EXAMINATION OF A SURFACE

SWELLING
INTRODUCTION
• A lump can be present in any part of the body. It may be:
• External—Visible to exterior.
• Internal—May or may not be visible. Detected due to its
effects on the organ of origin.
• COMPLAINT AND DURATION
• Complains of swelling in front of the right thigh— 2
years
– Pain in the swelling—1 month
• HISTORY OF PRESENT COMPLAINT:
• (NOTE THE FOLLOWING)
• How it started?
– Spontaneously
– Following trauma
– If there is any pre-existing lesion like :
• Keloid or
• Pigmented mole—Melanoma
• Where it started?
– Exact site of beginning in case of very large swelling
• Duration
– Short duration
• Inflammatory (days to weeks only) not more than 1 or
2 months
• Traumatic (hours to days only) not more than 72 hours
– Long duration
• Neoplastic
» Benign years (More than 1 year)
» Malignant (3-6 months)
– Since birth
• Congenital
• Some congenital swellings may present after some years, as
time is required for accumulation of secretions in the cyst.
Eg.Dermoid cyst, Branchial cyst, Thyroglossal cyst
• Mode of progress of the swelling.
• Slowly growing—Benign swellings
• Rapidly growing - Malignancy
• Recent history of rapidity of growth – Benign tumour turn
into malignancy
• Sudden increases in size of the swelling – Haemorrhage into
the swelling.
• (Rapidly growing, short duration—Malignant tumour)
• (Slowly growing and longer duration – Benign tumour)
 – Regression in the size of the swelling
– Inflammatory (In the early stages of inflammation a
swelling occurs in a wide area. But once inflammation
subsides the swelling is reduced to a small localized area
– abscess formation
• (Patient noticed a small swelling of Pea-nut size in front of
the left thigh which is growing very slowly and attain the
present size. No history of trauma. No history of recent
rapidity of growth. No history of decrease in the size of the
swelling)
• Associated symptoms
– Pain – Enquire about whether pain is continuous or
intermittent
• Character of pain – Throbbing type of pain – inflammation
• Burning type of pain – Nerve irritation
• Pins and needles type of pain – Peripheral neuritis.
• Colic type of pain - Exaggerated peristaltic activity of a
tubular
• structure like intestine, ureter, CBD, Fallopian tube.
• Squeezing type of pain (Compressing) – Irritation of spinal
nerves.
• Radiation of pain–
• Aggravating factors
• Relieving factors
• (Patient noticed pain since 1 month which is intermittent,
throbbing in nature, pain is aggravated on walking and
relieved on rest. No radiation)
• (Pain First, swelling later - Inflammatory)
• (Swelling First, Pain later – may be due to
• Haemorrhage
• Malignancy
• Pressure effects
• Secondary infection
• Any history loss of appetite and weight
• Any history of fever
• Enquire about bowels and micturation
• Bowels – Constipation or diarrhea
• Micturation – Burning pain, frequency, hesitancy, normal
stream or thin stream
• (No history of loss of appetite or weight. No history of fever.
Bows and micturation are normal)
• PAST HISTORY

• Any history of hospitalization either medically or surgically

must be enquired and mentioned.

• Any treatment underwent for chronic illness like tuberculous

or leprosy

• (Patient had not suffered with any medical or surgical illness

which require medical attention)

• PERSONAL HISTORY
– Patient married or unmarried, living with family or not,
number of children, male and female, age of last child, if
wife or husband died how many years back and what is
the cause of death.
– Patient is habituated to smoking or not
– Addicted to alcohol or not
– If smoker, how many cigars, chuttas per day since how
many years.
– If alcoholic, enquire how frequently and quantity of
alcohol - used to take
 – Whether patients is known diabetic or hypertensive.
– Whether he is suffering with any chronic illness like
tuberculous or leprosy.
• (Patient is married living with wife & two children. All are
healthy. Patient is habituated to smoking 2 cigars per day
since 10 years. Patient is used to drink alcohol about 120 ml.
twice a week. Patient is not known diabetic or hypertensive
and is not suffering with any chronic illness)
• FAMILY HISTORY
– Any member of the family suffered with similar
complaint.
– Any member of the family are known diabetic or
hypertensive.
– Any member suffered with chronic illness like TB or
leprosy.
• (All members of the family are healthy. No history of
diabetes, hypertension or any chronic illness in the family)
• DRUG HISTORY
– Patient is not allergic to any known drugs.
• PHYSICAL EXAMINATION

• Patient moderately built and moderately nourished

• Not anaemic, No jaundice,

• Oral cavity – Mucous membrane is pink and moist.

• Tongue – Moist, pink and healthy, all teeth are present,

gums are healthy

• No generalized lymphadenopathy

• No pedal edema.
• Pulse –

• 75/min, regular in rhythem, volume and tension - normal

• Vessel wall is not thickened (below 40 years)

• Vessel wall is thickened (above 40 years)

• Blood Pressure – 120/80mm of Hg (below 40 years)

• 130/90mm of Hg (above 40 years)

• Temperature – 98.40 F

• Respiratory rate - 18/min. regular

• (Thoraco abdominal – female)

• (Abdomino thoracic – male)

• SYSTEMATIC EXAMINATION

• Cardio Vascular System – Apex beat is palpable at 5th

intercostals space on left side at midclavicular line.

• 1st and 2nd heart sounds are heard normally. No murmurs are
heard.

• JVP – Normal. No pedal edema.

• Respiratory System - Chest is moving equally with

respiration on both sides.

• On oscultation bilateral vesicular breath sounds are heard.

No rhyonchi or crepitations.
• Central Nervous System - Patient conscious, coherent,
answering questions

• Pupils are normal in size and normally reacting to light.

• There is no neurological deficit.

• Gait normal.

• Gastrointestinal System - Abdomen is scapoid in shape,

moving equally with respiration, soft on palpation, no free
fluid, no mass palpable. No hepatospleenomegaly. Intestinal
sounds are normal
LOCAL EXAMINATION OF SWELLING
Inspection -
1. Number - Single
2. Shape - Hemioval
3. Size – Horizontally 10 cms, vertically 6 cms
4. Site – Front of the left thigh
5. Extent – Extending 10 cms below the inguinal ligament and
6 cms above the knee joint.
6. Surface – Uneven (Lobulated)
7. Skin over the swelling - Healthy
8. Colour of the swelling - Normal
9. Borders – Well defined, round and regular
10. Surround area - Healthy
11. Visible pulsations – No visible pulsations
12. Visible cough impulse (can be noted in case of swellings
present over the head and neck chest and abdomen only)

• (Six ‘S’ in examination of the swelling are

1. Site

2. Shape

3. Size

4. Surface

5. Surrounding area

6. Skin over the swelling.)

Summary of Inspection :

• There is a single any oval swelling measuring 10 cms

horizontally, 6 cms vertically present on the front of left
thigh extending 10 cms below the inguinal ligament 6cms
above the knee joint. Surface is uneven, borders are well
defined, skin over the swelling is healthy, colour of the
swelling is normal, surrounding area is normal, no visible
pulsations.
• Palpation

• 1. Local raise temperature – No local raise of temperature

• 2. Tenderness – Not tender

• (Tenderness means - Pain on touch) (Pain is symptom

whereas tenderness is a sign).

• 3. Site – Front of left thigh

• 4. Shape - Oval

• 5. Size – Horizontal 10 cms, vertically 6 cms.

• 6. Extent – Extending 10 cms below the inguinal ligament &

8 cms above the knee joint.

• 7. Surface - Lobulated
• 8. Borders – Well defined, round and regular

• Slip sign is positive

• 9. Surrounding area – Healthy, no other swelling is palpable

in the surround area.
XH

• 10. Consistency –Soft in consistency. Fluctuation is negative.

• (Soft or firm or hard, stoney hard)

• (If soft in consistency, verify whether the contents are

semisolid material (Sebaceous cyst or Dermoid cyst) or liquid
by doing fluctuation test.
• If the fluctuation test is positive indicates, the swelling
contain fluid.

• To know the nature of fluid i.e., clear fluid (serous fluid or

lymph) or

• turbid fluid (pus, blood, chyle) transillumination test is

performed (when light rays from pen torch is passed through
the swelling, if the swelling contain clear fluid, the swelling
appears as red glow – Transillumination test is positive.

• If the swelling contain turbid fluid, there is no red glow –

Transillumination Test is negative
• 11. Mobility – Swelling is mobile freely in both vertical

and horizontal directions.

• (Mobility of the swelling is tested in both horizontal and

vertical directions.

• Swellings arising from linear structures like tendon, nerve,

blood vessel move at right angles to that structure only but

not along the course of the structure).

12. (Expansile pulsations) –
• If visible pulsations are present on inspection, confirm
whether they are expansile or transmitted pulsations.
• Expansile pulsations – swelling will enlarge in all directions,
present in case of swellings arising from the artery
(dilatation of the artery known as aneurysm)
• In this case when blood is pumped into the vascular swelling
during systole the whole swelling enlarges as the volume of
contents (blood) increased uniformly.
• This is confirmed by keeping two fingers over the swelling. If
it is expansile pulsations, the fingers will be elevated and
separated.
• Further confirmed by two tests (A) Distal occlusion test (B)
Proximal occlusion test.
• Distal occlusion test – The artery distal to the swelling is
compressed by finger, so that, blood is not leaving the
swelling. The swelling increase in size with more prominent
pulsations.

• Proximal occlusion test – The artery proximal to the swelling

is occluded by finger, so that blood is not allowed to enter
the swelling. The swelling becomes decrease in size and
pulsations are absent.
13. Expensile cough impulse (When the swelling have
communication with the body cavities like cranial cavity,
thoracic cavity and abdominal cavity, whenever pressure is
increased in the cavity, the same pressure is transmitted to
the swelling leading to expansion of swelling in all
directions.
• This is confirmed by holding the swelling with fingers and
ask the patient to cough, so that to raise pressure in the
body cavity. If this swelling has communication with the
cavity, the size of the swelling increases in all directions,
indicated by elevation and separation of fingers. Eg.
Meningocele, encephalocele, hernia.
14. Plain of the swelling -

• Skin is pinchble. On contraction of underlying muscle the

swelling becomes more prominent with well defined borders
and mobility is not restricted.

• On palpation - No local raise of temperature and not tender.

• Summary of palpation, percussion and auscultation -

• (A single oval swelling present in front of the left thigh

measuring horizontally 10 cms vertically 8 cms, extending 10
cms below the inguinal ligament and 8 cms above the knee
joint.
• Surface is lobulated borders are well defined, round and
regular. Slip sign positive. Consistency is soft. No fluctuation
present.
• Skin is pinchble, all over the swelling and on contraction of
the underlying muscle, a swelling becomes more prominent
with well defined borders and mobility is not restricted. Dull
on percussion and auscultation no bruit is heard).
• (Anatomical part from which the swelling arises) Eg. Skin or
subcutaneous tissue or muscle or nerve or tendon or artery
or vein or bone.
• (A) Swellings arising from the skin – Skin is not pinchble from
the swelling and the swelling moves along with the skin.
• (B) Swellings arising from the subcutaneous tissue – Skin is
pinchble
• On contraction of the underlying muscle, the swelling
becomes more prominent and mobility is not restricted.
• Swelling arising from the upper part of the muscle – Skin is
pinchble
• On contraction of the underlying muscle, the swelling
becomes more prominent and mobility is restricted.
• Swelling arising from the middle of the muscle – Skin is
pinchble
• On contraction of the underlying muscle, the swelling
becomes less prominent and mobility is restricted.
• Swelling arising from the posterior part of the muscle - Skin
is pinchble

• On contraction of the underlying muscle, the swelling

disappears and mobility is restricted.

• Swelling arising below the muscles (intermuscular) – Skin is

pinchble

• On contraction of the underlying muscle, the swelling

disappears and mobility is not restricted.

• Swellings arising from the bone – Skin is pinchble but no

mobility (it move along with the bone).
• Purcussion – Dull on percussion

• (Solid and fluid filled swellings are dull on percussion.

• Air filled swellings like hernia which contain air filled

intestine, resonant on percussion).

• Auscultation – No bruit is heard

• (Bruit is heard in vascular malformations and A-V fistula

(Continuous sound on auscultation)

• REGIONAL EXAMINATION
• Examine regional lymph nodes
• Examine peripheral pulsations
• Peripheral neurological examination
• Function of joints above and below
• Examination of spine and other corresponding systems
• THERE IS NO REGIONAL LYMPHADENOPATHY. ALL
PERIPHERAL PULSATIONS ARE FELT NORMALLY.
• THERE IS NO NEUROLOCAL DEFICIT. ALL SENSATIONS ARE
NORMAL.
• FUNCTIONS OF JOINT BELOW AND ABOVE THE SWELLING
ARE NORMAL.)
• Summary - (Salient clinical findings regarding the swelling
which conclude the diagnosis)

• History - Swelling in front of the thigh since 2 years, slowly

growing. Since 1 month intermittent pain present during
walking.

• Swelling is in oval in shape with lobulated surface, well

defined round and regular borders, slip sign positive,
consistency soft, no fluctuation – Lipoma.

• Skin over the swelling is pinchble and on contraction of the

underlying muscles, the swelling becomes more prominent
with well defined borders and mobility is not restricted –
Plain of the swelling is subcutaneous.
Provisional diagnosis – Subcutaneous lipoma over the front of
left thigh
• (Provisional diagnose includes anatomical and pathological
diagnosis. Anatomical diagnosis includes plane of the
swelling and part of the body).
• Eg. Subcutaneous lipoma over the front of left thigh.
• Subcutaneous (anatomical) front of the left thigh (site of
body part) lipoma (pathological)
• Differential diagnosis (Mention the other possible swellings)
• Fibroma, lymphangioma, haemengioma, dermitofibroma,
sebaceous cyst
Investigations

• For confirmation of diagnosis - FNAC

• For surgery and anaesthetic purpose – Hb,TC, DC,

• Blood sugar & Blood urea

• Serum creatitine

• X-ray chest & ECG if patient is above 40 years.

• Treatment -
• Under local anaesthesia, the swelling is excised through a
linear incision along Langerhan’s lines. The incision is
deepened through skin and subcutaneous tissue and false
capsule. Then with the help of index finger or artery forceps,
the swelling is separated from the false capsule cutting all
the fibrous bands that pass from the swelling into the
surrounding area. The swelling is completely excised and
removed. Haemostasis secured using diathermic cautery or
ligation of blood vessels using 2.0 plain catget. Then wound
is closed without dead space using 2.0 plain catget.
• Skin is closed with non-absorbable material (Nylon). If the

swelling is very large to avoid collection of fluid, to prevent

abscess formation a corrugated drain is kept in the wound.

• (If the swelling is small and have no complications, reassure

the patient for observation.

• If the swelling is large and producing symptoms surgical

excision is performed).
• EXPLANATION
• Shape – May be
• Round
• Oval
• Irregular
• Piriform
• Surface – May be
• Smooth
• Uneven
• Lobulated
• Nodular
• Skin over the swelling may be
• Normal or
• Features of inflammation (erythmatous, edematous)
• Pigmentation
• Hypopigmentation
• Hyperpigmentation
• Presence of any “Punctum”. (Bluish spot indicates occluded
mouth of the sebaceous gland)
• Scar - whether it is liener with suture marks (Previous
surgery) or puckered scar (previous abscess formation,
ruptured and healed with irregular scar)
• Any dilated veins.
Surrounding area – Look for

• Features of inflammation

• Prominent veins

• Wasting

• Oedema

• Any other swellings

• Any dilated veins

• Any scars
Palpation
• - Local rise of temperature
• Tested with dorsal aspect of fingers — Most sensitive area
to appreciate temperature variation.
• Comparison Chart
• Hard - Feel like bone or metal object
• Firm - Feel like contracted muscle or tip of nose
• Soft - Feel like cheek, lip; relaxed muscle; cotton
wool
• Cystic - Balloon filled with water
Edge or border
• Smooth and rounded—Cyst or benign swellings like lipoma
• Sharp and irregular - Malignancy
• Slipping under the finger—Lipoma (Slip sign)
Slip sign — The edge slips beneath the examining finger when
try to define the border
• It is not slippery edge—finger slips over the edge only.
Mobility
• Freely mobile
• Restricted mobility
• Fixed (not mobile)
Sign of Compressibility

• When pressure is applied over the swelling, it reduces in size

but not disappear.

• Eg. Vascular tumours like haemengioma, lymphangioma

which contain fluid and vascular tissue, when pressure is
applied, the fluid is displaced leaving solid vascular tissue
which appears smaller than the original size of the swelling.
(For reappearance of the original size of the swelling,
opposite force is not required, as the fluid will fill the
swelling slowly from the communicating vessels either veins
or lymphatics).
Sign of reducibility
• If the swelling have communication with the body cavity as
in hernia or meningocele, when pressure is applied over the
swelling, all the contents of the swelling are displaced into
the body cavity with complete disappearance of the
swelling. (For reappearance of the swelling, opposite force
is required in the form of coughing (to raise the intra cavity
pressure).
Local bruit on auscultation – When a vascular tumour with an
arterial communication is present, a continuous sound is
hard on auscultation.
POSSIBLE COURSE OF DISCUSSION
• 1. What is your anatomical diagnosis?
A soft swellings in the middle of anterior part of the thigh.
• 2. What is the plane of swelling?
a) Subcutaneous tissue
• 3. What are the reasons to say?
a) Skin is pinchable
b) Swelling is freely mobile
c) On contraction of muscle, the swelling becomes more
prominent and mobility is not restricted.
PLANE OF THE SWELLING
1. What are the features of cutaneous (skin) swelling?
• Skin is not pinchable.
• Freely mobile in all directions along with the skin
• On contraction of the underlying muscle, the swelling
becomes more prominent and mobility is not restricted.
2. What are the features of subcutaneous swelling?
• Skin is pinchable
• Freely mobile in all directions
• On contraction of the underlying muscle, the swelling
become more prominent and movement is not restricted
with well defined borders.
3. What are the features of a swelling arising from or attached
to deep fascia or anterior sheath of muscle?

• Skin is pinchable

• Mobile in all directions, more of side to side than in vertical

direction

• On contraction of the underlying muscle:

– Swelling becomes more prominent with restricted

mobility.

• Borders are well defined

4. What are the features of a swelling arising from the muscle?
• Skin is pinchable
• Mobile in all directions, more of side to side mobility than in
vertical direction
• When muscle is contracted:
• Swelling becomes less prominent
• Borders become diffuse
• Movements become restricted
5. What are the features of a swelling arising from posterior
surface of muscle or posterior fascia of the muscle?
• Skin is pinchable
• Mobile in all directions.
• When muscle is contracted:
• Swelling disappears with diffuse borders and mobility is
restricted
6. What are the features of a swelling arising from the bone or
periosteum?
• Skin is pinchable
• No movement – Fixed swelling
• Moves along with the bone when the bone is moved
• When muscle is contracted, the swelling disappears
7. What are the features of a swelling arising from a linear
structure like, tendon, nerve, vessel etc.?
• Swelling is mobile side-to-side only at right angles to the
structure from which it arises , but not vertically
• If it arises from artery, pulsations are present
8. What are the features of a swelling fixed to the skin due to
infiltration from below?
• Skin is not pinchable
• Local puckering of the skin
• Oedema of the skin with Orange peel appearance (Peud-
O’orange)
9. What is slipping edge or slip test?
• When the edge of a swelling is palpated if it slips beneath
the finger it is called as a slipping edge or a positive slip sign.
• It is commonly seen with lipoma.
• One should not say “edge is slippery,” which gives a different
meaning.
8. What are the features of a swelling fixed to the skin due to
infiltration from below?
• Skin is not pinchable
• Local puckering of the skin
• Oedema of the skin with Orange peel appearance (Peud-
O’orange)
9. What is slipping edge or slip test?
• When the edge of a swelling is palpated if it slips beneath
the finger it is called as a slipping edge or a positive slip sign.
• It is commonly seen with lipoma.
• One should not say “edge is slippery,” which gives a different
meaning.
10. What type pulsations are seen or felt in a swelling?
• It can be :
• Transmitted
• Expansible
11. What are transmitted pulsations?
• If the swellings is situated in front of a pulsating artery, the
pulsations can be transmitted to the swelling and the
swelling appears pulsatile and is known as transmitted
pulsations.
• Disappears when the swelling falls away from the artery, by
changing the position of body part.
• When two fingers are placed over the swelling, the fingers
are elevated but separated Transmitted impulse.
12. What are expansible pulsations?
a) Swelling arises from the artery (aneurysm) due to
dilatation artery, the entire artery is pulsating and the
pulsations spread in all directions.
b) When two fingers are placed over the swelling they are
elevated and separated as the whole swelling enlarges with
filling of blood - Expansible impulse.
13. What is a thrill and a bruit?
• When a swelling has increased vascularity, the flow of blood
may give a feeling of thrill on palpation.
• The same when it is heard on auscultation, it is known as
bruit.
• Sometimes, if fluid is present in a swelling, tapping over it
may produce a thrill and is called as “fluid thrill” and is
appreciated by palpation.
14. What is your pathological diagnosis?

• Question yourself: Is it ‘Congenital’ or ‘Acquired’?

• If it is an acquired swelling, is it:

• Traumatic or

• Inflammatory or

• Neoplastic or

• Degenerative
• If by the presentation and examination, the swelling appears
to be neoplastic. It could be a:
• Benign swelling – Eg.
• Lipoma
• Neurofibroma
• Haemangioma
• Dermoid cyst, sebaceous cyst - etc.,
• Malignant swelling
• Epithelioma (squamous cell carcinoma)
• Malignant melanoma
• Basal cell carcinoma (Rodent ulcer)
• Soft tissue sarcoma.
15. How the swellings are differentiated depending on the
nature of behavior and outcome?
• They are grouped into two types:
• Benign
• Malignant
16. What are the features of benign swelling?
a) Slow growing
b) Does not produce any ill effects on the host
c) It produces pressure symptoms, if it is large
d) Long duration
e) No loss of weight
f) No local infiltration (freely mobile)
g) No enlargement of regional glands (Secondaries)
h) No distant secondaries may present
i) No recurrence following surgery
j) Good postoperative survival
17. What are the features of malignant swelling?
1) Rapidly growing
2) Ill effects on the host
3) Short duration
4) Loss of weight
5) Local infiltration give rise to fixidity (no mobility)
6) Regional lymph nodes are involved by secondaries
7) Distant secondaries
8) May recur following surgery
9) Bad prognosis
18. What are the clinical features of a cystic swelling?
a) Smooth surface + Rounded regular and well defined borders
= cyst
b) Presentation as
– Asymptomatic or
– Symptomatic -
• Due to pressure
• Due to growth
• Due to complications
c) Examination
– Smooth surface + Rounded borders
– Soft in consistency
– Fluctuation (+)
• Transillumination (+/-), depending on cyst wall and
Nature of content
• Cyst call was thickened or calcified transillumination is
negative even though it contain clear fluid
• Transillumination is positive if the swelling contains
clear fluid like water (exudates as in hydrocele or
lymph cyst)
• Transillumiantion is negative if it contain turbid fluid
like pus, blood and chyle.
19. What is fluctuation?

a) It is a clinical test to demonstrate the presence of fluid in a

swelling.

b) It is demonstrated by fixed the swelling with thumb and

middle, ring and little fingers of the both hands.

• The index fingers are placed over the swelling with a gap of
more than one inch. One finger is pressed over the swelling,
the other fingers is elevated indicating fluid is shifted from
one pole to other pole.

c) This displacement is demonstrated in both directions.

20. How will you investigate the case?
a) To confirm the diagnosis
• FNAC or
• BIOPSY depending on the condition
b) Ancillary
• Radiology of the part
– CT Scan
– MRI Scan
– Chest x-ray
c) Lab Studies
– CBP
– Blood Sugar
d) Tumour markers
21. What are the modalities of treatment?

a) Benign

• Enucleation

• Excision

b) Malignant

• Wide excision or Radical excision followed by

• Chemotherapy

• Radio therapy

• Hormone therapy
 LIPOMA (Case Sheet)

Complaint and duration -

Swelling over the back of the right side of chest – 3 years

duration.

Pain – 1 month

History of present complaint -

3 Years back patient noticed a lemon sized (3 cm

diameter) swelling on the back of the right side of chest
which is slowly growing and attain the present size.
• There is no H/o trauma,

• No h/o decrease in size of the swelling

• No h/o recent rapidity of growth

• No h/o sudden increase in the size of the swelling

• Since 1 month, patient is having mild, dull aching, pain in the

swelling which is intermittent, more on exercise. Pain is
relieved on rest, pain aggregates on lying over the swelling.
No history of radiation. Pain localized to the swelling only.

• No history of fever

• No history of loss of weight or appetite

• Bowels and mixturation normal

Past history :

Personal history :

Family history :

Drug History :

Physical examination :

Systematic examination :

Cardiovascular system

Respiratory system

Central Nervous System

Gastrointestinal system
 LOCAL EXAMINATION
Inspection –
• A single horizontally placed hemi-oval shaped swelling,
measuring horizontally 12cm, vertically 8 cm, present over
the back of right chest over scapular region, extending 3 cm,
lateral to midline (vertebral column) 4 cm below the spine of
the scapula.
• Surface is lobulated, borders are well defined, skin over
swelling is healthy, colour of the skin is normal, surrounding
area is healthy.
• No visible pulsations
• No visible cough impulse (Seen in case of swelling present
over the head, neck, chest and abdomen only)
Palpation – There is no local raise of temperature.
• Mild tenderness present
• Inspectory findings like Number, shape, size, site and extent
are confirmed.
• Surface is lobulated
• Borders are well defined, round and regular.
• Slip sign positive.
• Consistency is soft, fluctuation negative.
• Swelling is freely mobile in both vertical and horizontal
direction.
Plane of the swelling : Skin is pinchable
• On contraction of underlying muscles, the swelling becomes
more prominent with well defined borders and mobility is
not restricted.
Summary :
• History – Long duration, slowly growing tumour.
• On examination – Surface lobulated with well defined round
and regular borders, consistency is soft. Fluctuation absent.
Slip sign positive.
• Skin is pinchable.
• On contraction of the underlying muscles, swelling become
more prominent and mobility is not restricted (subcutaneous
plane)
Regional examination –
• No regional lymphadenopathy
• No dilated veins
• All peripheral pulsations are present
Provisional Diagnosis : Subcutaneous lipoma over the back of
right side of chest (Scapular region).
Differential Diagnosis :
• Fibroma
• Sebaceous cyst
• Lymphangioma
• Haemengioma.
Investigations : For confirmation of diagnosis – FNAC
Treatment: Excision or Enucleation
Anaesthesia : Local/General depending upon the size and site of
the tumour.
• Incision given along the Langerhan’s lines
• The incision is deepened through skin, subcutaneous tissue
and false capsule.
• With the help of index finger or curved haemostat, the
tumour is separated from the false capsule cutting all the
fibrous bands that pass between the tumour and
surrounding tissue.
• The tumour is excised from the surrounding tissue and
removed.
• Haemostasis secured by cauterizing or ligation of bleeding
vessels with plain catget.
• The cavity is obliterated without dead space by suturing with
2.0 plain catgut (Vicryl rapid)
• If the swelling is very large a corrugated drain is kept to
prevent seroma formation which later will develop into an
abscess.
FNAC –

• Shows large oval shaped clear cells with excentric nucleus.

• Straining for lipoma (Fat globules) is with Sudan blue.

• Excision is removal of the tumour along its capsule and

surround normal tissue.

• Enuclearion is removal of tumour along its true capsule from

the false capsule.

 LIPOMA
• A lipoma is the commonest benign tumour.

• It is arises from adult fat cell.

• It can occur anywhere in the body, that is why it is often

called ‘universl tumour’ or ‘ubiquitous tumour’.

• But the common sites are the subcutaneous tissue of (i) the
trunk (ii) the nape of the neck (iii) the limbs.

• Lipoma never occurs in brain tissue as there is no fat in the

drain but it can occur in the meninges.
Clinical classificationof lipoma :

Three varieties – (1) Encapsulated lipoma (2) Diffuse lipoma (3)

Multiple lipomas.

(1) Encapsulated lipoma is the commonest benign tumour.

(2) Diffuse lipoma – This is a rare variety and does not possess

capsule and typical features of lipoma, hence it is often called

‘pseudolipoma’.
• It is seen in the subcutaneous and intermuscular tissues of
nape of the neck, back of chest, retroperitoneum and gluteal
region.
• It is not a typical tumour but an overgrowth of the fat in this
region.
• It does not possess the capsule which is typical of a lipoma.
• It gives rise to a disfigurating swelling on the neck.
• It is often found in persons taking excessive alcohol.
• Treatment is excision of the excess of fat if it is required by
the patient due to cosmetic reason.
3. Multiple lipomas –

• It is often called lipomatosis.

• The tumours remain small or moderate in size (1-5 cms) and

the sometimes painful as these often contain nerve tissue.

• These are mostly seen in the limbs and in the trunk.

• Lipoma of different sizes and shapes may be seen.

• Macroscopically and microscopically these are not different

from solitary lipoma.

• Multiple painful lipometa over the trunk is known as

Dercum’s disease (adiposis dolorosa).
 PATHOLOGICAL CLASSIFICATION

i. Pure lipoma – contains fat tissue only.

ii. Fibrolipoma – A combinationof fat and fibrous tissue.

iii. Naevolipoma – when a lipoma contains blood vessels with

telangiectasis of the overlying skin.

iv. (iii) Neurolipoma – when a lipoma contains nerve tissue.

It is often painful.
 ANATOMICAL CLASSIFICATION
• Clinically a lipoma can occur in different anatomical
situations.

• According to this a lipoma can be classified into –

Subcutaneous type – This is the commonest variety.

– Although any part of the body can be affected, yet it

shows particular tendency to occur in the back, nape of
the neck and on the shoulders.

• Subcutaneous lipoma is usually sessile, but occasionally may

become pedunculated.
Subfascial lipoma – Lipoma may occur under the palmar or
plantar fascia and is often mistaken as tuberculous
tenosynovitis.
• Lipomas may also occur in the areolar layer under the
epicranial aponeurosis in the scalp.
• Such Subfascial lipoma can be confused with a dermoid cyst,
but there is no underlying bony indentation. (In dermoid cyst
bony indentation is present)
Intramuscular lipoma – Lipoma present within the muscle.
• It gives rise to mechanical interference with the action of the
muscles.
Intermuscular lipoma – Presents within a group of muscles.

• Commonly seen in the thigh or around the shoulder.

• Subserous lipoma – Found beneath the pleura or peritoneum

or beneath the serosa of the intestine.

Retroperitoneal lipoma - often misdiagnosed as hydronephrosis,

pancreatic cyst or teratomatous cyst.

• A retroperitoneal lipoma may attain a big size and malignant

transformation (Lipoma sarcoma) is common.

• This is a condensation of extraperitoneal fat rather than a

typical lipoma (Diffuse lipoma)
Submucous lipoma -

• It may occur below the mucous membrane of respiratory or

elementary tract.

• It is also seen in the tongue.

• In the respiratory tract it may cause respiratory obstruction.

Intra-articular - in side the joint

Subsynovial lipoma –

• Such lipoma occurs under the synovial membrane of a joint

or tendon sheath.

• If it is seen in the knee joint can be differentiated from

Bakers cyst or a bursitis.
Parosteal lipoma – Occurs under the periosteum of a bone

Extradual lipoma – Occurs from the dural layers of spinal cord or

brain.

• Spinal cord lipomas may be dumbel shaped with intraspinal

and extraspinal masses with communication through
vertebral foramina.

• Lipoma does not occur within the brain tissue because of

absence of fat in the brain matter, but lipomas can occur in
the meninges (Intracranial extramedullary).

Intraglandular lipoma – Lipoma may be seen – the breast,

pancreas, under the renal capsule and salivary glands
Lipoma arborescens –

• A pedunctulated subcutaneous lipoma is called lipoma

arborescens.

• Commonly seen in the thigh, because of strong muscular

contractions the lipoma is pushed outside with cutaneous
pedicle.

• Intraspinal lipomas may present as nerve compression.

• Dangerous lipoma – Submucous lipoma in subglotic region

produces narrowing of the respiratory passage and cause
death.

• Subserous lipoma of intestine may lead to intussusception.

Complications –

• Myxomatous degeneration.

• Saponification.

• Calcification.

• Malignant transformation to liposarcoma

• Commonly seen in retroperitoneal and gluteal regions.

 SUBCUTANEOUS LIPOMA
Duration – Long, more than 1 year
Shape – Spherical or over swelling
Surface – Lobulated
Borders – Well defined, regular and round
Slip sign – Positive
Consistency – Soft
Fluctuation negative
Skin – Pinchable
Mobility – Freely mobile with dimpling of skin.
On contraction of the underlying muscle, the swelling becomes
more prominent and mobility is not restricted.
 SEBACEOUS CYST (CASE SHEET)
Complaint and duration :
• Swelling over the face/chest/scalp – 2 years duration
• Pain – since 1 month
History of present complaint:
• 2 years back, patient noticed a swelling of 1 cm diameter
which is slowly growing and attain the present size.
• No history of trauma
• No history of decrease in the size of the swelling
• No history of sudden increase in the size of the swelling
• No history of recent rapidity of growth.
• Patient complains of pain since 1 month which is continuous,
throbbing in nature, relieved on standing position but
aggravated on lying down position.
• No history of radiation of pain.
• No history of fever
• No history of loss of weight or appetite
• Bowels and mixturation normal
• Past history -
• Personal history -
• Family history -
• Drug history -
PHYSICAL EXAMINATION -
SYSTEMATIC EXAMINATION -
Cardiovascular system
Respiratory system
Central Nervous System
Gastrointestinal system
Local examination
Inspection – A single spherical swelling measuring 5cm in
diameter present on the left side of occipital region of the
scalp extending 2 cm away from the midline, 3 cm above the
superior nuchel line.
Surface is smooth; borders are well defined, round and regular.
Skin over the swelling is healthy.
A bluish spot - punctum present over the centre of the swelling.
Colour of the swelling is bluish in colour.
Surrounding area is normal.
No visible pulsations
No visible cough impulse.
Palpation –
Mild raise of temperate present over the swelling.
Mild tenderness present over the swelling.
Inspectory findings – Number, Size, Shape, Site, extent are
confirmed.
Surface is smooth, borders are well defined round and regular.
Consistency is soft.
Paget’s test : positive (If it is positive indicate fluid is present in
the swelling, then transillumination test is performed)
Transillumination test – Negative (Indicate swelling contain
turbid fluid)
Paget’s test - Negative (Indicate semisolid material {Sebum}
present in the swelling)
Sign of moulding is positive (Indicate swelling contain semisolid
material).
Mobility – The swelling is mobile in both horizontal and vertical
directions along with the skin.
• Plane of the swelling – Skin is not pinchable in the centre of
the swelling at the site of punctum, but pinchable in the
periphery of the swelling.
• On contraction of the underlying muscle, the swelling
becomes more prominent and mobility is not restricted.
Summary:
History – Long duration, slowly growing swelling.
On examination – Spherical swelling. Surface is smooth with
well defined round and regular borders, punctum is present.
Consistency is soft and cystic. Paget’s test is positive.
Transillumination is negative
Skin is not pinchable in the centre of the swelling but pinchable
in the periphery.
On contraction of the underlying muscle, the swelling becomes
more prominent and mobility is not restricted.
• Provisional diagnosis :

• Sebaceous cyst over the scalp with secondary infection

• Differential diagnosis

• Lipoma, Dermoid cyst,Haemnngioma, Papilloma,

Dematofibroma.

• Investigations for confirmation of diagnosis -

• FNAC

• X-ray scalp – (To know any intracranial extension (Dermoid

Cyst).
Treatment :
1. Excision -
Local anaesthesia with 1% zylocaine
An elliptical incision given around the punctum.
The skin is separated from the cyst wall by blunt and sharp
dissection using haemostat or curved dissecting scissor.
The cyst is removed.
Haemostasis secured, the wound closed in layers.
Subcutaneous tissue with No.2.0 plain catgut (Vicryl rapid)
Skin - 2.0 nylon (Polyamide)
2. Incision and evulsion – Under local anaesthesia an elliptical
incision is given around the punctum opening the cyst wall.
The contents of the cyst are expressed. The cyst wall is held
with tissue forceps and evulsed completely from the
surrounding tissue. Haemostasis secured and wound closed
in layers.
3. Incision and drainage – If the cyst is infected and abscess
formed, the cyst wall is incised to drain the pus. Under
antibiotic cover, once infection subside, the cyst wall is
excised from the surrounding tissue.
If infection of the cyst is present without abscess formation, a
course of antibiotic for a period of 5-7 days is given. Once
infection is controlled the cyst can be excised.
 SEBACEOUS CYST
Sebaceous glands are present in the skin.
These glands secrete sebum which keeps the skin soft and oily.
The duct of the sebaceous gland mainly opens into the hair
follicle and rarely may open directly on to the skin.
If the duct or the mouth of the sebaceous gland becomes
blocked, the gland becomes enlarged due to retention of its
own secretion and forms a sebaceous cyst. So, it is an
example of retention cyst
Other retention cysts are – Mucous cyst of oral cavity,
Bartholain Cyst of labia majora
It also called ‘epidermoid cyst’ because it is present above the
dermis.
It arises from the basal layers of epidermis.
It is also called as WEN, when it occurs as multiple cysts on the
scrotum
Pathology -

Cyst is lined by squamous epithelium and contains sebum which

is yellowish pultaceous material with unpleasant smell.

Sebum contains fat and desquamated epithelial cells.

At the central point of swelling, it is adherent to the epidermis.

In the centre of the swelling, at a black spot is present, which
is keratin-filled punctum.

Common sites –

Sebaceous cyst occurs anywhere in the body except palm and

sole as there is no sebaceous glands present in palm and sole
of feet.
• Most commonly seen in those parts where there are plenty of
sebaceous glands like (i) The scalp (ii) Face (iii) Neck (iv)
Shoulders (v) Chest (vi) Scrotum
• The characteristic feature of sebaceous cyst in scrotum is –the
cysts are multiple, elevated above the dermis covered by thin
layer of epidermis and solid, known as WEN.
• C/F : Occur at any age from young to old, but rare in
childhood.
• Typical cystic swelling which is spherical in shape. Its size
varies from a few milli metres to about 5 cm in diameter.
• The surface is smooth and there is a blackish spot or punctum
which indicates the blocked opening of the duct.
• Cyst is always fixed to the skin, so the overlying skin cannot be
pinchble. (In case of dermoid cyst skin is pinchable)
Consistency is cystic.
Due to presence of sebum (semisolid material) there may
be indentation on pressure with finger tip. (Sign of indentation or
sign of moulding)
If the sebum degenerates and liquefies, fluctuation test
may be positive, but sign of indentation is negative.
Transillumiantion test is always negative, as the contents are
turbid fluid.
The swelling is not tender usually, but if it infected it is tender.
The cysts is free from underlying structures and move along with
the skin.
Treatment –
Total excision of the cyst is the treatment of choice.
If the cyst is infected, preliminary antibiotic treatment should be
given and the excision is only possible when the infection has
subsided.
If the cyst is a small one it can be excised under local
anaesthesia.
Three types of procedure may be adopted :
(a) Dissection method – An elliptical incision is made on the skin
including the punctum.
The cyst is gradually dissected from the surrounding skin till the
entire cyst can be removed intact.
It must be remembered that the whole of the cyst wall must be
removed, otherwise recurrence is inevitable.
(b) Incision-avulsion technique – Under local anaesthesia an
incision is made through the skin into the cyst.
Contents of the cyst are squeezed out.
The cyst wall is then held with a pair of dissecting forceps and the
cyst is carefully avulsed out from the surround tissue.
(c) If the cyst infected and abscess formed, incision and drainage
of the pus was performed under antibiotic cover. Later when
the infection is subsided the cyst wall is excised.
Complications –
i. Infection – Infection is treated with antibiotics and analgesics
until infections subsides.
If the infection subsides, excision of the cyst should be carried
out.
If infection does not subside, abscess formed, it should be incised
and drain the pus.
(ii) Ulceration (Cock’s peculiar tumour) – This complication arises
when an infected cyst ruptures by itself and discharges its
contents.
• The floor of ulcer is covered by granulation tissue with
fungation.
• It may look like on epithelioma.
• When the sebaceous cyst of the scalp ulcerates, excessive
granulation tissue forms resembling fungating epithelioma.
• This is called the Cock’s peculiar tumour.
(iii) Sebaceous horn – Slow discharge of sebum from the punctum
which hardens step by step leads to formation of sebaceous
horn.
(iv) Calcification – Commonly seen in sebaceous cysts of scrotum.
(v) Malignancy – Basal cell carcinoma may develop in a
sebaceous cyst.
Salient points of sebaceous cyst :
• Punctum is a block spot which is present on the summit of the
swelling due to blockage of the mouth of the duct.
• Spherical swelling with well defined round borders.
• Consistency – soft. Fluctuation (Paget’s test) is positive if it
contain liquid
• If it contains semisolid material, sign of indentation or sign of
moulding is present.
• Swelling is freely mobile along with the skin over the
underlying structures
5. Skin over the swelling is not pinchable

• Demodex follicularum – A parasite, found in the wall of the

cyst.

• Multiple sebaceous cyst in the scrotum is known as WEN

• Fordyce’s disease – Presence of ectopic sebaceous glands in

lips and oral mucosa.

WEN Cocks peculiar tumour Sebaceous horn

 DERMOID CYST
• Dermoid cyst is a which lies deep to the skin and is lined by
skin (squamous epithelium)
• Because it is below the skin, it is known as epidermal cyst.
• Cyst contains pultaceous or tooth paste like material a mixture
of sebum, desquamated epithelial cells, air and salts N.& Cl).
• Dermoid cysts are two types: (I) Congenital – 3 types (II)
Acquired – Implantation dermoid
Congenital - 3 types :
– Sequestration dermoid
– Tubulo-dermoid cyst
– Teratomatous dermoid
i. Sequestration dermoid – It is congenital dermoid cyst, formed
by inclusion of epithelium buried at the lines of embryonic
fusion.
• Found along the lines of fusion of the two embryonic
segments (Front of midline of body and in between union of
skull bones).
• Pathology - Cyst is lined by stratified squamous epithelium
with hair, hair follicles, sebaceous glands and sweat glands.
• Origin – At the line of embryonic fusion, a few ectodermal
cells are sequestrated into the deeper layer.
• These cells proliferate to form a sequestration dermoid cyst.
• The dermoid cyst lies near the mesoderm from which the
bones will develop, that is why indentation is often found in
the underlying bone.
• Prolongation of the cyst through the bones give rise to cyst in
the intracranial region.
• Common sites are –
• i. Midline of the body particularly in the neck.
• ii. External angular dermoid – above the outer canthus of the
eye – the line of fusion of frontonasal, orbital and maxillary
processes.
• iii. Post auricular – behind the ear – at the site of fusion of the
mesodermal hillocks.
• iv. On the skull- Line of fusion of the skull bones.
• v. Midline of the face at the root of the nose (Gabella) joining
of nasal bones and frontal bone –
Clinical features
• Painless and slowly growing cystic swelling
• Site must be at the embryonic fusion
• Size and shape – May not be more than 5 cms in diameter and
Ovoid or spherical in shape.
Surface – is smooth
Punctum - No punctum
• Consistency is soft and sign of indentation is present if the
material is semisolid.
• Fluctuation (Paget’s test) is positive.
• Transillumination is negative if the contents are liquefied due
to degeneration.
• No impulses on coughing
• No compressibility or reducibility
• Bony indentation is present deep to the cyst which can be
palpated by moving the base of the cyst with a finger.
• X-ray – Shows a depression in the bone underlying the cyst or
a defect in the bone (perforation) in the bone indicates
intracranial extension of the cyst.
Complications

1. Infection

2. Suppuration

3. Ulceration

4. Pressure symptoms

Treatment

• Complete excision of the cyst is the treatment of the choice

under local anaesthesia or GE

• The cyst is dissected from the sensitive pericranium

• Preliminary x-ray shows a gap in the underlying bone,

neurosurgical assistance may be taken.
• ii. Tubulo-embronic dermoid
• An epidermal cyst which develops from an unobliterated
portion of a congenital ectodermal duct or tube.
• Pathology -
• Cyst is formed by accumulation of the secretions of the lining
ectodermal cells of the unobliterated portion of an embryonic
duct.
Eg. 1. Thyroglossal cyst – It develops from the thyroglossal duct
2. Vitello –intestinal cyst – developed form vitello intestinal duct
3. Urecheal cyst – Developed from uracheas.
4. Post-anal dermoid cyst develops from remnant of neurrenteric
canal (Post-anal gut).
5. Ependymal cyst of brain – Sequestration of cells derived from
infolding neuroectoderm.
iii. Teratomatous dermoid –
• A systemic swelling develops from the totipotent cells with
ectodermal predominance with mesodermalelements like
bone, cartilage.
• Hairs are almost always present
• Usual contents are bone, cartilage, tooth, hair and cheesy
material.
Common sites are –

• (i) Ovary – Ovarian cyst

• (ii) Mediastinum – Mediastinal cyst.

• (iii) Retroperitoneum – Retroperitoneal cyst

• (iv) Testis – Teratoma.

Acquired type – Implantation dermoid

• It is a acquired dermoid arises from indriven epithelium

beneath the skin due to pucture injury

• Eg. Needle prick or thron prick.

Common sites
• Palm of the hand
• Any part of the finger
• Tip of the finger
• Sole
• They are commonly seen in gardners, tailors and women
• Pathology – Cyst is lined by stratified squamous epithelium
without hair follicle, sweat and sebaceous glands.
• Contain cheesy material made up of desquamated epithelial
cells.
• Clinical features – History of pin or thorn prick
• On examination a tense cystic swelling found in the finger or
palm or sole.
• Consistency is firm and cystic.
• Page’s test is negative if it contain semi-solid material.
• Complications – Infection, suppuration and bursting
• Treatment – Under local anaesthesia, excision of cyst.
 THYROGLOSSAL CYST
• H/o swelling in the midline of the neck in a young patient (15-
30)
• Onset, progress, pain and any discharge must be asked.
• On inspection, location of swelling in relation to hyoid bone.
• Size, shape, surface, movement with deglutation and on
protrusion of tongue.
• On palpation temperature and tenderness.
• Consistency – Soft, cystic, fluctuation - Positive.
• Transillumination – Negative.
• Swelling moves horizontally but not vertically.
• Swellings move with protrusion of tongue - Thyroglossal cyst
only.
Swellings move with deglutition –
1. Thyroid swelling.
2. Cyst in relation to the isthmus of the thyroid gland.
3. Ectopic thyroid.
4. Thyroglossalcyst.
5. Subhyoidbursal cyst.
6. Enlarged pretracheal glands.
7. Laryngocele
• Cystic swelling developed in the remnant of thyroglossal duct
or tract.
• Present in any part of thyroglossal tract from foramen caecum
to isthumus of thyroid gland.
• Common sites in order of frequency are – Subhyoid or over
the thyroid cartilage or suprahyoid or in the floor of mouth.
• Midline swelling slightly towards left

• Lined by psedostratified columnar epithelium with lymphoid

tissue

Complications –

• Infection and abscess formation

• Thyroglossal sinus after rupture of the abscess

• Papillary carcinoma
Management :
• I will do radio active iodine nuclear scan to exclude any ectopic
thyroid tissue in the swelling and also to know the position of
normal thyroid gland, because, this is the only thyroid tissue
that may be present in ectopic position. If normal thyroid is
present in its original position, I will do FNAC to confirmation
diagnosis.
• After investigating for fitness to surgery, under general
anaesthesia, Sistrunk operation is performed – Ellliplical
incision made around the cyst. The cyst is separated from the
surround tissue along the tract. The tract is dissected upto the
foramina caecum of tongue with excision of the body of the
hyoid bone.
 THYROGLOSSAL FISTULA

Aetiology

1. Infection with abscess formation give rise to thyroglossal

fistula

2. Latrogenic (Thinking it as an abscess and performed drainage.

3. Incomplete removal of the tract.

Treatment : Sistrunk operation

 BRANCHIAL CYST
• Cystic swelling arises from persistent cervical sinus which is
formed due to fusion of second branchial arch with 6th
branchial arch. (5th arch disappears)

• Clinical features : Age of presentation between 22-25 years

even though it is congenital.

• Location – Anterior triangle of neck at junction of upper 1/3rd

and lower 2/3rds of sternomastoid muscle along its anterior
border.
• Lining epithelium - squamous epithelium
• Shape - Oval or spherical in shape with smooth surface.
• Well defined round and regular borders
• Consistency soft as it contains pulsatious material.
• Fluctuation is positive, if the material is liquid.
Transillumination is negative.
• If the material is semi-solid, sign of indentation is present.
• Mobility - Freely mobile,
• skin is pinchable
• On contraction of the sternocledomastoid muscle the
swelling becomes more prominent and mobility is not
restricted.
Complications :
• Recurrent infection due to presence of lymphoid tissue in
the wall.
• Cyst may rupture or due to inadvertent incision may give rise
to branchial sinus.
• Squamous cell carcinoma may occur.
Treatment :
• Excision under general anaesthesia
• Hypoglossall nerve, glossal pharyngeal nerve, spinal
accessory nerve lie deep to the cyst and are at danger during
surgery.
Branchial Sinus : Incomplete fusion of second branchial arch
with sixth arch in its distal part results in branchial sinus.
• Internal opening is not found.
Types :
Congenital – Due to incomplete closure of cervical sinus in its
distal part.
Acquired - Due to infection or incomplete excision of
branchial cyst.
• External opening – Congenital – Typically located at the
junction of upper 2/3rd and lower 1/3rd of anterior border of
stenomastoid muscle.
Acquired - Typically located at the site of br. Cyst (Jn. Of Upper
1/3rd & Middle 1/3rd of sternomastoid muscle).
• There is no internal opening as it is a sinus.
Treatment : Excision of sinus tract.
 BRANCHIAL FISTULA
Congenital branchial fistula develops from failure of fusion
between the second and fifth branchial arches.
Acquired branchial fistula may be due to (1) Infection of the
branchial cyst and rupture (2) Due to inadvertent incision of
the infected branchial cyst.
Site – Congenital – External opening at the junction of upper
2/3rds and lower 1/3rd of anterial border of SCM muscle
Acquired – External opening is at the junction of upper1/3rd
and lower 2/3rds of anterior border of SCM muscle.
Internal opening on the posterior pillar of fauces behind the
tonsil.
Course of the sinus tract – The tract pierces the deep facia at
the level of upper border of thyroid cartilage passes through
the fork of common carotid artery. Ascends upwards and
pierces the superior constrictor muscle of the pharynx and
open just behind the tonsil.
Treatment – Sinogram is performed by injecting radio-opaque
dye to know the upper limit of the fistula.
• Under general anaestesia the whole tract is excised taking
care not to injuring caratid vessels as the tract passes
between the internal and external caratid arteries.
 CYST

• Cyst is a collection of fluid in a sac lined by epithelium or

endothelium. (Cyst means bladder)

• Cysts are classified as true cysts and false cysts.

True cyst : In true cyst, the Cyst wall is lined by either

epithelium or endothelium

• If infection occurs, the lining epithelium or endothelium is

replaced by granulation tissue.

• The cyst contain fluid, usually serous or mucoid derived from

the secretion of the lining.
False cyst :

Cyst does not have epithelial or endothelial lining, but the fluid
is collected in between the fascial sheaths, muscles or
walled off by intestine or omentum as in case of TB
abdomen.

• Fluid collection occurs as a result of exudation Eg.

Pseudocyst of pancreas or

due to degeneration of a tumour Eg. Cystic degeneration of

tumour.

• Apoplectic cyst formed in brain as a result of ischaemia with

collection of fluid.
 CLASSIFICATION OF CYSTS
(a) Congenital (b) Acquired
a. Congenital cyst –
(1) Sequestration dermoid
(2) Tubuloembronic dermoids – Thyroglossal cyst, urachal
cyst, vitallo-intestinal duct.
(3) Teratomatous dermoid – Cystic swelling develops from
the totipotent cellswith ectodermal predominance.
• It also contain mesodermal elements like bone, cartilage,
tooth and cheese material
Common sites are –

(1) Ovary – Ovarian cyst, (2) Testis – Teratoma, (3) Mediastinum

– Mediastinal cyst,

(4) Retroperitoneum –Retroperitoneal cyst (5) Post-anal

dermoid

• Hairs almost always present.

Cysts of embronic reminants – Cysts from paramesonephric

duct and mesonephric duct.
b. Acquired –

• (1) Implantation Dermoid – Acquired dermoid cyst arising

from indriven epithelium beneath the skin due to a pucture
injury Eg.Needle prick or thorn prick

• Common sites are – Palm or tip of the fingers of the hand

and sole of the feet.

• Common in gardeners, tailors and women.

• Cyst is lined by stratified squamous epithelim with no air

follicles, sweat and sebaceous glands.
• Contain white cheesy material formed by desquamated
epithelim cells and sebum.

• On examination tense cystic swelling found in the fingers or

palm

• Consistency is firm

• Paget’s test is positive, transillumination is negative.

• The swelling is small tense and cystic.

• Complications, infection, suppuration and bursting

• Treatment – Excision of cyst under local anaesthesia.

2. Retention cysts – Accumulation of secretion of a gland due
to obstruction of the duct

Eg. Sebaceous cyst, Bartholin’s cyst, cysts of parotid, breast

and epididymis.

3. Distention cyst – Lymph cyst, colloid goiter, follicular cyst of

ovary (PCOD)

4. Exudation cyst – Bursa, hydrocele, pseudopancreatic cyst

5. Cystic tumours - Dermoid cyst of ovary, cystadenomas

6. Traumatic cysts – Due to trauma, Eg. Haematoma occurs
usually in thigh, loin.

• Lined by muscular sheaths or fascial sheaths containing

brown coloured fluid with cholesteral crystals

7. Degenerative cyst –

• Due to cystic degeneration of a solid tumour (Necrosis of

tumour).

8. Parasitic cyst – Hydatid cyst, trichiniasis, cysticerosis

Clinical features :
• Hemispherical swelling with smooth surface well defined
borders, soft consistency fluctuation positive (Paget’s test)
transillumination negative.
Complications of a cyst –
• Compress of the surround structures (CBD-Choledochal cyst)
Swellings with brilliantly transilluminant :
• Ranula
• Meningocele
• Cystic hygroma and lymph cyst
• Hydrocele
• Epidymal cyst (Chinese-Lantern pattern)
• Infection Abscess formation
• Sinus formation
• Calcification (Hydatid cyst)
• Cachexia –In malignant
• Haemorrhage
• Torsion Eg. Ovarian cyst
Swellings with brilliantly transilluminant :
Ranula
Meningocele
Cystic hygroma and lymph cyst
Hydrocele
Epidymal cyst (Chinese-Lantern pattern)
Sequestration dermoid Sebaceous cyst

* Occurs in the line of fusion * Occurs anywhere except palm and

sole

* Skin is not adherent (free) * Skin is adherent over the summit

(Around punctum)

* Extends often into deeper plane or * Subcutaneous plane-do not extend

cavities through suture line to deeper plane

* Punctum is absent * Punctum is present – 70% cases

* Bone resorption and indentation is * No bone resorption(identation)

common

* Restricted mobility * Freely mobile along with skin

* Needs proper evaluation with X- No CT or x-ray required

ray/CT scan for intracranial extension

Excision is done under general *Excision is done under local

 EXAMINATION OF AN ULCER

COMPLAINT AND DURATION

• Ulcer over the left foot – 1 Month duration

HISTORY OF PRESENT COMPLAINT

• Ulcer following trauma cause or

• Swelling or oedema, later developed in to an ulcer

• May occur spontaneously or

• May follow after application of counter irritant.

Ulcer may develop

– On burns scar

– In association with peripheral vascular disease due to

ischaemia of tissue (tropic ulcer)

– In varicose veins due to venous hypertension.

– On genitalia following sexual exposure (chancres due to

syphilis and chrancoid (soft sore due to haemophylis
Ducrey).

• IMPORTANT POINTS IN HISTORY

• H/o injury
Initially swelling and then ulcerated as in

– Lymph nodal masses

– Tumours

H/o venous disorders

– Varicose veins

– Deep vein thrombosis

H/o any scars

– Post burns

– Post irradiation

H/o Peripheral vascular disease

• H/o of any neurological disorders

– Spinal lesion

– Peripheral neuropathy

– Leprosy

• H/o diabetes or/and hypertension

• H/o exposure to STD or H/o tuberculosis

– Syphilis

– Primary chancre on genitalia

– Gumma over the bones

 NATURAL H/O THE ULCER
– Site of occurrence
– Duration
– Discharge
• Serous
• Sero sanguinous
• Bloody
• Purulent
―Any complications
• Bleeding
• Deformity
• Malignant transformation
• Pain

– Type

– Site

– Radiation

– Relieving factors

– Aggravating factors

– Disturbance to sleep

– Claudication pain
• Nutritional status of the patient
– Anaemia
– Hypoproteinaemia
– Avitaminosis
– Obesity
– Hyperlipaedemic state
• Any chronic illnesses -
– Diabetes
– Hydertension
– Nephritis
• Rheumatoid arthritis
Past history -

• Any history of hospitalization either medically or surgically

must be enquired and mentioned.

• Any treatment underwent for chronic illness like tuberculous

or leprosy

Personal history -

– Patient married or unmarried, living with family or not,

number of children, male and female, age of last child, if
wife or husband died how many years back and what is
the cause of death.
– Patient is habituated to smoking or not

– Addicted to alcohol or not

– If smoker, how many cigars, chuttas per day since how

many years.

– If alcoholic, enquire how frequently and quantity of

alcohol - used to take

– Whether patients is known diabetic or hypertensive.

– Whether he is suffering with any chronic illness like

tuberculous or leprosy.
Family history -
– Any member of the family suffered with similar
complaint.
– Any member of the family are known diabetic or
hypertensive.
– Any member suffered with chronic illness like TB or
leprosy.
Drug history -
– Patient is not allergic to any known drugs.
 PHYSICAL EXAMINATION

• Patient moderately built moderately nourished

• Not anaemic

• No jaundice

• Oral cavity – Mucous membrane is pink and moist.

• Tongue – Moist, pink and healthy

• All teeth are present

• Gums are healthy

• No generalized lymphadenopathy

• No pedal edema.
Pulse –

– 75/min, regular in rhythem, volume and tension - normal

– Vessel wall is not thickened (below 40 years)

– Vessel wall is thickened (above 40 years)

Blood Pressure – 120/80mm of Hg (below 40 years)

130/90mm of Hg (above 40 years)

Temperature – 98.40 F

Respiratory rate - 18/min. regular

(Thoraco abdominal – female)

(Abdomino thoracic – male)

 SYSTEMATIC EXAMINATION
A. Cardio Vascular System –
– Apex beat is palpable at 5th intercostals space on left
side at midclavicular line.
– 1st and 2nd heart sounds are heard normally.
– No murmurs are heard.
– JVP – Normal. No pedal edema.
B. Respiratory System -
– Chest is moving equally with respiration on both sides.
– On oscultation bilateral vesicular breath sounds are
heard.
– No rhyonchi or crepitations.
C. Central Nervous System -

– Patient conscious, coherent, answering questions

– Pupils are normal in size and normally reacting to light.

– There is no neurological deficit.

– Gait normal.

D. Gastrointestinal System -

– Shape of abdomen is scapoid, moving equally with

respiration, soft on palpation, no free fluid, no mass
palpable.

– No hepatospleenomegaly. Intestinal sounds are normal

– Built and nourishment

LOCAL EXAMINATION

A) Inspection

1. Number - Single or Multiple

2. Shape - Rounded or Oval or Irregular

3. Size - Vertical and horizontal measurements

4. Site – Note where the ulcer is present

5. Margin – Pale or inflammed

6. Edge – Whether if it is

Edge may be sloping or Punched out or Undermined or Raised

and everted or raised and rolled out.

– Sloping edge – Non-specific ulcer

– Punched out edge – Neurogenic ulcer, syphilis

– Undermined edge – Tuberculous

– Raised and everted – Squamous cell carcinoma or

Malignant melanoma

– Raised and rolled out with beaded appearance – Basal

cell carcinoma
7. Floor
– Healthy granulations—Pink
– Unhealthy granulation—Pale
– Wash leather slough—Syphilis
– Blackish pigmentation—Melanoma
– Slough—Infected ulcer
8. Discharge
– Serous discharge – Healing ulcer
– Purulent discharge – Non-healing ulcer (spreading ulcer)
– Serosanguineous discharge – Malignant ulcer or Healing
ulcer (Blood stained serous fluid)
– Greenish discharge – Infection with pseudomonas
– Bloody discharge –Malignant ulcer
9. Surrounding area – Note any

• Pigmentation

• Signs of ischaemia (Pale and Cold, loss of hair, loss of

subcutaneous tissue as evident by prominent
intermetatarsal groove, absence of veins, brittle nails with
transverse ridges and minor ulceration in between the toes.

• Presence of varicose veins

• Scar tissue
• Deformity
– Talipes equino varus—Varicose ulcer
– Local gigantism—Congenital AV fistula
B) Palpation
• Tenderness – present or not
• Local raise of temperature - present or not
• Induration of margin edge and base – present or not
Mobility
– Mobile in both horizontal and vertical directions –
Subcutaneous
– Reduced mobility – may be fixed to the underlying
structures
– No mobility – fixed to bone or periosteum or infiltration
to surrounding tissue as in case of malignancy.
Bleeding on touch – present or not – Bleeding on touch present
in healthy granulation tissue of healing ulcer and in
malignant ulcer.
Regional examination

– Examination of Iymph nodes

– Examination for vascular insufficiency—Peripheral pulses

– Examination for nerve lesion—Local anaesthesia,

paraesthesia, movement of joints (Test for touch,
temperature and joint position).

– Venous system; if any varicose veins

– Any deformity

Provisional diagnosis – Non-specific healing ulcer

Differential diagnosis – Tropic ulcer, malignant ulcer

Investigations –

– Pus per culture and sensivity

– In case of longstanding ulcers of more than 6 months

wedge biopsy.

– Tests for diabetes (Blood sugar, serum creatitine & blood

urea)

– In case of old people – X-ray chest, PA view & ECG

Treatment –
POSSIBLE COURSE OF DISCUSSION
• What is an ulcer?
Ulcer is a discontinuity in the surface epithelium or mucous
membrane with molecular death of tissue.
• Gangrene is macroscopic death of tissue.
• What is the margin of an ulcer?
Margin of the ulcer denotes the junction between the
normal and the ulcerated area. It gives the shape of the
ulcer as:
– Round
– Oval
– Irregular
What is the floor of an ulcer?
• The exposed part of the ulcer seen on inspection is called
floor.
• The floor may be covered :
– Red granulation tissue – Healing ulcer.
– Unhealthy granulation tissue --- non-healing ulcer
– Slough – infected
– Wash leather – syphilis
– Apple jelly granulation - tuberculosis
Zones of an healing ulcer – Floor is divided into three zones,
from periphery to centre

• White zone - Outer zone - Indicates fibrous tissue

• Blue zone – Middle zone - Indicates granulation tissue

covered by 3 to 4 layers of epithelial cells

• Pink zone – Inner zone - Indicates granulation tissue covered

by single layer of epithelial cells.

– More of red zone and less of white zone=Healing ulcer.

– More of white zone and less of red zone=Non healing,

chronic ulcer.
What is the edge of an ulcer?
– The part of the ulcer between the floor and the margin.
– It denotes the nature of the ulcer- Eg. Sloping edge in
case of non-specific ulcer.
What are the types of edges?
An edge can be :
– Sloping—Non-specific

– Undermined—Tuberculous

– Punched out—Penetrating ulcer (Tropic ulcers due to lack

of sensation and nutrition) syphilis

– Raised and everted—Malignant ulcer

– Raised and Rolled out with beaded appearance —Rodent

ulcer (Basal cell carcinoma)
• What is undermined edge?
– Floor is more than the roof
– The margin of the ulcer overhangs upon the floor
– A small probe can be passed beneath the margin
• What is a punched out edge?
– The margin and the floor are of same size
– The sides are clear cut—punched (900)
– The floor can be deeply placed formed by bone in some
cases
– Seen typically with trophic ulcers (Neuropathic ulcers)
• What is raised and everted edge?
– Edge is raised above the surface and everted
– A probe can be passed between normal skin and edge
What are raised and rolled out edges?
– Edge is raised above the surface but not everted with
beaded appearance
– Eg. Basal cell carcinoma
What is the base of an ulcer?
– Base is the structure on which the ulcer lies.
– It is a palpatory finding.
– Induration is seen in case of chronic ulcer
– Marked induration is a feature of malignancy.
What is discharge in an ulcer?
– Discharge is secretions from the raw area of the ulcer.
– Mostly due to infection.
What are different types of discharges?
• Types:
– Serous—Healing ulcer
– Purulant —Infected ulcer
– Blood—Neoplastic, vascular
– Serosanguinous—Infected or malignancy
– Greenish—Pseudomonas
– Purulent with foul smelling—Gram –ve bacteria,
anaerobes and bacteroids
 CLASSIFICATION OF ULCERS
Clinical classification
– Spreading ulcer
– Non-healing ulcer
– Healing ulcer
– Chronic or callous ulcer
Pathological classification
– Nonspecific ulcers – Eg. Infective, traumatic, burns, acids,
alkalis, sun-burns
– Specific ulcers – Eg. Tuberculous, syphilis,
– Malignant ulcers – Eg. Squamous cell carcinoma
(epithelioma), basal cell carcinoma, malignant melanoma.
What are the stages in an ulcer development and healing?

• An ulcer passes through three stages:

A) Stage of extension

– It is the stage of spreading

– Floor is covered by slough without any evidence of

granulation tissue; the discharge is profuse, purulent with
foul smelling.

– The edges and surrounding tissue are inflamed and

oedematous
B) Stage of transition

– Preparatory stage for healing

– Separation of slough

– Discharge is decreased, may be serous or seropurulent

– Appearance of granulation tissue

– Base is less indurated

– Signs of inflammation are minimal

C) Stage of healing
– Whole floor of the ulcer is covered with red, healthy
granulation tissue.
– Spread of epithelium from margin across the ulcer
– Formation of scar tissue
– Minimal serous discharge without smell
– No signs of inflammation
What are the zones of healing ulcer?
– White zone—Outer zone, white in colour due to fibrous
tissue reaction.
– Bluish zone—Middle zone, granulation tissue covered by 3-
4 layers of epithelial cells.
– Red zone—Inner zone – Granulation tissue covered by
single layer of epithelium
What is a callous ulcer?

– History – Long duration more than 6 months

– Floor is covered by unhealthy, pale granulation tissue with

areas of slough

– Base is indurated

– Discharge is seropurulent, smell can be present

– Marked induration of base edge and surround tissue with

pigmentation
What are non-specific ulcers?
• No specific aetiological factors
• No special clinical features
• Etiology of non-specific ulcers:
– Traumatic
– Mechanical
– Physical
– Chemical
– Radiation
• Arterial
– Atherosclerosis
– TAO
– Raynaud’s disease
• Venous
– Varicose ulcer
– Post Deep Vein Thrombosis
• Trophic
– Bed sore
– Perforating
– Neurological conditions Eg. Parapleasia, quadriplegia,
syringomyelia
– Hansen’s disease (Leprosy)
• With associated diseases
– Anaemia
– Nephritis
– Rheumatic arthritis
– Diabetes
• Miscellaneous
– Bazini’s ulcer
– Morterelli’s ulcer
– Meleney’s ulcer
What are specific ulcers?
• Caused by specific aetiological factors
• Produces typical clinical features for that aetiology
• Types.
– Tuberculous
– Syphilis
– Actinomycosis
What are malignant ulcers?
• Epithelioma
• Rodent ulcer
• Malignant melanoma
How will you investigate a case of an ulcer?
• Laboratory investigations:
– CBP/ESR
– Urine routine for blood sugar and proteins
– Blood urea/creatinine
– Blood sugar
• Discharge from the ulcer for culture and sensitivity
• Staining of the discharge – AFB & gram stain
• Tests for tuberculosis
– Mantoux test
– Staining for AFB
• Genital ulcer
– VDRL
• Diagnostic
– Wedge biopsy
– Biopsy of the regional node

What is wedge biopsy?

• A triangular bit of ulcer along with normal skin is taken for

biopsy is called wedge biopsy.

• It is advantageous as the pathology can be properly studied

with comparison to normal tissue.
What is edge biopsy?
– A bit of tissue taken from edge of an ulcer without
including normal tissue
– Not ideal as normal tissue is not present for comparison
and infiltration cannot be seen in case of malignancy.
• If biopsy taken from the centre of the ulcer it may be a
nectrotic tissue only due to ischaemia, not useful for
pathological diagnosis. So biopsy can never be taken
from centre of the ulcer.
How you manage the ulcer?

a) Conservative

– Rest to the part

– Avoid local irritation

– Improve the nutrition through -

• Protein supplementation

• Vitamin supplementation

– Blood transfusion if patient is anaemic

– Proper antibiotics after c/s

– Treat the cause

b) Tuberculous ulcers
– Non-dependent aspiration of cold abscess.
– Excision of the underlying lymph node/sinus, etc.
– Antituberculous treatment for a period of 6-9 months
following any procedure
c) Venous ulcer
– Elevation
– Compression stockings
– Treat DVT
– Treat varicose veins
d) Genital ulcer
– Treat with antibiotics—Penicillin group of drugs
e) Malignant ulcer

– Wide excision

– Radiotherapy/chemotherapy

– Amputation

f) Chronic and callous ulcer

– Local care

– Infrared radiation

– Short wave therapy

– Ultraviolet therapy

– VAC therapy
e) Malignant ulcer

– Wide excision

– Radiotherapy/chemotherapy

– Amputation

f) Chronic and callous ulcer

– Local care

– Infrared radiation

– Short wave therapy

– Ultraviolet therapy

– VAC therapy
g) Trophic ulcer
– Protection and soft padding
– Amputation/disarticulation of the involved bone
h) Diabetic ulcer
– Control the blood sugar levels
– Perform c/s
– Debridement
– Antibiotics
– If gangrene - Local amputation/disarticulation
i) Role of amputation
– Penetrating ulcers with osteomylitis
– Malignant ulcers not fit for local therapy
j) Presence of excessive granulation tissue can be managed by -

– Excision of excessive granulation tissue or

– Currettage or

– Application of copper sulfate crystals—Cuatery effect

k) Antibiotic after c/s

l) Improve the nutrition

– Protein supplementation

– Vitamin supplementation
Separation of the slough can be achieved by -
– Hypochlorite solution – EUSOL (Edenburg University
Solution)
– 0.5% Silver nitrate
– 1% Zinc sulfate
– Normal saline soaks
Local coverage of the ulcer with -
– Amnion
– Silver foil
– Boiled potato peels
– Split skin grafting
– Gauze impregnated with antibiotic-Sofra tulle
What are the surgical methods that may be used?
– Excision of the ulcer + split skin grafting
– Covering the area with split skin grafting
– Rarely amputation—Penetrating and malignant ulcers
When amputation is indicated?
– Penetrating ulcers – Fixed to bone with osteomylitis
– Malignant ulcers – Not fit for local therapy
What are the different types of amputations?
1. Ray’s amputation – Amputation through heads of
metatarsal
2. Transmetatarsal (Gillies) amputation is done proximal to
the neck of the metatarsals, distal to the base.
3. Tarsometatarsal (Lisfranc’s) amputation – Disarticulation
of tarsometatarsal joint with long volar flap.
4. Mid tarsal (Chopart’s) amputation - Here talo navicular
joint and calcaneo-cuboid joints are disarticulated.
• Tibialis anterior muscle is suture to talus bone by drilling
with long volar flap.
5. Syme’s amputation –
• Removal of the with calcaneum and cutting of tibia and
fibula just above the ankle joint with retaining heal flap
(Dividing both malleoli).
• Heal flap is separated by medial and lateral calcaneal vessels
branches of posterior tibial artery.
• Many patients can walk well without difficulty.
• Elephant boot is used after amputation for walking.
6. Below-knee (Burgess) Amputation -
• Long posterior flap with scar placed over anterior aspect is
used.
• Prosthesis placement is better with greater range of
movement without limp and without support.
• Fibula is divided first higher than the proposed site of cut of
tibia.
• Posterior muscles are sutured across the bone and to the
periosteum in front.
• The length of stump is 14-17 cms. from the knee joined. But
a minimum of 8 cms. is required for prosthesis.
7. Transcondylar – Gritti-strokes amputation –

– With long posterior flap the femur is divided just above

the articular surface and petalla is anchored to the
divided femur (No longer performed).

8. Above-knee- amputation –

– Equal anterior and posterior flaps are used.

– Lower third and middle third level amputation is done.

– Idle length stump is 25 cms from the tip of the trochanter.

– Less than 10 cms stump is not possible to fit prosthesis

so, hip disarticulation is advised.
What are the complications of ulcer?
– Infection

– Haemorrhage

– Malignant transformation

– Local deformity
 POINTS TO REMEMBER
• Ulcer is a discontinuity in skin or mucous membrane with
superadded infection.
• Margin of the ulcer is the junction between the normal and
the beginning of the ulcer.
• Edge of an ulcer is the junction between the margin and the
floor.
• The floor is what we see and is an inspectory finding.
• Base of the ulcer is the one on which the ulcer sits. It is a
palpatory finding.
• Induration is a hard thickening of margin, edge and the base
of the ulcer.
– Present in case of chronic ulcers and malignant ulcers due
to fibrous tissue infiltration or malignant cells infiltration
• Sloping edge denotes healing ulcer.
• Undermined edge is seen with tuberculosis.
• Punched out edge is seen with penetrating ulcers.
• Raised and everted edges are seen with malignant ulcers.
• Raised and rolled out edges seen rodent ulcer.
• Ulcers can be specific, nonspecific or malignant.
• They can be healing, non-healing or callous ulcers.
• Wedge biopsy of the ulcer is diagnostic for malignant ulcers.

• Infection, haemorrhage, deformity and malignant

transformation are the common complications.

• Specific ulcers are managed by treating the cause.

• Nonspecific ulcers require excision of slough, dressings and

proper antibiotics.

• Chronic and non healing ulcers may require VAC therapy.

• Malignant ulcers are managed by surgery, RT and

chemotherapy.
 NON-SPECIFIC ULCERS
Ischaemic Ulcers :
1. What are the features of ischaemic ulcers?
– Due to vascular insufficiency.
– Develop over limbs
– Over pressure areas
– Starts as superficial ulcer, later become deep ulcer
– Can be multiple
– Painful
– Mostly toward lateral aspect of foot and leg
– Limb is cold and pale with absent or diminished
pulsations
2. What are the features of trophic ulcer?

a) They are also called as penetrating ulcers.

b) They are usually seen in:

– Neurological cases due to loss of sensation (Hansen’s

disease, paraplegia)

– Constant pressure - Decubitus ulcer (bed sores)

– Diabetes

c) Common sites are:

– Heel

– Ball of the toes

– Sacrococcoygeal region
d) Features:

– Deep ulcers

– Base may be formed by underlying bone

– Punched out edges

– Bone may be visible in the floor

– Foul smelling slough

– Surrounding insensitivity area

e) They are called trophic because of lack of nutrition to the

part. For proper nutrition nerve supply and blood supply are
necessary.
1. What are tropical ulcers?

– These ulcers are seen in tropical countries.

Eg. Delhi boil, Baghdad sore.

– They were thought to be due to Vincent’s organisms, but

now it is established due to a protzoal parasite
Lieshmania tropica.

– It starts as a indurated papule on exposed surface

commonly on the face,

– leads to formation of an indolent ulcer,

– Leaving black, ugly and pigmented scar.

2. What are the features of tuberculous ulcer?

– It results as secondary to cold abscess of caseous lymph

nodes.

– The edge of the ulcer are thin, pale and bluish

discolouration with undermined edges. A probe can be
passed beneath the edge.

– Size of the floor is more than the roof

– Discharge is thin and watery .

– Floor—Pale granulation tissue (Apple jelly granulation

tissue)

Commonly over the neck and face in lymphnodal areas

3. What is lupus vulgaris?

• It is a type of cutaneous tuberculosis.

• Sites:

– Face

– Hands

– Common in children and adults

• The ulcer is active at the periphery with areas of healing in

the centre.

• Lupus literally means a ‘wolf’.

4. What is a gummatous ulcer?
• Seen in tertiary stage of syphilis
• Sites:
– Subcutaneous bones
– Tibia
– Sternum
– Skull
– Ulna
– Testis
– Upper part of leg
• Features:
– Punched out edges
– Washed leather-like slough in the floor
– Healed with tissue paper type of scar tissue
5. What is a chancre (Hard chancre)?

– It is seen on ext. genitalia following exposure to syphilis

caused by treponema Pallidum

– Incubation Period: 3—4 Weeks following contact

– Painless ulcer

– Indurated base

– Associated with painless, firm, shoty, hard inguinal lymph

nodes
6. What is a soft Sore (Chancroid)
– It is caused by Ducrey bacillus—Haemophllus Ducrie
– Sexually transmitted disease seen on external genitalia
– Incubation Period is - 3-4 days
– Multiple, painful ulcers over genitalia
– May bleed
– Base is not indurated
– Painful, enlarged inguinal lymph nodes
– Suppuration take place in lymph nodes and leads to the
formation of a “bubo” – is a Fluctuant unilocular abscess
7. What is a Meleney’s ulcer?

– Seen in Post Operative wounds of abdominal surgery

contaminated with intestinal contents.

– Due to symbiotic action of microaerphillic organisms.

– It is a spreading ulcer seen over anterior abdominal wall.

– Associated with features of toxaemia with extensive

sloughing of the abdominal wall.
8. What is Marjolin’s ulcer?
– Slow growing squamous cell carcinoma developing on
chronic ulcer or Longstanding scar tissue of burns.
– Orginally described for ulcer developing in a scar tissue
– It locally malignant squamous cell carcinoma without
secondaries either in lymph nodes or by blood spread as
there is no lymphatic or blood vessels in the scar tissue
– It behaves as locally malignant tumour as long as it
confined to the scar tissue or ulcer, but if it encroaches
onto normal tissue it behaves like normal squamous cell
carcinoma with secondaries.
– Base is indurated with raised and everted edges
– It is radio insensitive, treated by wide excision or
amputation.
9. How it differs from squamous cell carcinoma?
– Regional lymph nodes are not involved due to lack of
lymphatics in scar tissue
– Lymph nodes may be involved once the ulcer encroach
to normal tissue and behavious like squamous cell
carcinoma.
– Response to radiotherapy is poor due to scar tissue
– Prognosis is good
10. How squamous cell cancinoma can develop in a scar tissue,
which is made up of fibrous tissue?

– It develops from islands of remnant of squamous

epithelium in the scar tissue.

11. Who was Marjolin?

– Rene Marjolin (1812-1895), Surgeon, Hospital Sainte,

Eugenic-Paris, originally described a carcinomatous ulcer
occurring in a post burn scar.
 MARTORELL’S ULCER
– Effects elderly over the age of 50 years, hypertensive
hence –
– Hypertensive ulcers.
– Atherosclerosis is precipitating factor but all peripheral
pulses are normal.
– It occurs due to sudden obliteration of arterioles of skin
on back (or) outside of calf region.
– Severe pain, ischaemic patch of skin results later into
deep, non healing ulcers.
– Healing is delayed due to vascular in sufficiency.
 MARTORELL’S ULCER
– Effects elderly over the age of 50 years, hypertensive
hence –
– Hypertensive ulcers.
– Atherosclerosis is precipitating factor but all peripheral
pulses are normal.
– It occurs due to sudden obliteration of arterioles of skin
on back (or) outside of calf region.
– Severe pain, ischaemic patch of skin results later into
deep, non healing ulcers.
– Healing is delayed due to vascular in sufficiency.
 BAZIN’S ULCER
• The ulcer exclusively occur in young females and in the lower
third of leg and ankle region.
• Usually seen in obese with thick ankles and abnormal
amount of subcutaneous fat.
• It begins with erythematous purplish nodules
(Erytherocyanosis frigida) on the calves which rupture
resulting non healing ulcer.
• Etiology of these ulcer is not clear, suppose to be ischaemia
due to spasm of branches of post tibial and peroneal
arteries.
• These vessels are abnormally sensitive to hot and cold
weather similar to Raynaud’s disease.
• In some cases tubercle bacilli isolated which respond to anti
T.B. Drugs.
• Sympathectomy may be helpful in patients hypersensitive to
weather changes.
• Diabetic ulcer –
• Due to three causes – 1. Diabetic neuropathy, vasculopathy
and superadded infection.
BURULI ULCER –
• Deep ulcer caused by mycobacterial ulcerans with dermal
necrosis.
BAIRNSDILE ULCER –
• Superficial ulcer caused by the same organism.
CURLING ULCER –
• Stress ulcers occur in stomach of burned patients.
CUSHING ULCER :
• Ulcers present in patients suffering from cushing syndrome
due to excessive corticosteroids.
• It is also seen in people who are taking steroids for long
time.
FOOTBALLER’S ULCER :

• Ulcers seen around the ankle in football players due to

repeated trauma.

What are traumatic ulcers?

– Ulcer developed following trauma

– Present on exposed parts of body.

– Usually heal with treatment

• Diabetic Ulcer

– It is a nonspecific ulcer due to ischaemia, neuropathy

and infection (Wet gangrene)

– Commonly occurs in foot – over the heads of metatarsals.

 – Foul smelling discharge with slough
– Loss of sensation.
– Normal peripheral pulsations.
– Managed by debridement, antibiotics and controlling the
blood sugar levels.
– VAC therapy is helpful following wide debridement
• Signs of diabetic neuropathy
- Loss of sensation
- Loss of sweating
- Loss of muscle strength
- Loss of curvature of foot
-Loss of normal joint position
- Loss of elasticity of skin
• Sequence of events in diabetic ulcer foot
– Following injury or infection ulcer develops with oedema
and swelling of foot – Stages of cellulitis.
– Infection takes virulent course, spreads to deeper fascial
planes – Stage of spreading cellulitis.
– Secondary infection caused by mixed organisms along
with anaerobes and non-clostridial gas forming organisms
produce multiple abscess – Stage of abscess.
– Tense oedema along with vascular compression produce
ischaemia and gangrenous patches of skin, toes etc., -
Stage of gangrene or untreated cases may develop
gangrene of the limb with septicaemia and diabetic keto
acidosis –Stage of septicaemia.
– In cases with chronic ulcer, infection involves the bone
results in osteomylitis – Stage of osteomylitis.
Investigations :

– CBP

– Blood and urine sugar estimation

– Pus for c/s

– X-ray foot to rule out osteomylitis

– LFT, ECG, X-ray chest, Blood urea and serum creatinine

Treatment :
1. Control of diabetes with insulin given 3 to 4 times per day
depending upon requirement.
2. Control of infection after c/s commonly gram positive,
gram negative and anerobic infection.
Triple antibiotics may be given for long time.
3. Local treatment of diabetic ulcer – It is a non-healing ulcer.
Initial treatment is debridement/dressings with iodine
solution until the ulcer is converted into a healing ulcer with
pink granulation tissue.
4. Later the ulcer is covered with split thickness skin graft.
Care of the patient : Treat for nutritional deficiencies,
preventive care for development of bed source, chest
infection and water and electrolyte depletion.
5. Revascularisation of foot in diabetic patients –
- If angiography shows short stenotic lesion, balloon
angioplasty with or without stent placement is the
treatment of the choice.
- Infrainguinal bypass surgery – If there is block present in the
posterior tibial or anterior tibial arteries present, a bypass
surgery using long sephenous vein between poplital to tibial
or pedal artery can be performed.
- Even after successful surgery amputation rate is 35% and two
year patency rate is around 70%.
• Public education to protect the diabetic foot (Remember
‘BEARFOOT’
• Bearing foot waling should be avoided. Use microcellular
rubber shoes. Keep the foot dry after proper cleaning.
Paring of the nails and trimming should be done carefully. If
infection occurs consult physician at the earliest.
• Avoid herbal/local ointment application
• Regular and Rigorous control of diabetes with diet and
exercises
• Foot care – dry, frequent cleaning and corn care
• Oxygenation to toes/foot, proper shoes (MCR)
• Trimming of nail should be done carefully
Cause of death in diabetic ulcer
• Ketoacidosis with septicaemia.
• Severe electrolyte abnormalities.
• Silent myocardial infarction.
Treatment of Spreading ulcer :
• After obtaining pus culture/sensitivity report, appropriate
antibiotics are given. Many solutions are available to treat
the slough, such as hydrogen peroxide and Eusol.
• Hydrogen peroxide (diluted) when poured over the wound,
liberates nascent oxygen which bubbles out and helps in
separating the slough. Eusol1 also separates the slough.
• There are reports that H2O2 and Eusol can cause more
damage. Hence, they are no longer used.
• Partially separated slough needs to be removed by excision
daily or on alternate days, in the wards.
• Excessive granulation tissue or pouting granulation tissue
(pround flesh) needs to be decapitated by excision or by
application of copper sulphate or silver nitrate solution.
• By repeated dressings, slough gets separated and discharge
becomes minimal, resulting in a healing ulcer with healthy
red granulation tissue.
• Once, the floor is completely covered with red granual
tissue, a swab is taken for c/s.
• If the discharge is negative for streptococcal infection, a split
thickness skin grafting is applied for rapid healing.
Treatment of healing ulcer :
• I will do daily dressings with antiseptic solutions such as
betadine or silver sulphadiazine ointment.
• A swab is taken to rule out the presence of Streptococcus
haemolyticus.
• If the swab is negative for Strepotococcus haemolyticus
infection,
– If the ulcer is small, it healed by itself with
epithelialisation from the margin of the ulcer.
– If the ulcer is large, split skin graft is applied for rapid
healing.
 – If the discharge is positive for strepotococcus, I will treat
the infection with antibiotics (Penicillin or
capholosporins) for a period of 5-7 days.
– Then I will take swab for c/s, if it is negative, then I will
apply split thickness skin graft.
Advantages of Split thickness skin graft:
– Wound healing occurs fast
– Secondary infection is avoided because early skin cover
– It prevents contractures
– Pain is lessened
– It prevents Marjolin’s ulcer
Treatment of chronic ulcers
• These ulcers results from chronic ischaemia - to improve
blood supply to the area I will treat the ulcer with infrared
radiation or short-wave therapy or ultraviolet rays.
• To accelerate epithelisation, I will cover the wound with
amnion.
• To decrease the size of the ulcer, I will apply VAC (Vacuum
Assisted Closure) therapy.
 EXAMINATION OF AN ULCER
Definition
An ulcer is a break in the continuity of the covering
epithelium – skin or mucous membrane. It may either
follow molecular death of the surface epithelium or its
traumatic removal.
Name: __________________________age________________
Sex______________ Occupation ______________________
Address_______________________________
Complaint and duration:
Ulcer over the left foot – 15 days duration
Pain :15 days
History of present complaint:
• 15 days back patient sustained injury by thorn prick
(trauma)
• Later patient developed swelling of the foot for which he
went to a local doctor who gave some medicines.
• But the swelling increases in size and extended to the leg
with development of blackish spots over the dorsum of the
left foot. Then he came and joined in this hospital for
which a underwent surgery leaving this ulcer.
• Patient complaints of continuous throbbing type of pain
which radiate along the leg relieved on elevation of the
foot and aggravated on elevation of the limb.
• Patient is a known diabetic and hypertensive (enquire
about diabeties and hypertension)
• No history of fever.
• Bowels and mixturation normal. Appitate good
Past history
• Patient is known diabetic taking treatment (Enquire about
any previous illness that require admission or treatment in
hospital)
Personal history:
• Patient married living with wife and children. All are
healthy.
• Patient habituated to smoking, 2 cigars per day since 5
years.
• Patient is used to take alcohol once in a week about 100 ml
per day since10 years.
• (For female patients – Note menstrual history) – Periods
are regular, flow moderate, lasts for 3-4 days, no clots, no
pain)
• Enquire about history of any chronic illness like diabetes,
hypertension, tuberculous etc.
Family history :
• All family members are alive and healthy (if any member
died, enquire cause of death)
• No members of the family suffered with diabetes,
hypertension or chronic diseases.
Drug history :
• Patient is not allergic to any known drugs.
 PHYSICAL EXAMINATION
• Patient is moderately built, moderately nourished, no
anaemic, no jaundice
• Oral cavity – Tongue - moist and pink
• Oral mucosa – Moist, pink and healthy
• All teeth are present, gums are healthy
• Pulse : 70/min. Regular, volume, tension, normal vessel
wall not thickened (if patient is less than 40 years. Vessel
wall is thickened if patient is more than 40 years)
• BP : 130/90mm of Hg (If patient is more than 40 years)
• 120/80 (if patient is less than 40 years)
• Respiratory rate : 18/min Regular (Thoraco abdominal in
case of females).
• (Abdomo thoracic in case of males).
SYSTEMIC EXAMINATION
Cardiovascular system :
• Apex beat is palpable at 5th intercostals space on left side
lateral to mid clavicular line.
• 1st and 2nd heart sounds are normal.
• No murmus are heard.
Respiratory system :
• Chest is moving equally with respiration.
• Bilateral vesicular breath sounds are heard.
• No advantious sounds are heard.
Central Nerve System :
• Patient is conscious and coherent.
• Pupils are normal in size and shape, normally re-acting to
light.
• No neurological deficit. Gait is normal.
Gastrointestinal system :
• Abdomen is full moving with respiration. No mass,
peristalsis, pulsations are visible.
• On palpation abdomen is soft.
• No mass is palpable. No hepato-splenomegaly.
 LOCAL EXAMINATION
Inspection :
Number – Single
Shape and size – Irregularly oval in shape, measuring
horizontally 15cms. vertically 10 cms.
Site and extent – Present over the dorsum of Left foot
extending 2 cms. above the toe line
and 3 cms. below the ankle joint.
Margin – Margin is red in colour (Erythematus).
Floor – Floor is covered by red granulation
tissue.
Surrounding area – Healthy and pigmented
PALPATION
• On palpation, there is no local raise of temperature.
Tenderness - Present.
• Inspective findings like number, shape, size, site, extent are
confirmed.
Edge - Sloping
Margin, edge and base are not indurated.
Mobility - The ulcer is slightly mobile over the underlying
structures.
Discharge – Slight serous discharge present.
The ulcer bleeds on touch.
Examination of arterial system – Femoral artery, poplitial
artery, posterior tibial artery, anterior tibial artery and
dorsalis pedis artery are palpable.
Examination of venous system – There is no varicose veins.
Examination of lymphatic system – There is no lymph nodes
are palpable in inguinal region.
(If lymph nodes are palpable, note – Number, size, tenderness
and mobility)
Examination of nervous system –
– Movements of joints are normal.
– Touch and temperature sensation are normal.
– Pin-prick sensation is normal
– Joint sensation is normal
Provisional diagnosis – Non-specific – Healing ulcer over the
dorsum of left foot due to diabetes.
Investigations –
• Blood – Fasting and postprondial blood sugar levels.
• Blood urea and serum creatinine.
• HB, TC, DC
• X-ray chest PA view
• X-ray left foot AP and lateral views - to exclude
osteomylitis.
• ECG
Culture & sensivity of discharge from the ulcer.
Management- I will control blood sugar by insulin.
• As the ulcer is covered with healthy granulation tissue, I
will do daily dressings with normal saline to keep hydration
of the granulation tissue.
• If the culture swab is negative for streptococcal infection,
as the ulcer is very large and take long duration for healing
so, I apply split thickness (Therish graft) skin graft to cover
the wound.
• If the culture is positive for streptococcal infection, I will
treat the infection with sensitive antibiotics for a period of
5-7 days. Then once again I will take c/s if the wound is
negative for streptococci, then I will apply skin grafting.
• (Streptococci produces streptolysins which will destroy the
graft).
Presence of streptococcal infection is a contraindication for
skin grafting.
 STERILISATION
• Sterilisation is a process of which all microorganisms like
bacteria, fungi, viruses and the bacterial spores are killed.
Disinfection
• Disinfection is the process by which microorganisms are
killed or removed excepting the bacterial spores.
Definition may be –
Low level disinfection : Decreases the overall number of
microorganisms. The tubercle bacilli and bacterial spores
are not killed.
Intermediate level of disinfection : Kills tubercle bacilli and
other microorganisms, most viruses and fungi.
High level disinfection: Kills almost all microorganisms but
does not kill the bacterial spores.
Different techniques of disinfection of instruments are:
– Boiling: Boiling at 1000C for 5 minutes at normal
pressure.
– Intermediate level of disinfection : Kills tubercle
Formaldehyde vapour : Instruments kept in
formaldehyde vaporiser at 500C.
Glutaraldehyde solution :
• Instruments kept dipped in 2% glutaraldehyde solution for
15-20 minutes.
Low temperature steam:
• Exposure to dry saturated steam at a temperature 730C for
20 minutes at subatmospheric pressure.
STERILISTION OF INSTRUMENTS
• There are various techniques for sterilisation of
instruments:
1. Autoclaving – Autoclaving is a method of sterilisation using
steam under high pressure. Standard autoclaving involves
sterilisation at a temperature of 1210C at 15 lb/sq. inch
pressure for 30 minutes for metallic instruments and 15
minutes for rubber goods (Catheters, gloves, drains etc.).
• High pressure autoclaving: In central sterilisation unit for
bulk sterilisation high pressure autoclaving is suitable. This
involves sterilisation at a temperature of 1340 C at pressure
of 30 lb/sq. inch for 3 minutes.
2. Boiling – Boiling for half an hour kills all the bacteria and its
spores. Boiling of the instruments should be continued for
half an hour after water achieves a temperature of 1000C.
• This is not suitable for sharp instruments as there is loss of
sharpness due to boiling and there is formation of crust
over the instrumen
3. Chemical sterilisation – A number of chemicals are used for
sterilisation of instruments. Sharp instruments are
particularly sterilised by keeping them dipped in chemicals.
(a) 2% Glutaraldehyde solution (Cidex) : For sterilisation,
the instruments should be kept immersed in
glutaraldehyde solution for 4 hours.
(b) Lysol: This is used for sterilisation of sharp instruments.
Dipping in concentrated lysol for 1 hour is adequate for
sterilisation. If dilute lysol is used the instrument should be
kept immersed for 24 hours.
(c) 70% alcohol : Needles, unused sutures may be kept
immersed in 70% alcohol for 12 hour for subsequent use.
(d) Sterilisation by peracetic acid (Steris): This is effective
against all microorganisms including the bacterial spores.
The method involves immersion of the instrument in the
chemical peracetic acid at a temperature of 50-56 0C for 12
minutes.
5. Others –
(a) Ethylene oxide gas: A special ethylene oxide gas chamber is
required for sterilisation of instrument using ethylene oxide gas.
Instruments are kept in the chamber exposed to ethylene oxide
for 12 hours i.e., overnight. Large ethylene oxide gas chambers
are also used for industrial sterilisation.
(b) Formaldehyde gas: Formalin tablets placed in a formalin
vaporiser lead to formation of formaldehyde gas. Optical
instruments like cystoscope, laparoscope may be sterilised by
keeping them in formalin vaporiser for 1 hour.
(c) Hot air oven: Ward articles like glass syringes, test tubes may
be sterilised in a hot air oven.
Keeping the instruments in hot air oven at a temperature of
1600C for 2 hours is adequate for sterilisation by this technique.
 INSTRUMENTS
PARTS OF AN INSTRUMENTS
A typical surgical instrument consists of –
– Two Finger bows for holding the instrument.
– A pair of Shaft or body of the instrument.
– A catch or a ratchet – Once the ratchets are pressed the
blades are kept in a closed position.
– Blades – A pair of blades constitutes the terminal part of
the instrument.
– Joint – The two parts of the shaft and the blades are kept
attached by a joint.
• This joint may be either box joint or pivot joint.
• In pivot joint the two shafts are attached by screw.
ARTERY FORCEPS
• Also called Spencer Well’s artery forceps
• It has a ratchet and two blades with uniform horizontal
serrations.
• It is used to control bleeding from arteries, veins and
capillaries.
• It is available in two forms - Straight & Curved.
• The curved artery forceps is commonly used for haemostasis
• The smaller version of this is called Mosquito artery forceps.
• Mosquito artery forceps is used for plastic surgery operation
Ex: Cleft lip and cleft palate.
• Straight artery forceps is used to hold the stay sutures.
ALLIS FORCEPS
– It has ratchet and triangular expansion at the tip with
teeth for better grip.
– Used to hold tough structures like fascia and aponeurosis
etc.
– It is also used in intestinal anastomosis to hold the
intestine
KOCHER’S FORCEPS
• This is similar to an artery forceps with horizontal serrations
on the blades and sharp tooth at the tip of the instrument
for better grip.
• It also available as curved and straight.
– Used to hold tough structures like aponeurosis and fascia.
– During thyroidectomy, it can be used to hold strap
muscles for dividing them.
– It is used to control bleeding during craniotomy by
holding epicranial aponeurosis.
– Theodor Kocher, German Surgeon, got Noble prize for
contribution to thyroid surgery.
SINUS FORCEPS
• This is also like artery forceps without ratchets and with long
blades.
• Serrations are confined to the tip only, so as to hold the wall of
the abscess cavity to take biopsy.
• The remaining part of the blade has no serrations.
• It is used for drainage of an abscess by Hilton’s method.
• Hiltons method of abscess drainage - This method is used to
drain abscess cavity when the is present at important vascular
sites. Eg. Neck, axilla, groin
• After anaesthesia, a small incision of 5-10 mm size is given in
the skin.
• Then, the sinus forceps is thrust in to the abscess cavity pears
in the deep fascia.
• The blades are opened in all directions, so that, all the loculi in
the abscess cavity are break open and pus is drained.
• Then the skin incision is enlarged and a finger is introduced
into the abscess cavity to break open the remaining loculi and
whole pus is drained.
• The cavity is washed with hydrogen peroxide and normal
saline.
• A corrugated rubber drain is kept in the cavity and wound is
dressed.
BABCOCK’S FORCEPS
– This is similar to artery forceps with ratchets.
– The terminal part of the instruments was expanded in a
triangular shape with fenestrations.
– It does not have any serrations or teeth.
– It is used to hold soft tissue like intestine during
anastomosis or resection.
– Used to hold thyroid gland, during thyroidectomy,
mesoappendix during appendicectomy and utrine tubes
during tubectomy.
– It also used to hold tongue during oral surgery.
DISSECTING SCISSORS : MAYO’S SCISSORS.
• This instrument have no ratchet. Available in straight and
curved varieties.
• Curved scissors is used to dissect tissue planes during surgical
operations and straight scissors is used to cut suture material
during operation
STRAIGHT SCISSORS
• Used to cut the sutures or knots.
• Hence, called as suture – cutting scissors.

Dissecting forceps : (A) Non-toothed (B) Toothed

It is available as toothed and non-toothed forceps.
It has no joint in the middle and no ratchets.
Two blades are joined at top end which have spring action, when
the two blades are pressed, the tips of the blades come together to
hold the tissue.
• When pressure is released, the blades are separated
unholding the grip on the tissue.
• The tip have serrations in case of non-toothed dissection
forceps.
• Tooth are present at the tip in case of toothed forceps.
• It is also called thumb forceps because their shafts are
closed by surgeon’s thumb.
• Used to grasp tissue in order to facilitate dissection or
suturing.
• Plain dissecting forceps cause no damage to tissue, so used
to hold soft tissue and intestine during anastomosis.
• Toothed forceps gives a firm grip, used to hold firm tissue
like skin, fascia and linea alba during dissection and suturing.
• Dissecting scissors & forceps make good tool for surgeon to
develop a tissue plane in majority of surgeries.

Non-toothed

Toothed
NEEDLE HOLDER
• It has long shaft with ratchet, small and stout blades with
criss cross serrations on the blades for better grip of the
needle.
• The instrument is used to hold curved needles during
surgery to suture the cut edges.
• The needle is hold just behind its mid point which gives
maximum advantage in curving action.
BROAD AND PARKER SCALPEL
HANDLE (BP HANDLE)
• Used to hold scalpels during
surgery for making incisions.
• Available in two forms, No.3 and
No.4.
• No.3 handle holds surgical blade
No.10 to 15.
• No.4 handle holds 1 6 to 24
numbers.
LANGENBECK RETRACTOR
• This instrument having single flat blade used to retract tissue
and muscles during surgery as in thyroidectomy,
appendisectomy and excision of lipoma.
 CUFFED TRACHEOSTOMY TUBE
• This is made up of polyvinyl chloride.
• It consists of two tubes, outer and inner tubes
• Once the tube is introduced in to the trachea, the cuff is
inflated by using 3-5 ml of air.
• The cuff prevent leakage of gases and prevents aspiration.
• If the inner tube is blocked, it may be removed and cleaned
while the patient is taking respiration through the outer-tube.
• The inner tube is cleaned, mucus plugs are removed and
reintroduced.
CORRUGATED DRAIN
• It is made of polyvinyl chloride.
• This is used to drain fluids from cavity after major surgery like
laparotomy and drainage of abscess.
• It is used after thyroidectomy, gastrectomy and
cholecystectomy etc.
• The drain is removed after it stops draining usually within 3-5
days.
FOLEY’S SELF-RETAINING URINARY CATHETER
• Made of latex rubber with silicon coating.
• At the tip, proximal to the side openings, a bulb is present.
• Capacity of the bulb is written on the side channel.
• Before inflating the bulb, one must make sure that the
catheter is in the urinary bladder but not in urethra.
• After introducing the catheter, bulb is inflated using saline to
become self-retaining.
• After its function is over, it is removed by deflating the bulb
after withdrawing the saline.
• It is used to drain the bladder for continuous drainage.
• Used to compress the prostatic bed to control bleeding after
prostatectomy.
• It is used to drain the urinary bladder after suprapubic
cystostomy.
• It is also used to drain the peritoneal cavity, plural cavity.
• It is used as gastrostomy tube for feeding purpose
RYLE’S TUBE

Also called as Nasogastric tube.

At the end of the tube there are lead shots useful to confirm the
position of the tube in the stomach.
It is having four openings on its lateral side.
• It is having three marks, if the first mark is at the nose, the
end of the tube is gastroesophageal junction,
• if the second mark is at the nose, the end of the tube is in the
middle of the stomach,
• If the third mark is at the nose, the end of the tube is in the
pyloric region.
• The tube is passed through the nose.
• It can also be passed through the oral cavity, but it interferes
with swallowing, so it is passed through the nose.
• The tube is used to aspirate the intestinal contents during
intestinal obstruction.
• Used for feeding purpose in comatous patients and in
patients with disease of the oropharynx.
• It is also used to diagnose upper GI haemorrhage and
malignancy of stomach through cytology.
 VOLKMANN’S SCOOP

• It is having blunt end like spoon used to take pus for C /S and
to add medicines to the ulcer.
• Another end is sharp called as scoop used for scraping of
infective granulation tissue in a sinus or fistula and to scrape
ostemomylitis cavity to remove dead bone.
• Used to scrape granulation tissue from wall of a
osteoclastoma and also dental and dentigerous cyst.
 SUTURING MATERIAL

Two types :
(1) Absorbable -
(a) Natural Eg: Catgut
(b) Synthetic Eg. Polyglactin (Vicryl)
Polyglycolic acid (Dexon)
(2) Non-absorbable
(a) Natural Eg: Silk, lenin
(b) Syntheic Eg: Polypropylene
(Proline)
Polyamide (Nylon)
Nature means – Available in nature
Synthetic means –Prepared in the laboratory by chemical
reactions.
 ABSORBABLE SUTURES
• The suture material is absorbed in the body either due to
phagocytosis or by enzyme action.
A) ABSORBABLE - NATURAL
1. Catget is obtained from submucosa of sheep intestine or
cattle’s intestine.
• As it resembles strings of a kitten, a musical instrument, it is
named as catgut.
• Advantages are - Knots are well placed and easy to handle
but as it is a foreign protein, it produce inflammation in the
tissue with abscess formation.
• It has a tensile strength of 15 days and is absorbed from the
body within 6 weeks.
It is available in two forms –
(a) Plain catgut : It is absorbed in a period of 1-2 weeks.
• Not useful for anastomoses as fibrosis will form after 3-6
weeks only. So it used to approximate subcutaneous tissues
during closure of incision to prevent haemotoma or seroma
formation.
• The material and foil are yellow in colour.
(b) Chromic catgut – the absorption period and tensile strength
is increased to 6-8 weeks by treating the catgut with chromic
salts. It is used to suture muscles, intestinal anastomoses and
closure peritoneum.
• The material and foil are brown in colour
B) ABSORBABLE - SYNTHETIC SUTURES
Polyglactin (Vicryl )or polyglycolic acid (Dexon).
• Maintain tensile strength for longer period of 6-8 months
• Strength is greater compare to natural ones (catgut)
• It is sterilized by Ethylene oxide
• As it is a synthetic, tissue reaction is minimal and commonly
used in all surgeries including plastic surgeries where tissue
oedema is not required.
• Material and foil are violet in colour.
• Vicryl rapid – It is absorbed in the body within 3-4 weeks.
• So, it is used to close the subcutaneous tissue like plain
catget.
• Material is in white in colour. Foil is red in colour.
 NON-ABSORBABLE
NON-ABSORBABLE – NATURAL
Lenin – Prepared from cotton, used for negation of bleeding
vessels and for skin suturing.
Silk is natural, non-absorbable suture material
It is derived from secretions of silk worm larvae
It has good tensile strength up to 2 years and with secured
knots.
It is sterilized by gama radiation.
It is used for skin closure
To ligate mesenteric vessels during intestinal resection.
Used for nerve suture and repair of inguinal hernia
(Herniorrhaphy)
Material is black in colour but the foil is sky blue in colour.
(B) NON-ABSORBABLE – SYNTHETIC
I. Proline (Prolypropeline)
It has low tissue reactivity.
Prevents tissue strangulation in postoperative period due to its
unique property of “extension”
It is mainly used when tissue swelling is expected.
It is very smooth, hence minimal or no tissue damage.
Tensile strength is for indefinite period.
No.1 is used to close midline abdominal incision and hernia
repair
No. 2-0 or 3-0 is used for repair of tendon injury.
Herniorrhaphy- No.1
No. 4-0 or 5-0 is used for vascular and nerve anaestomoses.
It is sterilized by gamma radiation.
The material and foil both are dark blue in colour
II. Nylon (Polyamide)
Non-absorbable synthetic suture material made of polyamide.
It is used to close the skin. Not suitable for deeper sutures like
hernioplasty or closure of abdomen as it has low tensile
strength.
The material is in black in colour. Foil is green in colour.
As Number (i.e., 1, 2) is increasing, the thickness of the

suturing material is increasing.

As Number is decreasing like 0, 2-0 so on the suture material

becomes thinner and thinner (Fineness).

The suture material is available attached with needles i.e.,

atraumatic needle (eyeless needle).

These are cutting, marked as full triangle ( ), reverse

cutting marked as opening triangle ( ) and round

body marked as circle. ( )

The needles are of different sizes and shapes which is noted on

suturing material.

Needles are also available as free needles with eye on which a

suturing material is threaded and used for suturing.

These are also available as cutting and round bodied, straight

and curved of different sizes and shapes.

 SURGICAL BLADES
Two types -
1. Blade No.11, 12, 15 commonly used for plastic and paediatric
surgery are mounted on No.3, BP handle.
2. Blade Nos. 20, 21, 22, 23, 24 are mounted on No.4 BP handle
used for all type incisions in adults.
 X-RAYS
DENTIGEROUS CYST

OPG X-ray – showing unerupted 3rd molar tooth surrounded by

radiolucent cystic area on left side of lower jaw.
It may be a case of Dentigerous cyst
COTTON WOOL APPEARANCE PAGETS DISEASE

X-ray of mandible showing radio opaque, cotton wool shaped

lesions all over the mandible with thickening of the bone.
May be a case of paget’s disease of jaw.
CLEFT PALATE

X-ray of the maxilla showing bilateral absence of lateral incisor

tooth and bilateral bony defect in soft and hard palate.
Nasal septum is present in midline.
This is a case of bilateral complete cleft palate.
COMMUNATED FRACTURE OF ANGLE OF MANDIBLE

OPG showing multiple fracture lines at both angles of

mandible.
May be a case of comminuted bilateral fracture at angles of
mandible. .
MANDIBULAR PARASYMPHASEAL FRACTURE

OPG showing single linear fracture line on left side of mandible

lateral to midline. For both upper and lower teeth on both
sides, restoration is performed.
This may be a case of Parasymphaseal fracture on left side of
mandible.
MULTILOCULAR AMELOBLASTOMA

X-ray skull lateral view – showing multiple punched out radio-

lucent shadows in this skull bones (Restoration of upper teeth
present).
May be a case of multiple myeloma.
OSTEOGENIC SARCOMA

OPG showing bilateral unerupted third molar tooth

Soft tissue shadow with new bone formation seen on the right
side of the mandible.
The new bone shows sun-ray appearance.
A case of Osteogenic sarcoma of right side of mandible.
 SUBMANDIBULAR GLAND - SIALOLITHIASIS
X-ray of the oral cavity showing oral
cavity and mandible.
One oval shaped radio-opaque shadow
present in the left side of the oral cavity
and a stag-horn shaped radio-opaque
shadow present on the left of the
mandible.
Submandibular salivary calculi, one in the
gland and one in the duct.
(Shadow on the mandible is calculi in the
gland.
Shadow in the oral cavity is calculi in the
duct)
 DENTIGEROUS CYST

OPG showing left unerupted third molar with surrounding radio-

lucent cavity extending over the ramus of the mandible.
May be a case of dentigerous cyst
 DENTAL CYST

X-ray of the mandible - showing radio-lucent unilocular cyst seen

at the root of the tooth. Restoration of the tooth is seen .
May be a case of Dental cyst or epical cyst
 LEFT ZYGOMATIC BONE FRACTURE

X-ray face showing fracture of left zygomatic bone.

A case of simple fracture of zygomatic bone.
 LEFT ZYGOMATIC BONE DEPRESSED FRACTURE

X-ray maxilla showing depressed fracture of the left zygomtic

bone
 OSTEOMYLEITIS OF JAW

OPG showing multiple irregular radio-lucent areas as moth eaten

appearance with restoration of upper and lower teeth.
May be a case of osteomylitis of lower jaw
 CARCINOMA OF BUCCAL MUCOSA

Photograph of the oral cavity showing exophytic growth with

nodular surface at the angle of the mouth.
May be a case of carcinoma of Buccal mucosa.
 CARCINOMA FLOOR OF MOUTH

Photograph showing irregular ulcer with raised and everted edges

seen in the right side of the floor of the mouth.
 ADVANCED CARCINOMA OF CHEEK

Photograph showing two ulcers with raised and everted edges.

One ulcer is on the cheek and another is in the submandibular
region.
A nodular mass present in the upper part of the neck.
May be a case of advanced carcinoma cheek with oro-cutaneous
fistula and ulcerating secondaries in the submandibular lymph
nodes (level - I B) and secondaries in upper deep survical lymph
nodes (level - II)
CARCINOMA LOWER LIP

Photograph of lower lip showing irregular shaped ulcer with

raised and everted borders. Floor is covered with tumour
granulation tissue and slough.
CARCINOMA OF TONGUE (LATERAL MARGIN)

Photograph showing ulcer with raised and everted borders on the

posterior part of later side of tongue.
A case of Carcinoma of lip on lateral side.
CLEFT LIP & PALATE

Photograph showing defect in the right side of upper lip with

flattening of ala of the nose.
A case of complete cleft lip on right side.
LEFT CLEFT LIP

Photograph showing incomplete defect in the left side of upper

lip.
A case of incomplete left side cleft lip.
TYPES OF CLEFTS
1 2 3

4 5 6

1. Incomplete right side cleft lip. 2. Incomplete left side cleft lip
3. Complete left side cleft lip. 4. Bilateral incomplete cleft lip.
5. Right side complete cleft lip with left side incomplete cleft lip.
6. Bilateral complete cleft lip.
STAPHYLOCOCCUS IN A SMEAR OF PUS

Microscopic side showing pus cells with bunches of gram positive

cocci seen both extracellular and intracellularly.
May be staphylococcus.
CLASTIDUM TETANI

Microscopic slide showing rod shaped gram positive organism

with terminal spore (Drumstick appearance).
May be clustidum tetani
Cl. Welsi-central spore (Fusiform appearance) (Gas gangrene)
Cl. Difficle-Subterminal spore (Pseudomembrane colitis)
ACTINOMYCOSIS ISRALIE

Microscopic slide of sulpher granules showing mycelia of gram-

positive and gram-negative filamentous bacilli.
A case of actinomycosis isralie.
CANDIDA SPECIES

Microscopic specimen of sputum showing filamentous fungai

with budding cells and psedohyphae.
A case of candida albicans.
MYCOBACTERIUM TUBERCULOSIS

Microscopic slide of sputum stained with Ziehl-Neelsen stained

smear showing rod shaped organisms.
A case of mycobacterium tuberculous