SOFT TISSUE MASSES ,

SINUS AND FISTULA

Assist. Prof. Alaa Jamel
MRCSI CABS

SOFT TISSUE MASSES

,SINUS AND FISTULA

Sinus; it’s a blind end tract lined by granulation tissue

which connects a cavity (usually an old abscess ) with
an epithelial surface , it produces a serious or purulent
discharge , its either
congenital or acquired .
congenital sinus arise from ruminant of embryonic
ducts that persist instead of obliterated .

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 CONGINTAL SINUSES

Priauricular sinuses; may be unilateral or bilateral .

Umbilical sinuses;
Urchal sinus; This occurs when the urachus did not
seal close to the umbilicus and leads to a blind
ending tract from the umbilicus into the urachus
called a sinus.

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 CLINICAL FEATURES;

*It may be a symptomatic .

*but it may have tendency to infection which may
lead to persistent discharge,
*pain if there is a swelling.

COMMON ACQUIRED SINUSES;

Post surgical and perineal sinuses;

mainly due to suture sinus (non absorbable suture
material act as a focus of infection).
Or may occur after anastemotic leaks or
post surgical intra abdominal abscess>
Perianal sinus; which occur after procto coloctomy
which more commonly occur with crohn's disease.

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 Pilonoidal sinus; (P.N.S)
Hydradenitis supurativa; abnormal of apocrine sweet
gland of the body which found in axilla . groin and
perineum and around the nipple.

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 EVALUATION OF SINUSES;

by
**micro bacterial examination of the discharge.
**Propping gently ,
**sinography ( who).
Treatment ;
depends on location of abscess cavity and eradicated
otherwise recurrence either at the
same location or adjacent to it

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 FAIL TO CLOSE IF;

1-the cavity is in adequately drained

2-its caused by specific chronic infection.
3-a foreign body is present in the bottom of the sinus
4- the cavity has epithiliazed
5- the cavity has undergone malignant changes
6- the surrounding tissue have poor vasculirized and or
irradiated..

FISTULA

it’s a pathological connection between two epithelial

surfaces, example
fistula between bowel and skin .
bowel and other loop of bowel
the bowel and bladder.
its usually lined by granulation tissue but can
becomeepithilized.
Congental or aquird..
Common fistula seen in practice is fistula in ano due to
purest of peranal abscess or in adequate drainage. Other
example is thyroglossal fistula who it occur or
tracheoesophageal fistulla?
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 CYST;

Its a collection of fluid in a sac lined by endo-or

epithelium which usually secretes the fluid.
We have 2 types true & false cysts .
what's the differences between them?

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 CL ASSIFICATION;

True; its lined between endo or epithelium tissue .

False ; are the results of exudation or degeneration
e.g. pseudo cyst of pancreas, cystic degeneration of
tumour. Brain cyst ,encystic pleural effusions.

CL ASSIFICATION;

Congenital; as sequestration dermoid cyst (lateral

margin of eye brow)

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 ACQUIRED;

1- retention cyst , as sebaceous cyst due to blocking

of execratory duct. Ranula (salivary gland) breast
cyst
2-Distension cyst; as thyroid or ovarian cyst occur
due to distension closed cavity with the fluid
3-Neoplastic; cyst adenoma of the ovary
4-Parasitic cyst hydatid cyst
5-implantation ; dermoid cyst

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 RANULA

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 DERMOID OF OVARY

Clinical feature; the swelling is smooth, spherical

which may be soft and fluctuated or may be tens
which may be produce pain in the cyst or surround
stricture , may be transilluminate if the fluid clear.
Effects; may compress surrounding stricture and
may cause pain if complication occur.
Complication;
Infection, torsion , rapture, hemorrhage and
calcification.

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 Treatments
Excisions ,drainage, marsupialization.

EPIDERMOID CYST

Also called sebaceous cyst ,pilar cyst .

it occur at any age groups but rarely in children .
found in the hair bearing part of the body
especially in the scalp, neck, scrotum, shoulder and
back.
They can occur whenever the sebaceous gland found
but not in palm or sole .why?
it vary in size from few millimeters up to 4 cm. its
slow growing and usually a symptomatic , it rise
from infundibular portion of hair follicle ,
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 Its more laible for infection why?.
90% arise in the scalp ,70 % multiple

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 COMPLICATIONS

1-infection why more susceptible to infection? (Punctum) discharge foul

smelling , cheesy material
2- malignant changes very rare or extremely rare reported at 1963
3- multiple cysts occur in gardener syndrome
4- pilar tumour , proliferation of epithelial lining cyst with ulceration give
appearance like seq. cell carcinoma (cocks peculiar tumour).
Treatments;
Complete surgical execion with its contents through un elliptical incision
including the punctum.
recur occur if a small portion of cyst lining left behind.

DERMOID CYST

Its deep to the skin ,which is lined by skin .

Skin can become trapped in the subcutaneous tissue
either during fetal development (congenital
dermoid cyst ) or following an injury which force
the skin in to the deeper tissues(
acquired/implantation cyst)

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 CONGENTAL DERMOID CYST
(SEQUESTRATION TYPES)

; it’s a subcutaneous cyst caused by developmental inclusion of

epidermis along lines of fusion. Its lined by stratified sequamous
epithelium but unlike epidermoid cyst the wall contains functioning
(not keratenizing) epidermal appendages such as hair follicles sweet
and sebaceous gland.
Site ; more commonly found on the lateral and medial end of eye
brow(external and internal angular dermoid), midline of the nose
(nasal dermoid), midline of the neck.

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 BY EXAMINATION

It has smooth surface and well defined adges its soft

and fluctuant but dose not transilluminated its not
attached to the skin above it but appear to be fixed
to the deeper structure. Surrounding skin and
regional L.N usually normal except in infection
causing painful regional l.n and may redness of
skin.

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 COMPLICATIONS;

1-may cause bony depression and penetrate to the

dura , meningeal penetration is a problem with
midline dermoid not occur in internal or external
angular dermoid. so need C.T SCAN before
operation.
Treatments by surgical excision if causing a
troublesome.

ACQUIRED (IMPLANTATION) DERMOID

CYST;

It occur after a survival of a piece of skin forcibly

implanted in to the subcutaneous tissues by an
injury such as a small deep cut or stab injury, the pt
may not remember the injury .histology is similar
to congenital dermoid .
Site ; occur in area subject to repeated trauma such
as finger

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 MANANGMENT ;

excision its commonly confused with sebaceous cyst

but the presence of scar and old history of trauma
is helpful in differentiation.

IMPLANTATION DERMOID CYST .

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 LIPOMA;

Lipomo are hamartoma ( over growth of cell types normaly found in

that organ) so it’s a clastur of mature fat cells that have become over
active and distended with fat .
its represent as a non tender lump ,lobulated ,smooth surface age are
also lobulated and sliped away from the fingers( sliped sign). Its soft
and flactulant why ?its not a fluid .
It occur any where when there is a fat but common on the back,
shoulder, neck, forearm, trunk. its not occur in palm ,sole and the
scalp why?( because fat is contained within dense fibrous septa)

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 Dercum's tumour; it’s a familial syndrome of
multiple lipomata.

Lipoma in intestine more common in the cecum in

large intestine although lipoma in large intestine
are less common in small intestine. Tumour in
intestine is submucous and more than half of cases
cause intussusceptions.

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