This presentation is about benign skin swellings. References : 1.Bailey and Love Short Practice of Surgery 2. S Das Clincial Manual of Surgery 3.S Das Textbook of Surgery

2. OVERVIEW
• Definitions – Lump , Swelling and Tumor
• Differences Between Benign And Malignant
Swellings
• Evaluation of a swelling – History
• Evaluation of a swelling – Physical Examination
• Benign Skin Swellings
• Congenital
• Inflammatory
• Traumatic
• Miscellaneous
• Neoplastic
• Special Investigations and Treatment Options

3. Lump: vague mass of body
tissue

4. Swelling: enlargement or protuberance in the
body due to any cause. A swelling may
be: - Congenital
-Traumatic
- Infalmmatory
- Neoplastic
-Miscellaneous

5. Tumor: growth of new cells which proliferate
independently.
- Benign tumour proliferates slowly with little
evidence of mitoses and invasiveness
- Malignant tumour proliferates fast with
invasiveness and mitosis.

6. Benign
Occurs at a younger age Malignant
Usually seen above 40 years
or might occur at a younger
age
Duration: Slow growth Duration: Rapid
growth
Pain: Usually absent Pain: May be painful
Loss of weight: Never Loss of weight: Present
seen
Loss of function: Not seen Loss of function: Seen
quite early

7. Mobility: Freely mobile Mobility: Fixed due to infiltration
Surface: Usually smooth Surface: Usually irregular
Margin: Definite and smooth Margin: Not definite and irregular
Consistency: Usually firm Consistency: Hard or varying
Pressure effects: Absent Pressure affect: Present
Lymph nodes: Not enlarged Lymph nodes: Enlarged
Distant metastasis: Not seen Distant metastasis: Seen in late stage.
Recurrence: Never recurs after excision Recurrence: Often recurs after excision
Secndary changes: Not seen Secondary changes: Often present

8. History
1. Duration
2. Mode of onset
3. Associated symptoms
4. Progress of the swelling
5. Exact site
6. Fever
7. Presence of other lumps
8. Secondary changes
9. Impairment of function
10.Recurrence of the swelling
11.Loss of body weight
Past history
Personal history
Family history

9. General Examination
Local examination:
Inspection:
Situation- Few swellings are peculiar in their positions
Colour
Shape
Size
Surface
Edge
Number
Pulsation
Peristalsis
Movement with respiration
Impulse on coughing
Movement on deglutition
Movement with protrusion of the tongue
Skin over the swelling
Any pressure effect

10. Palpation
• Important part of local examination – collaborate findings of inspection and
explore other findings
• BE GENTLE
• Temperature – MUST BE DONE FIRST !!!
• Tenderness – Look at facial expression , be gentle
• Size, shape and extent : try to find whole extent of swelling
• Surface – smooth (cyst) , lobular (lipoma) , nodular(matted
lymph nodes), irregular and rough (carcinoma)
• Edge – well defined or indistinct, elicit SLIP SIGN
• Consistency – uniform or variable  uniform ( soft – lipoma,
cystic – cyst, firm – fibroma, hard, but yielding – chondroma,
bony hard – osteoma, stony hard – carcinoma)

11. • Consistency – In gaseous swellings ( gas gangrene, surgical
emphysema) ; crepitus may be heard
• Variable consistency – carcinoma or sarcoma
• Also check – if swelling getting moulded to pressure –( ex:
sebaceous cyst , dermoid cyst ) or pitting on pressure ( indicates
edema – inflammatory swellings )
• FLUCTUATION TEST - swelling fluctuates when containing gas or
liquid
• Mechanism
• Always perform in two planes
• How to do fluctuation for 1. freely movable , 2. Very small
(Pagets test)
3. Very large swelling
REMEMBER FALSE POSITIVE FLUCTUATION!!!

13. • FLUID THRILL – swellings containing fluid
• mechanism – Percussion wave is conducted to the other pole
when one pole is tapped
• - Fluid thrill in small swelling ? Large swelling ?
• TRANSLUCENCY- Swelling containing clear fluid (even highly
refractile fat) transmits light
• A swelling may be fluctuant BUT NOT translucent ( sebaceous
cyst – pultaceous material )
• How to elicit ?
• COUGH IMPULSE – Swellings which are In communication with
the abdominal ( eg hernia), pleural or spinal or cranial cavity
• Mechanism and how to elicit?
• In children  it is performed when they CRY

14. • REDUCIBILITY – Hernia ( also lymph, varix, meningocele may
reduce partly or completely
• Swelling reduces and ULTIMATELY DISAPPEARS WHEN PRESSED
UPON.
• COMPRESSIBILITY – Swellings donot usually have
communication with abdominal ,pleural or other cavities
• Liquid filled , usually from vascular malformations like capillary
or cavernous hemangiomas.
• Contents reappear when pressure is taken off
• PULSATILITY – Maybe expansile ( arising from an artery) or
transmitted ( near an artery )
• - How to differentiate ??

15. • FIXITY TO THE OVERLYING SKIN : Swellings which originate from
skin will move with skin ( except malignancies )
• Other swellings – how to know attachment to overlying skin?
• RELATIONS TO THE SURROUNDING STRUCTURES
• Swelling arising from subcutaneous tissue – free from overlying
skin and underlying contracted muscle ( can be freely moved )
• Arising from deep fascia – Not be mobile as the one arising
from S/C tissue
• Arising from muscle – it will be mobile when muscle is relaxed
• Ask patient to contract muscle – if swelling ARISES from muscle it will
diminish in size , if it is arising from S/C tissue but attached to muscle , it will
become more prominent and cannot be moved along line of muscle fibres..if
it arises deep to the muscle, virtually disappear

16. State of the regional lymph nodes
Percussion: Not much of importance in case of a
swelling. Its sole place is to find out the presence
of gaseous content within the swelling. Ex.
Resonant note in hernia
Ascultation: All pulsatile swellings should be
ascultated to exclude presence of any bruits or
murmurs
Measurement
Movement- In case of a swelling you must
examine the movements of the nearby join to
exclude any impairment.

17. Examination for pressure effect: swellings may inevitably exert
pressure on the surrounding structures:
1. Arterial pulse distal to the swelling is felt. Sometimes the swelling
may press on the main artery of the limb and cause weak pulse
distally.
2. The nerves may be affected by the pressure of the swelling. This will
cause wasting, paresis or paralysis of the muscles supplied by the
nerve.
3. The swelling may exert pressure on the subjacent bone by eroding it.
Example: Dermoid cyst on the skull

18. NEOPLASTIC
- Lipoma
INFLAMMATORY - Fibroma
- Papilloma
TRAUMATIC
- ABSCESS - Neurofibroma
- BOIL, CARBUNCLE - Lymphangioma
- Erysipelas - Moles
- Cellulitis
CONGENITAL MISCELLANEOUS
- Sebaceous cyst
- Warts
- DERMOID CYST - Condyloma
- HEMANGIOMAS

19. • Cyst lined by squamous epithelium – containing desquamated
cells
• CONTENTS – mixture of sebum , sweat , desquamated epithelial
cells, hair
• COMMON SITES OF OCCURRENCE
• Outer angle of
orbit
• Sub-lingual
• Post – auricular dermoid

20. • Painless, slow
• Margins yield to the
growing
pressure of finger –
• Round , putty
DOES NOT SLIP AWAY
• Free from skin and
deeper structures
-- > Differentiates
• Soft , cystic
from lipoma
• Fluctuation Positive
• Translucency
negative
• TYPES – Implantation or acquired
dermoid
• Tubulo dermoid
• Teratomatous dermoid

23. Plexiform
hemangioma
• Capillary hemangioma • Cavernous hemangioma
Spider Nevus Campbell de
Port – Wine stain Morgan Spots
Strawberry
Salmon Patch angioma

24. • Capillary hemangioma • Cavernous hemangioma
• Usually flat • Soft , spongy
• Bright red or purple • Bluish swelling
patches
• Blanches on
• Blanches on pressure
pressure • Compressible
• Plexiform hemangioma
• Network of
interwoven dilated
arteries
• Bag of earthworms

25. Acute Inflammatory Chronic Inflammatory
All signs of acute inflammation – rubor , All signs are present BUT SUBDUED
calor, dolor, tumor and functio lesia
Pain , redness and heat predominate Swelling is more predominate
Brawny induration and edema Brawny induration and edema ABSENT
conspicuously PRESENT
• Some sarcomas like Tenderness , Brawny induration
osteosarcoma MIMICS and edema
acute inflammatory
Fluctuation – ( pus )
swelling with pain ,
redness, swelling and
Acute lymphadenitis of related
heat . How to lymph nodes
differentiate ??
Leucocytosis

26. • Chronic inflammatory Occasional dimunition in the size
swellings may sometimes of the swelling ( tumor never
recedes )
mimic malignancy . How
to differentiate ??
- Localized accumulation of PMNL
with tissue necrosis in the dermis
and Subcutaneous tissue
- Commonest organism –
Staphylococcus aureus

27. - CLINICAL FEATURES
- Erythematous swelling, tenderness ,
pain
- Pus draining from it
- Erythematous surroundings
- May / may not be fluctuant ( parotid
abscess is not fluctuant )
THREE MAIN TYPES :
- Pyogenic Abscess
- Pyaemic abscess
- Cold abscess

28. Pyogenic Pyaemic Cold
(most common )
-Source of infection Cellulitis or acute infective emboli – Sequel to
lymphadenitis lodge in different TUEBRCULAR
places -- MULTIPLE INFECTION of lymph
ABSCESSES nodes and bone
- Clinical features - red hot and tender - commonly occur in - NON-REACTING (
- pus  pain SUBFASCIAL PLANE NOT hot or painful )
becomes THROBBING
- Brawny induration - Acute features I,e - Caused by the
and EDEMA ( redness etc. caseation of lymph
pitting) ABSENT nodes
- Fluctuation +/- - Constitutional
(parotid) symptoms like high
fever, rigor etc.
Common sites anywhere (eg.liver) in the SUBFASCIAL Neck and axilla
plane ; multiple arise May originate from
when one has been ends of bones  coe
incised to surface through
fascial planes

29. - Infection of hair follicle by Staphylococcus aureus
- Clinical Features
- Starts as PAINFUL and INDURATED SWELLING
- TENDERNESS and EDEMA +++
- After some days  softening at the centre - PUSTULE  rupture spontaneously
 discharge GREEN
- Then, DEEP CAVITY  lined by granulation tissue  heals by itself
- COMMON SITES – Back and the neck
- Complications ???
- Bigger ; same causative organism ; common in males >40 and DIABETICS
- Starts similar fashion to boil – spreads rapidly  progress similar to boil
- PATHOGNOMONIC FEATURE – Sieve like or cribriform appearance
- Multiple openings coalesce  ULCER with ashy-grey slough base  slough separates
 granulation tissue

30. Erysipelas Cellulitis ( MORE FATAL)
- Spreading cuticular lymphangitis - Spreading inflammation of Subcutaneous
tissue and fascia
- Organism – Str. Pyogenes Str. Pyogenes
- Predisposing factors – debilitation or poor DIABETICS or debilitated state
health
- Features – RAISED RASH HAS SHARPLY No DEFINITE EDGE
DEFINED MARGIN
Starts as rosy-red rash – disappears on redness, itching and stiffness at site of
pressure innoculation ;
Red streaks (lymphangitis)  acute
lymphadenitis or regional nodes
Vescicles contain SEROUS FLUID Vescicles contain PUS

31. Traumatic:
Traumatic swellings arising from the skin and
subcutaneous tissue are rare. Hematoma following a
trauma may give rise to swelling.

32. Sebaceous Cyst:
- cyst of the sebaceous gland due to blockage of the duct of this gland
which opens intp the hair follicle. The gland becomes distended by
its own secretions.
- Contains sebum and always has a black spot on the swelling, which
is the obstructed opening known as, “punctum”.
- Common in scalp, face, scrotum
- Single or multiple
- Smooth and round shape whose margin yields to the palpating
finger
- Fluctuation test is positive
- Transillumination test is negative

33. Condyloma:
- Hypertrophy of the epidermis
occurring at the mucocutaneous
junction ex. angle of the mouth,
anus, vulva etc.
- Fungating, sessile raised but flat
growth with moist and sodden
surface.
Warts: patches of overgrown skin
with hyperkeratosis
- Found in hands, face, knees, sole of
the feet, axilla
- Firm and covered with rough
surface and filiform excrescences
- Painful when they are repeatedly
rubbed or become infected

34. - LIPOMA ( UNIVERSAL TUMOR ) – Commonest tumor of the
subcutaneous tissue
- Benign tumor of the adipocytes
-
COMMON SITES
-
Other places – Intermuscular, Subfascial , Submucosal , Intra-
articular etc.

35. VARITIES OF LIPOMA – ENCAPSULATED , DIFFUSE and MULTIPLE
- Skin overlying –
Slowly growing and PAINLESS
usually normal
Can occur at any age – RARE IN
But in LARGE  Skin
CHILDREN
may be stretched
- Freely mobile over
deeper structures
Usually SMALL , may
attain large sizes
- Skin can be pinched
up
SOFT and LOBULATED consistency

37. - DIFFUSE LIPOMA - Does not possess features of lipoma – PSEUDOLIPOMA
- Subcutaneous and Intermuscular tissue of neck – extending into cheek
- NO CAPSULE
- Seen in Persons taking EXCESSIVE ALCOHOL
- MULTIPLE LIPOMAS - Called LIPOMATOSIS
- Painful often contain NERVE TISSUE ( NEUROLIPOMATOSIS )
- Seen in limbs and Trunk
- COMPLICATIONS
- DECRUMS DISEASE - Myxomatous degeneration
- ( Adiposis Dolorosa ) - Saponification
– Tender lipomatous - Calcification
swellings - Infection
- Seen in TRUNK - Ulceration
- Affects Women - MALIGNANT CHANGE
- Complications mainly – S/c tissue of
thigh, buttock and Retroperitoneal
tissue

39. Pedunculated with
Central fibrovascular
Overgrowth of all layers of branched villous
core lined by epithelium
skin processes
- Sometimes, surface may be hard
- Swelling
– HORNY PAPILLOMA
- Papilliferous, pedunculated or sessile
- Usually Soft and solid - Complications- ulceration ,
- Moves with the SKIN bleeding , malignacy
- Other sites  lip, tongue, colon , rectum, kidney etc.

40. - Tumor of the fibrous tissue
- True fibroma rarely occurs ; mostly combined with
mesodermal tissues – Fibrolipoma, fibromyoma,
neurofibroma etc.
- Painless, Firm , WELL CIRCUMSCRIBED
- Freely mobile on underlying structures
- According to consistency maybe SOFT or FIRM ( usually FIRM )
depending on amount of fibrous tissue
- DESMOID TUMOR ( Paget’s
recurrent fibroid)
- Unusual
- Arises in rectus sheath
- Recurrence
- Potential for malignancy

41. Lymphangioma: localized cluster of dilated lymh
sacs in the skin and subcutaneous tissues which
cannot connect into the normal lymph system.
3 types: a) Simple or capillary
b) Cavernous
c) Cytic hygroma
Simple or capillary:
- Presents as small vesicle or blister
- Present on the inner side of thigh, buttock,
axilla
- 0.5-4mm in diameter
- Lesion is soft and spongy
- Multiple cysts or one or two large cysts
- Fluctuation, fluid thrill and translucency are
positive
- Swelling is not compressible
- Lymph nodes are not enlarged
- Margin of the swelling is indistinct.

42. Cavernous :
- Present as bigger lymphatic swellings which are
situated deep.
- Commonly occurs on the face, mouth, lips, axilla
- Lesion is soft and lobulated
- Single or multiple communicating lymphatic
cysts
- Fluctuation and translucency positive
Cystic Hygroma:
- Common form of lymphangioma
- Collection of lymphatic sacs
- Large cyst like cavities containing clear
watery fluid
- Found in axilla, mediastinum, groin,
pelvis
- Soft swelling, compressible
- Fluctuation and translucency test are
positive
- No lymph node enlargment

43. Neurofibromma: tumour contains both neural and fibrous
elements.
Local neurofibromma:
- Occur at any age but commonly seen in adults
- Present in subcutaneous tissue
- Firm, smooth swelling, slightly painful
- Cannot be moved in the direction of the nerve from
which it arises
- Parasthesia and tingle sensation is common
Generalized neurofibrmatosis
- Involve the cranial spinal and peripheral nerves
- Multiple nodules present all over the body
- Found in subcutaneous tissue and can become
pedunculated
- Nodules vary from being firm to soft

44. Plexiform Neurofibromatosis:
- Occurs in connection with the
branches of the 5th cranial nerve
- Enormous swelling which hangs down
and folds
- Mostly affects upper limb and may be
associated with generalized
neurofibromatosis
Elephentiasis Neurofibromatosis
- Affected skin becomes coarse, dry
thick and resembles an elephant’s
skin
- Subcutaneous tissue is replaced by
fibrous tissue which is thick and
oedematous

45. Moles: contain excess quantity of melanin derived
from melanocytes
Hairy mole:
- Flat and slightly raised above the level of skin
- Smooth or slightly warty epidermal covering
- Hair grow from its surface
Smooth mole:
- Surface is not elevated
- Epithelium is smooth and there is no hair growth
- Pigment is deeper
Blue naevus
- Occurs deep in the dermis as the thick overlying
layers of the dermis and epidermis mask the
colour of the melanin and make it look blue.
- Overlying skin is smooth and shiny
- Commonly seen on face, feet, buttock of children

46. Junctional naevus: clusters of cells of various
stages of maturity in the epidermis and dermis
when the growth and movements of melanocytes
stop before they have migrated into the dermis.
- Centered around the junctional or basal layer of
the epidermis
- immature, unstable and can turn malignant
- Smooth or elevated naevus of all shades
- Found in the palms, soles, digits, genetalia
Compound Naevus
- Two distinct varieties of mole are present-
intradermal and junctional
Freckle
- Area of dark pigmentation found on face and
neck
- Smooth surface however there might be
junctional activity and may turn malignant

47. - Routine – Blood, Urine, Aspiration
- Fine Needle Aspiration Biopsy / Cytology – To avoid extensive open biopsy 
Fine needle (22 or 23 gauge ) fitted with a tight syringe  tissue aspirated is
examined microscopically, chemically and bacteriologically
- X –ray : Mainly to check for erosions by a cyst ( eX dermoid cyst)
- Ultrasound –
- CT scan
- MRI
- Angiography
- BIOPSY – Most important investigation of swelling ( suspected malignant
tumors)
- NEEDLE BIOPSY
- DRILL BIOPSY (done for breast masses)
- PUNCH BIOPSY ( mainly for hollow viscus – tissue taken from margin of
tumor along with surrounding normal tissue
- OPEN BIOPSY  Incisional or excisional