Orbital dermoid cyst and sinus tract presenting with acute infection

A Unique Case of Frontotemporal Dermoid Cyst Presenting as Orbital Cellulitis

Dermoid cysts are benign developmental anomalies that can occur anywhere along the neuroaxis or embryonic lines of fusion. While intracranial dermoid cysts at the midline frequently have an associated nasal or subcutaneous sinus tract, it is quite rare to encounter an intracranial dermoid cyst off the midline with a lateral sinus tract. Standard practice for the treatment of dermoid cysts is surgical resection to minimize the risks of meningitis, abscess, mass effect, neurologic deficit, and/or death.  A 3-year-old male with a history of DiGeorge syndrome presented with right orbital cellulitis and a right-sided dermal pit. Computed Tomography (CT) imaging demonstrated a dermal sinus tract with an associated lytic bone lesion within the right sphenoid wing and posterolateral orbital wall with intracranial extension. The patient was taken to the operating room in conjunction with plastic surgery for resection of the dermal sinus tract and intraosseous dermoid.  This case presents a rare occurrence of a non-midline, frontotemporal dermal sinus tract associated with a dermoid cyst with intracranial extension presenting with pre- and post-septal orbital cellulitis. Important considerations include preservation of the frontal branch of the facial nerve, preservation of orbital structure and volume, complete surgical resection to prevent infectious complications including meningitis, and a multidisciplinary surgical approach with plastic surgery, ophthalmology, and/or otolaryngology.

Spheno-Orbital Dermoid Masquerading as Recurrent Orbital Abscess

A 10-month-old girl presented with eyelid edema and erythema that did not improve with systemic antibiotics. Due to a lack of improvement, MRI was performed to avoid ionizing radiation from CT. An orbital abscess was recognized and drained. However, the abscess recurred 2 times. CT scan was performed and a tract in the sphenoid bone helped to diagnose a congenital dural sinus tract with dermoid. Definitive surgery was performed with neurosurgery to remove the entire tract including cutaneous connection. CT scan proved critical to diagnosis and should be considered in infants in select cases despite the concern for ionizing radiation in this vulnerable age group.

Sphenofrontal intradiploic dermoid cyst with cutaneous dermal sinus tract

We report the case of a 5-year-old boy who presented with a draining cutaneous pit temporal to the lateral canthus, with recurrent periorbital infections. MRI and CT revealed a sinus tract leading from the pit at the skin surface to a 5 mm lesion located in the sphenoid bone near the left sphenofrontal suture. Intraoperative facial nerve monitoring and a lacrimal probe inside the sinus tract were used to guide dissection to the cyst through a minimally invasive temporal approach, without need for neurosurgical intervention.

Frontotemporal dermoid cyst with incomplete dermal sinus tract in an adult: A case report

Background

Non-midline supratentorial dermoid cyst with dermal sinus tract has been rarely reported especially in adults. We recently experienced a noteworthy patient with frontotemporal dermoid cyst with incomplete dermal sinus tract.

Case Description

A 43-year-old female presented with recurrent subcutaneous mass in the left superolateral orbital region. She had a history of active bronchial asthma, which precluded her from contrast-enhanced imaging studies. Plain imaging studies showed a subcutaneous mass which was continuous with an intrasylvian fissure mass by a tract in the sphenoid ridge and the lesser wing of the sphenoid bone. Frontotemporal craniotomy was performed to reset the mass and the tract. Intraoperative finding showed no intradural tumor components. Extradural component was carefully removed focusing attention on the frontal branch of the facial nerve. The pathology was consistent with dermoid cyst and dermal sinus tract. Postoperatively, she had mild facial palsy of the corrugator supercilii (House and Brackmann Grade II). She was discharged home with modified Rankin scale 1.

Conclusion

Dermoid cyst needs to be included in the differential diagnosis of adult-onset subcutaneous mass in the frontotemporal regions. After thorough imaging studies for the presence and extent of the sinus tract, the symptomatic lesion should be excised completely once and for all.

Congenital Dermal Facial Temporal Sinus: Rare Presentation of Intraorbital Dermoid in Children

We present a rare case of an intraorbital dermoid which was associated with a small temporal region dermal sinus in a 3-year-old child. This got infected and the child presented with orbital cellulitis. Definitive surgery involved excision of all the dermal elements using a superficial and intraorbital approach. We stress the need to evaluate, apparently benign lateral facial dermal sinuses as they may be the pointers of the underlying pathological deep dermoid cysts to avoid complications.

The spectrum of orbital dermoid cysts and their surgical management

PURPOSE

The purpose of this study is to describe a spectrum of surgical approaches to orbital dermoid cysts, influenced by the anatomic location of the expanded cyst wall and other factors.

METHODS

In this retrospective case series, we reviewed cases of dermoid cysts surgically excised during a 39-year period (1977-2016). Cysts were categorized according to the location of the expanded cyst wall and other considerations. The impact of these factors on surgical management was determined.

RESULTS

We identified six dermoid cyst growth patterns based on the anatomic location of the expanded cyst wall that influence the surgical approach: anterior to the frontozygomatic suture (FZS), superior to the FZS, medial to the FZS and other lateral wall sutures, traversing the FZS and other lateral wall sutures, nasoglabellar, and sinus tract from the orbit to the skin. Two additional factors influencing surgical methodology included satellite inflammatory pseudocysts and recurrence after surgical resection.

CONCLUSION

Orbital dermoid cysts are not monolithic lesions. Functional and aesthetic outcomes can benefit from considering the anatomic pattern of cyst wall expansion and other factors in their surgical management.

Frontotemporal Dermal Sinus Tract with 2 Connected Intradiploic Dermoid Cysts: A Rare Case and Review of the Literature

BACKGROUND

Frontotemporal dermal sinus tracts with associated dermoid cysts are very rare, with only 1 found in the largest series to date and 10 total documented case reports.

CASE DESCRIPTION

We present the first case to our knowledge of a dermal sinus tract associated with 2 intradiploic dermoid cysts in the rare location of the pterion and sphenosquamosal suture. The patient was a 15-month-old girl presenting with periorbital cellulitis who was found to have 2 connected intradiploic cysts on radiographic imaging. The mass was excised, and pathology was consistent with a ruptured dermoid cyst.

CONCLUSIONS

We review of the literature and argue for early identification and prophylactic surgical resection to avoid complications associated with infection and to mitigate risk of subtotal resection.

Orbital dermoid cyst presenting as chronic osteomyelitis

A dermoid cyst is a choristoma that arises from the displacement of ectoderm to a subcutaneous location along embryonic closure lines. Rarely dermoids have a deep intraorbital component that is connected to a superficial component through a defect in bone, also known as dumbbell dermoid. We report the case of a young boy who was misdiagnosed having chronic osteomyelitis of the zygoma, based on the clinical and radiological features. On surgical exploration he was found to have a dumbbell-shaped dermoid with a bony defect. Histopathological features were consistent with a diagnosis of dermoid cyst with chronic inflammation.

Infected Nasal Dermoid Cyst/Sinus Tract Presenting With Bilateral Subperiosteal Supraorbital Abscesses: The Midline Nasal Tuft of Hair, an Overlooked Finding

This case is, to the authors' knowledge, the first reported case in the literature of bilateral orbital abscesses as result of an infected nasal dermoid. The baby presented with what proved to be bilateral supraorbital subperiosteal abscesses with associated frontal osteitis/osteomyelitis and soft tissue infection of the glabella. Methicillin-sensitive staphylococcus aureus infection was found in the setting of a midline nasal dermoid with tuft of hair and infected sinus tract that was at least initially missed on diagnosis.

Diagnosis and treatment of pediatric frontotemporal pits: report of 2 cases

In contrast to more common nasal and cervical lesions, the frontotemporal pit is a rarely encountered lesion that is often associated with a dermoid and may track intracranially. Due to delays in diagnosis, the propensity to spread intracranially, and the risk of infection, awareness of these lesions and appropriate diagnosis and management are important. The authors present 2 cases of frontotemporal pits from a single institution. Epidemiology, presentation, and management recommendations are discussed.

Ectopic cilia associated with an orbital dermoid cyst and sinus tract: case report

Ectopic cilia are extremely rare congenital anomalies in which eyelash follicles appear in an abnormal place on the eyelid, most typically on the lateral quadrant of the anterior surface of the upper eyelid. In the majority of cases, simple surgical excision of ectopic cilia is indicated because of its cosmetic aspect. There is usually no associated medical co-morbidity with this anomaly. The authors report an unusual case of ectopic cilia associated with an orbital dermoid cyst and sinus tract. A 3-year-old boy was initially diagnosed with ectopic cilia on the left upper eyelid. There was no history of inflammation or swelling of the eyelid. An ophthalmological examination revealed only 1 mm of ptosis; no proptosis, inferior displacement, or palpable orbital mass was present. During surgical excision of the ectopic cilia, a thin sinus tract was identified, leading posteriorly to the orbit. Magnetic resonance imaging performed after the excision showed a supraorbital extraconal mass just below the roof of the left orbit. A supraorbital 2-piece craniotomy was performed with total extirpation of the dermoid cyst. The cyst was removed en bloc without damage to the extraocular muscles, but the sinus tract could no longer be identified. Follow-up MRI was performed 6 months after surgery and showed no evidence of recurrence. A follow-up ophthalmological examination showed no signs of inferior displacement or proptosis. To the best of the authors' knowledge, this case is the first reported instance of ectopic cilia associated with a dermoid cyst and sinus tract in which no typical clinical signs and symptoms of possible orbital pathology were present. This case highlights the value of radiological examination in all cases of ectopic cilia prior to surgical excision.

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.

A clinical update and radiologic review of pediatric orbital and ocular tumors

While pediatric orbital tumors are most often managed in tertiary care centers, clinicians should be aware of the signs of intraocular and orbital neoplasms. In the pediatric population, a delay in diagnosis of orbital and intraocular lesions, even if benign, can lead to vision loss and deformity. Intraocular lesions reviewed are retinoblastoma, medulloepithelioma, and retinal astrocytic hamartoma. Orbital neoplasms reviewed are rhabdomyosarcoma, neuroblastoma metastases, optic pathway glioma, plexiform neurofibroma, leukemia, lymphoprolipherative disease, orbital inflammatory syndrome, dermoid and epidermoid inclusion cysts, and Langerhans' cell histiocytosis. Vascular lesions reviewed are infantile hemangioma and venous lymphatic malformation. In conjunction with clinical examination, high-resolution ophthalmic imaging and radiologic imaging play an important role in making a diagnosis and differentiating between benign and likely malignant processes. The radiologic imaging characteristics of these lesions will be discussed to facilitate prompt diagnosis and treatment. The current treatment modalities and management of tumors will also be reviewed.

Beware frontotemporal dermoids - they may have intracranial extension: a case of a middle cranial fossa cyst

Congenital orbitofacial dermoid cysts are epithelial lined structures of ectodermal origin that may be associated with sinus tracts and variable deep extension. Midline lesions may extend intracranially, while lateral lesions are thought never to do so. Consequently only midline lesions are usually imaged prior to surgery. We describe a lateral dermoid sinus communicating with an intracerebral dermoid cyst within the middle cranial fossa in a 3 year-old with recurrent periorbital cellulitis and intermittent discharge from a small pimple in the temporal region. This case demonstrates that some lateral "dermoids" need to be treated with more caution if there are unusual features such as dimpling, discharge of material or recurrent wider infection, and preoperative imaging should be carried out to exclude intracranial extension.

Neuroimaging findings in a child with dumbbell-shaped frontosphenoidal dermoid cyst presenting as preseptal cellulitis

We report the CT and MRI findings in a 5-year-old girl with histologically proven frontosphenoidal dumbbell-shaped dermoid cyst with sinus tracts in the frontal bone extending to the dura. Although the most common location for dermoid cyst in the head and neck is at the frontosphenoidal region, presentation with a tract extending deep to underlying bone or the intracranium is rare for this location. Complete surgical excision has been widely accepted as the basic treatment for dermoid cyst. However, the relatively extensive nature of such surgical interventions may be associated with serious risks to both visual acuity and cosmesis. From a clinical viewpoint, even if these are rare cases, radiological imaging is crucial for orienting the deeper extension of the lesion for presurgical planning.

Orbital Dermoid Cyst Presenting with a Discharging Sinus Tract

This report describes a case of orbital dermoid cyst presenting with a discharging sinus tract. The embryologic basis for orbital dermoids in general is discussed, as well as their typical presentation and management. In the current case, patient presentation and management were somewhat different because of signs of infection and a communicating sinus tract, both highly unusual for orbital dermoids. However, after complete excision of the dermoid and sinus tract, the patient showed complete recovery.

Orbital inflammatory disease: a diagnostic and therapeutic challenge

The spectrum of orbital inflammatory disease (OID) ranges broadly from specific disease diagnoses, for example, Wegener's granulomatosis or sarcoidosis, to nonspecific inflammation which may involve one or multiple structures of the orbit. Mimics of idiopathic OID must be considered in a comprehensive differential diagnosis and include malignancies, congenital mass lesions, infectious diseases, and occult or distant trauma. Idiopathic OID may be secondary to an underlying systemic inflammatory disease, which must be diagnosed in order to develop a comprehensive therapeutic plan, or may represent localized pathologic processes without systemic involvement. Evaluation of the patient with suspected OID must include a careful history, physical examination, directed laboratory, and radiologic studies, and may sometimes require tissue for diagnostic studies. Therapeutic options for inflammatory diseases are expanding as biologically targeted agents become available that act on specific segments of the inflammatory cascades. The purpose of this paper is to provide a framework for the evaluation and management of patients with the spectrum of diseases known as OID and to discuss some of the new advances in immunologic monitoring and targeted immune therapies that will likely play an increasingly important role in the care of these patients.

Magnetic resonance imaging of orbital tumors

This contribution provides an overview of diseases of eye and orbit and their appearance on magnetic resonance imaging. In recent years the diagnosis of eye and orbit pathology has profited significantly from increasingly sophisticated technical developments in the field of tomographic methods. Due to the small size of the examination area the improvement in spatial resolution and soft tissue contrast leads to an increase in image quality. In most clinical questions concerning eye and orbit pathologies magnetic resonance imaging is superior to computed tomography and should be early performed.