SURGERY (SWELLINGS TOPICS)

1. DERMOID CYST
&
ABSCESS
BY: NITHIN PRABHAKAR
4TH YEAR MBBS
MIMS

2. A cavity lined by Epithelium containing
desquamated cells
CONTENTS: mixture of sweat, sebum,
desquamated epithelial cells, hair follicles
SITES: along the lines of embryonic
fusion(midline of the body or face)

3. CLINICAL TYPES:
A. Congenital/sequestration dermoid:-
External and internal angular dermoid (along
the fusion of front-nasal and maxillary
processes)
Sublingual dermoid
Pre- auricular & post-auricular dermoids
B. Tubulo-dermoids
C. Implantation dermoids
D. Teratomatous dermoids

4. A. SEQUESTRATION DERMOID:
PATHOGENESIS:
1
• DURING EMBRYONIC FUSION DERMAL CELLS GET SEQUESTRATED
IN THE SUBCUTANEOUS PLANE
2
• THESE CELLS UNDERGO PROLIFERATION AND LATER UNDERGOES
LIQUEFACTIVE NECROSIS RESULTING IN THE FORMATION OF THE
CYST
3
• THE CYST SLOWLY GROWS N INDENTS THE MESODERM -BONY
DEFECTS

5. CLINICAL FEATURES:
AGE OF ONSET: presents in the 2nd or 3rd decade
of life
Swelling is insidious in onset & gradually
progressive
Smooth, soft ,non-tender swelling
Skin over the swelling is pinchable
Paget’s test: +ve
Method: fix the swelling with two fingers(watching
fingers) summit is indented with the index
finger of other hand(displacing finger)yeilding
sensation over the watching fingers

6. Swelling is fluctuant in nature
Transillumination test: -ve
Cough impulse : may be present if the swelling
has intracranial extension
Resorption & indentation of bone beneath the
swelling
DIFFERENTIAL DIAGNOSIS:
LIPOMA
SEBACEOUS CYST
BURSITIS

7. INVESTIGATIONS:
Blood: Total count, differential count ,Hb% ,
ESR
Fine needle aspiration cytology (FNAC)
X-RAY: reveals resorption and indentation of
the underlying bone
CT-SCAN: to indentify the size,shape& local
spread of the swelling

8. TREATMENT:
Excision under general anesthesia . Often
neurosurgical approach is required by raising
the osteocutaneous flaps of the cranium

9. B. TUBULODERMOIDS:
Arises from the embryonic tubular structures
Pathogenesis : Increased secretions from the
lining epithelial cells of the ectodermal tube
accumulation of the secretions  foramtion of
swelling
Examples: thyroglossal cyst, ependymal cyst,
postanal dermoid

10. C. IMPLANTATION / ACCQUIRED DERMOIDS:
Seen in individuals like tailors,gardeners who
sustain repeated minor injuries
Sites: fingers,toes,feet
Minor trauma epidermal cells gets buried in
the subcutaneous space cyst formation
Signs: painless,soft ,smooth,adherent to skin,
tensely cystic,mobile swelling
Managed by surgical excision under local
anaesthesia

11. D. TERATOMATOUS DERMOID:
A benign or malignant tumor arising from all
the germ layers consisting of
hair,teeth,cartilage, sebum and muscle
Occurs in the testis, ovaries,mediastinium or
retro peritoneum
COMPLICATIONS OF DERMOIDS:
INFECTIONS
RUPTURE AND PRESSURE EFFECTS
CALCIFICATION
SURFACE ULCERATION

12. Implantation & teratomatous
dermoids

13. It is the collection of pus within the body
Mainly of four types:
i. Pyogenic abscess
ii. Pyaemic abscess
iii. Metastatic abscess
iv. Cold abscess

14. PYOGENIC ABSCESS:
It is the most commonest variety of abscess
usually resulting from cellulitis or lymphadenitis
Etiopathogenesis:
Pathogens: staphylococcus aureus streptococcus
pyogenes ,anaerobes
Mode of infection may be direct,
haematogenous,lymphatics or by extension from
the adjacent tissue
Organisms enter the tissue activation of
immune cells release of mediators and
lysozyme destruction of cells and release of
proteinsfibrin deposition formation of pus and
pyogenic membrane

15. CLINICAL FEATURES:
Patient presents with fever associated with chills
and rigors, throbbing type of pain over the
swelling(
 Localised,red,tender,warm,soft,smooth swelling
Visible pus & brawny indurations around the
swelling
Fluctuation: may or may not be present
DIFFERENTIAL DIAGNOSIS:
Haematoma
Sarcoma
Aneurysm?
cold abscess

16. PYAEMIC ABSCESS:
 These are generally multiple in number
 This condition is caused when an Infective emboli
circulating in the blood gets lodged in multiple places
in the body n thus leading to abscess formation
 These emboli contain bulk of organisms derived from
an infective focus such as vegetations of the valves ,
thrombus, skin bones
 The peculiarity of these abscess is that they lie in the
subfascial plane(deeper lesions)& do not present the
features of common abscess
 They are non reacting but the constitutional symptoms
like weakness, weight loss ,fatiguability are severe
 Managed by evaluating the focus of infection,
antibiotic therapy & drainage of surface abscess if any.

17. NOTE THE MULTIPLE LESIONS.

18. METASTATIC ABSCESS:
These occurs as a spread from other abscess
Ex: lung abscess spreading to the brain
COLD ABSCESS:
These are non reacting abscess caused due to
chronic inflammation usually secondary to
tubercular infection
Caeseation of the lymph nodes, bones abscess
formation
Sites: commonly around the neck,axilla.
also seen around the loin , back(pot’s
spine),chest wall

20. INVESTIGATION
• Blood: Total count will be elevated
Differential count (lymphocytic elevation
suspect TB)
• Urine examination for presence of Glucose
• Chest X-RAY in cases of lung abscess
• USG Abdomen done as and when required
• CT SCAN to identify the number size and
shape of the abscess
• And other investigation relevant to the organ
is done(eg.LFT for liver abscess)

21. MANAGEMENT:
• Medical management: Broad spectrum Antibiotic
therapy is started
• Surgical management:-
. Incision and drainage of the abscess by HILTONS
METHOD
PROCEDURE:
1) The abscess is draped, cleaned using a sterile swab,
presence of pus confirmed by aspirating the abscess
2)Under general or regional block anaesthesia,an
incision is made parallel to the nuerovascular bundle
using a No.11 blade

22. 3) The pyogenic membrane of the abscess is
ruptured using a sinus forceps and the pus is
collected in kidney tray.
4) With the little finger the loculi is inspected for
remant purulent material
5) The abscess cavity is injected with normal saline
and a drain like roller gauge is placed.
6) The wound is left open, which later heals by
formation of granulation tissue

24. COMPLICATIONS:
• Bacteremia,Septicemia and pyemia
• Multiple abscess formation
• Sinus and fistula formation
• Pressure effects over the underlying structures
• Antibioma formation: This is typically seen in
case of breast abscess.
• Metastasis to other organs

25. MOTIVATIONAL QUOTE?
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