Congenital Epidermoid Cyst Presenting as Isolated Painful Trigeminal Neuropathy: Indications for Neuroimaging in the Diagnostic Process

This article reports a case of a cerebellopontine angle epidermoid cyst presenting as isolated painful trigeminal neuropathy. The indolent nature of these uncommon benign tumors leads to frequent delays in their presentation and diagnosis, with patients often initially undergoing dental procedures. This is illustrated in the present case reported here, which highlights the difficulties in identifying trigeminal neuralgia (TN), particularly in its early phases, and supports current recommendations for routine neuroimaging in suspected cases of painful trigeminal neuropathy, which, unlike classic TN, is caused by a disorder other than neurovascular compression (even in the absence of additional neurologic symptoms or signs) and is present particularly in younger patients with atypical features. Additionally, this case report offers a unique patient perspective of living with TN, with a detailed description by one of the authors of the nature of the pain and its impact.

Scrotal pearl is not always a sign of anorectal malformation: median raphe cyst

Pearls of meconium can be seen on the raphe of the scrotum and are considered as a sign of anorectal malformation (ARM). Scrotal pearls without ARM are rare in children and designated as median raphe cyst of the scrotum (MRC). A six-month-old boy with scrotal pearls without ARM is presented to discuss the clinical features and treatment modalities of MRC in infants.

A midline cyst containing clear fluid in an infant and review of management

A 3-month-old healthy girl had a cyst present from birth, located in the midline, in the area of the anterior fontanel. A magnetic resonance imaging was performed at age 7 months, which did not show communication between the cyst and the central nervous system. At a subsequent examination, while the cyst was being probed, it broke and expressed clear fluid. The cyst was subsequently removed surgically and was found histopathologically to be an epidermal inclusion cyst without communication with the central nervous system. Epidermal inclusion cysts very rarely occur on the midline in the area of the anterior fontanel, and none have been reported to contain clear fluid. Their proper management requires focused clinical assessment, noninvasive imaging, and consideration of surgical removal, in particular, if they communicate with the intracranial space.

Congenital inclusion cyst of the subgaleal space: a case report

BACKGROUND

Subgaleal cysts are epidermal cysts located under the galea aponeurotica. They are rare lesions but are commoner among the children of African descent. To the authors knowledge, none has been described in Kano, Northwestern, Nigeria.

METHODS

We present the management of a 6 month old Nigerian boy with scalp swelling.

RESULT

The scalp swelling was noticed soon after birth and was progressively increasing in size. There was no preceding fever or trauma to the scalp and no associated pain. At six months, the child could sit without support and had attained adequate neck control. Examination revealed a swelling over the anterior fontanelle, measuring 3x2cm. The swelling was hemispherical, firm, fluctuant, and non-tender. It was not pulsatile. Its size did not increase on crying. Diagnosis was confirmed by plain x-ray film and transfontanelle sonography. Total excision of the mass was carried out under general anesthesia and histology confirmed the diagnosis of epidermal inclusion cyst. The child was discharged home in good condition.

CONCLUSION

Awareness of this lesion will avoid misdiagnosis and inappropriate treatment.

Partial laparoscopic decapsulation of congenital splenic cysts. A medium-term evaluation proves the efficiency in children

BACKGROUND

In children, laparoscopic decapsulation of large congenital splenic cysts has occasionally been advocated, but substantial series focusing on its long-term success are still lacking. We report the follow-up experiences from two pediatric surgical centers.

METHODS

The decision to proceed to surgery was based on patient symptoms and cyst size (>4 cm and/or progression), after strictly exclusion of a parasitic cause (by serology and CT scan). With the use of three ports (5-10-mm) and a Harmonic Scalpel, the epithelial portion of the cyst was radically excised. The remaining hilar epithelium was coagulated carefully. After discharge, the children were examined regularly by ultrasound to detect recurrences.

RESULTS

From 1998 until 2002, eight children (mean age, 11.1 years; range, 3.1-16.4) were treated for cysts ranging from 4 to 15 cm in diameter. All procedures were completed without significant intraoperative complications (no major bleeding, no conversions). The mean operating time was 75 min (range, 56-184). Postoperatively, one child developed a cystic remnant (2 cm), which remained unchanged during 30 months of observation. After a mean follow-up of 2.2 years (range, 13-38 months), none of the patients showed any evidence of recurrent growth, and all of them had healthy splenic remnants.

CONCLUSION

Partial laparoscopic decapsulation is an advantageous approach to large splenic cysts in children, because it is effective, preserves splenic tissue, and provides good medium-term results.

MR imaging for evaluation of lesions of the cranial vault: a pictorial essay

PURPOSE

A variety of diseases affect the calvaria. They may be identified clinically as palpable masses or incidentally in radiologic examinations. There are many diagnostic possibilities, including congenital, neoplastic, inflammatory and traumatic lesions. The purpose of this study is to illustrate the main calvarial lesions through MR imaging, their signal intensity and extension to neighboring sites.

METHOD

A retrospective analysis of 81 cases, from November 1996 to July 2001, was conducted. The examinations were performed on a 1.5 T equipment and each one of the cases was pathologically proven.

RESULTS

The results were: dermoid cysts [4 cases (5%)], epidermoid cysts [2 cases (2.5%)], cephalocele [14 cases (17.5%)], sinus pericranii [3 cases (3.7%)], leptomeningeal cysts [4 cases (5%)], Langerhans cell histiocytosis [10 cases (12.5%)], lipoma [4 cases (5%)], fibrous dysplasia [13 cases (16.2%)], osteoma [8 cases (10%)], hemangioma [1 case (1.2%)], meningioma [3 cases (3.7%)], chondrosarcoma [5 cases (6.2%)], hemangiosarcoma [1 case (1.2%)], multiple myeloma [3 cases (3.7%)], sarcomatous transformation of Paget disease [1 case (1.3%)], and metastasis [5 cases (6.2%)].

CONCLUSION

MRI identifies bone marrow abnormalities and invasion of adjacent tissues at an early stage. Therefore, it is an essential method when it commes to properly evaluating calvarial lesions.

Plunging congenital epidermoid cyst of the oral cavity

Epidermoid cysts are rare lesions in the oral cavity. They usually present early in life and are confined to one anatomical area. Simple excision is all that is needed. However, they may present late in life and be large in size, making their excision a real challenge. We present a case of congenital epidermoid cyst of the sublingual space that presented late, at the age of 17 years, after it plunged into the submental area. The presentation of the patient and the surgical approach are discussed.

Recurrent Meningitis Associated With Complete Currarino Triad in an Adult-Case Report-

A 58-year-old woman presented with Currarino triad manifesting as recurrent meningitis. Currarino triad is a combination of a presacral mass, a congenital sacral bony abnormality, and an anorectal malformation, which is caused by dorsal-ventral patterning defects during embryonic development. She had a history of treatment for anal stenosis in her childhood. Radiographic examinations demonstrated the characteristic findings of Currarino triad and a complicated mass lesion. The diagnosis was recurrent meningitis related to the anterior sacral meningocele. Neck ligation of the meningocele was performed via a posterior transsacral approach after treatment with antibiotics. At surgery, an epidermoid cyst was observed inside the meningocele. The cyst content was aspirated. She suffered no further episodes of meningitis. The meningitis was probably part of the clinical course of Currarino triad. Radiography of the sacrum and magnetic resonance imaging are recommended for patients with meningitis of unknown origin. The early diagnosis and treatment of this condition are important.

Presacral tumor associated with the Currarino triad in an adolescent

A 17-year-old woman presented with pain over the sacral region. Plain radiographs of the sacrum demonstrated a bony deformity of the sacrococcygeal region in the shape of a scimitar. Magnetic resonance imaging showed a cystic mass of the presacral region which appeared to be continuous with the dural sac. An anteroposterior view myelogram revealed caudal elongation of the dural sac, and on the lateral view it was recognized as an anterior meningocele. At surgery, we confirmed a connection between the presacral mass and the rectum. In light of the combination of a sacral bony deformity, presacral mass including meningocele, and mass-rectum connection, we made the diagnosis of the Currarino triad, which is a rare complex of congenital caudal anomalies. The patient underwent excision of the presacral mass. Histologic examination of the resected specimen revealed features of an epidermoid cyst.

Congenital splenic cyst--a report of two cases

We report on two girls with large epidermoid splenic cysts. They presented with abdominal pain, fever, and non-bilious vomiting. In both cases the cyst was diagnosed by means of computer tomography and ultrasonography. One of the patients was successfully treated with partial splenectomy. In the other case percutaneous drainage was initially carried out, but this treatment was insufficient. Splenectomy was then performed.

[Intratesticular epithelial cyst in an infant]

We report on a 7-month-old boy with a simple cyst of the testis who was treated with excision and testicular preservation. Benign testicular tumors are more common in children than in adults (30%). Ultrasound may permit identification of benign testicular lesions. As simple cysts are isolated benign entities they may be treated by testisparing surgery.

Splenic cysts--aspiration or partial splenic decapsulation?

We report on 2 children who had partial splenic decapsulation for splenic cysts--a pseudocyst and a congenital epidermoid cyst. Ultrasound-guided percutaneous needle aspiration with drainage was attempted in both patients but resulted in rapid cyst reaccumulation. Used on its own in the management of splenic cysts, percutaneous drainage has limited therapeutic value and delays definitive surgery. Partial splenic decapsulation is a simple and safe procedure.

MR of epidermoids with a variety of pulse sequences

PURPOSE

To assess the usefulness of fluid-attenuated inversion recovery (FLAIR) and constructive interference in steady state (CISS) sequences in depicting epidermoid tumors.

METHODS

Six patients with surgically confirmed epidermoid tumors in the subarachnoid space were examined with T1-weighted MR imaging with a spin-echo sequence, and with T2- and proton density-weighted imaging with a fast spin-echo sequence, a FLAIR sequence, and a CISS sequence. In the qualitative analysis, three observers compared the five sequences for visibility of tumors and presence of artifacts. A quantitative analysis was also performed by measuring the contrast-to-noise ratio.

RESULTS

On visual assessment, the FLAIR sequence depicted all tumors as hyperintense relative to cerebrospinal fluid. The CISS sequence depicted all tumors as hypointense relative to cerebrospinal fluid and was considered to show tumor extension better than the FLAIR sequence. At quantitative analysis, the mean contrast-to-noise ratios of tumor to cerebrospinal fluid on T1-, T2-, and proton density-weighted images, and on FLAIR and CISS sequences were 2.85, 3.41, 4.42, 16.13, and 20.23, respectively. The contrast-to-noise ratios for the FLAIR and CISS sequences were significantly higher than those for the T1-, T2-, and proton density-weighted sequences. The contrast-to-noise ratio was not significantly different between FLAIR and CISS sequences, although the CISS sequence was slightly superior.

CONCLUSION

CISS and FLAIR sequences depicted epidermoid tumors in the subarachnoid spaces better than conventional spin-echo images did. The CISS sequence produced a relatively constant contrast between the tumors and less artifactual interference.

[Organ preserving surgery of testicular epidermoid cyst in the newborn infant]

Epidermoid cysts are rare, benign tumors of the testis or, less frequently, the inguinal cord. Generally, they affect males between 10 and 39 years. In newborns they are rare. We report on a newborn with an epidermoid cyst of the right testis that had been diagnosed in utero and was removed with preservation of the testicle.

[Congenital abnormalities of the prenasal space: glioma, fistulas and epidermoid cysts]

BACKGROUND

Nasal gliomas are uncommon neurogenic malformations, which derive from the prenasal space. They may appear as intranasal masses, frontonasal masses, or deformities of the nose, brow, or lower central forehead. Almost all of these tumors were diagnosed shortly after birth. The clinical findings of meningoencephaloceles, nasal fistulas, dermoides and epidermoid cysts are presented additionally for differential diagnosis.

PATIENTS

Following some interesting case reports, the management of these types of benign tumors is discussed.

RESULTS

Complete radiologic evaluation with computed tomography and magnetic resonance imaging should be performed, because a possible intracranial connection must be considered. The preferred surgical treatment of glioma is an endoscopically controlled procedure. In most cases craniotomy is not required. Open rhinoplasty can be helpful for removal of ectodermic malformations.

CONCLUSIONS

The surgeon should be familiar with the diagnosis and management of the rare congenital tumors of the nose to ensure proper therapy and to provide the requisite information for patients, parents, and colleagues.

Bregmatic epidermoid inclusion cyst eroding both calvarial tables

Dermoid and epidermoid cysts are uncommon masses in the head and neck region of children. Although the most common location of inclusion cysts in the head and neck is the bregma, masses in this region must be differentiated from midline hemangiomas, lipomas, hematomas, or encephaloceles. Inclusion cysts should be considered in the differential diagnosis of all midline cystic lesions in infants, because, if left untreated, it may lead to devastating complications. We present the case of a slowly enlarging midline mass in a female infant to illustrate the potential for serious sequelae from inclusion cysts.

Splenic preservation in the management of splenic epidermoid cysts in children

Splenic epidermoid cysts are a rare entity. The traditional treatment was splenectomy, performed to prevent infection, hemorrhage, or rupture of the cyst. The authors reviewed their series of 19 children with congenital splenic cysts from 1914 to 1993 to assess the change in management of these lesions. The age of time of presentation ranged from newborn to 17 years (median, 12.0 years) The male:female ratio was 1.0:1.1. Five cysts were found incidentally at the time of autopsy. The cysts were 0.5 to 24 cm in diameter (median, 12.0 cm). Only cysts greater than 8 cm presented with clinical symptoms: 64% with an abdominal mass and/or 78% with abdominal pain. One patient presented with a left varicocele. There were no complications related to the cysts. A variety of radiographic studies were performed, but ultrasonography provided all required diagnostic information. All patients treated before 1971 (n = 9) underwent splenectomy, and five patients treated since 1983 had hemisplenectomy or cystectomy. Postoperative spleen scans (obtained in three of these patients) and platelet counts showed preservation of splenic function. Pathological examination showed epidermoid cysts in all cases. There were no postoperative complications. In conclusion, in this series of epidermoid splenic cysts in children, (1) the cysts presented with an abdominal mass and/or abdominal pain only if they were greater than 8 cm in size, and there were no complications owing to the cysts; (2) ultrasonography was the most cost-effective and least invasive method of evaluation; and (3) splenic preservation by hemisplenectomy or cystectomy, used to avoid the long-term risks of splenectomy, proved to be a safe, easy procedure, with maintenance of splenic function.

Reevaluation of a kindred with congenital absence of dermal ridges, syndactyly, and facial milia

We observed a newborn infant of a previously reported kindred with absent dermal ridge pattern, syndactyly, and facial milia. The infant's features were consistent with three other kindreds, suggesting that this entity is a single disorder with variable expression. Furthermore, this entity should be considered in the differential diagnosis of excessive congenital facial milia and erosions.

Unusual presentation of a first branchial cleft

An atypical case of a first branchial cleft presenting with a cutaneous fistula and an epidermoid cyst of the external auditory canal is reported. The relevant embryology of the branchial apparatus is summarized, and variations of first branchial anomalies are discussed. The relationship with a congenital cholesteatoma is discussed.

Epidermoid cyst of the liver complicated by microscopic squamous cell carcinoma: CT, ultrasound, and pathology

Though cystic hepatic lesions may have features that help characterize them by noninvasive imaging modalities, these findings are often nonspecific and may be unable to establish the presence of malignancy. This is illustrated here by describing an epidermoid cyst of the liver containing microscopic foci of squamous cell carcinoma. The importance of totally resecting an epidermoid cyst of the liver is emphasized.

Spinal epidermoid cysts without congenital anomalies associated. Report of two cases

MR findings in two patients with intradural spinal epidermoid tumors without spinal anomalies are reported. In one case this tumor was congenital, the other one was considered iatrogenic. Origin and MR characteristics of this lesion are discussed.

Treatment of complicated congenital splenic cysts

Although rare in occurrence, the potential for congenital splenic cysts to enlarge, rupture, or become infected has been well documented. Presented is the case of a 13-year-old boy with an infected epidermoid cyst of the spleen, which presented as a solitary splenic abscess. The entity has traditionally been treated by splenectomy or, more recently, percutaneous drainage. However, given the inability of percutaneous drainage or sclerotherapy to permanently obliterate congenital splenic cysts, the authors managed this condition with percutaneous drainage and interval partial splenectomy. This achieves complete removal of the lesion while preserving splenic function.

Congenital inclusion cysts over the anterior fontanel in Japanese children: a study of five cases

Congenital inclusion cysts over the anterior fontanel are rare in children in Asia and Europe. However, recent evidence of an increase in cases in both areas has been presented. In the period from 1980 to 1989, four patients with a dermoid cyst and one with an epidermoid cyst have undergone total excision in our department. Including the previously reported Japanese cases, the number of recorded Japanese cases is now 15, the number of Asian cases thus corresponding to the number in Europe. Although these lesions are unlikely to have intracranial extensions, noninvasive neuroimaging methods such as computed tomography and magnetic resonance imaging are recommended for preoperative investigations.

Intradiploic epidermoid cyst of the sphenoid wing

Epidermoids are blastomatous malformations of abnormal epithelial proliferation. Intradiploic epidermoids are very rare lesions that may occur in all flat bones of the calvarium and in the paranasal sinuses, maxilla, temporal bone, and sphenoid bone. This article describes the unique case of an intradiploic epidermoid tumor located in the greater sphenoid wing. Theories of pathogenesis, clinical behavior, diagnosis, and treatment of diploic epidermoids are reviewed.

Otologic manifestations of the hydantoin syndrome

The temporal bones of a newborn infant with hydantoin syndrome showed multiple middle ear and inner ear anomalies. There was a constellation of bony and membranous defects involving the oval and round windows, cochlear ducts, cochlear aqueducts, endolymphatic ducts and sacs, and vestibular labyrinths. To the authors' knowledge, supernumerary vestibular sensory epithelial structures and an inner ear epidermoid cyst have not been previously reported. Wide communications between the subarachnoid space and inner ear were of surgical relevance.

Congenital dermal sinuses, dermoid and epidermoid cysts of the posterior fossa

Dermal sinuses are abnormal communications between the skin and deeper tissues. Seven cases are presented of occipital dermal sinuses associated with dermoid or epidermoid cysts of the posterior fossa. The cysts were interdural, subdural and intracerebellar. Although they are benign lesions, there is a high incidence of complications, especially infections such as bacterial or aseptic meningitis and cerebellar abscess. The clinical features, radiological and tomographical characteristics, and the relationship to meningeal structures, dural sinuses and cerebellar parenchyma are described.

NMR imaging of congenital intracranial germinal layer neoplasms

NMR images in five patients with surgically proved, congenital germinal layer intracranial neoplasms (two dermoid and three epidermoid tumors) were reviewed. The dermoids were typically midline (suprasellar or parapineal) masses with sharply-defined margins. Relaxation times were variable, but if fat was present, T1 was decreased, and T2 was increased. The epidermoids were off the midline (cerebellopontine angle, temporal lobe, frontal lobe) masses with generally long T1 and T2 relaxation times. Obstructive hydrocephaly was noted in one patient, and tumor to ventricular communication was demonstrated in another.

[Congenital spontaneously ruptured epidermoid cyst of the iris]

At the age of 8 months a healthy boy developed a epidermoid cyst of the iris which increased rapidly in size and ruptured when he was 12 months old. Because of the clinically suspected diagnosis of medulla epithelioma an en-bloc excision was performed. The tumor consisted of keratinizing squamous epithelium producing masses of keratin. After an unremarkable postoperative course lasting four months, the boy developed an immunologic reaction to the tectonic graft in association with Coats' disease six months after the operation.

Congenital epidermoid cysts over the anterior fontanelle

Epidermoid cysts over the anterior fontanelle were once regarded as rare and exclusive to blacks. The latest reports in the literature indicate a more widespread incidence. Only a few cases have been described in Europe. The authors report three cases of epidermoid cysts in this location occurring in Spaniards. Clinical, radiological, and surgical features are briefly discussed and pertinent literature is reviewed.

Congenital inclusion cysts of the subgaleal space

Congenital inclusion cysts of the subgaleal space in 23 white children are reported. Twenty-two cysts were dermoid and one was epidermoid in nature. The lesions were extracranial and had no intracranial extension. Their location in the subgaleal space was median or paramedian. Their clinical, radiologic, biochemical, and histologic characteristics are detailed and compared with those from Africa. This series counters the motion that such cysts are extremely rare in whites and that the anterior fontanel is their only site of location, as claimed by various authors from Africa.

Congenital subgaleal (epidermoid) inclusion cyst of the anterior fontanel in a Mexican female child: case report

A 30-month-old Mexican girl with an inclusion subgaleal cyst located over the anterior fontanel is described. This is the first such case ever diagnosed at our institution and, we believe, the first reported from Mexico. Radical excision of the lesion was accomplished. The internal table of the skull was eroded, but no intracranial extension was noticed. As the cyst contained no hair follicles nor any sebaceous or sweat glands, it was histologically classified as an epidermoid cyst. This is another example of such a lesion in an infant of non-African descent.

Congenital inclusion cyst of the subgaleal space

An unusual type of congenital subgaleal cyst, either dermoid or epidermoid, was found in 21 Nigerian infants. This entity was located in the midline of the scalp, anywhere from above the nasion to the inion, and occupied the subgaleal space. These cysts were noted soon after birth and gradually enlarged. They had no intracranial extension and were easily excised intact. Clinically, radiologically, and histologically they were similar to congenital inclusion dermoid cysts of the anterior fontanel. The histology and some of the peculiarities of these cysts are described. Although most of these cysts occur at the anterior fontanel, they can occur anywhere in the midline, and the subgaleal space of the anterior fontanel is not the exclusive site, as has been claimed by previous authors.

Growth rates of epidermoid tumors

Consideration of the most likely method of growth of epidermoid tumors, either congenital or traumatic in origin, suggests that they grow linearly, at rates approximately those reported for normal human skin, rather than exponentially, as most tumors do. Such a linear rate of growth would be expected of tumors derived from a single layer of basal germinal cells spread out over a surface area.

Epidermal cyst of median raphe

Cysts of the penis are rare and references to them in standard textbooks are sketchy. A case report of a congenital epidermal cyst of the median raphe of the penis is presented; therapy involved excision of the mass. Review of the literature is given.

Diagnosis and management of primary tumors of the petrous apex

Five patients with primary tumors of the petrous apex were diagnosed and treated between the years 1968 to 1974; two had congenital epidermoids, two had chondromyxosarcomas and one had neurofibroma. The embryological development of the foramen lacerum and the pattern of expansion of these primary tumors support the contention that these three categories of tumors arise in the foramen lacerum. Knowledge of the structures surrounding the foramen lacerum can provide a guide to early diagnosis of petrous apex tumors. Since these tumors cannot be completely removed, the goal of surgery is to obtain histological diagnosis and to produce permanent fistulization of the petrous apex. Although there are several recommended surgical approaches to the petrous apex, the transmastoid-translabyrinthine procedure was used in this series.