complete my examination by…”
“Looking for similar lesions elsewhere”
13. HAEMANGIOMA
Background Information
Vascular malformations o Types
Capillary: ⅔ of cases, include the cutaneous haemangiomata, telangiectasias Predominantly venous: venous angioma
Deeper levels of subcutaneous tissue, may extend into muscle / joint May have distended veins over the surface of the mass
Empty with pressure, may have bruit Predominantly lymphatic: lymphangioma circumscriptum o Features
Develop as abnormal proliferation of embryonic vascular network Hamartomas
May ulcerate, induce hyperkeratosis in overlying stratum corneum Many forms of cutaneous haemangiomata: (see table)
o Strawberry naevus (cavernous haemangioma) o Port-wine stain (naevus vinosus)
o Spider naevus
o Campbell de Morgan spot
Strawberry Naevus Port-Wine Stain Spider Naevi Cambell de Morgan Spot Inspection
Site (can be anywhere) Head & Neck Lips, face, mucous membranes of mouth, shoulders, neck, buttock Upper torso, head and neck (drainage of SVC) Trunk (bilat) – upper > lower Occasionally on limbs Number May be multiple Usually single Usually multiple Usually multiple
Colour Bright red / dark red Purple-red Bright red Dark red / deep purple
Size Variable; 1-10 cm Variable Variable; few mm 1-3 mm
Edge Well-defined Well-defined – Well-defined
Shape Sessile → pedunculated as they grow larger Variable Variable Circular, may be raised
Skin
Changes of ulceration with scabs May have small areas May have dilated subcutaneous veins around lesion – –
Palpation
Surface smooth, pitted epithelium Irregular, covered with Smooth – Smooth
Consistency Soft – – –
Mobility Mobile – – –
Relations Confined to skin – – –
Special Tests
Compressible: pressure squeezes mass, leaves it
collapsed: slowly refills Not pulsatile
– Compressible, fade completely –
Background Information
Age Infants (congenital) Infants (congenital) – Middle-age → elderly
Gender ♂ = ♀ – – –
Symptoms • Cosmesis • May ulcerate, bleed on trauma • Cosmesis • Bleeding may occur – • Cosmesis • Non-tender
Pressure • Collapses on pressure • Diminishes colour but doesn’t revert to normal • Branches fade when arteriole compressed • Fade slightly
Remarks Regress spontaneously (few months – 3 years)
• Extensive, intradermal • Present from birth, does not change in size
• Sturge-Weber syndrome: facial PWS with corresponding haemangioma in brain – contralateral focal fits • Found in limbs when a/w Klippel-Tranaunay Syndrome
• Form of telangiectasia • Dilated skin arteriole feeding small branches (leaving radially) • Increase in number • Associated with pregnancy, chronic liver disease (> 5) – request for abdominal examination
• Formed by collection of dilated capillaries fed by single / small cluster of arterioles • Have appearance of drops of sealing wax
• No clinical significance
Pictures
Also
Telangiectasias
o Dilatation of normal capillaries o Can be secondary to irradiation
o Can be part of hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) Autosomal dominant disease
Overt and occult haemorrhage can present as haematuria, haematemesis, melaena, epistaxis, iron-deficiency anaemia
Vin rosé patch
o Congenital intradermal vascular abnormality
o Mild dilatation of vessels in sub-papillary dermal plexus o Can occur anywhere, gives skin pale-pink colour
o Associated with other vascular abnormalities (e.g. haemangiomata, AV fistulae, lymphoedema) o Usually not disfiguring