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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1060_Библиотеки_им_академика_М_И_Перельмана
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Examination of a Swelling/Lump
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occur between 4th and 5th toes due to friction of bases
of adjacent proximal phalanges. Corn consists of severe
keratoses with central degenerated dead cells and
cholesterol. Corn should be differentiated from plantar
wart by removing the top layer of the lesion so as to
expose dead deep core of corn or soft branching process
of wart.
Chordoma
It is tumour arising from the remnants of notochord.
It is seen in sacrococcygeal region; sphenoidal sinus
region or around the foramen magnum. It invades
into surrounding structures like nerves. Often it is
aggressive (Fig. 3.84).
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with pitting oedema without any edge are the typical
features (Absence of edge; absence of fluctuation;
absence of pus; absence of limit). Cellulitis will
progress rapidly in diabetic and immunosuppressed
individuals like patients with HIV infection. Associated
lymphangitis is often seen as raised red streaks which
blanch on pressure. Tender palpable regional lymph
nodes are common due to associated lymphadenitis.
Often these lymph nodes get suppurated forming an
abscess eventually (Figs 3.85 to 3.87).
Orbital cellulitis: Cellulitis in orbit causes proptosis,
leading to impairment of ocular movements and
blindness. It can spread through ophthalmic veins into
cavernous sinus causing cavernous sinus thrombosis.
It requires admission and immediate aggressive
treatment with higher generation antibiotics.
Fig. 3.84: Chordoma over the sacrum.
Cellulitis
It is spreading inflammation of subcutaneous and
fascial planes. Infection may follow a small scratch
or wound or incision. Common causative agents are
Streptococcus pyogenes organisms and other gram
positive organisms. Often gram negative organisms
like Klebsiella, Pseudomonas, E. coli are also involved.
Cellulitis can be superficial or deep. Sequelae of
cellulites - Infection can get localised to form pyogenic
abscess; Infection can spread to cause bacteraemia,
septicaemia, pyaemia; Often infection can lead to
local gangrene.
Clinical features are fever, toxicity (tachycardia,
hypotension); diffuse swelling which is spreading in
nature; pain and tenderness, red, shiny, boggy area
with stretched warm skin. Brawny look of the area
Fig. 3.85: Cellulitis left leg with redness, oedema.
Fig. 3.86: Cellulitis face.
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Fig. 3.87: Extensive cellulitis of arm and forearm with
abscess formation.
SRB’s Clinical Surgery
Ludwig’s angina: It is cellulitis of upper part of the
neck involving submandibular region and floor of the
mouth along the fascial planes.
Clinical features: Diffuse swelling, redness, tender -
ness and induration in the floor of the mouth and
submandibular region; difficulty in opening the mouth
(Trismus); toxic features like fever, tachycardia and
tachypnoea; severe laryngeal oedema (presents with
respiratory distress, stridor and cyanosis).
Complications—Septicaemia; spread of infection into
the parapharyngeal space leads to thrombosis of
internal jugular vein which may extend above into
the sigmoid sinus which may be fatal.
Erysipelas: It is a spreading inflammation of the skin
and subcutaneous tissues due to infection caused by
Streptococcus pyogenes. There will be always cutaneous lymphangitis with development of rose pink
rash with cutaneous lymphatic oedema. V esicles which
form eventually will rupture to cause serous discharge.
Common sites are—orbit, face and scrotum. In face
and orbit it causes severe oedema.
Clinical features are toxaemia; rash which is fast
spreading and blanches on pressure; rash is raised with
sharp margin; discharge is serous (In cellulitis discharge
is purulent); Milian’s ear sign is a clinical sign used
to differentiate erysipelas from cellulitis wherein ear
lobule is spared. Skin of ear lobule is adherent to the
subcutaneus tissue and so cellulitis cannot occur.
Erysipelas being a cutaneous condition can spread
into the ear lobule. Disease is common in poor hygienic
debilitated individuals.
Erysipeloid disease is also called as ‘Fish handler’s
disease’. It is a self limiting disease with mild features
of both cellulitis and erysipelas. It occurs following
minor trauma in fish and meat handlers. It is common
in hands.
Abscess
Pyogenic Abscess
It is a localised collection of pus in a cavity lined
by granulation tissue, covered by pyogenic membrane.
It contains pus in loculi. Pus contains dead WBCs,
multiplying bacteria, toxins and necrotic material.
Spread may be direct, haematogenous, lymphatics from
adjacent tissues. Staphylococcus aureus and Strepto-
coccus pyogenes are common organisms. It is often
an effect of cellulitis or lymphangitis. Abscess is more
common in malnourished people, people with anaemia,
diabetes mellitus, HIV , immunosuppression or old age.
Trauma, haematoma, virulence of the organisms are
other factors.
Clinical features: Throbbing pain; fever with chills
and rigors; soft, smooth, tender, fluctuant swelling with
often visible pus and pointing tenderness. Brawny
induration is common in surrounding area. Redness,
warmth with restricted movements of the part or adjacent joint are observed (Figs 3.88A and B). Visible
(pointing) pus, tenderness, fluctuation are the features
of formed abscess (Commonly cellulitis occurs first
which eventually gets localised to form an abscess).
Sites of an abscess: It can be external or internal
depends on whether the abscess is on the surface or
in the deeper cavities like abdomen. Examples of
external sites are: fingers and hand; neck; axilla; breast;
foot; thigh-here it is deeply situated with brawny
induration; ischiorectal and perianal region; abdominal
wall; dental abscess; tonsillar abscess and other
abscesses in the oral cavity. Examples of internal
abscess are: abdominal: subphrenic, pelvic, paracolic,
amoebic liver abscess, pyogenic abscess of liver,
splenic abscess, pancreatic abscess; perinephrenic
abscess; retroperitoneal abscess; lung abscess; brain
abscess.
Complications of an abscess: Bacteraemia, septicaemia, and pyaemia; multiple abscess formation; metastatic abscess; destruction of tissues due to necrosis;
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A
Fig. 3.89: Abscess in forehead
region in a diabetic patient.
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regions (Fig. 3.89). So using a needle always aspirate
and confirm the pus; Soft tissue tumours—Sarcomas
may be smooth, soft/ firm and warm with dilated vessels
on the surface.
A
Figs 3.88A and B: Abscess in the groin. Redness, pain,
localised swelling, warmness, fluctuation, often visible pus,
brawny induration are the features of an abscess. Abscess
should be aspirated prior to surgical drainage to rule out
differential diagnosis like aneurysm.
antibioma formation due to antibiotic therapy without
drainage (common in breast abscess); sinus and fistula
formation; large abscess may erode into adjacent
vessels and can cause life threatening torrential
haemorrhage (examples: pancreatic abscess causing
splenic vessel haemorrhage, psoas abscess causing
iliac vessel haemorrhage); abscess in head and neck
region can cause laryngeal oedema, stridor and
dysphagia. Specific complications of internal abscess:
Brain abscess can cause intracranial hypertension,
epilepsy , neurological deficit; liver abscess can cause
hepatic failure, rupture, jaundice; lung abscess can
lead on to bronchopleural fistula or septicaemia or
respiratory failure or ARDS. Abscess should be
formed before draining. Exceptions for this rule are :
Parotid abscess; breast abscess; axillary abscess; thigh
abscess; ischiorectal abscess. Differential diagnoses
to be remembered befor e draining an abscess are—
Aneurysm especially in popliteal, femoral and axillary
Cold Abscess
It means there are no signs of acute inflammation like
redness, warmth, tenderness. It is painless, smooth,
soft, fluctuant, nontransilluminating. Oedema, brawny
indurations are absent. Cold abscess is due to caseative
necrosis of tuberculous disease. It is commonly
observed in caseating tuberculous lymphadenitis;
tuberculosis of spine; joint tuberculosis; tuberculosis
of ribs, mediastinum, etc. Cold abscess can occur at
the site of the disease like in the neck (neck is the
commonest site) (Fig. 3.90) or often caseating fluid
Fig. 3.90: Cold abscess sternum.
Neck is the common site.
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SRB’s Clinical Surgery
can travel along the fascial or neurovascular bundle
to cause abscess at different sites. Such cold abscess
is frequently observed in tuberculosis of spine (T10).
Psoas abscess; groin abscess; abscess in paraspinal
region; abscess in intercostal space are the examples
of such type of cold abscess.
Difference between pyogenic and cold abscess
Pyogenic abscess Cold abscess
Red, warm, tender, with No signs of acute
signs of acute inflammation inflammation
Pyogenic bacteria are Tuberculous bacteria
nonspecific organisms
(Streptococci / Staphylococci)
For drainage, dependent Nondependent
incision is used incision is used
Suturing of the wound is Cavity is curetted and
not done sutured
Drain is placed Drain is not placed
Pyaemic Abscess
These are formation of multiple abscesses in the
different parts of the body like subfascial plane, deeper
planes, in the organs like liver, lungs, brain, spleen,
etc. It is due to lodging of the multiple infective bacterial
emboli from the circulating blood at different places
which cause suppuration and abscesses formation (Fig.
3.91). Subfascial pyaemic abscesses often do not show
the features of acute abscess like warmness, fluctuation,
pointing tenderness.
Fig. 3.91: Multiple abscesses. It could be due to septicaemia
(pyaemia), immunosuppression or diabetes mellitus.
Boil (Furuncle)
It is an acute Staphylococcus aureus infection of a
hair follicle with perifolliculitis which usually proceeds
to suppuration and central necrosis. It is common in
neck, back and upper limb. Often boil opens on its
own and subsides. Furuncle in external auditory meatus
is very painful because of rich cutaneous nerves and
firmly adherent skin to perichondrium. Pain, indurated
swelling, greenish pustule that eventually rupture to
create a deep cavity with green slough, often with tender
palpable regional nodes are the features (Fig. 3.92).
Once it ruptures red granulation tissue forms in the
surface/floor and spontaneous healing takes place with
antibiotic coverage.
Complications: Cellulitis; lymphadenitis; hydradenitis (in axilla—infection of group of hair follicles).
Fig. 3.92: Furuncle/boil—infection
of hair follicle.
Hidradenitis Suppurativa
It is a chronic infective and fibrous disease of the skin
which bears apocrine sweat glands. Apocrine sweat
glands are coiled sweat glands which open into hair
follicle. It is common in axilla, areola, umbilicus, groin
and perineum. In the axilla condition is often bilateral.
It is related to obesity, smoking, poor hygiene, diabetes
mellitus, steroids. Common bacteria are staphylococci,
streptococci and propioni bacterium acnes. Keratin
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blocks the duct of the apocrine sweat glands causing
dilatation of the duct leading into infection and
suppuration of the glands. Many adjacent glands
involve eventually causing fibrosis, scarring and sinus
formation. Commonest site is axilla (Fig. 3.93). It
is common in females (4:1). Discharging sinuses,
induration, tenderness and oedema are common. It
often looks like tuberculosis or malignancy.
Fig. 3.93: Hidradenitis suppurativa—axilla.
Carbuncle
W ord meaning carbuncle is charcoal. It is an infective
gangrene of skin and subcutaneous tissue. Staphylococcus aureus is the main causative organism.
Common site of occurrence is back and nape of neck
(Fig. 3.94). It is common in diabetics and after forty
years age. It is common in males. Infection → red,
indurated oedematous area → small vesicles develop
→ discharge through multiple openings → sieve-like
pattern/cribriform pattren → many fuse together to
form a central necrotic ulcer with peripheral fresh
vesicle looking like a ‘rosette’ with ash gray slough
→ skin becoming black due to blockage of cutaneous
vessels → disease spreads to adjacent skin rapidly.
Patient will be toxic and in diabetic they are ketotic.
Renal carbuncle is an entity which occurs in kidney
due to infection, forming localised infective mass
lesion.
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Fig. 3.94: Carbuncle in the nape of neck. It is an
infective gangrene of skin and subcutaneous tissue.
Pott’s Puffy Tumour
It is formation of diffuse external swelling in the scalp
due to subperiosteal pus formation and scalp oedema.
It originates commonly in frontal region and may
extend into other regions. It is usually due to chronic
frontal sinusitis which eventually suppurates and
extends into subperiosteal region but trauma also can
cause the same.
Clinical features: Pain and diffuse swelling in frontal
region which is warm, tender. Swelling often extends
to face and eyelids (Fig. 3.95). Patient will be toxic
and drowsy.
Complications:Osteomyelitis of frontal bone; spread
of infection into intracranial cavity leading to
intracranial abscess (Extradural or subdural abscess).
So it may present with features of raised intracranial
tension like headache, coning and convulsions.
Pyogenic Granuloma (Granuloma Pyogenicum)
It is a common condition which occurs in face, scalp,
nose, fingers and toes (Figs 3.96A and B). It may
be due to minor trauma or minor infection. Infection
leads to formation of unhealthy granulation tissue
which protrudes through the wound.
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Fig. 3.95: Pott’s puffy tumour.
SRB’s Clinical Surgery
Clinical features: Usually single, well localized, red,
firm, nodule, which bleeds on touch. It is rapidly
growing relatively painless and often mimics haemangioma, papilloma, skin adnexal tumour, squamous
cell carcinoma and melanoma.
A
Bacteraemia, Septicaemia, Pyaemia
These conditions are discussed here as they may cause
multiple abscesses in the body or these conditions may
occur due to existing abscess itself. Bacteraemia is
presence of bacteria in blood. It causes fever with
chills and rigors, tachycardia and leucocytosis. It may
get controlled by antibiotics or may lead into
septicaemia (septic shock). Septicaemia is presence
of overwhelming, multiplying bacteria in the blood
with toxins causing systemic inflammatory response
syndrome (SIRS) or multior gan dysfunction syndrome
(MODS). Patient presents with fever, oliguria, jaundice,
hypotension, feeble pulse, respiratory failure and
drowsiness. Fever often may be absent or hypothermia
may be evident due to severe sepsis wherein pyogenic
response is absent. Septicaemia may be due to gram
positive or gram negative organism. Gram positive
septicaemia is due to staphylococci, streptococci,
pneumococci, etc. Overwhelming Postsplenectomy
Infection (OPSI) is a classical example of gram positive
septicaemia. Gram negative septicaemia is commonly
observed in urinary infection, biliary sepsis, peritonitis,
B
Figs 3.96A and B: Pyogenic granuloma
post-auricular region and nose.
abdominal infection, sepsis in diabetics and immunosuppressed. It is also called as endotoxic shock due
to endotoxins released from lysed bacteria. Common
gram negative organisms causing gram negative
septicaemia are E. coli, Klebsiella, Pseudomonas and
Proteus. Initial warm reversible stage when becomes
severe forms eventually irreversible cold stage which
is often difficult to manage. It is always better if
septicaemia is diagnosed in initial warm stage itself.
Pyaemia is presence of multiplying bacteria in blood
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as emboli which spreads and lodges in different organs
in the body like liver, lungs, kidneys, spleen, brain
causing metastatic abscess. This may lead to Multi
Organ Dysfunction Syndrome (MODS). It may
endanger life if not treated properly.
Seborrhoeic Keratosis (Seborrhoeic Wart,
Basal Cell Papilloma)
It is a benign overgrowth of the basal layer of epidermis
with excess of small darkly stained basal cells, which
protrudes from the surface of the epidermis to give
oily appearance.
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Senile or Solar Keratosis
It is multiple, hyperkeratotic, dry, scaly/patchy,
yellowish gray/brown lesion in the sun exposed parts
of the skin like face, rim of the ears, dorsum of hands
and fingers often forming an ulcer with a raised edge.
It is often seen in elderly men who were working
outdoors for many years. It is a benign lesion confined
to skin but with malignant potential. Squamous cell
carcinoma can occur in a long standing solar keratosis
after ten years or more. Fixity or tethering, everted
edge, recent increase in size and nodal spread may
be the features of malignant transformation.
Features: It is common in elderly. It is common in
Caucasians. It is often familial with autosomal
dominant gene transmission. Common sites are the
back, face and neck. It grows slowly with widening
in area without altering in thickness. It often gets
infected but uncommonly bleed on touch. It is
pigmented due to melanin and so mimics naevus or
melanoma or pigmented BCC. Often when it scabs
of it leaves a pale pink patch on the skin with visible
small surface capillaries. It is not a premalignant
condition (Note: Solar keratosis is a premalignant
condition). It is hard and stiffer than normal skin.
Lymph nodes are not involved. It does not occur in
palms and soles. It can be picked off from the skin.
’Stuck on’ appearance is characteristic (Fig. 3.97).
Impetigo
It is highly infectious superficial skin infection caused
by staphylococci/streptococci organisms. It is usually
seen in children, with formation of multiple blisters
that rupture and coalesce, to be covered with honey
coloured crust. Scrumpox is a type of impetigo seen
in Rugby players due to staphylococcal infection.
Keloid
W ord meaning keloid is ‘like a claw”. It is abnormal
proliferation of immature fibroblasts, immature blood
vessels and type III thick collagen stroma. There is
defect in maturation and stabilisation of collagen
fibrils. It is common in blacks (15 times), females,
Negroes. It is often familial. It may be associated with
Ehlers-Danlos syndrome or scleroderma. It is common
over sternum, upper arm (BCG vaccination scar), upper
chest wall, ear and lower neck (Figs 3.98A to D).
Scar of minor injury also can form keloid. Fibrous
tissue continues to grow even after 6 months to many
years. It extends like finger into adjacent normal skin
and attains vascularity. It forms pinkish black, painful,
hyperaesthetic, tender swelling (not a tumour but
tumour like) which spreads and causes itching. It can
occur as spontaneous keloid without a scar after an
unnoticed trauma which is common in Negroes.
Recurrence is common if excised.
Fig. 3.97: Seborrhoeic keratosis in face. It is not a
premalignant condition.
Hypertrophic Scar
It is overgrowth of fibrous tissue (type III fine collagen)
in any scar which is limited to scar area only; which
grows upto 6 months; not genetically predisposed
(unlike keloid); will never extend to normal adjacent
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A
SRB’s Clinical Surgery
C
B
Figs 3.98A to D: Keloid over the chest (sternum), ear lobule (ear prick site) and shoulder.
skin; occurs anywhere in the body ; self limiting; not
vascular. It is common on the flexor aspect. It is equal
in both sexes. There is no racial descrimination.
Precipitating factors are lacerated wounds, infected
wounds, scars healed by secondary intention, burns
wound, scars which cross the Langer’s line (Fig. 3.99).
Fig. 3.99: Hypertrophic scar in the thigh.
Warts
They are usually multiple hyperkeratotic skin patches
with finger like projections, common in children and
D
adolescents. They are common in fingertips, face,
axilla and sole of the feet. It may be familial but often
stimulated by virus. They are dry, overgrown
projections from the skin of finger often painful, tender
and disfiguring. Repeated rubbing may cause infection.
It can spread to other fingers and other parts of the
body . Kiss lesions can occur . Plantar wart (Verruca
plantaris) is wart in the sole. Specialty of this is it
gets pushed into the sole of the foot. It is common
in ball and heel of the foot. It is pearly white in colour
with brownish flecks. It is often covered by apparently
normal skin because wart is buried into the skin. It
looks like a circular pit. It is gray white finger/filiform
like strands in the centre of the lesion and is soft. Plantar
warts can be multiple. It is painful and very tender
on pressing (more than callosity or corns).
Keratoacanthoma
It is also called as Molluscum sebaceum. It is an
overgrowth and subsequent spontaneous regression
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of the sebaceous gland which opens into hair follicle
often seen in adults (males 3:1). It is self limiting benign
neoplasm probably of papilloma virus origin. It is
proliferating squamous cells of the sebaceous glands
which protrude out through the sebaceous duct. This
solitary lesion is more common in the skin where more
sebaceous glands are present. It is a painless rapidly
growing hard mobile swelling of the skin (grows upto
4-8 weeks) with a central brown area which over 46 months leads into spontaneous regression. Central
brown area is hard, peripheral rim is firm and rubbery
(volcano like). Central area separates from lesion
leaving a deep scar. Regional lymph nodes are not
enlarged. It can be recurrent in lips and fingers. It
mimics squamous cell carcinoma (epithelioma). It is
a pseudomalignancy (Fig. 3.100).
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Fig. 3.101: Rhinophyma—typical look.
nodular, hard, indurated and often fungation occurs
with palpable significant regional lymph nodes. It often
mimics epithelioma of skin (Figs 3.102A and B and
3.103).
Fig. 3.100: Keratoacanthoma. Note the central brown
area. It mimics epithelioma.
Rhinophyma (Potato Nose, Bottle Nose)
It is a glandular form of acne rosacea causing immense
thickening of distal part of the skin of nose with visible
openings of sebaceous follicles. It is due to hypertrophy
and adenomatous changes in sebaceous glands. Nose
is bluish red in colour with dilated capillaries (Fig.
3.101).
Skin Adnexal Tumours
They are tumours arising from accessory skin structures
like sebaceous glands, sweat glands and hair follicles.
They can be benign or malignant. Clinical features
are painless well localised swelling in the skin. Skin
is adherent and often ulcerated. Malignant lesions are
Turban Tumour
It is a descriptive term wherein entire scalp looks like
a turban because of multiple scalp swellings. It can
be due to multiple cylindroma; multiple hidradeno-
mas; subcutaneous neurofibr omas; nodular multiple
basal cell carcinoma. Multiple cylindroma is usually
considered disease under this term. Cylindroma is a
variant of eccrine spiradenoma (skin adnexal tumour).
Multiple firm pinkish nodules in the scalp are the
presentation in multiple cylindroma. Hidradenoma
is a rare benign sweat gland tumour. Multiple tumours
commonly look like a turban in the scalp. They are
painless, disfiguring, cosmetically problematic soft,
boggy, nonfluctuant, noncompressible cutaneous
swellings; commonly observed in middle age group.
Dermatofibroma (Sclerosing Angioma,
Subepithelial Benign Nodular Fibrosis,
Dermal Histiocytoma)
It is a benign tumour containing ‘mat like or cart wheel’
pattern spindle cells arising from dermal dendritic
cells. It presents as red or brownish yellow (due to
lipid) or bluish black (due to haemosiderin), firm, single
or multiple nodules occurring commonly in limbs.
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A
Figs 3.102A and B: Benign skin adnexal tumour in the
face and scalp.
Fig. 3.103: Malignant skin adnexal tumour.
Note the dilated veins.
Dermatofibrosarcoma Protuberans
B
It is a low grade slowly growing fibrosarcoma occurring
in trunk (common site-50%), back, head and neck and
abdominal wall. It is nodular, hard, with often multiple
swellings with redness and ulcerations over the summit.
Regional lymph nodes may get enlarged. Spread to
lungs can occur only rarely . It should be differentiated
from squamous cell carcinoma or skin adnexal tumour.
Often there is melanin pigmentation over the surface
(Bedner’s tumour) (Figs 3.104A and B).
A
B
Figs 3.104A and B: Dermatofibrosarcoma protuberans
in two different patients.
Basal Cell Carcinoma (BCC, Rodent Ulcer)
It is low grade, locally invasive, carcinoma arising
from basal layer of the skin or mucocutaneous junction.
It does not arise from mucosa. It is the commonest
skin tumour. It is more common in white skinned
people. It is common in places where exposure to
ultraviolet rays is more like Australia. It is common
in males and older people. It is common over the face.
In the face it is common above the line drawn between
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