2. OBJECTIVES
• At the end of this presentation students will be able to :
1. Name the common causes of superficial swellings
2. Describe clinical presentation, treatment, examination,
management of most common superficial swellings
3. SUPERFICIAL SWELLINGS
• Swelling denotes enlargement or protuberance in any
part of the body
• Can be called ‘’mass’’ or ‘’lump’’
4. HISTORY
1. Duration
2. Mode of onset & progress (trauma or spontaneous; rate
of progression)
3. Pain
4. Fever
5. Other lumps or swellings
6. Other features (movements, secondary changes loss of
weight or appetite)
5. INSPECTION OF A SUPERFICIAL
SWELLING
1. Site
2. Size
3. Shape
4. Surface (smooth : epidermoid cyst, lobular or irregular)
5. Skin (tense, glossy with prominent veins)
6. Surrounding area (changes, pigmentation/edema,
wasting, discoloration)
7. Others (number, colour, edges, extent, movements)
6. SUPERFICIAL SWELLINGS : MOST
COMMON CAUSES
• Swellings or lumps which are superficial to the
underlying muscle and fascia are commonly caused by:
1. Sebaceous cysts (epidermoid cysts)
2. Lipoma
3. Neurofibroma
4. Carbuncle
5. Ganglion
7. 1- SEBACEOUS CYSTS
• Also called Epidermoid cysts
• Most common cutaneous cysts
• Can occur anywhere on the body and typically present
as a skin-colored dermal nodules, often with a clinically
visible central punctum.
• Epidermoid cysts unusual in number and location (on
extremities rather then face, base of ears and trunk) may
be seen in the setting of Gardner syndrome, a rare
inherited condition characterized by familial
adenomatous polyposis of the colon associated with a
number of extracolonic abnormalities.
8. 1- EPIDERMOID CYST : SKIN-COLORED
SUBCUTANEOUS NODULE
Central punctum corresponding to
the follicular opening
9. 1- EPIDERMOID CYST : DIAGNOSIS
• Diagnosis usually clinical, based upon the clinical
appearance of a discrete nodule or cyst, often with a
central punctum freely movable on palpation.
• Cyst wall consists of squamous epithelium similar to skin
surface.
• Cavity filled with laminated layers of keratinous material.
11. 1- EPIDERMOID CYST :TREATMENT
• Inflamed uninfected epidermoid cysts may resolve
spontaneously without therapy, although they tend to
recur.
• Treatment not necessary unless desired by patient.
• Injection of Kenalog® into the inflamed lesion can hasten
the resolution of inflammation in uninfected epidermoid
cysts.
12. 2- LIPOMA
• Superficial subcutaneous lipomas are the most common
benign soft-tissue neoplasms.
• Consist of mature fat cells enclosed by thin fibrous
capsules
• Can occur on any part of the body
• Develop superficially in the subcutaneous tissue
• Rarely, they may involve fascia or deeper muscular
planes
13. 2- LIPOMA : PRESENTAITON
• Soft, painless subcutaneous
nodules ranging in size from
1 to > 10 cm
• Occur on the trunk and upper
extremities and can be round, oval
or multi-lobulated
• Patients may have more than one
lipoma, occasionally patients can
have genetic condition :
development of multiple lipomas in
several family members
• Malignant transformation of a lipoma
into a liposarcoma is rare
14. 2- LIPOMA : DIAGNOSIS
• Made clinically
• If suspected lipoma causes symptoms (pain or restriction
of movement), if it is rapidly enlarging , or is firm, then a
biopsy is indicated
15. 2- LIPOMA : TREATMENT
• Treatment indicated if pain or for cosmetic purposes or
concerns over diagnosis
• Surgical removal of the fat cells and fibrous capsule
• Recurrence of an excised lipoma is not common
• Side effects of surgery includes : scarring, seroma, and
hematoma formation.
• Surgical technique with segmental extraction and
minimal surface incision may limit the scar size.
16. 3- NEUROFIBROMA
• Cutaneous neurofibromas are benign nerve tumors
composed of cells of neuromesenchymal origin.
• Cutaneous neurofibromas occur as sporadic, solitary
lesions in healthy adults.
• Asymptomatic, soft, flesh-colored or hyperpigmented
papules or nodules that are <2 cm in diameter.
• Multiple cutaneous neurofibromas and their variants
(plexiform, dermal) may occur in the setting of
neurofibromatosis.
17. 3- CUTANEOUS NEUROFIBROMA
Soft, flesh-colored papules or
nodules.
Applying direct pressure to some
neurofibromas may make them
seem to retract into the skin, a
finding that has been described
as the ‘’button-hole’’ sign.
19. 3- NEUROFIBROMA : TREATMENT
• Treatment is not necessary for solitary cutaneous
neurofibromas.
• Surgical excision can be used to remove lesions when
the diagnosis is in question or when removal is desired
due to discomfort or cosmetic concerns.
20. 4- CARBUNCLE
• Coalescence of several inflamed follicles into a single
inflammatory mass with purulent drainage from multiple
follicles
Series of abscesses in the
subcutaneous tissue that drain
via hair follicles.
22. WHAT IS A GANGLION CYST?
• A ganglion cyst is the most
common soft tissue mass in
the hand and wrist.
• These cysts are sacs that
arise from a joint or tendon
sheath and become filled with
a gelatinous fluid.
• It is believed the cysts are a
result of a weak spot or
degeneration of tissue lining
a joint or tendon sheath.
23. COMMON TYPES OF GANGLIONS
• DORSAL CARPAL GANGLION CYST
• Most common location of a ganglion cyst.
• Often arises from a weak spot in the scapholunate ligament on the
back of the hand.
24. • VOLAR GANGLION CYST
• 2nd most common location of a ganglion cyst of the wrist.
• Often arises from a weak spot in either the radiocarpal joint or STT
joint
25. • RETINACULAR CYST
• This variant of a ganglion cyst occurs on the palm side of the hand
at the joint where the fingers join the palm.
• These cysts arise off the A1 or A2 pulley of the flexor tendon
sheath.
26. • MUCOUS CYST
• These are ganglions that occur on the back of the finger at the DIP
(distal interphalangeal) joint, the joint closest to the fingernail.
• Most often are associated with underlying osteaoarthritis at this
joint.
27. TREATMENT OPTIONS
• Splints
• May be used to provide pain relief by resting the offending
joint or tendon sheath
• Anti-inflammatory medications
• Can be taken orally to reduce swelling and relieve pain
• Try to modify or avoid activity that causes pain
28. ASPIRATION OF THE CYST
• In the office, it can be attempted to puncture the cyst
with a needle and aspirate the fluid from it.
• This may eliminate the cyst completely, but there is
a high rate of recurrence following this procedure.
29. SURGICAL OPTIONS
• Ganglion cysts are often
removed for a variety of
reasons, inluding:
• Pain relief
• If causing limitations to range of
motion
• Aesthetically unpleasing
• Specifically in the case of
mucous cysts, it is important to
surgically remove them if they
rupture. This is to prevent
infection of the underlying joint.
• Sometimes an MRI is ordered to
confirm origin of the stalk of the
cyst so we can ensure this area
is addressed intraoperatively.
30. SURGICAL TREATMENT
• Surgical treatment for this involves removing the
cyst sac and addressing the underlying cause, such
as ablating the weak spot in the ligament or
removing the bone spurs from an arthritic joint.
• This is an outpatient procedure and takes about 15-
20 minutes to perform.
31. SURGERY DETAILS
• Dorsal carpal ganglion cysts:
• This procedure is performed under regional
anesthetic, which involves a nerve block at the
shoulder.
• Near the location of these cysts there is a
nerve called the PIN (posterior interosseous
nerve). Its function is to provide pain fibers to
the wrist capsule and can be a contributing
factor to pain in this location. It is also
removed during the procedure.
• Volar carpal ganglion cysts:
• This procedure is performed under regional
anesthetic, which involves a nerve block at the
shoulder.
32. SURGERY DETAILS
• Retinacular cysts:
• This procedure is performed under local anesthetic, involving an
injection near the site of the cyst.
• Mucous cysts:
• This procedure is performed under local anesthetic, involving an
injection that will the numb the finger.
• These cysts can thin the skin and sometimes require transfer of
nearby skin to cover the defect.
In all situations, we are able to
give you some sedative
medication through an IV to keep
you comfortable.
34. POST-OPERATIVE CARE
• A soft dressing is applied after
surgery. You will be able to
use your hands for light activity
later that day.
• Keep the surgical dressing and
incision clean and dry. After 48
hours you may remove the soft
dressing and your incision may
get wet in the shower, but no
soaking. Apply a band-aid to
keep the incision clean if
necessary.
• Approximately 10-14 days
post-operatively for a follow-up
visit and suture removal.
