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Unexplained swelling/cyst?- Help!

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  #1  
Old 10th May 2011, 08:41 PM
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Default Unexplained swelling/cyst?- Help!

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Hi there,

Completely stunned when I saw this case today.

A 68 yro male with clean medical history, not on any medication has been referred by local GP for sore "ingrown toenail".

Patient noticed swollen spot on tibial side of L hallux for about 6 months. Not really sore except for one spot (distal medial end). No trouble in feet before and no direct trauma. The lesion itself is completely away from the nail edge. In fact, there was no ingrowing of the nail at all, the nail was not involuted nor had any spike left in the sulcus. There was no hard skin or corns in the sulcus.

There was also no trauma or cut to the skin.

No bite marks or redness, nor inflammation were observed.

Patient also don't wear tight shoes (have checked shoes today, very roomy - wear these shoes most of the time).

I tried drawing it out with 5mL syringe but got nothing out of it.

Checked the nail edge thoroughly with nail file - nothing.

Completely stunned as what it could be as it's definitely not ingrown toenail.

My gut feeling is that it's some sort of cyst.

I have referred patient for ultrasound but don't think it'll find anything conclusive, then I'll truly be clueless.

So if you got any idea what it could be, would really appreciate your opinion.

Thanks.

Mike
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  #2  
Old 10th May 2011, 08:52 PM
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LuckyLisfranc LuckyLisfranc is offline
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Default Re: Unexplained swelling/cyst?- Help!

Mike

You are describing a soft tissue mass.

Try to provide information in terms of size/diameter, likely tissue layer/depth, firm/soft, fluid-filled, mobile, connected, etc.

The foot is a common place for benign soft tissue tumours, inclusion cysts, lipoma's, ganglions and the like.

You should be able to develop a differential diagnosis based on these descriptors. Generally biopsy or excision with histology will be the only firm path to diagnosis.

A clinical image would also assist. Most mobile phone's will provide a decent image these days.

This article may assist you,

LL
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Old 11th May 2011, 09:06 AM
W J Liggins W J Liggins is offline
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Default Re: Unexplained swelling/cyst?- Help!

As LL says, an image would be a great help. Do not overlook the possibility of sub-ungual exostosis with a soft tissue cap, and bear in mind the possibility of a non-pigmented melanoma. The U/S should be helpful.

Please let us know the outcome.

All the best

Bill Liggins
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Old 12th May 2011, 03:28 PM
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Jose Antonio Teatino Jose Antonio Teatino is offline
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Default Re: Unexplained swelling/cyst?- Help!

Waiting photo.

Jose A. Teatino
Professor of Surgery
The Academy Ambulatory Foot & Ankle Surgery
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Old 13th May 2011, 02:41 AM
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Default Re: Unexplained swelling/cyst?- Help!

Mucoid cyst should be on the top of your differential diagnosis list. Photo would be helpful. Also transilluminate the mass w a penlight. It should be translucent if a mucoid cyst. Excision should include a rotation flap as they have a high recurrence rate. Also take down underlying bony prominence if present.
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Old 16th May 2011, 09:52 PM
yvonnespod yvonnespod is offline
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Default Re: Unexplained swelling/cyst?- Help!

One of my patient recently had cyst removed from 2nd toe not ingrow first I have seen in 30 years practise yvonnespod
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Old 17th May 2011, 01:49 PM
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Default Re: Unexplained swelling/cyst?- Help!

Thanks for the reply guys. Ya should have taken a photo.

I think he's coming to see me again next week. Will hopefully remember to take a photo and keep you posted.

I've seen mucoid cyst before but this one is slightly different (doesn't have the semi translucent top).

Cheers
Mike
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Old 19th May 2011, 08:20 PM
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Default Re: Unexplained swelling/cyst?- Help!

Thanks for your anticipation guys.

Sorry, just ended up talking to the patient on the phone and not bought him back into the clinic to take a photo.

I did however though sent him for an ultrasound, which found a "non specific complex cystic lesion without a foreign body".

I'm trained in NZ so don't have the qualification to do the surgical excision. So have sent him back to the GP to be referred on to the appropriate people.

Was just wondering for the future though, who else can normally deal with these surgically? Obviously the pod surgeon can but can a general surgeon or orthopod, or dermatologist do it?

cheers.
Mike
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Old 20th May 2011, 02:52 AM
W J Liggins W J Liggins is offline
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Default Re: Unexplained swelling/cyst?- Help!

Hi Mike

Any one of those; also plastics. However, you may find that none of them is terribly interested, until, that is, you mention the words 'podiatric surgeon' when you will have orthopods crawling out of the woodwork 19 to the dozen claiming that you are infringing their territory. Of course, you may have utterly charming and helpful orthopods in NZ who are nothing like their tribal UK species.

All the best

Bill

PS If the patient has good private insurance they'll all fall over themselves!
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