Recurrent giant orbital dermoid of infancy

Giant Deep Orbital Dermoid Cyst Presenting in Infancy

ABSTRACT

Orbital dermoid cysts are benign choristomas that are very common in children and occur most often as a lateral or medial mass associated with the frontozygomatic or frontoethmoidal suture line. The authors present an unusual case of an occult giant deep orbital dermoid cyst in infancy that initially presented with a small, benign appearance and central upper eyelid location on clinical exam. Orbitotomy with complete excision prevented further ocular sequelae in this 11-month-old.

A giant dermoid cyst of the orbit

To describe a unique case of a non-germinomatous germ cell tumor, a giant orbital dermoid, present in adulthood. A 31-year-old male presented in our clinic with gradual, painless, progressive proptosis in the left eye since 28 years associated with gradual loss of vision. The left eye showed gross proptosis. Ocular structures could not be made out. Computed tomography scan showed a well-circumscribed oval heterogeneous mixed solid and cystic lesion completely filling the left orbit with calcification. The differential diagnosis was that of either teratoma or optic nerve glioma. The patient underwent excision of the lesion. Histopathology revealed a capsulated tumor with multiple cystic components filled with blood and eosinophilic material suggestive of a dermoid cyst. Non-germinomatous germ cell tumors may present atypically in adults and neglected benign dermoid cysts can attain massive size mimicking malignant lesions.

Dermoid cysts: clinical predictors of complex lesions and surgical complications

PURPOSE

To evaluate the clinical characteristics and role of imaging in the evaluation of dermoid cysts and to determine predictors of cyst rupture during surgical excision of dermoid cysts.

METHODS

In this single-center, consecutive, nonrandomized comparative case series, the records of consecutive patients with suspected dermoid cysts who underwent surgery between January 1, 2000, and December 31, 2014, were reviewed retrospectively for demographic information, clinical findings, preoperative imaging, surgical details, and pathology reports.

RESULTS

A total of 100 patients were included. Cyst volume was similar between superomedial and superotemporal lesions (P = 0.61) but greater in patients >10 years of age (P < 0.001). Immobility of the cyst was present in all complex dermoids (4/4), but there was no difference in the mobility of superotemporal or superomedial cysts (P = 0.69). Forty-two patients underwent imaging; superomedial lesions were more likely to be imaged than superotemporal lesions (P = 0.073). All 4 patients with complex dermoids presented with orbital signs and underwent preoperative imaging. None of the remaining 38 patients who underwent imaging had orbital signs, and the results of imaging had no effect on surgical planning. Intraoperative cyst rupture occurred in 18 patients. There was no significant difference in cyst rupture between superotemporal and superomedial cysts (P = 0.452). Smaller cyst volume was associated more often with intraoperative cyst rupture (P < 0.001).

CONCLUSIONS

Preoperative imaging of superomedial and superolateral dermoid cysts is likely unnecessary unless associated with orbital signs. Intraoperative cyst rupture is not influenced by cyst location but does appear to be more likely in smaller cysts.

[Intraorbital dermoid cyst. Case report and review of the literature]

Periorbital dermoid cysts are benign tumors most often seen in young children. Intraorbital location, though rare, should not be overlooked. Good quality imaging plays a major role in the etiological diagnosis, providing a precise analysis of the location of the lesion, its components, and its effects on adjacent and nearby structures, as well as in planning the surgical approach. The authors report a case of a 46-year-old male with an intraorbital dermoid cyst presenting with progressive left proptosis. Appearance on imaging (CT and MRI) was consistent with intraorbital dermoid cyst. The tumor was extirpated. Histopathologic examination confirmed the diagnosis of dermoid cyst. We also present a review of the literature.

Orbital Dermoids in Children

Orbital dermoid cysts are benign congenital choristomas. They are common in pediatric population, developing adjacent to suture lines, most commonly located in antero-lateral fronto-zygomatic suture, and are slowly progressive. Complete surgical excision without rupture of cyst is the standard of care. Deep orbital cysts cause proptosis, require imaging, and may present a surgical challenge with a difficult approach. Rupture of the cyst leads to severe inflammatory reaction in surrounding tissues. Overall prognosis remains good with isolated reports of malignancy masquerading as dermoid cysts.

Orbital cysts of childhood—classification, clinical features, and management

There is little in the literature about the clinical spectrum of orbital cysts of childhood and no comprehensive classification has been proposed. The authors propose a classification of orbital cysts of childhood and review their clinical features, pathology, and management. The major categories in the classification include cysts of surface epithelium, teratomatous cysts, neural cysts, secondary cysts, inflammatory cysts, and noncystic lesions with cystic component. Cysts of the surface epithelium are further divided into simple epithelial cyst (epidermal, conjunctival, respiratory, and apocrine gland), and dermoid cyst (epidermal and conjunctival). Epidermal dermoid cyst (dermoid) is by far the most common orbital cystic lesion in children, accounting for over 40% of all orbital lesions of childhood and for 89% of all orbital cystic lesions of childhood that come to biopsy or surgical removal. Neural cysts include those associated with ocular maldevelopment (congenital cystic eye and colobomatous cyst) and those associated with brain and meningeal tissue (cephalocele and optic nerve meningocele). The most important secondary cyst is mucocele that can occur in children with cystic fibrosis. Inflammatory cysts are generally due to parasitic infestations and are more common in tropical areas of the world. Noncystic lesions that can have a cystic component include adenoid cystic carcinoma, rhabdomyosarcoma, lymphangioma, and others. Each type of cyst has rather characteristic, but not pathognomonic, clinical features. Computed tomography and magnetic resonance imaging can help differentiate a cystic lesion from a solid tumor, suggest the type of cyst, and help in planning management. The pathology varies with the cells that line the cyst and with the inflammatory agent. Management varies from local excision to observation, depending on the location and type of cyst. Orbital cysts of childhood can be classified into categories, based mainly on their histopathology. The clinical, radiologic, and histopathologic features can be correlated with the classification in order to better evaluate a child with a cystic lesion in the orbit.

Risk factors associated with complications of orbital surgery in children

PURPOSE

To assess the overall complication rate of orbitotomies performed in children and to determine the nature of complication to identify possible risk factors.

METHODS

Thirty children <13 years underwent 33 orbitotomies for space-occupying lesions of the orbit or orbital decompression. A detailed evaluation of the surgical procedures and outcomes was conducted. Follow up averaged 2.5 years (range: 6 months to 5 years).

RESULTS

The complication rate was 20% (2 of 10 cases) for anterior orbitotomies, 40% (8 of 20 cases) for primary lateral orbitotomies, and 100% (3 of 3 cases) for secondary orbitotomies. Dense amblyopia was noted in 6 of 9 patients. Major complications were frozen eyeball, diplopia, and ptosis. Less serious complications were enophthalmos, internal ophthalmoplegia, dry eye, and eyelid retraction. Six patients underwent extraocular surgery, levator muscle surgery, or both at a later date.

CONCLUSION

Although the scope of complications is the same in children as in adults, the frequency of cystic benign lesions and small orbits in children can cause more frequent serious complications. Additionally, dense amblyopia of a complicated nature makes visual outcome unpredictable. The most significant risk factors identified were the need for a secondary procedure for recurring pathology and the presence of an intraconal lesion.