Cases I have seen include:
1. Removing a box thorn embedded deep in the tissues
2. Metallic foreign body – located by the use of a magnet; not always possible to remove it – especially if it is deeply located; sometimes one has to use an image intensifier in theatre, this is often an injury from work-related cause(eg miner in Broken Hill, apprentice on first day at work with mechanic; worker in factory)
3. Deeply penetrating large splinter – part of it was initially removed at a major trauma centre, patient was referred to me weeks later as persisting pain and granuloma. On exploration, 4cm remnant of penetrating splinter found and removed
(It is not always possible to remove every single fragment especially if friable object)
4. Spines of fish – this can be very hard to find, sometimes can be radioopaque
5. Broken glass – again also can be hard to find, I would say it is sometimes harder than looking for a needle in a haystack! But is it often satisfactory to be able to find the broken fragment.
6. Splinters, rose thorns etc

Sometimes by the time I am referred, a small abscess has formed around the foreign body – then it is easier to incise over the abscess, drain the abscess and remove the foreign body.

Reminder for residents:
Check tetanus status
Consider oral antibiotics treatment
Xray can be helpful to the surgeon ?radioopaque – some glasses are

What is it?
There is a dimple or pit in the skin in front of the ear. From here a tract heads under the skin. This tract may or may not branch out. Frequently, the tract ends up being infected leading to redness of the overlying skin and a purulent discharge.

Why does it occur?
During foetal development, different parts of the head(called branchial arches) join together. Failure of this may lead to congenital problems such as cleft lip or cleft palate. In a similar fashion, the preauricular tract is due to different parts of the head not fusing together completely during foetal development. Occassionally, there may be other associated anomalies for example in the kidneys.

Treatment

When acutely infected, antibiotics is required. Sometimes if there is an abscess, this requires drainage. If possible, this should be drained by enlarging the pit opening and the tract washed out with Betadiene.

Surgery is the definitive treatment if there has been previous infections. This involves excising the whole tract and is best done in an operating theatre. Often the tract needs to be identified by injecting it with a blue dye. There is significant risk of recurrence with surgery(rates published are as high as 15-40%) – usually this occurs when the tract has branched and the the other tract has not been excised. Sometimes more radical surgery is required to excise out all the tissue in front of the ear to prevent recurrence and this would required a general anaesthesia.

Risks of surgery
Scar
Wound problems – infection, discharge, ooze, redness
Pain
Bleeding, bruising
Nerve damage – the facial nerve lies close
Recurrence

Examples:
Warts in foot – often because of the long duration, the roots of the warts are digging deep into the sole causing pain on walking
Warts in fingers and palms
Warts on the nostril, around the face

Treatment options

1. Cryotherapy – liquid nitrogen. I often find it useful to consider this option first before considering surgery. For cryotherapy to be effective, the roots of the warts need to be frozen off as well. This requires a more prolonged application of the liquid nitrogen and often several repeat freeze-thaw cycles. The benefit is that it avoids surgery and leaves less scar. Risks with cryotherapy – discomfort and pain on application, blood blister(this can form after but the benefit is that the wart will usually fall off with time). Cryotherapy also needs to be repeated several times for it to work especially in chronic warts with deep roots. Once the warts resolves, the area may be darker or lighter than the surrounding skin.
2. Surgery – excision with scalpel or diathermy. This is more painful and requires either a local anaesthesia or general anaesthesia. Risks – the smoke from the diathermy may contain carcinogens(and be potentially infectious); surgery will cause bleeding and leave a scar.

What are these?
These are lumps under the skin. Occasionally one can find a small punctum(opening) on the overlying skin(You might be able to see more easily this if you pinch the skin to dimple it). The cyst is lined by wall and it contains white cheesy material. Common sites include the body and scalp. There can be more than one present.

What happens to the cyst?
The cyst will usually enlarge with time – the largest I have seen on the scalp measured about 15cm wide!!  Sometimes, the lining will burst. This will lead to an inflammation in the surrounding tissue and overlying skin. This is often mistaken for an infection and treated with antibiotics. Rarely, the cyst can become infected primarily. It is best not to lance the cyst as this will cause scarring and make the surgery to excise the cyst completely more complicated

What other conditions can mimic a cyst?

Lipoma – esp if the overlying skin is thick, can sometimes be hard to distinguish

Other soft tissue tumour

What treatment is needed?
Surgery is usually recommended.  Local anaesthesia is injected around the cyst. An incision is made over the skin. The cyst wall is carefully dissected(often best with an artery forceps) and the cyst removed with its contents. The wound is closed with sutures – usually non-absorbable. These are left in for 7-14 days. A waterproof dressing is usually used to cover the wound.
What are the risks of surgery ?

1. Wound problems – scarring, infection, breakdown

2. Recurrence – sometimes a fragment of the cyst wall is stuck down in the surrounding scar tissue and the cyst may regrow.