Intramuscular lipomas are usually found on the extremity, but rarely occur in the head and neck region.1 To the best of our knowledge, only four cases of intramuscular lipoma in the sternocleidomastoid muscle have been reported in the literature.1,2,22,24 In addition, because important structures are present densely in small spaces of the head and neck region, it is important to establish a preoperative plan by determining the size and location of the tumour through preoperative clinical and radiologic tests.

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Pete S.’s response was indicative of the volume and variety of tools firefighters carry in their pockets: “Officer’s tool, couple of door chocks, 6-plus-foot piece of 2-inch webbing tied in a loop, multi-tool attached to bunker pants, rescue harness I would don before putting on my bunker coat and 50-feet of single-use rescue rope small diameter for self-rescue kept in small deployment bag.”

I also appreciated this response from my former colleague at Chesterfield (Virginia) Fire and EMS Department, Captain (ret.) Michael Brigiati: “When captain of Station #14, we conducted a class of sorts where we not only displayed what was pocketed, but listened as to ‘why’ some [tools] were kept and other discarded. What intrigued me most was the ‘why.’ Great insight into the character of the firefighter – what was important to them. The greatest ‘resource’ has less to do with the tool, per se, than who wields it and why.”

One of my favorite responses came from Paul G., who may have figured out a clever approach to the tool-carrying: “I learned a long time ago that the only thing you had to carry was what was going to save your butt. For anything else you just asked, ‘Anyone have a [fill in the blank],’ and six or eight firefighters would pull one out with a real proud look on their face and be happy they finally got some use out of whatever it was that they carried. Saved me a lot of hassle.”

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© The Royal Australian College of General Practitioners 2021. The Royal Australian College of General Practitioners, 100 Wellington Parade, East Melbourne, Victoria 3002, Australia

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Take a good look at what’s in your turnout coat pockets and why you carry them. Keep those items of real value and protect them from contamination while they’re in your pockets.

On examination, lipomas are soft compressible masses with normal overlying skin.12 They often display a positive ‘slippage sign’ when the fingers are slid gently over the edge of the tumour.12,19 These tumours are rarely considered in the differential diagnosis of parotid tumours when initial diagnosis is based on clinical findings.6 Before any imaging is performed, the most commonly reported preoperative clinical diagnoses are pleomorphic adenoma and Warthin tumour.20

From pliers and screwdrivers to nylon webbing and multi-tools, your average firefighter is ready for anything and everything.

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Nathan B. shared this piece of advice to consider: “Carry what you feel is needed, but don’t forget the GOLDEN RULE! If you have to take your gloves off to get something out of your pockets, you are carrying too much stuff!”

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The treatment of choice is complete excision after a thorough preoperative clinical and radiological assessment in order to prevent recurrences.1,2 However, complete excision can be difficult, given its infiltrating capacity, and thus, unlike a general lipoma, its resection should include adjacent normal muscular tissues including a portion of the attached muscles.1,26 Although great differences were shown, depending on the investigators, the recurrence rate of intramuscular lipoma is high, reported to be 3–62.5%.22

Fine needle aspiration biopsy (FNAB) is of great value in the diagnostic work-up and the differential diagnosis for parotid mass, but it does not provide sufficient data for diagnosis and its accuracy drops to <50% in the case of lipomatous lesions of the parotid gland.12,20,21

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Preoperative image studies can be particularly useful in identifying the size, location, and even the histological characteristics of lipomatous lesions.7 Ultrasonography can be used as the initial study. The characteristic sonographic appearance is that of an elliptical or rounded mass parallel to the skin surface that is hyperechoic relative to adjacent muscle.8 However, because echogenicity is influenced by the volume of nonfat tissue,9 it may appear as sometimes iso-echoic10 or even hypo-echoic.9 High resolution CT scan imaging can usually be diagnostic even though magnetic resonance imaging (MRI) shows better definition of soft tissue.11 CT shows a well-encapsulated homogeneous mass with few septations and typically low-attenuation with values of –50 to –150 Housefield units.2 MRI presents the typical signal intensity patterns that a black rim is present around the mass clearly defining the borders from the subcutaneous tissue.10,12 Infiltrative margins are not often apparent on CT scanning, but using MRI with fat suppression techniques, this can become more evident.13 Most lipomas pose no diagnostic dilemmas. However, when presented with large (>10 cm) or rapidly growing masses, especially in the head and neck region, physicians should be concerned about malignancy. Among various disease entities of differential diagnosis, the main diagnostic dilemma is to distinguish a lipoma from a well-differentiated liposarcoma.5

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The extent of surgery should be determined at the time of operation with dual goals of complete mass resection (when possible, with a cuff of normal parotid tissue around the mass) and facial nerve preservation.12 Most clinicians recommend superficial parotidectomy for tumours located within the superficial lobe, with dissection and preservation of the facial nerve and total parotidectomy for deep lobe tumours.12

Although adipose tissue is normally present in the parotid gland, intraglandular lipomas of the parotid gland are rare benign lesions that occur in about 1% of all parotid tumour cases.12,17 The typical history of patients with intraglandular lipoma is that of a slowly growing, painless mass over the parotid area, the unilateral swelling of the parotid gland.12 They might be associated with ductal obstruction leading to sialadenitis, depending on the type of lipoma present.18

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Clinically, intramuscular lipomas present as slow-growing diffuse masses, arising from the muscle and giving them a rounded appearance.1 They show the characteristic of becoming soft and flat when surrounding muscles are relaxed; on the other hand, during muscle contraction, they change to a hard round shape, which is of help to differentiate them from other soft-tissue tumours.22,25 Lipomas of the sternocleidomastoid muscle are seldom considered in the preoperative differential diagnosis because of their rarity. According to the previous reports, FNAB with sonography may help in making an early diagnosis of intramuscular lipoma, but the results of FNAB can be supported with CT and confirmed with a histopathological report.1,2

Modern turnouts certainly contain more “cargo space” than gear from previous decades, so it’s no surprise that firefighters are filling the extra space with their favorite tools. Ask any firefighter to empty the pockets on their turnout gear and it’s likely you’ll have enough inventory to stock a small hardware store. From pliers and screwdrivers to nylon webbing and multi-tools, your average firefighter is ready for whatever comes next.

In 2013, I posed the question “what’s in your turnout coat pockets?” to Facebook community and revealed the answers in an article of the same name. Six years later, we posed the same question to the FireRescue1.com Facebook community, as well as my own social network, to see what’s changed over the years – or if we’re sticking to our old standby tools.

Several responses also mentioned the Halligan and flathead axe – called “the marriage” by one member – but I can’t picture a turnout pocket large enough to fit those tools!

The views expressed by the authors of articles in Australian Family Physician are their own and not necessarily those of the publisher or the editorial staff, and must not be quoted as such. Every care is taken to reproduce articles accurately, but the publisher accepts no responsibility for errors, omissions or inaccuracies contained therein or for the consequences of any action taken by any person as a result of anything contained in this publication. The content of any advertising or promotional material contained within, or mailed with, Australian Family Physician is not necessarily endorsed by the publisher.

Another reason to limit the amount of stuff carried in your turnout gear pockets – one that’s become more of a priority in recent years: Whatever is in your pockets must be cleaned after you’ve worked in the hot zone of a structure fire. Even if it wasn’t out of your pocket.

More space equals the opportunity to carry more stuff, but does that translate into being better equipped? Let’s be real. How much of that stuff in your pockets ever sees the light of day except when you’re washing and drying your gear? It’s an important question to consider when selecting the right tools to fill that valuable space.

Following are the most common responses we received about the tools that firefighters are carrying in their turnout gear (in no particular order), along with some quotes from individuals about how or why they carry the tools:

Intramuscular lipomas can be divided into the well-circumscribed type and the infiltrative type, on the basis of the appearance of the margins in relation to the adjacent muscle fibres. The infiltrative type, which accounts for 83% of intramuscular lipomas is characterised by margins that irregularly invade the surrounding muscle fibres and, in places, completely replace them. The well-circumscribed type, on the other hand, is composed solely of a discrete mass of uniform, mature adipocytes that are clearly delineated from the surrounding muscle.23

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Further, carrying lots of tools in your turnout gear may encourage what I call the “round peg in the square hole syndrome.” Who hasn’t seen a fellow firefighter try to make a tool – the one in their pocket – fit the task they are trying to accomplish (usually with a less than desirable outcome), rather than taking the extra time to get the right tool for the job?

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Lipomas are usually located subcutaneously without infiltrating the adjacent tissues. However, intramuscular lipomas are rare benign tumours that account for 1.8% of all lipomas. These tumours of fat tissues are not confined within the subcutaneous fat layer, but infiltrate the skeletal muscles.22

Printed from Australian Family Physician - https://www.racgp.org.au/afp/2014/december/unusual-locations-of-lipoma-differential-diagnosis© The Australian College of General Practitioners www.racgp.org.au

Lipomas are the most common benign neoplasms of mesenchymal origin and may arise in any location where fat is normally present.1 Lipomas are composed of mature fatty cells and occur predominantly on the upper back, shoulder and abdomen.2,3 In the head and neck region, where only 13% of lipomas are seen,4 the posterior neck space is the most common site, but the anterior neck space is a rare location.4,5 Besides frequent aesthetic consequences, clinical symptoms depend on the size, location and rate of growth of the lesion.5 The most common presentation of lipoma is a painless, well-circumscribed mass with progression in size over time.5 Although the aetiology of lipoma has not been elucidated as yet, heredity, obesity, diabetes, trauma, radiation, endocrine disorder, insulin injection and corticosteroid therapy are occasionally implicated as possible aetiological factors.6 Rarely, lipomas can be associated with syndromes such as hereditary multiple lipomatosis, adiposis dolorosa, Gardner’s syndrome and Madelung’s disease.5

Instead of using your turnout gear pockets as a toolbox or personal care compartments, consider “emergency use only” items, such as the following, which you can keep in a plastic bag that can be replaced after every exposure:

Although most lipomas can be observed without treatment,14 they need excision if there is diagnostic uncertainty, lack of homogeneity to palpation, large neck mass (>10cm), rapid growth, associated pain, deep-seated locations (intramuscular or intermuscular) or cosmetic concern. Treatment is complete surgical excision, but liposuction can be useful in certain locations such as the face.14 Liposuction is sometimes preferred as there is less scarring following the procedure but there is higher chance of recurrence, compared with excision.15,16

Australian Family Physician was the peer-reviewed, scholarly journal of The Royal Australian College of General Practitioners (RACGP) from 1971 to 2017. From January 2018, it was superseded by AJGP: Australian Journal of General Practice

Apart from particulates, like soot, pretty much every other chemical, chemical compound and carcinogen to which you’re exposed during interior structural firefighting is a gas. And that means those gases are completely enveloping you from the moment you enter the IDLH, and those gases are getting into the turnout coat pockets, especially those soft items, like gloves and nylon webbing.

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