Benign Tumours Types Notes

Tumours Definition

A tumour is a new growth consisting of cells of independent growth arranged atypically and serves no function.

Tumours Cysts Types

Benign and malignant.

Benign Tumours Papilloma

This is a benign tumour arising from skin or mucous membrane. It is characterised by finger-like projections with a central core of connective tissue, blood vessels, lymphatics and lining epithelium. It can be called a hamartoma or a skin tag. It is an example of the overgrowth of fibrous tissue.

Read And Learn More: Clinical Medicine And Surgery Notes

Overgrowth Of Fibrous Tissue

• Keloid
• Desmoid tumour
• Hypertrophic scar
• Papilloma

Benign Tumours Types

1. Skin papilloma

1. Squamous papilloma occurs in the skin, cheek, tongue, etc.
   • Soft papillomas are squamous papillomas seen in elderly patients on the eyelid as small, soft, brownish swellings.
   • Squamous papilloma can also be congenital, sometimes multiple in number, and can be sessile or pedunculated.
2. Basal cell papilloma (seborrhoeic keratosis) is seen on the trunk of elderly patients as a brownish elevated patch of skin, which gives a semitransparent, oily appearance.

2. Arising from the mucous membrane of visceral organs:

1. Transitional cell papilloma in the urinary bladder is a cause of haematuria.
2. Columnar cell papilloma in the rectum as a cause of mucous diarrhoea.
3. Cuboidal cell papilloma in the gall bladder.
4. Squamous papillom in the larynx can cause respiratory obstruction.
5. Papilloma of the breast (duct papilloma) causes bleeding per nipple.

Benign Tumours Treatment

Excision is only if the papilloma causes discomfort, or if it is symptomatic.

Benign Tumours Complications

• Skin papilloma can get secondarily infected resulting in pain and swelling.
• Papilloma in the breast, rectum, tongue and gall bladder can undergo malignant change.

Fibroma

Fibroma is a benign tumour, consisting of connective tissue fibres only. Clinically, it presents as a firm subcutaneous swelling. However, a true fibroma is rare. They are combined with neural elements, muscle tissue or fatty tissue.

¹Students should not give the diagnosis of fibroma because, in the majority of cases, it is neurofibroma or fibrolipoma.

Fibromas Types

1. Soft fibromas — Less fibrous tissue
2. Hard fibromas — More fibrous tissue
   • Neurofibroma — Fibroma mixed with nerve fibres
   • Fibrolipoma — Fibroma mixed with fat
   • Myofibroma — Fibroma mixed with muscle fibres
   • Angiofibroma — Fibroma mixed with blood vessels.

Benign Tumours Treatment

They are treated by excision because of the chance of developing into a sarcoma.

Lipoma

Lipoma is a benign tumour arising from fat cells of adult type.

Lipoma Types

1. Single subcutaneous lipoma

• This is a single, slow-growing, painless swelling.
• The swelling is soft and may feel cystic with fluctuation. This is also called pseudo fluctuation because fat at body temperature behaves like a fluid.
• The surface is lobular. Lobulations are better appreciated with firm palpation of the swelling. Due to the pressure, lobules bulge out between the fibrous tissue strands.
• Edge slips under the palpating finger which is a pathognomonic sign of lipoma.
• Being a subcutaneous swelling, it is freely mobile. The flank is the commonest site. The shoulder region, neck, back, and upper limbs are the other common sites. A few lipomas are also found in the neck.

2. Multiple lipomatosis

Such lipomas are multiple and very often tender because of nerve elements mixed with them. Hence, they are called multiple neurofibromatosis. Dercum’s disease is one example of this variety (adiposis dolorosa) wherein tender, lipomatous swellings are present in the body, mainly the trunk

3. Uncapsulated lipoma

Diffuse variety is a rare type of lipoma. It is called pseudolipoma. It is an overgrowth of fat without a capsule.

Histological Types Of Lipoma

1. Fibrolipoma: Since fibrous tissue is mixed with fat, lipoma feels hard.
2. Neurolipoma: Painful lipoma, because of nerve elements.
3. Naevolipoma: Lipoma is relatively avascular but this variety is vascular.

Histological Types Of Lipoma Treatment

Excision of lipoma is done by incising the skin followed by dissecting it all around.

Liposarcoma Complications

1. Liposarcoma: The present view is that benign lipomas do not turn into malignancy. However, a few retroperitoneal lipomas and lipomas in the thigh can turn into liposarcoma after many years of growth. Malignancy should be suspected when

• The swelling grows rapidly
• It becomes painful due to the infiltration of nerves.
• The swelling becomes vascular with a red colour, and dilated veins over the surface.
• The surface is warm due to increased vascularity.
• Skin fungation or fixation occurs later.
• Mobility gets restricted because of infiltration into the deeper plane to the muscle.
• The liposarcoma rarely spreads by lymphatics. It spreads by blood. Metastasis in the lung can rarely occur from liposarcoma-producing cannon ball secondaries.
• Liposarcoma is treated by wide excision followed by reconstruction either by split skin graft or by flaps. In the thigh, sometimes radical surgery may amount to compartmental excision. Chemotherapy and radiotherapy can also be used.

2. Calcification

3. Myxomatous degeneration

4. Intussusception: Abdominal emergency

5. Saponification.

Lipoma

• Subcutaneous—Most common type
• Flanks—Most common site
• Soft, lobular, slipping edge
• Does not occur in the cranial cavity
• Very few turn into liposarcoma

Clinical Notes

A 32-year-old man presented with gross swelling of the right leg. He had seen two surgeons earlier wherein he was told to have deep vein thrombosis and nothing was offered. Examination revealed an obvious mass which was palpable in anteromedial and posterior compartments. MRI revealed an intermuscular mass. At exploration intermuscular lipoma weighing 700 gm was excised

 

Hamartoma

• It is a tumour-like developmental malformation of the tissues of a particular part of the body wherein it is arranged haphazardly
• Hamartoma is a Greek word which means fault or misfire.

A Few Examples Of Hamartoma

Haemangioma, neurofibroma, glomus tumour, benign naevus, lymphangioma.

Hamartoma Characteristic Features

• Being a developmental anomaly, they are seen at birth or in early childhood
• In adults, there is a long history of swelling
• Being a malformation (not a tumour), it does not have a capsule.
• They can be single or multiple
• Some may regress as in strawberry angioma
• They are benign lesions.
• Hamartoma is not a clinical diagnosis

Hamartoma Treatment

• Excision is not only curative but also gives a correct diagnosis.
• Care should be taken when it contains vascular tissue such as haemangioma or neural tissue as in cases of neurofibroma
• As shown in the figure above, the facial nerve and its branches may be damaged while excising hamartomatous lesions over the face

Chordoma

• Rare tumour
• Remnant of notochord
• Sacrococcygeal region (common site)
• Resection is difficult, and chances of neurological deficit and bleeding are high.
• Radio resistant.

Ganglion

It is a tense, cystic, swelling and occurs due to myxomatous degeneration of the synovial sheath lining the joint or tendon sheath. They are common around joints because of abundant fibrous tissue. They contain gelatinous fluid.

¹Pott’s puffy tumour refers to osteomyelitis of the frontal bone with oedema of the scalp secondary to frontal sinusitis. This and Cock’s peculiar tumour are favourite viva questions.

Sebaceous Cyst

• Syndrome—Gardner’s syndrome
• Tumour—Cock’s peculiar tumour
• Parasitic worm—Demodex folliculorum

Common Sites

• The dorsum of the hand is the common site, at the scapholunate articulation.
• In the foot, dorsal or lateral aspect.
• Small ganglion in relation to the flexor aspect of fingers.

Ganglion Clinical Features

1. The majority of patients are between 20 and 50 years.
2. A round to oval swelling in the dorsum of the hand, with a smooth surface and round borders. Skin over swelling is normal.
3. The swelling is tensely cystic, and fluctuant and transillumination is negative. It is mobile in the transverse direction.
4. When the tendons are put into contraction, the mobility of the swelling gets restricted.
5. A ganglion is not connected with the joint space. Sometimes, it gives an impression of becoming small due to slipping away between bones.

Ganglion Treatment

1. The symptomless ganglion is better left alone.
2. Aspiration of the ganglion and injection of sclerosants may reduce the size of the ganglion.
3. Sometimes, rupture of the cyst due to trauma may result in a permanent cure.
4. Surgical excision can be done. However, the recurrence rate is high.

Differential Diagnosis

1. Implantation dermoid cyst occurs in the feet or hand.
2. Exostosis of the bone has to be considered if swelling is very hard.
3. Bursa (vide infra).

Transilluminator Swellings In The Body

These are the cystic swellings containing clear fluid characterised by fluctuation and transillumination.

1. Lymphangioma
2. Ranula
3. Meningocele
4. Epididymal cyst
5. Scrotal hydrocoele.

Lymphangioma (Lymphangioma Circumscriptum)

• Failure of one of the lymphatics to join the major lymph sacs of the body results in a lymphangioma. Hence, it occurs in places where lymphatics are abundant.
• Common sites: Posterior triangle of the neck, axilla, mediastinum, groin, etc.
• In the neck, it is called cystic hygroma of the neck. As the sac has no communication with lymphatics by the time swelling appears, the lymph is absorbed and is replaced by thin watery fluid (mucus) secreted by endothelium. Hence, it is also called the hydrocoele of the neck.
• When it is largely confined to the subcutaneous plane, it is called Cystic Hygroma.

Lymphangioma Clinical Features

1. Usually, cystic hygroma presents during infancy or early childhood. Occasionally present since birth and rarely before birth. They can also present as small vesicles.
2. When the child cries or strains, the swelling increases in size and becomes prominent due to increased intra-thoracic pressure which is transmitted through the root of the neck. Typical locations — Lateral aspect of neck (posterior triangle), groin, buttocks.
3. Soft, cystic, fluctuant, partially compressible swelling. Lymphangioma is a multilocular swelling consisting of aggregation of multiple cysts. These cysts may intercommunicate and sometimes may insinuate between muscle planes. Hence, it gives the sign of compressibility! However, complete reducibility is not a feature.
4. The swelling is brilliantly transilluminator because it contains clear fluid (watery lymph)

Lymphangioma Treatment

Surgical excision is the treatment of choice. AH, the loculi or cysts should be removed. A careful search has to be made for the extension of lymphangioma through the muscle planes so as to avoid recurrence. Sclerotherapy was being used earlier for lymphangioma. But tissue planes are distorted because of sclerosants. Hence, dissection becomes difficult. Thus, the injection type of treatment is not favoured at present.

Lymphangioma Differential Diagnosis

1. Haemangioma: The posterior triangle of the neck is one of the common sites for haemangioma. Haemangioma is soft, cystic and fluctuant, but transillumination is negative and the sign of compressibility is positive.
2. Lipoma: This is a soft lobular swelling with fluctuation because the fat behaves like a fluid at body temperature. However, the edge slips under the palpating fingers. Both transillumination and compressibility tests are negative for lipoma.
3. Cold abscess.

Lymphangioma—Sites

• Jugular lymph sac            Neck
• Posterior lymph sac         Groin
• Cisterna chyli                    Retroperitoneum

Transillumination Test

1. Should be done In a dark room
2. Avoid surface transillumination
3. Transillumination may be negative because of infection, sclerotherapy and haemorrhage

Lymphangioma Complications

1. In neonates and infants, lymphangioma can cause difficulty in breathing due to its large size.
2. Occasionally, secondary infection can occur.
3. Lymphangioma in the mediastinum can give rise to dyspnoea, and dysphagia due to compression on the trachea/oesophagus.

Ranula

Ranula is a cystic swelling arising from the sublingual salivary gland and from accessory salivary glands which are present in the floor of the mouth called glands of Blandin and Nuhn.

• The word ranula is derived from the resemblance of the swelling to the belly of a frog — Rana hexadactyla.

Ranula Aetiology

1. Ranula occurs due to obstruction to the ducts, secreting mucus. Hence, an example of a retention cyst.
2. Some surgeons consider it an extravasation cyst.

Ranula Clinical Features

1. Seen in young children and adults.
2. Swelling is typically located on the floor of the mouth or under the surface of the tongue, to one side of the midline.
3. Soft, cystic, fluctuant swelling, which gives brilliant transillumination.
4. It is covered by thin mucosa containing clear, serous fluid. Hence, it is bluish in colour.
5. The surface is smooth, borders are diffuse, non-tender swelling.
6. Plunging ranula: It is an intraoral ranula with cervical extension when it passes on the side of the mylohyoid muscle and produces a swelling in the submandibular region. Thus, one swelling in the floor of the mouth and the other in the neck gives rise to a plunging ranula. The diagnosis is confirmed by cross cross-functioning test.

Ranula Treatment

1. Complete excision of the ranula is the treatment of choice in plunging ranula. Since the cyst wall is very thin, it should be carefully dissected and removed.
2. Marsupialization is indicated in simple ranula. The ranula is incised and the wall of the cyst is sutured to the mucosa of the floor of the mouth, so as to leave an opening to the exterior (Marsupials = Kangaroos). After 5–10 days, the cyst collapses, fibrosis occurs and the entire cavity gets obliterated. Marsupialisation avoids surgical dissection and chances of injury to the submandibular duct.

• • Plunging ranula can be excised by the intraoral approach. Once the intraoral dissection is completed the cervical extension can be mobilised by the same incision dissecting close to the cyst wall. However, rupture and chances of leaving a portion of the cyst wall are high.

Cross Fluctuation Test

• Indicated when a cyst has two components interconnected
• Gentle pressure on one component, impulse on the other component.
• Demonstrated by digital palpation

Differential Diagnosis

A sublingual dermoid cyst is a thick-walled cyst, whitish in colour and not transilluminate.

Ranula Complications

1. Rupture of the cyst decreases the size but it can reappear at a later date.
2. When the swelling is big, the tongue is pushed upwards and may cause difficulty in speech or swallowing.

Thyroglossal Cyst

• This is an example of a tubuloembryonic dermoid cyst.
• It arises from the thyroglossal tract/duct which extends from foramen caecum at the base of the tongue to the isthmus of the thyroid gland. Hence, the thyroglossal cyst can develop anywhere along this duct.
• It is lined by pseudostratified, ciliated, columnar or squamous epithelium which produces desquamated epithelial cells or mucus at times.

Sites Of Thyroglossal Cyst

1. Subhyoid—The most common type
2. At the level of thyroid cartilage—2nd common site
3. Suprahyoid — Double chin appearance
4. At the foramen caecum — Rare
5. At the level of cricoid cartilage — Rare
6. In the floor of the mouth.

Thyroglossal Cyst Clinical features

1. Even though congenital, thyroglossal cyst appears around the age of 15–30 years.
2. They are more common in females who present with painless, midline swelling. However, in the region of thyroid cartilage, the swelling is slightly deviated to the left side.
3. The cyst is soft, cystic, fluctuant, transillumination—negative swelling (very rarely, it can give rise to transillumination). It can be firm if the tension within the cyst is high.
4. Mobility: Thyroglossal cysts exhibit 3 types of mobility which are characteristic of this condition:

• • The cyst moves with deglutition.
  • Moves with protrusion of tongue: Hold the thyroglossal cyst with the finger and thumb and ask the patient to protrude the tongue outside. The movement of the cyst upwards is described as a tug because of its attachment to the hyoid bone.

The swelling moves sideways but not vertically as it is tethered by the thyroglossal duct.

Thyroglossal Cyst Treatment

• Before the excision of the cyst, a thyroid scan is mandatory since it may be the only functioning thyroid tissue.
• Sistrunk operation: Excision of the cyst along with the entire thyroglossal tract which may include part of the hyoid bone, is the recommended treatment. The intimate relationship of the hyoid bone can be explained by its development from 2nd and 3rd branchial arches.

Thyroglossal Cyst Complication

• The wall of the thyroglossal cyst sometimes contains lymphoid tissue which can get infected, resulting in an abscess. If it ruptures or is incised it results in the thyroglossal fistula.
• Rarely, a papillary carcinoma can occur in the thyroglossal cyst.

Thyroglossal Fistula

Thyroglossal fistula is never congenital.

It is always acquired due to the following reasons:

1. Infected thyroglossal cyst rupturing into the skin.
2. Inadequately drained infected thyroglossal cyst.
3. Incompletely excised thyroglossal cyst. The track is lined by columnar epithelium.

Movement On Protrusion Of The Tongue

• The cyst is attached to the hyoid bone. Hence, it gives a classical TUG
• Not always present, cyst below the thyroid cartilage—tug is absent
• Better appreciated for holding the swelling

Examination Of Thyroglossal Cyst

• Cyst proper, mobility
• The base of the tongue to rule out lingual thyroid
• Lymph node examination

Thyroglossal Fistula Clinical Features

1. Previous history of swelling in front of the neck, which is now painful, red and ruptured resulting in discharging pus. Once the pus is drained, the opening closes. However, after an interval of time, the pain and discharge reappear.
2. When there is no infection, the fistula discharges only mucus and the surrounding skin is normal. Infected fistulae are tender, discharging pus and the skin is red hot.
3. The majority of the patients presenting are young in the age group of 10–20 years.
4. A fistulous opening in the centre of the neck which is covered by a hood of skin can occur due to the increased growth of the neck when compared to that of the fistula. This is described as a semilunar sign or hood sign.

Thyroglossal Fistula Treatment

• Infection is controlled with antibiotics
• Surgical excision should include the fistula with removal of the entire tract up to the foramen caecum. Otherwise, recurrence will occur.
• The central portion of the hyoid bone is removed due to close proximity of the fistula.
• An elliptical incision is preferred as it gives a neat scar.

Recurrent Abscess—Rupture Fistula Or Sinus

• Thyroglossal fistula
• Pilonidal sinus
• Median mental sinus
• Cold abscess

Thyroglossal Fistula

• Always acquired
• The first opening is in the midline
• Semilunar sign or hood sign
• It gets pulled up with protrusion of the tongue

This operation is called Sistrunk’s operation.

Anomalies Of Thyroglossal Duct

• The thyroglossal duct extends from the foramen caecum to the thyroid cartilage.
• Various anomalies have been given.
• However, thyroglossal cyst is common and lingual thyroid and ectopic thyroid tissue are uncommon swellings.
• They have to be kept in mind as a differential diagnosis of the swellings in the midline of the neck.

Sistrunk’s Operation

• The fistula with the entire thyroglossal tract is excised
• A central portion of the hyoid bone and lingual muscle are removed
• Removal is facilitated by pressing the posterior 1/3 of the tongue
• Do not perforate the thyrohyoid membrane
• Incomplete removal results in recurrence

Thyroglossal Duct Anomalies

• Lingual thyroid
• Levator glandular thyroidal
• Ectopic thyroid tissue
• Thyroglossal cyst

Swelling Arising From Isthmus Of The Thyroid Gland

Almost all the diseases of the thyroid gland result in enlargement of the isthmus. However, solitary nodules and cysts can occur in relation to the isthmus. The swelling moves with deglutition. However, it does not move on protrusion of the tongue.

Pretracheal And Prelaryngeal Lymph Nodes

These lymph nodes produce nodular swelling in the midline. One or two discrete nodes are palpable.

They can enlarge due to the following conditions:

1. Acute laryngitis: The nodes are tender and soft.
2. Papillary carcinoma of the thyroid: The nodes are firm without matting, with or without evidence of thyroid nodule.
3. Carcinoma of the larynx: The nodes are hard in consistency.
4. In India, tuberculosis should be considered as a possible diagnosis when other diseases are ruled out.

 

Pharyngeal Pouch

• Herniation or protrusion of the mucosa of the pharyngeal wall through the Killian’s dehiscence.
• Killian’s dehiscence is a potential area of weakness between the two parts of the inferior constrictor — Upper oblique fibres (thyropharyngeus) and lower horizontal fibres (cricopharyngeus).

Etiopathogenesis

Due to an increase in the retropharyngeal pressure, in between the parts of inferior constrictor muscles, mucous membrane bulges due to neuromuscular imbalance, hence it is a pulsion diverticulum.

A course of the Diverticulum

Pulsion diverticulum deviates to one side mostly to the left because of the rigid vertebral column in the midline posteriorly.

Laryngoscope

• Very rare
• Increased laryngeal pressure
• Expansile impulse on cough
• Ligation of its neck and division of the whole sac is the treatment

Diagnosis

• Initially, a foreign body sensation is present in the throat. Later, regurgitation of food on turning to one side, a sense of suffocation, cough or dysphagia is present.
• Gurgling sounds and aspiration may cause dyspnoea later.

LAryngocoele Treatment

• Barium swallow followed by excision of the pouch
• Cricopharyngeal myotomy is also given.

Neurofibroma Of The Vagus Nerve

• This condition produces swelling in the carotid triangle in the region of thyroid swelling.
• It is a vertically placed oval swelling
• It is firm to hard in consistency

Pressure over the swelling may result in dry cough and in some cases bradycardia.

Differential Diagnosis Of Swelling In The Posterior Triangle

The posterior triangle (Key Box 17.26) is an interesting area as far as swellings are concerned. It is the most common area of metastasis in lymph nodes from occult primary. Lymphangiomas, haemangiomas, cold abscesses, and lymphomas commonly occur here. Interesting cases of cervical rib, Pancoast tumour, and aneurysms also occur here.

Most of the swellings have been discussed under appropriate chapters. Haemangioma, metastasis in the cervical lymph nodes and Pancoast tumour have been discussed below.

Posterior Triangle Classification

Common swellings in the location are given below.

Boundaries Of Posterior Triangle

• Anteriorly: Sternomastoid (posterior border)
• Laterally: Trapezius (anterior border)
• Above: Mastoid process
• Below: Clavicle

Clinical Analysis Of Common 4 Cases—Model Cases

CASE 1: A 50-year-old man with painless swelling in the face near the inner aspect of the eye of 3 years duration

Discussion: 3 years duration suggests it is benign. The very look of the swelling suggests the possibility of a sebaceous cyst but the punctum is absent. Part of it is near the midline but he says it started not in the midline and his age is 50 years so a dermoid cyst is unlikely.

• On palpation, it had putty—paste—like consistency hence lipoma is ruled out. It was not compressible, haemangioma is also ruled out.
• So even in the absence of punctum, signs of indentation and moulding were positive, hence the diagnosis of sebaceous cyst was made.

What else can occur in this location?

Mucocoele of the frontal sinus can present in this location with fluctuating swelling. With the intracranial extension, the cough impulse will be positive. Features of recurrent sinusitis, and headache may clinch the diagnosis.

Case 2: A 10-Year-Boy With Swelling Behind The Left Ear 5 Years Duration

Discussion: 5 years duration suggests it is benign. He is only 10 years old, and possible swelling is congenital in origin such as a dermoid cyst and haemangioma. Lymphangioma is unlikely because it is not the site. The inspection diagnosis looking at the site is a congenital dermoid cyst.

• It was soft, so dermoid cyst and haemangioma are likely. The slip sign is negative. Also, remember that lipoma is very rare in children.
• Transillumination was negative, hence lymphangioma is unlikely (Remember this is not the site for lymphangioma.) It was compressible. This one physical sign clinches the diagnosis of haemangioma. Dermoid cyst is ruled out.

What else can occur in this location?

Lipoma and sebaceous cysts can be the differential diagnosis in adults (universal rumour)

Case 3: A 35-year-old woman with swelling in the lower left arm of 1-year duration

Discussion: She had swelling in the inner aspect of her lower arm for 1 year duration. Painless to start with, since the last 2 months, it has been rapidly growing and pain is present. For the last 15 days, it has ulcerated and started bleeding.

• This suggests a malignant transformation in a benign lesion. Soft tissue sarcoma is likely. Pain suggests infiltration into the skin or underlying nerves or bones. Since the lesion is near the joint, synovial sarcoma is one possibility.
• However, malignant fibrous histiocytoma was the final diagnosis. Since swelling started first in the deeper plane and the skin was normal, malignant skin tumours are unlikely possibilities.

Case 4: A 55-year-old man with swelling in the upper part of the back on the right side—2 months duration

Discussion: Look at the size — within 2 months means rapidly growing swelling suggests malignant swelling. On palpation it was firm and a few areas were hard. Neurofibroma, fibrolipoma were considered. Please note deep-seated lipoma may give a feeling of hardness.

• On contracting the trapezius muscle, mobility of the swelling was restricted. It suggested it is in the deeper plane and may be arising from muscles or infiltrating muscles. This sign is a strong indicator of malignancy along with rapid growth and hardness. Tru cut report was Malignant Fibrous Histiocytoma.
• Some cases in this location may feel firm or soft, due to degeneration of the tumour. If it is near the midline, the cold abscess is one of the differential diagnoses. Cough impulse and examination of the spine are mandatory.

Swellings In The Parotid Region

Strictly speaking parotid swellings are also swellings on the face — laterally. Since they are separate groups of diseases, they are discussed in more detail along with salivary glands. For the sake of completion of the list, swellings in the parotid region are:

• Parotid tumours
• Cysts in the parotid gland-Haemangioma, lymphangioma
• Pre-parotid lymph nodes: Tubercuouls, metastatic and lymphoma

Surgical Wisdom Pathognomonic Features

1. An epidermoid cyst (Sebaceous cyst): Punctum
2. Dermoid cyst: Location and bony depression
3. Lipoma: Slip Sign
4. Neurofibroma: Swelling with Coffee brown pigmentation—café-au lait spots
5. Cystic hygroma: Brilliantly transilluminant
6. Haemangioma: Sign of compressibility.