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Examination of a Swelling/Lump
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Associated syndromes
• Klippel-Trenaunay-Weber syndrome : Naevus flam-
meus + osteohypertrophy of extremities (soft tissue and
bone hypertrophy) + varicose veins of lower limbs. If
there is an association of arteriovenous fistula (AV
fistula), it is called as Parkes-Weber syndrome
• Kasabach Merritt syndrome: Capillary haemangioma
+ DIC (Disseminated intravascular coagulation) with
thrombocytopenia
• Sturge-Weber syndrome: Haemangiomas (Naevus
flammeus) + hemiplegia and Jacksonian epilepsy
(calcified vascular cerebral and meningeal deposits) +
glaucoma.
• Maffucci syndrome: Cavernous haemangioma +
dyschondroplasia
• Proteus syndrome: Naevus flammeus + regional gigantism with lymphaticovenous malformation (asymmetrical
hypertrophy)
• Osler-Rendu-Weber syndrome: Haemangioma of skin
and lip with gastrointestinal tract haemangioma
(hereditary haemorrhagic telangiectasia) (autosomal
dominant).
Fig. 3.129: Laparoscopic view of cavernous haemangioma
of liver. It is commonest benign tumour of the liver.
Vascular Malformations
It is secondary to defect in development of vascular
components, in 8th week of intrauterine period. It is
associated with many syndromes. It can be in skin
or in deeper planes. It is present at birth and grows
in proportion to child’s growth. Low flow malformations can cause skeletal hypoplasia; high flow malformations can cause hypertrophy. Consumption coagulopathy (DIC) can occur. It is equal in both sexes.
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Vin Rose Patch
It is a congenital intradermal pale pink vascular malformation with dilatation of vessels in subpapillary dermal
plexus. It may be associated with haemangiomas; AV
malformations in limbs; congenital lymphoedema.
Parry-Romberg Disease
It is hemifacial atrophy of skin, soft tissue and bone.
It is common in females. It usually begins at twenties.
Atrophy of skin, fat, muscle, cartilage and bone causing
coupe de sabre deformity—are the features. It is a
self limiting disease. Aesthetic reconstruction is of fered
when severe deformity develops.
Campbell de Morgan Spots
It is usually smaller, elevated (2-6 mm), circular and
bright red swelling. It is common in trunk; common
in elderly. It is also called as cherry angiomas. It usually
does not require any therapy.
Spider Naevus
It is an acquired solitary lesion. It contains a single
dilated skin arteriole which acts like a feeding vessel;
having multiple small branches in radial manner.
Central arteriole of spider naevus is bright red with
less prominent (less red) radiating vessels. Central
arteriole is usually less than 1.0 mm in size with
surrounding radiating vessels occupying around 2 mm
area. It is commonly associated with alcoholic
cirrhosis. Multiple spider naevi are common in face,
upper arms, and proximal chest. It is completely
compressible on pressure using finger or glass slide
which refills entirely after releasing the pressure.
Cirsoid Aneurysm
It is a rare variant of capillary haemangioma occurring
in skin, beneath which abnormal artery communicates
with the distended veins. It is commonly seen in
superficial temporal artery and its branches. Here the
underlying bone often gets thinned out due to pressure.
It sometimes extends into the cranial cavity . Ulceration
is the eventual problem which leads on to uncontrollable haemorrhage. It presents as a pulsatile swelling
(pulsating bag of worms) in relation to superficial
temporal artery, which is warm, compressible, with
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SRB’s Clinical Surgery
arterialisation of adjacent veins and with bone
thinning (due to erosion).
Lymphangioma
It is congenital localised clusters of dilated lymph
sacs in the skin and subcutaneous tissue that has
failed to join the normal lymph system during
development period.
Simple type is also called as capillary lymphan-
gioma, can be present at birth but noticeable skin
vesicles often develop in few years. It is common at
the junction of body to limbs—like near shoulder,
axilla, groin or buttock. Skin vesicles contain clear
watery or yellow fluid. Bleeding within the vesicle
may turn it into brown or black. Its features includes
multiple, indistinct white/brown/black coloured vesicles of 0.5 to 4 mm size at typical locations in children
involving around 5-20 cm area of skin in the particular
location. If it is less than 5 cm in size it is called as
lymphangioma circumscriptum (Fig. 3.130). If it is
more than 5 cm in size it is called as lymphangioma
diffusum. If it is with reticulated ridges, it is called
as lymphedema ab agne. Area is soft, spongy, often
fluctuant with fluid thrill and translucency. It is not
compressible. V esicles will not fade on pressure. Often
lesion may get infected to make it painful and tender.
Condition will not block the lymph drainage in normal
lymphatics and skin oedema is absent. Regional lymph
nodes are not enlarged.
Cavernous Lymphangioma
It is soft, lobulated, fluctuant, brilliantly transilluminant large lymphatic swelling with often multiple
communicating lymphatic cysts. It often extends into
deeper plane like muscle. It is common in face, mouth,
lips (macrocheilia), tongue (macroglossia).
Cystic Hygroma
It is collection of clustered sequestered lymph sacs
(occurring during developmental period in utero)
presenting in newborn as large swelling which is soft,
smooth, fluctuant, brilliantly transilluminant, and
compressible. It is common in posterior triangle of
neck (75%); axilla (20%). Rarely it can occur in cheek,
tongue, retroperitoneum, groin or mediastinum. In the
neck it is called as hydrocele of the neck. It contains
soap bubble like aggregation of multiple cysts with
larger cysts on the surface and smaller ones in the
deeper plane giving a mosaic appearance. Cysts within
are communicating and so make it compressible. It
is lined by endothelium containing clear fluid which
does not coagulate. It is present at birth. Due to its
size it can cause obstructed labour, respiratory obstruction, rupture, infection and septicaemia (Fig.
3.131).
Fig. 3.130: Lymphangioma circumscripta (Courtesy
Dr Balasaraswathy MD, Consultant Dermatologist, Mangalore).
Fig. 3.131: Cystic hygroma—typical site.
Examination of Sinus and Fistula
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Examination of Sinus
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4
Sinus is a blind track lined by granulation tissue
leading from an epithelial surface into the surrounding
tissues. Sinus means ‘hollow’ or ‘a bay’ (Latin).
Causes: Congenital like preauricular sinus; acquired
like actinomycosis, tuberculosis, pilonidal sinus,
chronic osteomyelitis, median mental sinus.
Fistula is an abnormal communication between the
lumen of one viscus to another or the body surface
or between the vessels. Fistula means ‘flute’ or ‘a pipe
or tube’. Causes: Congenital like branchial fistula,
tracheo-oesophageal fistula, congenital arteriovenous
fistula, umbilical fistula (patent vitellointestinal duct);
acquired like trauma (abdomen), instrumental (during
delivery), surgical, inflammatory (intestinal tuberculo
sis/actinomycosis), malignancy (rectovesical fistula
in carcinoma of rectum). Fistula can be external fistula
like orocutaneous; branchial fistula; thyroglossal
fistula; enterocutaneous fistula; appendicular fistula
or can be internal fistula like tracheo-oesophageal
and Fistula
fistula; cholecystoduodenal fistula; colovesical fistula;
rectovesical fistula (Fig. 4.1).
Clinical Features of Sinus
Discharge from the opening of sinus—pus, caseating
material, bone spicules, sulphur granules depending on
the aetiology; no floor; raised often indurated edge;
indurated base; nonmobile; often sprouting granu-
lation tissue over the sinus opening (Figs 4.2A and B).
Causes of persistence of a sinus or fistula: Insuffi-
cient or nondependent drainage; foreign body or
necrotic tissue underneath, e.g. suture, sequestrum,
external foreign body like metal or wood pieces;
persistent obstruction in the lumen, e.g. in faecal fistula,
biliary fistulas (distal obstruction); lack of rest; walls
become lined with epithelium or endothelium; dense
fibrosis prevents contraction and healing; specific
infections like tuberculosis, actinomycosis; presence
of malignant disease (Fig. 4.3).
Fig. 4.1: Diagrammatic representation of sinus and fistula.
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SRB’s Clinical Surgery
A
Figs 4.2A and B: Secondaries in neck causing discharging sinus (A) and (B) in two different patients.
History of Present Illness
Mode of Onset and Progression
B
Relevant history regarding how exactly sinus has
started and progressed should be asked for, whether
it was healing in between and recurring again. History
of trauma should be asked as osteomyelitis can occur
after traumatic fracture. Detailed history about events
happened prior to formation of sinus like swelling,
pain, fever, deformity , difficulty in walking, etc. should
be asked.
History of Discharge
Discharge is important history in sinus or fistula.
Fig. 4.3: Fistula in ano both sides.
Discharge may be purulent, yellowish/caseous like in
tuberculosis, with bone spicules in chronic osteomyelitis, with necrotic material, bile/faeces/saliva/urine
History
in different internal fistulas, sulphur granules in
actinomycosis, mucus in branchial fistula, etc. Quantity
Name:
Sex:
of discharge, variations at different time, relation to
food intake should be clarified (Discharge—quantity;
quality; duration; colour; smell).
Age: Certain sinus or fistulas are more common in
certain age groups. Pilonidal sinus, branchial fistulas
are common in younger age group.
Occupation:
History of Pain
History of pain suggests inflammation/blockage/pus
formation.
Place:
Chief complaints: History of discharge and its
duration should be mentioned. History of specific
related condition also should be mentioned.
History of Fever
History of fever suggests acute/recurrent inflammation.
Examination of Sinus and Fistula
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History Related to Associated Diseases
History related to associated diseases like of bowel
disease, tuberculosis, ulcerative colitis, previous
surgery , malignancy, etc. Whether patient has earlier
undergone surgery like hysterectomy, with details of
surgery—when it was done; immediate postoperative
problem; sepsis after surgery; recovery; how long after
surgery discharge or present symptom appeared.
V esicovaginal fistula may develop after hysterectomy.
Faecal fistula may develop due to anastomotic leak
after emergency resection and anastomosis for
intestinal gangrene.
Past History
Past history of tuberculosis, Crohn’s disease, actinomycosis, surgery for fistula in ano, etc. should be asked
for.
Personal History
History of alcohol consumption/smoking/tobacco
chewing/history of sexual contact/dietary habits are
also important. Altered appetite or weight loss can
also be mentioned under personal history—may be
due to advanced malignancy or tuberculosis.
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This occurs due to failure of fusion of ear tubercles.
Branchial fistula occurs in the lower third of the neck.
Pilonidal sinus occurs in sacral region. Tuberculous
sinus is common in neck but can occur in axilla, groin,
etc. (Figs 4.4 to 4.6).
Number
Usually fistulae/sinuses are single. In actinomycosis,
anal fistula due to Crohn’s disease and water can
perineum they are multiple.
Family History
Family history of any specific diseases should be asked.
General Examination
Detailed general examination is very essential.
Anaemia/oedema/jaundice/clubbing/lymphadenopathy looked for. Radial pulse/blood pressure/raise
in temperature are recorded. Attitude of the patient/
nutritional assessment by skin texture, subcutaneous
fat, weight, body mass index/any other relevant
findings should be mentioned. Increased pulse rate
and temperature suggests ulcer with acute
inflammation. Features suggestive of tuberculosis,
spinal disease, abdominal conditions or chest disease
should be looked for.
Local Examination
Inspection
Site of the Sinus or Fistula
Preauricular sinus is located in the tragus of ear or
root of helix. It is directed upwards and backwards.
Fig. 4.4: Pilonidal sinus showing primary and
secondary sinus.
Fig. 4.5: Discharging sinus in the neck due to tuberculosis
of lymph nodes with a cold abscess underneath.
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Fig. 4.6: Sinus on the scrotum could be tuberculous or
syphilis or other infective focus in the testis or postsurgical
cause. Tuberculosis commonly involves epididymis causing
tuberculous epididymitis forming sinus on the posterior
aspect. Syphilis involves commonly testis causing syphilitic
orchitis forming ulcer/sinus on the anterior aspect.
SRB’s Clinical Surgery
Surrounding skin should be inspected for scar/
colour/texture/dilated or visible veins/hair loss/
pigmentation/dermatitis, etc.
Palpation
Tenderness and local raise in temperature over
surrounding area.
Sinus wall/margin should be palpated for induration
or thickening. Chronic long-standing sinuses due to
fibrosis will have thick wall.
Mobility of sinus/fistula: Most of sinus/fistula are
from deeper plane; Hence are fixed and nonmobile.
Occasionally superficial sinus when exists, may be
mobile.
Palpate for underneath swelling which may be lymph
nodes and detailed description of such swelling should
be mentioned. Swelling in surrounding area should
be looked for. It may be lymph nodal mass as in
tuberculosis or malignant mass.
Size and Appearance of External Opening
Size is small with sprouting granulation tissue. Margin
is raised usually . In tuberculosis it is undermined thin
and blue. Sequestrum or foreign body may extrude
from the sinus.
Discharge should be inspected.
Different discharges in a sinus/ fistula: Purulent—
bacterial infection; creamy yellow —staphylococcal;
watery opalescent—streptococcal; greenish—pseu-
domonas; caseous—tuberculous sinus; sulphur
granules—actinomycosis; red or black granules—
Madura foot; mucus—branchial fistula; saliva—
parotid fistula; faeces—faecal fistula; bile—biliary,
duodenal fistula; bone—osteomyelitis sinus; anchovy
sauce like pus discharge—amebiasis cutis from amebic
liver abscess. Odour of the discharge is also
significant—smell of gas gangrene discharge is
sickly—sweet odour (decayed apple); Bacillus coli
infection in an abdominal wall sinus-objectionable
odour; Escherichia coli discharge—odourless; Proteus
vulgaris—proteolyitc odour; bacteroides infection in
abdominal wall sinus—over ripe Camembert cheese
odour; faecal odour with bubbles of gas in faecal fistula
Surrounding skin, tissue and adjacent bone should
be palpated for bone thickening (in chronic osteomyelitis), induration, etc. Tuberculous osteomyelitis does
not show bone thickening as there is very less new
bone formation (Fig. 4.7).
Fig. 4.7: Mandibular sinus. It is usually due to infected tooth
causing osteomyelitis of mandible. It also could be due to
tumour, trauma, actinomycosis and radiation. X-ray (orthopantomogram) study of discharge and biopsy are relevant
investigations. Such fistula should be excised with extraction
of the causative tooth.
Examination of Sinus and Fistula
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Examination Using a Probe
Ideally probe examination of sinus or fistula should
be done under general anaesthesia with all aseptic
precautions and with gentleness. During probing
following points to be looked for—direction, depth
and length of the sinus, presence of foreign body,
communication to hollow viscus in the depth (free
mobility of the passed probe), fresh discharge while
removing the probe.
Regional lymph node examination: In tuberculosis,
infection, malignancy regional nodes may be palpable
with different textures like matted in tuberculosis; hard
in malignancy.
Relevant systemic examination should be done:
Examination of respiratory system is done in case of
chest wall sinus. Thoracic and lumbar spine examination is done in case of psoas abscess, paraspinal abscess;
urinary system examination in case of urinary fistula,
loin abscess; skeletal system examination in case of
osteomyelitis; digital examination of rectum in case
of fistula in ano; vaginal examination in case vesico
vaginal fistula; adjacent joint examination like that
of hip joint in groin abscess.
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fistula). Contrast GI study; pyridium intake orally and
looking for its excretion as coloured urine.
Classification of Sinus
Congenital—Preauricular sinus; traumatic with presence of foreign body; inflammatory like tuberculosis,
osteomyelitis, chronic abscess; neoplastic; other
acquired conditions like pilonidal sinus.
Commonest cause of sinus in neck is tuberculosis.
Commonly it is tuberculous lymphadenitis. It shows
yellowish cheesy discharge with bluish margin (Fig.
4.8). Usually tuberculous sinus/ulcer do not show any
induration.
Investigations
Fistulogram/sinusogram using ultrafluid lipiodol or
water soluble iodine dye (lipiodol is poppy seed
oil containing 40% iodine); very essential and simple
is examination of discharge for C/S, AFB, cytology ,
staining (gross/physical/chemical/microscopic/stain-
ing/culture); biopsy from the edge; chest X-ray or
relevant X-ray of the part like bone/joint to see
osteomyelitis; ESR; CT sinusogram is very useful;
MRI is most reliable in assessing the track anatomy;
three swab test in vesico vaginal fistula (Vagina is
packed with three swab, first swab high up in the
anterior fornix, second one at middle of vagina, third
one at lower part of vagina and 10 cc sterile methylene
blue is infused into the bladder. Patient is asked to
walk for 5 minutes and staining of the swab is looked
for. S taining of topmost swab suggests vesicovaginal
fistula or vesicocervicovaginal fistula, middle one
suggests vesicovaginal fistula and lower one urethrovaginal fistula or urethral incontinence. Wetting but
no staining of top most swabs suggests ureterovaginal
Fig. 4.8: Secondaries in neck with discharging sinus.
Classification of Fistula
Based on number: It may be single or multiple.
Based on type: Simple with direct track or complicated
with track having variable course.
Based on opening: Lateral fistula if fistula opening
is from lateral aspect of the hollow viscus; end fistula
if end of the viscus opens as fistula.
Based on involvement of tissues: From viscus to skin
is external; from viscus to viscus is internal.
Based on output: High output > 500 ml/day; moderate
200-500 ml/day; low output < 200 ml/day. In pancreatic
fistula-high output is > 200 ml/day; low output is
< 200 ml/day.
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SRB’s Clinical Surgery
Based on aetiology: Congenital like branchial fistula;
traumatic like urinary, rectal fistulas; inflammatory
like appendicular fistula; neoplastic like advanced
carcinoma rectum with rectovesical fistula, carcinoma
cervix with uterovesival fistula, external fistula with
infiltration into abdominal wall, etc.
Classification of external intestinal fistula (Irving and
Beadle’s): Category 1: Single orifice separate fistula
with intact or healed abdominal scar may be through
previous drain site (Figs 4.9A and B). Category 2:
Single or multiple orifices close to abdominal wound
or scar or any bony prominences. Category 3: Fistula
(small) through a small gap of main abdominal wound.
Category 4: Large fistula through a large dehiscence
of bottom of main wound.
Sequestrum
Sequestrum is dead bone in situ. It can be pyogenic,
tubercular (feathery), salmonella (granular), syphilitic
(ivory), tubular and ring (in amputation stump). It can
be unformed—means separation between sequestrum
and adjacent normal bone has not occurred or
formed—means there is proper adequate separation
between normal bone and sequestrum by forming
granulation tissue. Radiologically formed sequestrum
shows clear lucent area/zone of demarcation (Figs
4.10A and B). Sequestrum is denser because of the
A
B
Figs 4.9A and B: Postoperative gastrointestinal fistula. Note
the skin excoriation. It can be controlled by local application
of zinc oxide cream.
A
B
Figs 4.10A and B: (A) Multiple discharging sinus with
scar—osteomyelitis sinus. (B) X-ray shows sequestrum.
Examination of Sinus and Fistula
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Fig. 4.11: Diagram showing osteomyelitis with sequestrum
and sinus. Sequestrum is dead bone in situ.
absence of decalcification in the dead bone as there
is no blood supply (dead bone is dense bone) (Fig.
4.11). Sequestrum should be formed prior to surgical
intervention—sequestrectomy and saucerisation.
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A
Median Mental Sinus
It is a chronic infective condition wherein there is
infection of roots of one or both lower incisor teeth
forming root abscess which eventually tracks down
between two halves of lower jaw in the midline
presenting as discharging sinus on the point of chin
midline (Figs 4.12A and B).
Clinical features: It is usually painless discharging
sinus in the midline on the point of chin. Often incisor
infection may be revealed (in many patients clinically
tooth looks normal even though root is infected
invariably). It is often mistaken for infected sebaceous
cyst. Osteomyelitis of the mandible is the possible
complication.
Differential diagnoses are: Infected sebaceous cyst,
tuberculous sinus, osteomyelitis.
Actinomycosis
It is caused by Actinomyces israelii. It is an anaerobic
gram positive fungal like bacterium, which is a
branching filamentous organism. It is called as ‘ray
fungus’ because of sunray appearance.
B
Figs 4.12A and B: Median mental sinus. Note the origin
of the sinus from the root/roots of the lower jaw.
Clinical types: Faciocervical: Infection is either from
tonsil or from adjacent infected tooth. Initially an
induration develops. Nodules form with involvement
of skin of face and neck. It softens and bursts through
the skin as sinuses which discharge pus containing
sulphur granules (60%).
Thorax: Lungs and pleura get infected by direct spread
from pharynx or by aspiration. Empyema develops.
Later nodules appear in chest wall leading to sinuses
with discharge (20%). In right iliac fossa it presents
as a mass abdomen with discharging sinus. Liver is
infected through portal vein.
Pathogenesis: Organism enters through deeper plane
of the tissue, causes subacute inflammation with
induration and nodule formation. Discharging sinus
eventually forms over the surface. Pus collected in
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a swab or sterile tube will show sulphur granules.
Lymph nodes are not involved. It may cause pyaemia
and may endanger life.
Investigations: Pus under microscopy shows branching filaments. Gram staining shows gram positive
mycelia in centre with gram negative radiating
peripheral filaments. These clubs are due to host
reaction which is lipoid material.
Differential diagnosis: Chronic pyogenic osteomye-
litis; carcinomas at the site; tuberculous disease.
SRB’s Clinical Surgery
Madura Foot (Mycetoma Pedis)
It is a chronic granulomatous condition of the foot
causing multiple discharging sinuses in the foot. It
was first identified in Madurai by Gill. It is common
in India and Africa. It is common in Tamilnadu.
Organisms: Nocardia madurae (commonest);
Nocardia brasiliensis; Nocardia asteroides;
Actinomyces israelii.
Pathogenesis: Organism enters through a prick in the
foot usually who walks barefoot → reaches deeper
plane in the foot → evokes chronic granulomatous
inflammation → causes pale, painless, firm nodule
→vesicles form → burst to form discharging sinuses.
Features: Discharging granules may be black, red,
and yellow. In black type of Madura foot, infection
is mainly subcutaneous. In red and yellow types, it
burrows into the deeper plane including bone causing
bone necrosis (osteomyelitis). Eventually gross
swelling of the limb with multiple discharging sinuses
with disability will occur (Fig. 4.13). Muscles, bones,
tendons and nerves are involved. Regional lymph nodes
Fig. 4.13: Madura foot. Note the
multiple discharging sinuses.
are not involved. Condition will deteriorate by
secondary bacterial infection.
Clinical features: Painless diffuse swelling in the foot
of long duration; Later multiple discharging sinuses
develop on the skin; Lymph node involvement will
not occur unless secondary bacterial infection is
present; Significant limb disability is common.
Differential diagnosis: Chronic osteomyelitis; tuberculous osteomyelitis; carcinoma. If infection occurs
in the hand it is called as Madura hand. Discharge
study, gram’s stain, X-ray foot and biopsy are the
relevant investigations.
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