A concise chapter on common surgical swellings. This chapter aims at educating undergraduate students.

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MOTI LAL NEHRU MEDICAL COLLEGE
S. R. N. HOSPITAL, PRAYAGRAJ
DEPARTMENT OF GENERAL SURGERY
Chapter-: SWELLINGS
TEAM-:
Dr. Sanjay Singh (DNB) [Associate professor]
Dr. Sarthak Uttam [Resident , General Surgery]

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LIPOMA
-Definition -:A cluster of overactive adipocytes .
•Tumor arising from brown fat⇒Hibernoma
• Most common benign tumor in body ⇒Lipoma
• Lipomas can occur anywhere in the body [Universal Tumor]
• Most common site ⇒Subcutaneous Lipomas
Classification
Based on Encapsulation
1. Encapsulated [Most common] - lobulated , septated , capsulated
Most common site-: neck, back, shoulder, upper limbs .
Overall most common site ⇒Trunk.
2. Diffuse non- lobulated , aseptate, non-capsulated
Also called as "pseudolipoma"
More common in alcoholics
Based on Number
1. Single
2. Multiple(5%)
-associated with MEN
- also called "lipomatosis"
- Neurolipomatosis -:painfull lipomas .
- Example.: Dercum's disease( Adiposis dolorosa) , common in females
SPECIAL TYPES-:
i) Naevolipoma-: lipoma containing dilated blood vessels .
ii) Fibrolipoma-: lipoma containing excess fibrous tissue.
iii) Lipoma arborigens.:pedunculated lipomas, common site is axilla.
CLINICAL FEATURES - :
i) Usually non tender, localised swelling of varying sizes.
ii) Symptoms may occur due to compression of adjacent/underlying structures.
iii) On palpation
- SLIP sign- edges slip under the palpating fingers (differentiates from a cyst)
- Semifluctuant- slight fluctuation due to semi-liquid state of fat under body
temperature.
- Non-transilluminant- except large lipomas.

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DIAGNOSIS-: usually a clinical diagnosis but a FNAC/incisional biopsy can be performed for
confirmation.
- USG for large sized lipomas.
- CECTG for vascular invasions.
TREATMENT-:
i) Reassurance
ii) Excision (with capsule)
COMPLICATIONS - : mostly seen in retroperitoneal, subcutaneous lipomas of thigh and buttock.
i) Myxoematous degeneration
ii) Saponification
iii) Calcification
iv) Infection
v) Ulceration
 Malignant lipomas are de-novo in origin and doesnot occur in pre-existing benign
lipomas.

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CYSTS
Definition- Any fluid filled sac which is lined by an epithelium
CLASSIFICATION
Based on lining Based on origin
True cyst False cyst 1) Congenital Cyst – dermoid cyst
2) Acquired Cyst –
Retention Distension Exudation
3) Traumatic
4) Infectious / Parasitic
1) Dermoid Cyst – These are slow growing benign lesions that arise from part of dermal or epidermal
tissue amd may contain various skin appendages
. They occur at the line of embryonic fusion
. Common sites are scalp , forehead , neck , post auricular space
. Usually asymptomatic but dermoids of the scalp may erode into skull and penetrate into brain
. Investigations- Usually a clinical diagnosis
- CT Scan to rule out any communication with underlying structures
(specially the midline dermoid)
. Clinical Feature – Smooth , soft , non- tender , fluctuant
- Paget’s test positive
. Treatment- Excision
Cyst wall is lined by
epithelium
No epithelial lining
Eg- Pseudocyst of
pancreas , a hematoma
 Acquired Cyst- a) Retention – Ranula ,
Sebacious cyst.
b) Distension – ovarian cyst
c) Exudation-Hydrocoel
 Degenerative cyst- Due to necrosis of
tumor
 Parasitic - Hydatid cyst.

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Sebaceous cyst -: is a cyst of sebaceous gland which occur due to blockage of duct of the gland
which mostly opens into a hair follicle.
 Common sites-: face,scalp and scrotum
 Never a site-:palm & soles(no sebaceous gland)
 Infective etiology-: Demodex folliculorum
Clinical features – smooth, round, palpable swelling.
-fluctuation/paget’s test positive
-transillumination negative
-a black coloured ‘punctum’ present at the opening (70% cases)
-if sebaceous gland duct opens into the hair follicle, punctum is not seen (30%
cases)
 FORDYCE SPOTS-: yellow coloured enlarged sebaceous glands in mucosa of lip and oral
cavity.
Complications-:
1) Infection- makes it enlarged and painful
2) Rupture-a painful, boggy, fungating and discharging mass => Cock’s peculiar tumour.
3) Sebaceous horn- slow discharge of sebum from a wide punctum
4) Calcification
TREATMENT-: excision with the puncta.
-if abscess forms then incision and drainage
-if cyst capsule not removed properly=> recurrence.
Glomus tumour-: is an arterio-venous communication (“GLOMANGIOMA”) surrounded by
myoepithelial cells called glomus cells.
-these arterio venous communications/shunts are called “suequet –Heyer canals”
-extremely painful because of the rich sensory nerve supply
Site- most common-> Nail bed(corium)
Others-: extremities, middle ear, carotid body tumour

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 Glomus tumour in temporal bone
Glomus tympanicum glomus jugulare (jugular bulb) glomus vagale(skull base) (middle
ear)
Clinical features- reddish blue spot(2-3mm in size)
-painful (paroxysmal digital pain)
-sensitive to cold exposure
-always a benign lesion.
Treatment- excision
Papilloma- a simple overgrowth of skin or mucous membrane with a central axis of connective tissue
containing blood vessels and lymphatics.
TYPES
True papilloma Warts
A localised overgrowth of all layers of skin -hyperkeratotic skin patches
Contains all skin appendages (cutaneous) with finger like projections.
Cutaneous mucosal SITE-finger and feet
tips,axilla,face
Squamous cell type basal cell type -oral cavity
May progress to -urinary bladder example
Squamous cell carcinoma -Rectum 1. Plantar warts
-larynx (verruca plantaris)
-gall bladder 2. Pathologist’s wart
(verruca necarogenica)
Treatment-excision,
Salicylic acid,

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Podophyllin application
Infective papilloma- treatment is excision with its base along with surrounding 1cm margin.
FIBROMA- is a tumor of fibrous tissue
. Painless , firm , circumscribed lesion which moves freely over the underlying structure
TYPES
OTB OF CONSISTENCY OTB OF FORM
HARD SOFT FIBROLIPOMA FIBROMYOMA
NEUROFIBROMA
Special types-:
i)Aggressive fibromatosis -abdominal and chest wall .
- encapsulated proliferation of fibrous tissue
ii) Paget’s recurrent fibroid –Recurrent fibroma of rectus sheath
- May advance to fibrosarcoma
BURSAE- A small fluid filled sac meant to provide a cusion between bone and tendon/muscle .
Due to trauma / friction, ‘bursitis ‘ (inflammation of bursa ) may occur .
Clinical feature- Pain , swelling , tenderness, redness.
Types of Bursae - :
1) SUBCUTANEOUS BURSAE-
i) Olecranon bursa – lie between skin and olecranon process of ulna in elbow . eg-
student’s / minor’s elbow .
ii) Prepatellar bursa – lie beneath skin of the knee infront of lower half of patella and the
patellar tendon . eg- housemaid’s /Minor’s beat knee .
iii) Infra – patellar bursa –lie between skin and lower part of the tibial tuberosity and
ligamentum patellae.eg- Clergyman’s knee.
2) SUBMUSCULAR BURSAE –
i) Psoas Bursa- lies between psoas tendon and lesser tronchanter

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- When enlarged , it persists as a diffuse swelling over outer
part of femoral triangle lateral to femoral vessels but never
extends above the inguinal ligament (unlike a psoas abscess)
ii) Bursa Anserina – under the tendons of Guy’s rope . eg-Goose’s feet.
3) SYNOVIAL BURSAE - i) Subacromial Bursa
ii)Retrocalcneum Bursa
4) ADVENTITIOUS BURSAE – Occurs in unusual sites due to friction between tissues.
Examples-:
5) i) Bunion Bursa – between head of 1st
metatarsal and skin. Occur in patients of hallus valgus
ii ) Tailor’s Bursa – Between lateral malleolus and skin. iii)Porter’s bursa – between skin
and clavicle at shoulder.
INVESTIGATION- FNAC, X- RAY
TREATMENT – Excision , sclerotherapy
6) SEMIMEMBRANOUS BURSA- between semimembranous tendon and femoral condyle.
- most common swelling of the popliteal fossa.
Clinical Feature – non- tender , cystic , fluctuant , transilluminant
-doesn’t communicate with knee joint space .
- swelling becomes tense on extension of knee .
Investigation – USG popliteal fossa
-X-ray knee
Treatment – Excision
Complication – Recurrence
BAKER’S CYST – A cystic swelling in the popliteal fossa.
- A type of pulsion diverticulum
- Occurs due to herniation of synovial membrane of knee joint
- Associated with gout and arthritis .
 Clinical Feature- asymptomatic, joint stiffness.
 Investigation – X – Ray knee , MRI .
 Treatment – Excision
 Complication – Rupture, DVT .
LYMPHATIC CYST – a type of distension cyst .
- Lie in subcutaneous plane of neck and limbs
 Clinical Feature- non – tender , mobile , smooth , brilliantly transilluminant .
 Complication – Infection – Abscess
 Treatment – Excision
BRILLIANTLY TRANSILLUMINANT –
i) Cystic hygroma
ii) Ranula
iii) Vaginal hydrocoel
iv) Epidermal cyst

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LYMPHANGIOMA – network of vascular channels filled with lymph/clear fluid .
2 types
. Small in size . Large
. Capsulated . Non Capsulated
. Shoulder , axilla, groin . Face, lips , tongue .
Eg- Lymphangioma circumscripta Eg- Cystic Hygroma
CALCINOSIS CUTIS
 Dystrophic calcification in or under the skin of waist due to prolonged friction
 More common in females
 Treatment- Excision
Capillary Cavernous

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Neuroma-: a benign overgrowth of neural tissue.
CLASSIFICATION
False neuroma. True neuroma
 Arises from connective tissue of nerve sheath. • rare
 Consists of fibrous tissue alongwith nerve fibres. •3 types
Two types-: 1. Neuroblastoma- arises
End neuroma. Lateral neuroma. from immature nerve cells.
o Post amputation. Post trauma. - infants and children
o C/F- tender, localised. C/F – tender, firm - adrenal glands
swelling. swelling. 2. Ganglioneuroma- arises
[Stump Neuralgia]. from mature ganglion cells and
o To prevent end neuroma nerve fibres.
Surgeon must pull the - associated with sympathetic
cut ends of nerves and then chain.
resect it. - sites : neck, thorax,
retroperitoneal, adrenal
medulla.
3. Myelinic neuroma
- consists of only nerve
fibres.
- spinal cord and pia mater.

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NEUOFIBROMA-: a connective tissue tumor containing both neural and fibrous
elements.
 Its origin is hence both ectodermal and mesodermal.
 Types-:
1.Localised. 2. Generalised
o Occur in subcutaneous tissue. – Autosomal dominant
o C/F-: slightly painful, firm, smooth
Nodular swelling.
-paraesthesia & tingling along the NF type 1. NF type 2
Distribution of nerve. ( Pressure effect} - Gene : NF1. NF2
o Example- acoustic neuroma [ 8th
CN]. - chromosome :17. 22
o COMPLICATIONS- may rarely undergo. – Protein : neurofibromin. Merlin
Cystic or sarcomatous changes. – Function :MAP kinase Contact
Pathway Inhibition
- C/F : café-au-lait spots. - B/l acoustic
Cutaneous NF. Neuromas
Lisch nodules. - Juvenile
Cataract
- Meningioma.
. Eppendymoma
 NF type 1 is also called Von Recklingausen disease.
 NF type 2 is also called central neurofibromatosis.
3.Plexiform neurofibromatosis - :
o Involves 5th
CN : skin of face.
o Often large sized, unsightly.
o Tumor hangs down over the face.
o PACHYDERMATOCELE : a variant of plexiform neurofibromatosis.
~neck involvement
~folded pendulous thickened skin over neck.
4.Elephantiasis neurofibromatosis - :

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o Sub Cutaneous tissue gets replaced by fibrous tissue.
o Skin becomes coarse, dry and thickened resembling that of an elephant.
o Congenital.
o Involves limbs.
o Other cause of elephantiasis
- Filarial elephantiasis
- Elephantiasis graecorum
 Indications for excision-
1. Symptomatic- pain and pressure symptoms.
2. Cosmetic
3. Increase in size
4. Malignant transformation ~ 5%
SCHWANNOMA ( NEURILEMMOMA)
 Arise from Schwann cells (neurilemmal cells).
 Only ectodermal in origin.
 Benign and encapsulated.
 Sites-: involves Acoustic nerve most commonly
Posterior mediastinum
Retroperitonium
 C/F - : single 1-2cms large round, firm, mass along the course of a major nerve.
 Treatment – tumors gradually displaces the nerve of origin and can be easily excised.
GANGLION-:A cystic swelling.
 Sites of origin-
1. Tendon sheath – due to cystic degeneration.
2. Synovial sheath – due to enlarged micropores.
3. Joint capsule- due to leakage of synovial fluid.
-dorsum of hand, flexor aspect of wrist, ankle joint.
 C/F : well localised, non tender, smooth, cystic swellin
May rarely present with pain and tenderness.
 Treatment – Reassurance
Sclerotherapy, excision under local anaesthesia.
 High recurrence rate.