Cranial dermal sinus: presentation, complications and management

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.

Intradural dermoid cyst with complete dermal sinus of the posterior fossa: Contribution of 3D imaging with histopathological correlation

A 5-year-old girl who presented with two episodes of meningitis, had a patchy red area and a small skin dimple in the midline of the occiput on physical examination. Imaging revealed a well-demarcated oval intradural lesion of the posterior fossa with restricted diffusion and peripheral enhancement, raising the possibility of an abscess. The 3D volume rendering of CT images of the inner surface of bone showed chronic bone remodeling and a tiny bone defect of the outer table. This detailed anatomical evaluation has an added value to MRI characteristics to orient for a preoperative diagnosis of an intradural dermoid cyst with a dermal sinus, that was confirmed by histopathological analysis after surgical excision.

Infected intracranial dermal sinus tract in a child

Dermal sinus tracts (DSTs) are rare congenital defects occurring along the cranial spinal axis. They may extend from the skin into the deeper structures of the central nervous system. While most DSTs remain clinically occult, they can provide a route of entry for skin pathogens to cause intracranial infection. We report a child with a recent history of fever of unknown etiology who presented to our emergency department with a subcutaneous occipital mass. She was ultimately diagnosed with an infected intracranial dermal sinus tract. In this report, we provide a review of the literature on the diagnosis and management of this unique entity.

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.

Brain abscess in pediatric age: a review

OBJECTIVE

The purpose of the paper is to examine the current state of the art about epidemiology, diagnosis, and treatment of this infection.

METHODS

A review of the literature was performed through a PubMed search of original articles, case reports, and reviews using the key words "brain abscess," "cerebral abscess," "brain infection," "intracranial suppuration," "otogenic brain abscess," "otitis complications," and "sinusitis complications."

RESULTS

Pediatric brain abscess is a rare but serious infection, often involving patients with specific risk factors and burdened by a high risk of morbidity and mortality. Brain abscess incidence and mortality decreased over the years, thanks to improved antibiotic therapy, new neurosurgical techniques, and the wide spread of vaccinations. There are no guidelines for the adequate diagnostic-therapeutic pathway in the management of brain abscesses; therefore, conflicting data emerge from the literature. In the future, multicentric prospective studies should be performed in order to obtain stronger evidences about brain abscesses management. Over the next few years, changes in epidemiology could be observed because of risk factors changes.

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.

Occipital intraosseous dermoid cyst with restricted diffusion on magnetic resonance imaging in a child

A 4-year-old girl presented repeatedly with a complicated occipital mass, which was erroneously treated as a pyogenic granuloma. Imaging performed before a planned surgical resection detected an underlying intraoccipital dermoid with a sinus tract to the skin surface and extension into the posterior fossa. This case highlights the value of high-resolution computed tomography imaging for depiction of anatomic details and the value of magnetic resonance imaging for differential diagnosis and surgical management. A comprehensive literature review of intraosseous dermoid cyst and detailed discussion of the differential diagnoses are provided.

Unusual Clinical Presentation and Association of Cranial Dermoid Tumor and Tethered Cord Syndrome

Tethered cord syndrome (TCS), a neurological disorder characterized by the lower settlement of the conus medullaris, is a congenital spinal disease which is caused by split cord syndrome, meningomyelocele, and spinal tumors. Cranial dermoid tumor (CDT) is a congenital benign tumor which is generally located on the midline of the cranium. Even though TCS is highly associated with spinal dermoid tumor, the relationship of CDT and TCS is unusual. We pre-sent a case with an unusual symptom of CDT, motion-dependent pain, and an uncommon togetherness with TCS.

Paucisymptomatic Dermoid Cyst with Fatal Outcome

Dermoid cysts of the central nervous system can cause devastating complications because of the mass effect of meningitis due to sinus tract. We report the case of a 5-month-old girl who presented with a crusted lesion of the occipital region of the scalp. Clinical examination noted skin abnormalities suggestive of occult dysraphism. Magnetic resonance imaging (MRI) was recommended, however, 40 days after this evaluation, and before the MRI could be performed, the girl presented with neurologic complications. Unfortunately, the diagnosis of dermoid cyst was made after the onset of severe complications that led to her death. The findings in this case emphasize the importance of more prompt MRI evaluation, particularly in cases where cranial or spinal dysraphism is suspected to have any connection to the skin as a pit or tract. Should we perform an urgent MRI for any cutaneous sign of dysraphism to avoid a dramatic evolution?

Posterior fossa infected dermoid with congenital heart disease: A novel hypothesis of an unusual association

Intracranial dermoid cysts commonly present as a discharging sinus, local swelling, mass lesion, or abscess formation. These can sometimes be found in association with congenital anomalies. The author presents two original cases of infected posterior fossa dermoid associated with congenital heart diseases (CHDs) that is very rare. The embryologic basis for this unique occurrence is reviewed, and a new hypothesis proposed. Two infants with CHD presented with infected midline posterior fossa dermoid. Excision of the dermoid cyst with the sinus tract was performed. Postoperative period was uneventful. Both the infants had undergone surgery for congenial heart disease a few months prior to the present clinical presentation with uneventful recovery. Infected posterior fossa dermoid cyst without a discharging sinus should prompt a thorough examination to detect CHD. Early diagnosis and timely management results in better outcome.

Are mothers always right? When acute meningitis is something more

A 22-month-old girl with a history of a congenital occipital cutaneous cyst was brought to the paediatric emergency department for lethargy and occipital headache. She had been discharged 5 days before for acute meningitis without bacterial isolates. At physical observation, she presented with irritability and neck hyperextension, with negative meningeal signs. CT scan revealed a vermian cyst and hydrocephalus. She was submitted to neurosurgery with removal of an infected midline dermoid cyst with a fistulous track to the skin. Surgery was successful and without complications. During follow-up, the child was asymptomatic with normal psychomotor development.

[Recurrent meningitis due to anatomical defects: The bacteria indicates its origin]

INTRODUCTION

Recurrent meningitis is a rare disease. Anatomical abnormalities and immunodeficiency states are predisposing factors. Four cases, in which immunodeficiency was excluded, are presented. The causal microorganism led to the detection of the anatomical defect responsible for the recurrences.

PATIENTS AND METHODS

Retrospective review of 4 cases with clinical diagnosis of recurrent bacterial meningitis.

RESULTS

Case 1: a thirty month-old boy with unilateral hearing loss, diagnosed with Mondini abnormality by magnetic resonance imaging (MRI) after 2 episodes of Haemophilus influenzae meningitis. Surgical repair after third recurrence. Case 2: fourteen year-old girl diagnosed by MRI with cribriform plate defect after 3 episodes of meningitis due to Streptococcus pneumoniae. Ventriculoperitoneal shunt was placed. Case 3: girl with meningitis due to Staphylococcus aureus at 2 and 7 months. MRI shows occipital dermal sinus requiring excision. Complication with cerebellar abscesses because of a coexisting dermoid cyst. Case 4: child with meningitis due to Streptococcus bovis at 9 days and Enterococcus faecium, Klebsiella pneumoniae and Escherichia coli at 7 months, with positive cultures to Citrobacter freundii and E. faecium later on. Spinal MRI led to the diagnosis of Currarino syndrome with CSF fistula, which was surgically repaired. The 4 patients had undergone image studies reported as normal during the first episodes.

CONCLUSIONS

In patients with recurrent meningitis the possibility of an anatomical defect should be considered. The isolated microorganism should help to locate it. It is essential to know the normal flora of the different anatomical sites. The definitive treatment is usually surgical.