Bumps and swellings

Dr Philip Marazzi outlines some of the commonly presented bumps and swellings

Incisional hernia

This 62-year-old man presented with a swelling arising from his abdomen. He had previously had peritonitis due to a perforated appendix, requiring a laparotomy. This fairly large incisional hernia had subsequently grown and was causing considerable discomfort. He was referred back to the surgeons for repair. This was undertaken laparoscopically in order to minimise any further damage to weakened tissues.

Keratoacanthoma


This elderly lady presented with a rapidly growing swelling on her arm. It had the characteristic appearance of a keratoacanthoma with a dome-shaped swelling and a central hyperkeratotic core. Although previously regarded as benign, these lesions may harbour a squamous cell carcinoma and should always be referred for excision biopsy. In this case there was no sign of malignancy and no further action was required.

Asymmetrical neck swelling


This woman presented with an asymmetrical swelling in her neck. It had the characteristics of a goitre. Her thyroid function was checked and found to be normal. She was referred for an ultrasound scan, which suggested it was a complex cyst. She was sent for further investigation to an endocrinologist, who undertook fine needle aspiration. This revealed that there had been a haemorrhage into an existing colloid nodule. No further action was necessary and the patient was happy not to have any surgery.

Head injury


This young boy presented following a fall. He rapidly developed a large swelling on his forehead. This had worried his mother who brought him to the surgery. On questioning, it was clear he had not sustained a significant injury. He had cried immediately with no loss if consciousness. In spite of the swelling, he was quite cheerful. There were no other signs to suggest a serious injury, so his mother was reassured and given written advice about any signs to look out for.

Pleomorphic adenoma


This man presented with a mass under his ear, which had been present for a while. He was anxious about not having any treatment as it did not produce any significant symptoms. It was a benign tumour arising from the parotid gland. It will probably continue to grow slowly and it is likely he will need surgical intervention at some stage. This would take the form of a partial or total parotidectomy. The main concern with this type of surgery is damage to the facial nerve.

Pyogenic granuloma


This 49-year-old male patient was embarrassed about this lesion on his perineum. It had appeared relatively quickly and was causing some soiling of his underwear. He described it as a skin tag, but it was clearly was not just a 'normal' skin tag. It was excised and the histology came back as an ulcerated pyogenic granuloma. This is a benign lesion requiring no further treatment.

Gouty tophus


This 83-year-old woman has a long history of gout, and in recent years began to develop a number of these swellings.

She has a complex history including heart failure treated with diuretics, upper GI haemorrhage and a high alcohol intake. She has unfortunately had a number of episodes where the tophi have broken open in spite of taking allopurinol. Colchicine has been effective in calming down acute flare ups, and surgery is being considered as an option to deal with the tophi.

Epidermoid cyst


The epidermoid cyst is one of the commonest cysts seen in general practice. This term covers a group of cysts arising from the epidermis. They are filled with greasy white sebum and often present when they become secondarily infected. This patient had a longstanding cyst, which had not been infected. It was fairly large so she was referred for surgical assistance. The cyst was fully dissected and removed. If part of the cyst wall is left behind, as often happens if the cyst is ruptured, there is a high chance of recurrence.

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