Be careful: it might be a nasal dermoid cyst

Management of a Rare Case of Central Nasal Dermoid Cyst Deformity in an Adult Patient

Congenital nasal dermoid and sinus cysts (NDSCs) are rare congenital deformities with a prevalence rate of 0.005% to 0.0025%. Early diagnosis is usually made during the first three years of life, but in some cases, the diagnosis may be delayed. The present case study elaborates the treatment course of a 22-year-old adult with a rare congenital nasal midline dermoid cyst. The patient had no family history of the deformity, and intracranial extensions were also ruled out before surgery. Open rhinoplasty technique was used along with osteotomies during the surgical process. The cyst was removed in entirety. The total operating time was six hours, and no complications were observed during the intra-operative or post-operative period. In conclusion, the case presentation focuses on various techniques and methods that can be used during surgery that have not been practiced before to correct the deformity while achieving a good aesthetic result as well.

Midline nasofrontal dermoids in children: A review of 29 cases managed at Mansoura University Hospitals

OBJECTIVES

Nasal dermoids are congenital anomalies constituting 3.7-12.6% of dermoids in the head and neck. Most of lesions are superficial but there is always a risk that it may end blindly within the deep structures of the nose or extend intracranially. Complete excision, regardless of extension, is essential and must be balanced against cosmoses. This study reviews the clinical characteristics and imaging findings as well as the appropriate surgical approach adopted for 29 cases managed at Mansoura University Hospitals.

METHODS

A retrospective analysis was performed in 29 patients admitted for management of nasal dermoid between Jan 2001 and Jan 2015 at the Otolaryngology department of our tertiary referral university hospital. Recorded data included patient's demographics, complaint, lesion's site, pre-operative radiological findings, surgical technique, intra-operative findings, and post-operative squeal.

RESULTS

This series included 12 (41%) female and 17 (59%) male children, with a mean age of 2.5 years. Twenty seven children presented with a nasofrontal swelling of which 20 had an apparent sinus. Other presentations included a swelling in the inner canthum (1), nasal tip and columella (1). Nine (31%) patients had a history of infection and two patients gave a positive history of meningitis. Intracranial extradural extension was identified in 10 patients (34.5%) during preoperative imaging. Surgical modalities included local excision and direct closure (12), open rhinoplasty (7), bicoronal excision and craniotomy (10). In 9 cases, the tract was adherent to the dura but was carefully dissected and in one case resection required excision of a segment of dura and reconstruction. In a follow up period of 1-8 years, recurrence was detected in one case and the cosmetic results were satisfactory.

CONCLUSIONS

Those lesions are rare and require early precise surgical planning to achieve complete en bloc excision. This study reports a low morbidity associated with management of nasal dermoids with intracranial extension.

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 dermoids in children: a proposal for a new classification based on 103 cases at Great Ormond Street Hospital

OBJECTIVES

Nasal dermoids are rare developmental anomalies seen in children. This study reports the largest case series of 103 patients seen in a quaternary specialist unit over a 10-year period. We report the surgical and radiological findings and propose a new classification system, which clearly describes the extent of the lesions, thus allowing better surgical planning.

METHODS

A retrospective review of case notes was conducted. Data collection included demographics, initial presentation, site of lesion, pre-operative CT and MRI imaging, surgical procedure, intraoperative findings (including depth of lesion), complications and recurrence. Surgical findings were correlated with radiological findings.

RESULTS

A total of 103 patients were included in the study. The mean age at presentation was 29 months. 89% of children presented with a naso-glabellar or columellar lesion and 11% had a medial canthal lesion. All the patients underwent preoperative imaging and were treated with surgical excision. 58 children had superficial lesions, 45 had subcutaneous tracts extending to varying depths. Of these, 38 had intraosseous extension into the frontonasal bones, eight extended intracranially but remained extradural and two had intradural extension. There was good correlation between radiological and surgical findings. The superficial lesions were locally excised. The lesions with intraosseous tracts were removed via open rhinoplasty and the frontonasal bones drilled for access. Intracranial extension was approached either via a bicoronal flap and frontal craniotomy or the less invasive anterior small window craniotomy.

CONCLUSIONS

This report describes the largest published cases series of nasal dermoids. The cases demonstrate the presenting features and the variable extent of the lesions. The new proposed classification; superficial, intraosseous, intracranial extradural and intracranial intradural, allows precise surgical planning. In the presence of intracranial extension, the low morbidity technique of using a brow incision and small window anterior craniotomy avoids the more invasive and commonly used bicoronal flap and frontal craniotomy.

Midline nasal dermoid cyst with Tessier's 0 cleft

This is a rare anomaly of midline nasal dermoid cyst (NDC) along with Tessier's 0 cleft. Midline NDCs present most commonly result from aberrant embryological development, and most commonly give rise to bifid nasal deformity resulting in midline cleft of the nose. Craniofacial clefts are among the most disfiguring of all facial anomalies. They exist in a multitude of patterns and with varying degrees of severity. The bifid nose deformity is generally an indicator of Tessier number 0 cleft. We present a rare combination of midline NDC with a mild Tessier's 0 cleft in a 4-year-old female child who was surgically treated with wide emphasis given on its diagnosis and other treatment modalities.

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.

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.

The managament of rare nasal mass-nasal dermoid sinus cysts: open rhinoplasty

The differential diagnosis of midline nasal masses includes inflammatory lesions, post-traumatic deformities, benign neoplasms, malignant neoplasms, congenital and vascular masses. Midline congenital lesions of the nose are rare congenital anomalies. Their incidence is estimated at 1 per 20,000 to 40,000 births consisting of gliomas, encephaloceles, and nasal dermoid sinus cysts. Nasal dermoid sinus cysts account for 1–3% of dermoid cysts overall and 11–12% of head and neck dermoids. Most lesions are diagnosed within the first three years of life but in some cases the diagnosis can be prolonged. We present an 18-year old and a two and a half-year old male patients who are concerned about drainage from the tip of the nose with recurrent infection and operated with a diagnosis of nasal dermoid sinus cyst.

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.