Tumor,ulcer,cyst,sinus,fistula.pptx

Basics, etiology, types, examination, treatment of tumor, cyst, ulcer, sinus and fistula.

1. Tumor, ulcer, cyst, sinus & fistula dr yash sharma MBBS, MS, DNB Sr , department of general surgery, Medical college kolkata

2. A. Tumor Definition : A tumor is a mass or lump of tissue that may resemble swelling . A mass of abnormal tissue that arises without obvious cause from preexisting body cells, has no purposeful function, and is characterized by a tendency to independent and unrestrained (uncontrolled) growth.   Enlargement or protuberance in the body due to any cause. Suffix “ _ oma ” suggestive of swelling.

3. Cause of swelling (tumor) Congenital – cystic hygroma , hemangioma Traumatic - hematoma Inflammatory - ludwigs angina Neoplastic / malignant – sarcoma, carcinoma Miscellaneous - abscess

4. 5 cardinal signs of inflammation redness   ( rubor ) swelling  ( tumour ) heat    ( calor ) pain    ( dolor ) loss of function  ( functio laesa )

5. Basics of Case presentation in exams Chief complains Proper history  present,past,personal,family,treatment,etc …….( menstrual,obstetric history in females) General examination  vitals, performance score, nutrition, P/I/Cy/ Cl / Pe Oral examination Neck examination Local examination  Inspection, palpation, percussion and auscultation Case summary Provisional diagnosis Differential diagnosis

6. Benign Malignant

7. Examination Inspection Palpation Purcussion Auscultation

8. Inspection   “ REMEMBER NOT TO TOUCH THE PATIENT DURING INSPECTION “ Typically remember first the “ 6 – S ” in the method of inspection. 1 . S ite Exact anatomical location Relation – bony pt / surface landmark 2 . S ize - Vertical or Horizontal dimension - Noted in cms 3 . S hape - Oval/globular/spherical pear or irregular – diffuse or localised 4 . S urface - Smooth / nodular / lobular or bosselated 5 . S kin - Tense , glossy with prominent veins / Red edematous , Pigmentation/ulceration / fungation / discharge , Scar & nature of healing 6 . S urrounding area - Changes - pigmentation/edema wasting

9. Others – Number – single / multiple Color Edges / Margins Extent Visible pulsations Visible cough impulse Movements Joints – above / below

10. Palpation Be Gentle & do not hurt the patient Methodical , follow a definite order Purpose - To define anatomically To find out – nature of content

11. Temperature – Best – back of hand Increased in - Inflammation / Infection Tumours with ↑ vascularity Tenderness – Pain due to pressure exerted over the swelling Palpate gently observe the face of patient Inspectory findings - Size, Shape, Surface, Edge and Extent  confirm with palpation & co-relate both Note the third dimension depth which could not be exactly determined by inspection. Consistency -Nature or feel of the swelling  soft/cystic/ puttacious /firm/hard

12. Fluctuation - Transmission of impulse in 2 directions at right angle to each other. - Implies – fluid or gas Eliciting method –First fix the swelling. Keep 2 index fingers on opposite poles. When one finger is pressed the finger at opposite end feels the impulse & passively lifted up. Repeat the manouevre in a plane at right angles to the 1st one. If impulse is felt in both planes it is a + fluctuation test . Pseudo-fluctuation – not positive in cross fluctuation test For small swellings < 2cm  Pagets’s test - The margins of swellings is fixed using thumb & ring fingers. Using index finger summit or centre of swelling is pressed to feel the displacement of fluid. Principles to be used –Always perform in 2 directions at right angles to each other. Two fingers should be kept as far apart as possible. Freely mobile swellings should be fixed first . Very large swellings more than one finger should be used. Translucency - Transmission of light through a swelling. Positive in swellings – Clear fluid & thin transparent walls. No transillumination - wall is thick, or turbid fluid [ Blood,pus,lymph ] Dark room with transilluminoscope .

13. Reducible or irreducible Reducible vs compressible Pulsatility – Swelling may be pulsatile – It raises with each beat . 2 types of pulsations - seen. Two fingers are placed over the swelling and finger movements are noted. 1.Transmitted pulsation – Fingers are only raised but not separated. 2.Expansile pulsation – Fingers are raised & separated. Fixity to skin - Skin is lifted up over different parts of the swelling – cannot be lifted if fixed to skin. Skin is made to move over the swelling – the skin will not move if it is fixed to skin. Mobility/Plane-swelling - Mobility – swelling can be moved in relation to underlying structures. - Plane – co-relates to the probable site of origin or its relationship to deep fascia.

14. Relationship to structures – Sub. Cut.Tissue : more prominent & less mobile. From muscle : fixed & diminished – Deep to muscle : disappears on muscle contraction & difficult to palpate Tendon – - Moves with the tendon & fixed Vessels & nerves – - Moves little extent at rt angles to axis. Bone – - Fixed

15. Percussion - Limited value in swellings - Not needed -To find out content or elicit tenderness Auscultation - Look for any bruit over pulsatile swellings. Machinery murmur – aneurysmal varix

16. Management Investigations – 1. Confirm the diagnosis  aspiration cytology / biopsy(core needle/surgical) 2. Radiological Imaging 3 . Routine investigations Treatment – Benign inflammatory – conservative management Cystic lesion – excision / marsupialization Infective /abscess – Incision and drainage Benign – excision Suspicious – excision / incisional / punch Bx Malignant – wide local excision / radical excision

17. B . cyst   Killey and kay (1966) – cyst constitutes an epithelium –lined sac filled with fluid or semifluid material. revised definition ” A cyst is an abnormal cavity in hard or soft tissue which is contains fluid, semifluid or gas and is often encapsulated and lined by epithelium .” Kramer’s(1974 ) – A cyst is pathologic cavity having fluid, semifluid, or gaseous contents that are not created by the accumulation of pus; frequently, but not always, is lined by epithelium.

18. B. ulcer A break in the continuity of the covering epithelium of the skin or mucous membrane It may either follow molecular death of the surface epithelium or its traumatic removal. What is an ulcer ? Latin origin ULCUS means break in the skin. A mouth or oral ulcer is an open sore in the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth.

19. Parts of ulcer Ulcer consists of: Edge :- area between the margin and floor of ulcer . This is an important finding of an ulcer which by itself not only gives clue to diagnosis ulcer but also to the condition of ulcer. 2 . Floor:- this is the exposed part of an ulcer. The covering of floor is important. 3 . Base (on which the ulcer rests):- floor is the exposed surface of an ulcer whereas the base is on which the ulcer rests. Floor is seen but the base is felt. 4 . Margin:- it’s the point where the ulcer joins the normal epithelial tissue.

20. ETIOLOGY Traumatic causes Mechanical Physical – electrical, radiation etc Chemical Vascular insufficiency Arterial Venous Neoplastic conditions SCC BCC KS Malignant melanoma etc

21. Cont … Metabolic diseases - diabetes mellitus Malnutrition Beriberi Tropical ulcer Inflammatory processes - cellulitis Infective processes TB Syphilis Fungal infections

22. Cont … Neurogenic causes Bed sores Perforating ulcers Cord Lesions Peripheral Neuropathies Other causes Bazin ulcer Martorell’s (hypertensive ulcer)

23. CLASSIFICATION Etiological classification Clinical classification Pathological classification

24. Etiological classification Traumatic ulcers Vascular ulcers Neoplastic ulcers Metabolic ulcers Ulcers due to malnutrition Inflammatory ulcers Infective ulcers Miscellaneous ulcer Drug induced Clinical classification Spreading ulcer Healing ulcer Callous ulcer Pathological classification Non-specific ulcers Specific ulcers Malignant ulcers

25.   Infective ulcer Viral - Vesiculobullous diseases caused by viruses Human herpesvirus 8 (HHV-8) Human Immunodeficiency virus Bacterial Acute Necrotizing Ulcerative Gingivitis (ANUG ) Syphilis Tuberculusosis Fungal - Chronic Mucocutaneous Candidosis (CMC)

26. Drug Induced Drug-induced neutropenia/ anaemia ( cytotoxics ) Lichenoid drug reactions (e.g. β- blockers, NSAIDs) Drug-induced mucositis (cyclophosphamide)

27. Examination General survey Inspection Palpation Examination of lymph nodes Vascular insufficiency Nerve lesions

28. Inspection SIZE AND SHAPE NUMBER POSITION EDGE FLOOR DISCHARGE SURROUNDING AREA

29. Floor

30. Surrounding area

31. Palpation TENDERNESS EDGE AND MARGIN BASE INDURATION BLEEDING RELATIONS WITH DEEPAR STRUCTURES SURROUNDING SKIN

32. Induration  ( hardness) of the edge is very characteristic of squamous cell carcinoma. It is said to be a host defense mechanism. Tenderness of the edge is characteristic of infected ulcers and arterial ulcers. Base  It is the area on which ulcer rests . Marked induration at the base is diagnostic of squamous cell carcinoma. The edge, base and the surrounding area should be examined for induration. Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer .

33. Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. Granulation tissue as in a healing ulcer also causes bleeding. Thickening and induration is found in squamous cell carcinoma. Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer. REGIONAL LYMPH NODES Tender and enlarged Acute secondary infection. Non-tender and enlarged Chronic infection. Non-tender and hard Squamous cell carcinoma. Non-tender, large, firm, multiple Malignant melanoma.

34. Management Treat the cause Stabilize co-morbidities Healing vs non healing ulcer Regular dressing Non healing or suspicious ulcers  biopsy  incisional wedge biopsy / punch biopsy / excision biopsy Reconstruction or cover using skin graft  STSG / Full thickeness Skin flaps  rotation/advancement/free flaps

35. D. sinus Blind track lined by granulation tissue leading from epithelial surface down into the tissues. Latin : Hollow (or) a bay  CAUSES CONGENITAL - Preauricular sinus ACQUIRED – TB sinus Pilonidal sinus Median mental sinus Actinomycosis

36. E. Fistula   ABNORMAL communication between lumen of one viscus and lumen of another (INTERNAL FISTULA) (or) between lumen of one hollow viscus to the exterior (EXTERNAL FISTULA) (or) between any two vessels Latin : flute (or) a pipe (or) a tube . CAUSES CONGENITAL  Branchial fistula , Tracheo -esophageal ,Umbilical , Congenital AV fistula ACQUIRED I . Traumatic II . Inflammatory III.Malignancy IV.Iatrogenic

37. Causes for persistence of sinus (or) fistula Presence of a foreign body. e.g., suture material Presence of necrotic tissue underneath. e.g., sequestrum Insufficient (or) non-dependent drainage. e.g., TB sinus Distal obstruction. e.g., faecal (or) biliary fistula Persistent drainage like urine/ faeces /CSF Lack of Epithelialisation (or) endothelisation of the track. e.g., AVF Malignancy. Dense fibrosis Irradiation Malnutrition Specific causes. e.g., TB, actinomycosis Ischemia Drugs . e.g., steroids Interference by the patient

38. CLINICAL FEATURES Usually asymptomatic but when infected manifest as- Recurrent/ persistent discharge. Pain . Constitutional symptoms if any deep seated origin.

39. Examination INSPECTION : 1 . Location: usually gives diagnosis in most of the cases. SINUS : pre-auricular- root of helix of ear median mental- symphysis menti TB- neck. FISTULA: branchial - sternomastoid ant border parotid- parotid region thyroglossal - midline of neck below hyoid.   2. Number: usually single but multiple seen in HIV patients (or) actinomycosis .

40. 3. Opening: sprouting with granulation tissue-foreign body. b) flushing with skin- TB 4. Surrounding area: erythematous- inflammatory bluish- TB excoriated- faecal pigmented- chronic sinus/fistulae. 5 . Discharge: White thin caseous , cheesy like- TB sinus Faecal - faecal fistula Yellow sulphur granules- actinomycosis Bony granules- osteomyelitis Yellow purulent- staph. infections Thin mucous like- brachial fistula Saliva- parotid fistula

41. Palpation : Temperature and tenderness: Discharge : after application of pressure over the surrounding area. Induration : present in chronic fistulae/sinus as in actinomycosis , OM TB Sinus induration absent. Fixity : Palpation at deeper plane: lymph nodes- TB Thickening of bone underneath- OM

42. Management INVESTIGATIONS CBP- Hb , TLC, DLC, ESR. Discharge for C/S , AFB, cytology, Gram staining. X-RAY of the part to rule out OM, foreign body. X-RAY KUB and USG abdomen in cases of lumbar fistula to rule out staghorn calculi. BIOPSY from edge of sinus Radiological imaging  digital fistulogram / sonogram/MR or CT Fistulogram Sinogram

43. Treatment Treat the cause Stabilize co-morbidities Exclude healing barriers Good nutrition Conservative Surgical management  drainage Ligation of fistula tract excision and biopsy Followed by reconstruction