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

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.

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.

Diagnosis and treatment of congenital nasal dermoid and sinus cysts in 11 infants: A consort compliant study

There have been few studies on congenital nasal dermoid and sinus cysts (NDSCs) in infants.This study was performed to obtain clinical data for the diagnosis and treatment of NDSCs in infants.We performed a retrospective analysis of 11 infants admitted with NDSCs between 2014 and 2019. Patient demographics, lesion site, preoperative radiological findings, surgical technique, intraoperative findings, and postoperative sequelae were analyzed.In total, 11 infants (average age, 19 months; lowest age, 10 months) were included in this study. All patients presented with a nasal root mass, 2 patients also had nasal tip fistula, and only 1 case had a history of preoperative infection. Preoperative enhanced computed tomography (CT) examination showed nasal surface lesion (type I) in 3, nasal intraosseous (type II) in 5, intracranial epidural (type III) in 2, and intracranial dural (type IV) in 1 patient. The main surgical methods included direct resection with a vertical midline incision (9 patients), vertical incision + transnasal endoscopic resection + skull base repair (1 patient), and transverse incision of the lower margin of the left eyebrow (1 patient). All wounds healed well without serious complications.Using the 4-type classification method in combination with the preoperative CT findings to analyze the extent of NDSC in infants is helpful for formulating the surgical plan. Using vertical incision approach alone or combined with nasal endoscopy for minimally invasive surgery can meet the needs of complete resection and reconstruction.Our results provide clinical data that can help establish standardized criteria for the diagnosis and treatment of NDSCs in infants.

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.

Nasal dermoid cyst with intracranial extension in a cat

Case summary

An 11-month-old female neutered Ragdoll cat was presented for focal seizures, aggression and altered behaviour. A diagnosis of a nasal dermoid cyst with intracranial extension was made following MRI, cytology and histopathology. The cyst was surgically excised with a resolution of clinical signs, with the exception of ongoing seizure activity requiring anti-seizure medication.

Relevance and novel information

To our knowledge, this is the first reported case of a nasal dermoid cyst in a cat, and the first reported case in the veterinary literature of any species with a nasal dermoid cyst presenting with neurological signs.

Endoscope-assisted nasal dermoid excision with an open rhinoplasty approach

Congenital midline nasal masses have been traditionally excised through rhinotomies and bicoronal incisions. These approaches are disfiguring and potentially morbid, leading pediatric otolaryngologists to seek out less invasive, endoscopic-assisted approaches. Here we present a nasal dermoid excised with a minimally invasive, endoscopic assisted open rhinoplasty approach. The preoperative workup as well as perioperative steps for excision are documented, with the hope that this will assist other practitioners with this approach. An endoscopic open rhinoplasty technique affords excellent visualisation, with a superior cosmetic outcome. A preoperative MRI is essential to ensure the lesion is amenable to this approach.