Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base

Transnasal Endoscopic Approach for Excision of Intracranial Nasal Dermoid Sinus Cysts

OBJECTIVE

Nasal dermoid sinus cysts (NDSCs) with intracranial extension in the form of dermal sinus tracts require careful and complete resection to prevent recurrence. Resection techniques necessitate adequate intracranial exposure, but morbidity associated with historical resection approaches has presented unique multidisciplinary challenges for surgeons treating cysts with intracranial extension.

METHODS

The authors primarily employed a transnasal approach through a midline nasal incision, utilizing endoscopic or microscopic access between the lateral cartilages for resection of NDSCs with intracranial extension. A retrospective review was completed for patients treated for NDSCs at the authors' pediatric quaternary referral center from 2017 to 2023. Data collection included demographics, comorbidities, perioperative data, pre and postoperative imaging, surgical outcomes, and complications.

RESULTS

Eighteen patients with NDSCs with possible or confirmed intracranial extension were surgically treated from 2017 to 2023. Fifteen were treated with resection performed through a midline transnasal approach with endoscopic assistance, achieving successful total resection while avoiding nasal osteotomy or frontal craniotomy. One patient had a slow cerebrospinal fluid leak from an operative durotomy, successfully treated with a lumbar drain. No other complications occurred. No patients required transfusion. Incision length and postoperative scar burden were less than approaches that used osteotomies or craniotomies and demonstrated excellent cosmetic results. No patients have had cyst recurrence or required reoperation.

CONCLUSIONS

A transnasal approach through a midline incision with endoscopic assistance is an effective approach for resection of NDSC with intracranial extension, but utility may vary with cyst size and complexity. This approach leverages appropriate exposure for resection with decreased morbidity and decreased incision length through avoidance of osteotomies.

Surgical approach to congenital nasal dermoid sinus cyst in adult with external rhinoplasty and endoscopic approach: a case report

Introduction and importance

Nasal dermoid sinus cysts (NDSCs) are rare congenital nasal lesions which typically arise in early childhood. Complete surgical excision is the only therapy, and many approaches have been used according to the location and the extension of the mass. Several studies have advocated external rhinoplasty and endoscopy.

Case presentation

A 21-year-old female presented with a mass on the root of the nose, which appeared since childhood, and enlarged after puberty. Investigations including imaging revealed a lobulated mass extending from the osteocartilaginous junction towards the nasion, affecting the left lateral nasal wall. And its upper pole was resting on the floor of the left frontal sinus. Complete resection was performed using external rhinoplasty and endoscopy approaches, which improved esthetic results. Lateral osteotomy was used to compensate for the lateral nasal bone loss by narrowing the width of the nose. After 10 weeks of follow-up, no complications occurred, and the patient was satisfied with the cosmetic results.

Clinical discussion

Nasal dermoid sinus cysts are congenital midline nasal lesions that can present as an isolated mass, or associated with intracranial extension. External rhinoplasty and endoscopy approaches are recommended for complete excision of NDSCs extending to the anterior skull base, especially when there is no intracranial involvement or in case of small intracranial extension. These two methods allow for repairing bone defects of the anterior skull base and improve esthetic results. However, in cases of large intracranial extension, craniotomy is preferred.

Conclusion

The surgical approach used in the treatment of nasal dermoid sinus cysts should be a minimally invasive technique that reduces bone morbidity and provides good cosmetic results.

Paediatric nasal dermoid: evaluation and management

PURPOSE OF REVIEW

The aim of this study was to present the evaluation and current management of congenital paediatric nasal dermoid.

RECENT FINDINGS

There has been a trend towards less invasive surgical excision techniques, including purely endoscopic excision, endoscopic-assisted approaches and midline excision with nasal bone osteotomies and bone flap. These approaches allow adequate access for both total resection and nasal contour and skull base reconstruction. Following resection, if nasal bone osteotomies are insufficient for restoring nasal appearance, free temporoparietal fascial graft and/or conchal cartilage can be considered. For nasal tip deformities, interdomal sutures and free fat grafting are a suitable option.

SUMMARY

Complete surgical excision remains the treatment of choice for nasal dermoid lesions. The surgical approach taken and reconstruction depends on the type of lesion (cyst versus sinus or fistula), location (intranasal versus extranasal), whether or not there is intracranial extension, and experience of the surgical team.

Pediatric nasal dermoid- a decade's experience from a South Indian tertiary care centre

INTRODUCTION

Nasal dermoid sinus cyst (NDSC) are uncommon congenital lesions in children.

OBJECTIVE

To review the clinical and radiological presentation and study the surgical outcomes of this uncommon lesion.

METHOD

Retrospective chart review of all children diagnosed with nasal dermoid from 2010 to 2020 at a tertiary referral hospital in South India was executed. The medical records were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes and literature review was performed.

RESULT

A total of 25 children [Mean age 3.7 yrs (Range 2-9 yrs)] with nasal dermoid sinus cysts were treated in the last decade. While 13 presented with a sinus, 11 presented with cyst and 1 had both. The lesions mainly involved the upper third of the nose in 10 children, middle one third in 6 and upper one third in 9 children. All underwent Magnetic Resonance Imaging, in 11 Computed Tomography also was done. A flow chart of the lesion characteristics and its management has been presented. Intraoperatively intracranial extension was present in four children. The approach to intracranial extension and corresponding literature review has been presented. Follow up ranged from one to six years. (Median 3.5 yrs) and no recurrence or complication was noted.

CONCLUSION

Nasal dermoid is an uncommon congenital anomaly. Preoperative evaluation must include imaging to assess extent and rule out intracranial extension. Surgical strategy depends on whether presentation is as sinus or cyst and location and extent of lesion. All surgical approaches have a good surgical and cosmetic outcome.

Meet in the middle: a technique for resecting nasocranial dermoids-technical note and review of the literature

INTRODUCTION

Nasal dermoids with intracranial extension are benign lesions that can have life-threatening consequences, as a nasal punctum may serve as a portal of entry for infection into the central nervous system. The surgical management of these lesions can be challenging, as the extracranial and intracranial cysts and sinus tract must be resected to prevent recurrence, and the surgery must be carried out with an acceptable esthetic result.

TECHNIQUE

The authors present a technique for the resection of nasocranial dermoids that eliminates the need to remove and replace the frontonasal segment. Working through a small frontal craniotomy enables the surgeon to drill out the sinus tract through the foramen cecum and inferiorly into the nose. This exposure eliminates the need to enter the frontal sinus, if it is present.

CONCLUSION

The extracranial punctum and tract are resected from below in a minimally invasive fashion that permits removal of the lesion without a disfiguring scar.

Nasal dermoid cysts with intracranial extension: avoiding coronal incision through midline exposure and nasal bone osteotomy

OBJECTIVE

Up to 10% of midline nasal dermoid cysts have intracranial extension. Previous techniques of excision include frontal and frontonasal craniotomies via a coronal approach, combined with a direct cutaneous excision of the dermoid cyst. While the coronal incision allows for wide visualization, it carries significant risks of transfusion, blood loss, and scarring. The authors present an alternative technique in which access is gained through a midline extension of the dermoid cyst excision that provides direct access for a keyhole frontal craniotomy.

METHODS

The authors utilize a nasal bone osteotomy, pericranial flap, and keyhole-type craniotomy performed through a nasal midline incision for the treatment of nasal dermoid cysts with intracranial extension. They performed a retrospective chart review of all patients with nasal dermoid cysts treated at the Ann & Robert H. Lurie Children's Hospital of Chicago from 2009 to 2017. Patient demographic data, operative data, and in- and outpatient complication data were collected.

RESULTS

In 10 patients with cyst extension near or into the intracranial cavity (7 with true intracranial extension), the nasal osteotomy technique was performed. The mean blood loss was 13 ml, with a 0% transfusion rate. The mean length of inpatient stay was 1 day. A durotomy was made and repaired as part of the dermoid cyst dissection in 3 patients. One patient underwent intraoperative placement of a lumbar drain. The mean operative time was 228 minutes. There were no intraoperative or postoperative complications, including the need for a reoperation. No patients had any long-term complications, and no patients have had dermoid cyst recurrence. The appearance of the scar was acceptable in all cases.

CONCLUSIONS

The midline approach to nasal dermoid cysts with intracranial extension is safe and results in limited blood loss, short operative times, and short lengths of inpatient hospital stay. This is a viable technique for the treatment of this challenging pathology.

Combined minimally invasive surgical management of a nasal dermoid sinus cyst affecting the frontal sinus: literature review and new classification

Introduction

Nasal dermoid sinus cysts (NDSCs) are the most common lesions associated with midline craniofacial anomalies, in the majority of cases diagnosed during childhood. NDSCs affecting the frontal sinus are rare.

Aim

To demonstrate the clinical, radiological and diagnostic pitfalls of NDSCs affecting the frontal sinus.

Material and methods

A retrospective analysis of NDSCs affecting the frontal sinus with a literature review and a novel classification is presented.

Results

We present a rare and complex case of an NDSC in an adult patient that affected the frontal sinus. Endoscopic-assisted open rhinoplasty with endoscopic sinus surgery – Draf type 2B approach – was performed as an effective removal method of choice. A literature review supports our report.

Conclusions

NDSCs affecting the frontal sinus can mimic complications of sinusitis. A minimally invasive combined technique of endoscopic-assisted open rhinoplasty with endoscopic sinus surgery – Draf type 2B frontal sinus approach – is recommended for treatment.

Endonasal endoscopic skullbase surgery in children

OBJECTIVE

The role of endonasal endoscopic approach for pathologies in the paediatric population is evolving and has still not been accepted as standard of care in neurosurgery. It represents a challenge in terms of narrow access, instrument manipulation and adequate reconstruction of defects. We have described our experience in 49 cases from a single neurosurgical unit in paediatric skull base surgeries through this approach over the last 12 years.

MATERIAL AND METHODS

A case series of 59 paediatric skull base surgeries in 49 children through endoscopic endonasal route over the last 12 years is presented. The age ranges from 4 months to 18 years. Out of 49 cases, 22 cases were of craniopharyngiomas, 8 cases of pituitary adenomas, 5 cases with CSF rhinorrhea, 5 cases with meningoencephalocele, 3 cases of Rathke's cleft cysts, 2 cases of odontoidectomy and 4 miscellaneous cases viz. mucocele, hypothalamic glioma, esthesioneuroblastoma and epidermoid. CSF leaks were repaired with free graft in the initial years and by vascularized flap more recently.

RESULTS

The goal of surgery was achieved in all but two cases in whom the tumour excision was unsatisfactory due to failure of the cyst wall to collapse after decompression. Extent of tumour excision was not compromised by the choice of this approach. Revision surgery for CSF leak was required in three patients. Local vascularized nasoseptal flap has been possible even in very young patients and has now become the standard for reconstruction.

CONCLUSION

In spite of the challenges posed by small nostrils and ill-developed sinuses in the paediatric age group, surgery from endoscopic endonasal corridor is possible to be carried out successfully in selected cases.

Paediatric nasal dermoids: Our experience

OBJECTIVES

Nasal dermoids are rare developmental anomalies seen in children. This study reports our experience in a developing country of the clinical and radiological findings as well as the management of nasal dermoids.

METHODS

A retrospective analysis was performed, from 2012 to 2017, for 10 patients admitted for the treatment of nasal dermoids at a tertiary care center. The clinical presentation, preoperative imaging (CT/MRI), surgical approach, intraoperative findings, complications and recurrence were reviewed.

RESULTS

Ten patients were included in this study, 6 males and 4 females, with an average age of 10.2 years at the time of presentation. Three patients presented with a mass located on the nasal dorsum, 1 had a nasoglabellar mass, 2 patients had a mass located on the nasal dorsum with visible sinus, and 4 patients presented with a sinus on the nasal dorsum, in which 1 patient had a tuft of hair. CT was performed in all the cases. It was not suggestive of intracranial extension in 9 patients, and was non-diagnostic in one patient. Both CT and MRI were performed on 2 patients, with no evidence of intracranial extension. Surgical and radiological findings were concordant in 8 patients (80%).

CONCLUSION

Nasal dermoids require preoperative imaging and precise surgical planning to achieve complete removal.

Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience

OBJECTIVE

Epidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of endoscopic endonasal approaches for resection of these tumors has been rarely reported.

METHODS

The authors retrospectively reviewed the medical records of 21 patients who underwent endoscopic endonasal surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.

RESULTS

Total resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0.008 and 0.0005, respectively). In the whole series, surgical complications were seen in 6 patients (28.6%). No complications were observed in patients with extradural cysts. Among the 15 patients with intradural cysts, the most common surgical complication was postoperative CSF leak (5 patients, 33.3%), followed by postoperative intracranial infection (4 patients, 26.7%). Larger cysts and postoperative CSF leak were associated with intracranial infection (p = 0.012 and 0.028, respectively). Subtotal resection was marginally associated with intracranial infection when compared with total resection (p = 0.091). All patients with neurological symptoms improved postoperatively with the exception of 1 patient with unchanged abducens nerve palsy.

CONCLUSIONS

Endoscopic endonasal approaches may be effectively used for resection of epidermoid and dermoid cysts in carefully selected cases. These approaches are recommended for cases in which a total or near-total resection is possible in addition to a multilayer cranial base reconstruction with vascularized tissue to minimize the risk of intracranial infection.

Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review

Objectives  To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods  PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results  Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n  = 239) and chondrosarcomas ( n  = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n  = 193, 41.2%) and endoscopic extended transsphenoidal ( n  = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n  = 36, 17.3%) and endocrinopathy ( n  = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion  Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.

Endoscopic Management of Sinonasal Tumors: A Preliminary Report

Background

The increased experience with the endoscopic approach to sinonasal inflammatory disease has resulted in the increased use of endoscopes to manage many different sinonasal pathologies.

Methods

A chart review of patients with sinonasal tumors treated with primary endoscopic management, from January, 1993 to November, 2003 was performed.

Results

Forty patients were identified (26 men and 14 women). The mean age was 53.2 years, and the mean follow-up was 31.1 months. For benign tumors, 24 patients were identified with a mean age of 50.7 years, a mean follow-up of 17.5 months, and a recurrence rate of 4.2%. For malignant tumors, 16 patients were identified, with a mean age of 57.3 years, a mean follow-up of 51.5 months, and a recurrence rate of 31.3%. The overall survival rate was 87.5%.

Conclusion

Endoscopic surgical excision of selective sinonasal tumors may be an effective therapeutic modality. In some cases, adjuvant external procedures may be required based on tumor location.

Endoscopic Management of Developmental Anomalies of the Skull Base

Developmental anomalies of the skull base may present in childhood or as an adult. The most common pathologies include dermoid, encephalocele, and glioma. Encephaloceles may present as part of a syndrome. Other entities include infantile hemangiomas and teratoma. Endoscopic techniques provide a less invasive and morbid option for treatment. Proper evaluation and treatment is necessary to prevent complications such as meningitis.

Considerations in the management of congenital cranial dermoid cysts

OBJECTIVE Congenital dermoid cysts (CDCs) develop from the entrapment of the surface ectoderm along the lines of embryonic fusion and have a capacity to grow. Given this capacity for continual expansion, the timing of removal and anticipation of possible epidural extension is important. METHODS The authors retrospectively reviewed records of patients with the diagnosis of dermoid cyst presenting over a period of 10 years. Baseline characteristics, histological reports, and surgical records were collected and analyzed. Only those patients with histological confirmation of dermoid cyst were included in the study. RESULTS One hundred fifty-nine (64 male and 95 female) patients were studied. The average age at the time of surgery ranged from 1 month to 63 years (mean 3.55 ± 9.58 years, median 11 months). Eighteen (11.3%) CDCs were in the midline anterior fontanelle, 52 (32.7%) were frontozygomatic, 14 (8.8%) occurred along the coronal sutures, and 75 (47.2%) occurred along the lambdoid sutures. In 74 (46.5%) cases the cysts were found to insignificantly erode the cranium, 30 (18.9%) eroded through a partial thickness of the cranium, 47 (29.6%) eroded through the full thickness of the cranium, and 8 (5.0%) eroded through the full thickness of the cranium and demonstrated epidural extension. The study population showed female predominance (n = 95, 59.7%). Although cyst location and patient sex were not found to vary significantly with cranial involvement (p = 0.196 and p = 0.066, respectively), delay in time to surgery did vary significantly (p < 0.00001). CONCLUSIONS Congenital cranial dermoid cysts found in infants and children are best removed early.

Intracranial Nasal Dermoid Sinus Cyst: Transnasal Endoscopic Resection by Open Rhinoplasty Approach, With Intraoperative Video

Nasal dermoid sinus cysts are rare congenital lesions that may lead to recurrent soft tissue infections and severe intracranial complications. In case of an intracranial extension, the traditional surgical approach includes a frontal craniotomy with significant morbidity. As a less invasive alternative, a transnasal endoscopic approach has been recommended.This report describes the transnasal endoscopic resection of an intracranial nasal dermoid sinus cyst via an open rhinoplasty approach, which achieved a wide surgical exposure with minimal invasivity and ideal aesthetic results. An intraoperative video demonstrates this combination of techniques in this rare skull base/intracranial pathology.

Excision and Fat Grafting of Nasal Tip Dermoid Cysts Through an Open Rhinoplasty Approach

Nasal tip dermoid cysts that are present in pediatric patients can be complicated by mass effect causing compression and distortion of underlying cartilaginous structures. The purpose of this report is to describe a single surgeon's technique and results of nasal tip dermoid cyst excision in pediatric patients through an open rhinoplasty approach followed by tip reconstruction and immediate fat grafting. A series of 3 pediatric patients presented with 1 to 1.5 cm nasal tip dermoid cysts that were causing distortion of the lower lateral cartilages. All 3 underwent excision of the cyst through an open rhinoplasty approach. The nasal tip was reconstructed with interdomal sutures and immediate fat grafting. Fat grafts were harvested from the abdominal wall and implanted in the nasal tip. The grafts filled the resulting dead space and were secured with the fibrin glue. The soft tissue was redraped, and the skin was closed. The final postoperative result, 2 years after surgical intervention, included a well-proportioned and appropriately shaped nasal tip without obvious incisional scars in all patients. The skin overlying the previously excised dermoid cyst was supple and healthy. Excision of nasal tip dermoid cysts in pediatric patients can be approached through an open rhinoplasty approach, tip reconstruction, and immediate fat grafting. This approach can provide assistance in correcting contour deformities and may help preserve an at-risk soft-tissue envelope.

Update on current evaluation and management of pediatric nasal dermoid

OBJECTIVES/HYPOTHESIS

To review the presentation of congenital pediatric nasal dermoid and present guidelines for its evaluation and management.

STUDY DESIGN

Retrospective chart review from 1970 to 2014 at a tertiary referral children's hospital.

METHODS

The medical records of all patients diagnosed with a nasal dermoid during the study period were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes.

RESULTS

Ninety-six patients underwent excision of a congenital nasal dermoid during the study period. The mean age at presentation was 3.1 years (range, 0.1-19.3 years). Thirty-four (35%) females and 62 (65%) males were included. The most common presentation was a nasal dorsal mass in 66 (69%) patients. Ninety-two (96%) of the patients underwent preoperative imaging. Seventy-eight (82%) of the patients did not show any clinical or radiographic evidence of intracranial extension preoperatively. Eighty-five (89%) of the patients underwent extracranial excision, and 11 (11%) underwent combined intracranial and extracranial excision. Eight patients (8%) presented with recurrence, on average 3.3 years (range, 1-6 years) after initial excision. Mean follow-up time was 8 years (range, 1-18 years).

CONCLUSION

Preoperative imaging of nasal dermoid is crucial to evaluate for intracranial extension, thus facilitating complete removal. Thin section, high-resolution magnetic resonance with contrast provides excellent detail of the extent of the nasal dermoid including intracranial extension. Thin-section high-resolution computed tomography with multiplanar reformatted images provides complimentary information regarding the bone anatomy of the frontonasal region. Surgical strategy is dictated by preoperative imaging and is dependent on the extent of the lesion, but limited facial incisions are preferred.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2151-2160, 2016.

The "stepped caudal exposure" technique for excision of nasal dermoids with intracranial extension

Nasal dermoid sinus cysts (NDSCs) are rare congenital malformations derived from ectodermal and mesodermal tissues. There are numerous reports on surgical approaches for extirpation of NDSCs with intracranial extension. Here we describe the "stepped caudal exposure" approach, a technique that minimizes the risk for bacterial infection of the central nervous system from the nasal space. This procedure involves a stepwise osteotomy of the frontal and nasal bones that permits sufficient exposure to allow complete extirpation of NDSCs; it was used successfully to treat a 20-month-old boy with NDSC extending into the intracranial space and an infectious abscess. After NDSC extirpation and debridement of the abscess, the anterior skull base was reconstructed with bone grafts placed on both the intracranial and intranasal sides of the widened foramen cecum. Thereafter, each graft was covered by frontal pericranial flaps for blood supply. These modified surgical techniques may enhance the safety of surgical removal of NDSC, particularly in cases accompanied by infectious lesions such as abscesses.

The management of midline frontonasal dermoids: a review of 55 cases at a tertiary referral center and a protocol for treatment

BACKGROUND

The incidence of midline frontonasal dermoid cysts is one in 20,000 to one in 40,000. These lesions may have intracranial extension. This is explained by the anatomy and embryology of nasofrontal development. Skin involvement may also be extensive. Incomplete excision frequently leads to recurrence. The authors report their experience and pathway for management of midline dermoids.

METHODS

Databases were searched to identify patients who had undergone surgery for removal of a dermoid cyst. Preoperative imaging and indications for surgery were reviewed. Cases were grouped according to surgical approach, and outcomes and complications were identified.

RESULTS

Fifty-five patients were treated. Magnetic resonance imaging or computed tomography was used to delineate the anatomy, and surgical excision was expedited if there was a history of infection, especially if imaging suggested intracranial extension. Twelve patients were treated endoscopically (one was converted to open). Eleven required transcranial approaches for intracranial extension (20 percent). Of these, one lesion breached the dura. The remaining 32 patients had dermoids excised with an open approach (direct, bicoronal, or rhinoplasty). There were no recurrences in the open group and there was one recurrence in the transcranial group. This was treated by reexcision.

CONCLUSION

Midline dermoid cysts are relatively uncommon. However, knowledge of the pathogenesis of these lesions together with the authors' experience over 15 years has allowed them to develop a protocol-driven approach, with a low incidence of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

[Nasal dermal sinus in children: a review based on a series of 6 cases]

INTRODUCTION

Nasal dermal sinus in children (NDSC) is a rare malformation (1/20,000 to 1/40,000). Apart from local infection, they present as median nasal lump or pit on the dorsum and their diagnosis and treatment are often delayed. Consequences of untreated NDSC are: local infection, meningitis, and empyema, due to their frequent intracranial extension.

PATIENTS AND METHODS

Six cases of NDSC were retrospectively reviewed (5 boys and one girl), all treated between 2006 and 2012 in our institution (Nancy University Hospital). All patients underwent a brain and facial CT-scan and MR imaging to check any bony lesions, skull base extension by foramen cæcum, course of the sinus and the possible associated brain malformations. Evolution, treatment and follow-up (FU) were conducted by the same multidisciplinary team (neurosurgeon, ENT surgeon, and plastic surgeon). Children were operated on by a conjoined approach (cranial and facial) for removal of the sinus and its intracranial extension.

RESULTS

Mean age at diagnosis was 12 months (birth-36 months). Initial presentation consisted of three local infections, one dorsum nasal lump, one CSF leakage, and one asymptomatic child. Five children presented with a skull base extension. There were no associated brain malformations. We observed only one surgical complication (bleeding from the anterior part of the superior sagittal sinus during dissection) leading to blood transfusion. Pathology results confirmed three dermoid cysts, one epidermoid cyst, one cyst with granulation tissue, and negative in one case. Average FU was 30.8 months (4-84 months). Two recurrences (same child) occurred, leading to two re-operations. There were no recurrences or complications at the end of FU.

CONCLUSION

NDSC are rare malformations, mostly diagnosed before the age of three years, due to an infectious complication. The aim of the treatment is complete removal to avoid recurrence, and a multidisciplinary strategy is required.

Dermoid cysts: a report of 75 pediatric patients

Dermoid cysts (DCs) are benign cutaneous tumors that tend to persist and grow. The aim of this study was to examine the clinicopathologic features of congenital DCs. We present a case series of 75 children with a clinicopathologic diagnosis of DC. Seventy-two cysts were located on the head, one on the neck, and two on the trunk. Six cysts were located along the midline. Eight patients had symptoms other than changes in cyst size. Imaging studies were performed on 15 patients. Surgical excision was the primary treatment in all 75 cases. Neurosurgery and ophthalmology services were involved in the care of some patients. Histopathologic studies reported a foreign body giant cell reaction in 17 of the cysts. No recurrence was documented. DCs can remain stable for years, but they can become symptomatic as a result of enlargement and rupture or, more rarely, as a result of extension into surrounding tissues. Physicians should be aware that certain locations have a higher risk of DC extension, and adequate diagnostic investigations should be performed before their complete resection.

Endoscopic removal of a dermoid cyst via scalp incision

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar.

Subcranial approach in pediatric craniofacial surgery

We report our experience with the subcranial approach, developed at the Plastic Surgery Unit of Hospital "Ricardo Gutiérrez," for the treatment of injuries in the frontoethmoidal orbital region in pediatric patients. The subcranial approach was described by Raveh et al for the treatment of fractures in the frontoethmoidal area. The subcranial approach was used later for surgery of tumors and deformities of the frontoethmoidal region. We have used this approach in nine cases of nontraumatic injuries (one meningioma, one orbital bone fibrous dysplasia, one vascular malformation, five nasal dermoid cysts, and one fronto-orbital mucocele). One patient with vascular malformation died of a stroke 10 days after surgery. The patient with the meningioma had a recurrence. Another patient developed an infection that needed surgical resolution and hardware removal. A third patient suffered a mild infection that receded with medication. No other complications were registered. The surgical exposure obtained through this approach was always excellent and left no cosmetic defects. There was no evidence of facial growth disturbance in this group of patients, except in one patient who received radiotherapy after surgery. Operative time and hospitalization were lower in this group than in patients with conventional frontal craniotomy.

Endonasal endoscopic approach for intracranial nasal dermoid sinus cysts in children

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. The frequency of intracranial extensions varies from 5% to 45%. Complete surgical excision of nasal dermoid cyst and any associated sinus tract is essential for cure and any residual ectodermal elements result in a high rate of recurrence and complicated infections. Many different approaches have been described for the removal of nasal dermoids in the past two decades, ranging from a simple extracranial excision to complex procedures in which a combined extracranial-intracranial approach is required. We hereby report two cases of nasal dermoid sinus cysts in children with intracranial extension which were managed with an endonasal endoscopic procedure. We describe the technique we implemented for this procedure and for the reconstruction of the skull base defect.

Endoscopic endonasal surgery for nasal dermoids

Midline congenital lesions are rare and commonly comprise nasal dermoids (NDs), encephaloceles, and gliomas. This article discusses the epidemiology of NDs. Management is also discussed, as well as prognosis.

Witch nose: an embarassing metaphor for nasal tip dermoid cysts

Nasal dermoid cysts are one of the most frequent congenital pathologic lesions of the nasal area. These lesions may have intracranial extensions without any clinical evidence, which can be explained by the pathophysiologic development of the lesion, thought to be related to a delay or pause during the separation period of the dura and skin during embryogenesis. This factor is independent from the location and size of the lesion and may lead surgeons to misdiagnoses or inadequate treatments.In this article, 2 cases of nasal dermoid cysts localized at the tip of the nose are presented. Although these lesions can be seen anywhere from the root to the columella, nasal tip location is rare in previously published series. In the cases presented in this study, both patients are school-aged and are faced with social and psychologic problems, as their friends call them "witch nose," in reference to the lesion at the tip of the nose. Vertical tip incision for complete excision of these lesions was performed after accurate radiologic imaging of the brain and possible intracranial extension. No complications or recurrence was seen in either patient.Although the treatment of dermoid cysts is surgical, operative planning should be made after complete physical and radiologic examinations. As the lesion may lead to psychologic and social problems because of its appearance, especially in children, therapy should not be delayed.

[Nasal dermoïd cyst with intracranial extension: which approach?]

Dermoïd cyst is the most common midline congenital nasal tumor. Intracranial extension is rare but possible, must be suspected and confirmed by a cerebral magnetic resonance imagining (MRI). Only total surgical removal via a combined intracranial/extracranial approach appears to provide a complete resolution and effective protection against late recurrence. We report a case of a 2 years old patient who was operated for a nasal congenital cyst extending to the nasal septum. Anatomopathology showed a dermoïd cyst. Five years later, he presented local recurrence of the dermoïd cyst with intracranial extension through a bifid crista galli. We conclude that to avoid recurrence, the removal of the nasal cyst and sinus tract must be followed to its dural attachment. A transfacial approach can be associated with frontal craniotomy, which can provide adequate exposure for complete removal of the intracranial component of the cyst and sinus tract. A literature review was performed.

Endoscopic resection of intracranial dermoid cysts

INTRODUCTION

Nasal dermoid cysts are congenital lesions which are often diagnosed in infancy or childhood. However, a small number present in adulthood, and some extend intracranially. Traditional treatment for the intracranial portion of these cysts includes frontal craniotomy.

CASE REPORTS

Two intracranial dermoid cysts were resected via a transnasal endoscopic approach, using 70° nasal endoscopy for complete visualisation and intracranial tumour removal. We describe our technique for the procedure itself and for reconstruction of the skull base defect.

DISCUSSION AND CONCLUSION

The endoscopic transnasal skull base approach is an excellent alternative to a traditional frontal craniotomy, to achieve complete resection of intracranial dermoid cysts.

Adult nasal dermoid sinus cyst

Midline congenital nasal lesions are rarely encountered in adults. We present the case of a 31-year-old man with a nasal dermoid sinus cyst who presented with a nasal dorsal abscess. We review the embryology of nasal dermoid sinus cysts, and we discuss their presentation, evaluation, and management in adults.

Surgical correction of midline nasal dermoid sinus cysts

Nasal dermoid sinus cysts (NDSCs) are rare congenital anomalies affecting approximately 1 in 30,000 live births. Nasal dermoid sinus cysts are unsightly, prone to infection, and, importantly, may communicate with the central nervous system. Treatment is complete surgical excision. This study retrospectively evaluated management of a large single-center cohort of intracranial NDSCs.Nineteen patients with NDSC were identified from all patients presenting to the Leeds craniofacial service between June 2000 and August 2008. Patient demographics, clinical presentation, preoperative investigations, and surgical procedures undertaken were analyzed.Mean age at presentation and surgery were 6.3 and 7.6 years, respectively. Fifty-three percent were males. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed in 15 and 17 patients, respectively. One patient (5.3%) required local excision only. Eighteen (96.7%) underwent a bicoronal approach, and 13 (68.4%) of these required a craniotomy. The dura was opened in 7 (36.8%) patients. Neither CT nor MRI predicted the presence or absence of intracranial extension in all patients. Positive and negative predictive values for intracranial extension were 85.7% and 50% for CT and were 100% and 50.0% for MRI. Mean follow-up of 4.1 years shows no deep recurrences and 5 (26.3%) were superficial nasal recurrences only.A multidisciplinary approach can achieve good results with infrequent intracranial recurrence. We used a bicoronal approach to facilitate craniotomy when required intraoperatively because imaging is unable to diagnose intracranial extension with sufficient accuracy.

Closed rhinoplasty approach for excision of nasal dermoids

OBJECTIVE

To assess the efficacy of excision of nasal dermoids through a closed rhinoplasty incision. This is the first description of the use of this approach for excision of superficial nasal dermoids.

METHODS

Three boys aged five, nine and 12 years presented with midline nasal dermoids with minimal cutaneous involvement. Magnetic resonance imaging demonstrated distinct, cystic, superficial nasal masses. The cysts were excised through a closed rhinoplasty approach. In each case, completeness of extirpation was judged by histopathological examination of the excised specimen. Aesthetic outcome was recorded photographically.

RESULTS

All three patients' cysts were completely excised, with excellent cosmetic results.

CONCLUSIONS

The closed rhinoplasty incision is another approach in the surgeon's armamentarium for excision of small, superficial nasal dermoid cysts. In well selected cases, this approach gives optimal cosmetic results, provides adequate exposure with minimal dissection, and allows total extirpation.

Excision of nasal dermoids with intracranial extension - anterior small window craniotomy approach

OBJECTIVE

Dermoid cysts are the most common midline congenital nasal masses and may extend intracranially. They commonly become infected, may distort nasal growth, and are cosmetically unacceptable. The treatment of nasal dermoids is complete surgical excision. Removal of any intracranial extension traditionally required a bicoronal incision and frontal craniotomy, with significant associated morbidity. This retrospective study describes a new minimally invasive approach for excision of the intracranial component of the dermoid.

METHODS

We present three cases where a brow incision was used. The intracranial part was removed by cutting a small window in the frontal bone directly over the dermoid, minimizing complications of formal craniotomy.

RESULTS

Good access allowing complete excision of the dermoid and very low morbidity was achieved in all patients. The dura was breached in one patient at operation but this was easily repaired with a periosteal patch. All patients recovered quickly and hospital stay was short. The resultant scar was cosmetically acceptable.

CONCLUSION

The use of a brow incision and small window craniotomy is a successful low morbidity technique for excision of nasal dermoids with intracranial extension.

Congenital nasal malformations

The nose is a prominent feature of the human face. Congenital malformations of the nose, whether functional or anatomic, affect the physiologic and psychologic wellness of children who have these anomalies. Congenital nasal abnormalities may be overt or subtle and can occasionally cause life-threatening emergencies at birth. A discussion of nasal embryology and development provides the basis for the discussion of some of the important congenital abnormalities seen in clinical practice. The final portion of the article is devoted to several of the more common syndromes in which nasal abnormalities are encountered.

Nasal dermoids

PURPOSE OF REVIEW

Midline congenital nasal lesions are rare, occurring in one out of every 20,000-40,000 births. Of these midline lesions, nasal dermoids are the most common. This review centers on diagnosis of nasal dermoids, the role of imaging in diagnosis and surgical planning and the various approaches to surgical management of these lesions.

RECENT FINDINGS

Multiplanar, high-resolution thin section magnetic resonance imaging allows for excellent soft tissue detail, particularly when intracranial extension is expected. Open rhinoplasty is favored by many authors for excision of dermoids. Transnasal endoscopic excision of nasal dermoids has been reported but is not recommended for dermoids extending into or beyond the falx cerebri.

SUMMARY

Imaging of the midface and brain is essential for accurate diagnosis, assessment for any intracranial extension and appropriate surgical planning. Any surgical approach for removal of nasal dermoid cysts should permit adequate access, allow repair of the skull base and cerebrospinal fluid leak, facilitate nasal reconstruction and result in acceptable cosmesis. The head and neck surgeon should be able to consider various surgical approaches to manage these lesions.

The management of midline transcranial nasal dermoid sinus cysts

The most common congenital midline nasal masses are nasal dermoid sinus cysts (NDSC) [Hughes GB, Sharpino G, Hunt W, Tucker HM. Management of the congenital midline nasal mass--a review. Head Neck Surg 1980;2:222-33.]. Their clinical importance hinges on their potential to communicate with the central nervous system. Preoperative diagnosis of an intracranial extension allows for referral to a craniofacial team with the appropriate skills and experience for a transcranial approach. All patients with a NDSC require imaging with high resolution multiplanar MRI scans and complimentary fine cut CT scan to reveal the anatomical extent of the tract and its relationship to the anterior cranial fossa. A single-stage craniofacial approach to resection of midline NDSC extending to the anterior cranial base is effective with minimal morbidity [Yavuzer R, Bier U, Jackson IT. Be careful: it might be a nasal dermoid cyst. Plast Reconstr Surg 1999;103:2082-3; Denoyelle F, Ducroz V, Roger G, Garabedian EN. Nasal dermoid sinus cysts in children. Laryngoscope 1997;107:795-800; Rohrich RJ, Lowe JB, Schwartz MR. The role of open rhinoplasty in the management of nasal dermoid cysts. Plast Reconstr Surg 1999;104:2163-70; Rahbar R, Shah P, Mulliken JB, et al. The presentation and management of nasal dermoid-a 30-year experience. Arch Otolaryngol Head Neck Surg 2003;129:464-71; Posnick JC, Bortoluzzi P, Armstrong DC, Drake JM. Intracranial nasal dermoid sinus cysts: computed tomographic scan findings and surgical results. Plast Reconstr Surg 1994;93:745-54 [discussion 755-56]; Bartlett SP, Lin KY, Grossman R, Kratowitz J. The surgical management of orbitofacial dermoids in the pediatric patient. Plast Reconstr Surg 1993;91:1208-15.]. The cyst and tract are accessed through a combination of a nasal and transcranial approach. This allows visualisation and dissection of the tract with only a small incision on the nasal dorsum to include the cutaneous punctum when present. Transnasal endoscopic techniques have been advocated where the dermoid is located within the nasal cavity and there is little or no cutaneous involvement [Weiss DD, Robson CD, Mulliken JB. Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base. Plast Reconstr Surg 1998;101:2119-23.]. We present a review of five cases referred to our unit between 1999 and 2004 with a diagnosis of a midline nasal dermoid sinus cyst and radiological evidence of intracranial communication. All cases had a communication with the anterior cranial fossa diagnosed preoperatively and were treated surgically with a craniofacial approach. An intracranial extension was identified at operation in each case and this was confirmed on histopathology. The only significant complication resulted from an early postoperative infection, requiring re-operation. There were no recurrences and acceptable aesthetic outcomes have been observed in all cases.

Frontonasal osteotomy to facilitate removal of an intracranial nasal dermoid

Dermoid sinus is the most common midline nasal anomaly. Intracranial extension has been reported in up to 45% of cases and requires a combined intracranial-extracranial besection. We present a technique of en-bloc ostectomy of the central bandeau and nasal bones to approach this malformation. This allows unobstructed visualization of the entire cyst and sinus tract, including portions that traverse or lie under the nasal bones, and ensures complete excision. Additionally unnecessary disruption of the nasal bones and facial scarring are avoided.

Endoscopic Surgery of the Anterior Skull Base

OBJECTIVES/HYPOTHESIS

Traditional surgical approaches to the anterior skull base often involve craniotomy, facial incisions, disruption of skeletal framework, tracheotomy, and an extended hospital stay. As experience with endoscopic sinus surgery has grown, the techniques and equipment have been found to be adaptable to treatment of lesions of the anterior and central skull base. A minimally invasive endoscopic approach theoretically offers the advantages of avoiding facial incisions, osteotomies, and tracheotomy; surgery should be less painful, recovery quicker, and hospital stays should be shorter. The study attempted to assess endoscopic approaches to the anterior and central skull base for its ability to achieve those goals.

STUDY DESIGN

Retrospective review of 72 cases performed at a single institution from November 1996 to July 2003. A subgroup of 15 patients who underwent endoscopic approach to their pituitary tumors was compared with a similar group of 15 patients who underwent traditional open trans-sphenoidal surgery for their pituitary tumors.

METHODS

Patient records were analyzed and information tabulated for age, sex, disease, location of lesion, operative time, use of image-guided surgical systems, blood loss, length of intensive care unit stay, duration of operative pain, length of postoperative hospitalization, complications, and completeness of resection.

RESULTS

Of the cases, 86.1% were performed exclusively endoscopically, and 13.9% used a combination of endoscopic and open techniques. An image-guided surgical system was used in 83% of cases. Hospital length of stay was 2.3 days for the exclusively endoscopic group as opposed to 8 days for the combined group. With the patients with pituitary tumors, operative times were similar between the two groups (255.13 vs. 245.73 min), blood loss was less in the endoscopic group (125.33 vs. 243.33 mL), pain duration was shorter in the endoscopic group (10 of 15 patients pain free on postoperative day 1 vs. 2 of 15 patients pain free in the open group), and intensive care unit stay and hospital length of stay were both shorter in the endoscopic group. Complication rates and completeness of resection was similar in both groups, although the open group had a higher rate of complications related to the approach to the sella.

CONCLUSION

The study demonstrated the safety and efficacy of judicious endoscopic approaches to anterior skull base lesions. An outcomes assessment in pituitary surgery demonstrates advantages of an endoscopic approach in appropriate cases.

The transglabellar subcranial approach for nasal dermoids with intracranial extension

OBJECTIVES/HYPOTHESIS

Nasal dermoids are the most common congenital midline nasal lesions. When a midline nasal pit or cyst is identified, scans should be obtained to look for an intracranial connection. The intracranial portion of the lesions has traditionally been approached by the performance of a frontal craniotomy. The transglabellar subcranial approach is a useful technique to resect these lesions and offers several advantages over a traditional craniotomy approach.

STUDY DESIGN

Retrospective case review.

METHODS

Records of two patients who underwent excision of nasal dermoids by way of a subcranial approach were analyzed.

RESULTS

Two patients underwent successful resection of nasal dermoids with intracranial extension by way of a subcranial approach. The patients were 13 months and 19 months old at the time of excision and have been followed for 7 years and 6 years, respectively. There has not been any recurrence of the lesions. There has been no apparent negative impact on facial growth in either of these cases.

CONCLUSIONS

The subcranial approach is an effective technique for the resection of nasal dermoids with intracranial extension. These lesions have traditionally been managed with lateral rhinotomy, midface degloving, or external rhinoplasty approaches combined with a frontal craniotomy. The subcranial approach offers excellent exposure, minimizes frontal lobe retraction, reduces the likelihood of cerebrospinal fluid leak, and provides for excellent cosmetic result. This approach was used in two cases with long-term follow-up. The lesions were successfully resected in both cases. Long-term follow-up has shown no recurrence or negative effect on craniofacial growth.

Angular Dermoid Cysts in the Endoscopic Era: Retrospective Analysis of Aesthetic Results Using the Direct, Classic Method

The concept of the endoscopic approach was recently introduced for the removal of angular dermoid cysts. Therefore, it was considered necessary to evaluate the conventional direct incisional approach for angular dermoid cyst excision, with respect to long-term aesthetic results and complications. The need to change from the direct excisional technique to the endoscopic approach in hair-bearing areas was investigated. During a 25-year period, 95 children were surgically treated by a single surgeon (H.G.T.) for removal of angular dermoid cysts. Only 22 patients (23 percent) were available for reassessment. The follow-up periods after the excisional procedure were 1 to 12 years. Assessments were performed by a 15-member team of assessors, who scored the aesthetic results of the scars with comparative slides. In addition, a questionnaire was mailed to each family, to document the family members' perceptions of the aesthetic appearance of the scar. Twenty-eight families (29 percent) responded. The complications were determined through the medical records department. For 19 of 22 patients (86 percent), the scar was scored by 85 percent of the assessors as excellent or good. No assessor stated that a scar was unacceptable. In the family questionnaires, 26 of 28 families (93 percent) reported an excellent scar and two (7 percent) reported a fair scar. No family stated that the scar was unacceptable. The operative notes for the 95 patients revealed that only two cysts had ruptured during the surgical procedure (2 percent) and only one infection had occurred (1 percent). No other major complications were reported. It is concluded that the direct method for dermoid cyst excision is an excellent approach, with a low complication rate and a very high aesthetic success rate, when performed through a supra-eyebrow or infra-eyebrow incision.

Anthropometric study of synostotic frontal plagiocephaly: before and after fronto-orbital advancement with correction of nasal angulation

Surgical correction of synostotic frontal plagiocephaly (unilateral coronal synostosis) focuses on the asymmetry of the forehead and orbits. However, there is controversy regarding whether nasal angulation should be addressed during primary fronto-orbital advancement in infancy. This prospective study was undertaken to answer that question. Preoperative and postoperative anthropometric measurements were obtained for 19 infants with nonsyndromic synostotic frontal plagiocephaly. The measurements included nasal angulation, nasion-to-endocanthion distance, nasion-to-exocanthion distance, and exocanthion-to-tragion distance. All patients underwent bilateral parallelogrammatic fronto-orbital correction. Closing wedge nasal ostectomy was performed for group I (n = 14) and was not performed for group II (n = 5). The average age at the time of follow-up assessments was 3 years 8 months (range, 1 to 14 years) in group I and 5 years 5 months (range, 2 to 15 years) in group II. A statistically significant change was observed for patients who underwent primary correction of nasal angulation; the change correlated with improved naso-orbital symmetry, as judged with nasion-to-endocanthion and nasion-to-exocanthion measurements (p < 0.01 and p < 0.05, respectively). Group I patients exhibited an average preoperative nasal angulation of 9.15 +/- 0.8 degrees that decreased to 3.1 +/- 0.6 degrees postoperatively (p < 0.01). Group II patients exhibited an average preoperative nasal angulation of 6.4 +/- 0.7 degrees that was unchanged postoperatively at 7.2 +/- 1 degrees. The improvement in nasal angulation in group I was particularly striking because the patients in group II exhibited, on average, a lesser degree of preoperative nasal deviation (p < 0.01). This prospective comparison of fronto-orbital correction of synostotic frontal plagiocephaly with and without nasal correction confirmed an earlier study and demonstrated that angulation of the nasal pyramid does not self-correct within 5 years after traditional bilateral fronto-orbital repair. Closing wedge nasal ostectomy results in improved nasal angulation and naso-orbital symmetry, without evidence of distortion or inhibition of nasal growth.

Imaging and surgical approach of nasal dermoids

OBJECTIVE

Determine the most accurate and cost effective radiographic evaluation for nasal dermoids. Determine the best surgical approach for excision of nasal dermoids.

DESIGN

Retrospective chart review.

SETTING

Division of Pediatric Otolaryngology, Children's Hospital and Health Center, San Diego, California.

PARTICIPANTS

All patients with nasal dermoids evaluated and treated from 1990 to 2000.

INTERVENTION

Preoperative radiographic evaluation and surgical excision.

OUTCOME MEASURES

Accuracy of CT and MRI correlated with surgical findings and results.

RESULTS

Ten patients were identified with the diagnosis of nasal dermoid. The age at diagnosis ranged from 0 to 24 months, with a mean of 3 months. Six children presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. Six children underwent a computed tomogram with contrast of the head. Seven children underwent a MRI study of the head. Three children underwent an initial CT followed by MRI. Twenty percent of children were found to have intracranial extension. CT scan accurately diagnosed intracranial extension in one case, was indeterminate in a second case and falsely positive in a third case. MRI correctly diagnosed intracranial extension in two cases and had no false positive or false negative results. No children were found to have associated intracranial anomalies. In the early years of the review, a simple excision was made over the mass with blunt and sharp dissection for removal. (An external rhinoplasty incision is now used with better exposure and improved cosmetic results.) In cases with intracranial communication, a combined approach of external rhinoplasty and craniotomy was used.

CONCLUSIONS

MRI alone is the most cost effective and accurate means of evaluating nasal dermoids and is essential for preoperative planning. The surgical approach of choice is external rhinoplasty for both cosmetic reasons and exposure of nasal dermoids with and without intracranial extension.

Nasal dermoid sinus cysts and the role of open rhinoplasty

All suspected congenital abnormalities of the nose require further evaluation. The nasal dermoid sinus cyst (NDSC) is one of the many midline nasal masses that often pose diagnostic and treatment dilemmas for the plastic and reconstructive surgeon. NDSCs are distinct from other facial dermoids in their potential for involving deeper contiguous structures, and intracranial extension. Accurate diagnosis and effective treatment are essential to avoid craniofacial skeletal deformation, cyst rupture, and infection that could cause cutaneous, ocular, or intracranial complications. A comprehensive discussion of the embryogenesis, pathogenesis, diagnosis, and surgical management of the NDSC is presented to delineate the role of open rhinoplasty in optimizing the management of this congenital nasal deformity.

Autosomal dominant familial frontonasal dermoid cysts: a mother and her identical twin daughters

A dermoid cyst is an ectodermal cyst that contains an epithelial lining as well as adnexal structures, and may occur in numerous areas of the body. The nasal dermoid accounts for 1% of all dermoid cysts and 3-12% of head and neck dermoid cysts. While there have been familial cases reported, a genetic inheritance for nasal dermoids has not been suggested. We present the first reported case of a mother and her identical twin daughters who were all found to have evidence of frontonasal dermoid cysts. Our case and a review of literature seem to implicate an autosomal dominant inheritance in certain instances of nasal dermoids.

Application of minimal-access techniques in lag screw fixation of fractures of the anterior mandible

A modification of the traditional open methods for the surgical management of anterior mandibular fractures using the principles of minimal-access surgery is presented; it was successfully performed in five patients. This technique incorporates the use of lag screws introduced through small incisions transmucosally or percutaneously after anatomic reduction of the fracture, and it relies on accurate preoperative radiologic assessment of the fracture pattern and location. This technique is indicated for any favorable fracture in the anterior mandibular arch that could achieve osteosynthesis with lag screw fixation, and it depends on the use of a dental arch bar as a tension band. Contraindications include unfavorable fracture patterns (long oblique, comminuted, or flat mandibular plane), inadequate dental support to maintain an arch bar due to missing or loose teeth, the inability to determine the fracture pattern preoperatively, and operator inexperience. Potential advantages include a shorter operative time, economic savings, decreased patient morbidity (swelling, scarring, and mental nerve and lower-lip muscle dysfunction), and improvement in functional rehabilitation.