Journal of the Egyptian Ophthalmological Society

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 106  |  Issue : 4  |  Page : 235--238

Evacuation of dermoid cysts before excision


Ayman A El-Ghafar, Hosam A ElKhair 
 Ophthalmology Department, Mansoura University, Mansoura, Egypt

Correspondence Address:
Ayman A El-Ghafar
Ophthalmology Department, Mansoura University, Mansoura
Egypt

Abstract

Purpose The aim of this work is to evaluate safety and efficacy of evacuation of dermoid cysts before excision. Patients and methods Twenty patients with orbital dermoid, 10 patients with external angular dermoid, seven patients with internal angular dermoid, and three patients with deep orbital dermoid were included in this study. The patients attended the outpatient clinic of Mansoura Ophthalmic Center from January 2011 to September 2011. All patients were operated by puncture of the cyst wall, aspiration of the contents with a suction device, and then complete removal of the cyst wall. Results Twenty patients were operated, 11 males (55%) and nine females (45%), mean age 6.8 (ranged from 2.5 to 27 years). There were three patients (15%) with deep orbital dermoid, 10 patients (50%) with external angular dermoid, and seven patients (35%) with internal angular dermoid. Patients with external and internal angular dermoid were operated through external and internal sub-brow incisions (85%); however, in patients with deep orbital dermoid (15%), they were located in the lacrimal fossa and were operated through lateral orbitotomy without a bone flap. All cases were excised successfully without postoperative recurrence. In one patient (5%), rupture had already occurred before surgery, and this patient developed postoperative recurrent orbital inflammation that responded to a local triamcinolone injection. Conclusion Evacuation of dermoid cyst before excision represents a safe and efficient technique.



How to cite this article:
El-Ghafar AA, ElKhair HA. Evacuation of dermoid cysts before excision.J Egypt Ophthalmol Soc 2013;106:235-238


How to cite this URL:
El-Ghafar AA, ElKhair HA. Evacuation of dermoid cysts before excision. J Egypt Ophthalmol Soc [serial online] 2013 [cited 2020 Oct 24 ];106:235-238
Available from: http://www.jeos.eg.net/text.asp?2013/106/4/235/131563


Full Text

 Introduction



Dermoid and epidermoid cysts are examples of choristomas, tumors that originate from primordial tissue. As two suture lines of the skull close during embryonic development, dermal and epidermal elements are pinched off and form cysts. Approximately 50% of these tumors that involve the head are found in or adjacent to the orbit [1].

Histologically, the cysts are classified as either epidermoid or dermoid cysts. Both cysts are lined with keratinizing epithelium, but the dermoid cyst wall also contains adnexal structures such as hair follicles, sebaceous glands, and sweat glands [2].

The cyst cavity typically contains a combination of sebaceous fluid, keratin, calcium, and cholesterol crystals [3].

Dermoid cysts are classified according to the site of their attachment in relation to the orbital rim either as exophytic cysts (external and internal angular dermoid) that grow externally and are discovered early in childhood or as endophytic cysts (deep orbital dermoid) that grow internally in the orbit and are usually discovered in adulthood [4].

Excision of dermoid cysts is recommended in most cases because of the possibility of spontaneous rupture or cutaneous fistula [5].

The goal is to remove the dermoid with an intact cyst wall and to avoid iatrogenic rupture, which results in significant inflammation and recurrence [6].

An orbital surgeon may be concerned about the possibility of a rupture of the cyst during excision. Thus, evacuation of the cyst contents, followed by excision of the cyst wall may be a safe and an easy technique for excision of a dermoid cyst.

 Patients and methods



This is a prospective interventional case series that included 20 patients who presented with orbital dermoid cysts. Ten patients had external angular dermoid, seven patients had internal angular dermoid, and three patients had deep orbital dermoid occupying the lacrimal gland fossa. Computed tomographic orbit was performed in all cases to exclude intracranial extension. Patients with angular dermoids presented with a swelling on the head and tail of the brow. Patients with deep orbital dermoids presented with down and in proptosis. One of the patients with a deep orbital dermoid showed bone erosion in the adjacent orbital roof without intracranial extension [Figure 1], and this patient presented with orbital inflammation that was controlled with a course of prednisolone (60 mg/day) for 2 weeks. Before surgery, a full ophthalmological examination was performed for all patients.{Figure 1}

Operative technique

Cases with external and internal angular dermoids are approached through external and internal sub-brow incisions [Figure 2]a. Deep orbital dermoids are approached by lateral orbitotomy without a bone flap.{Figure 2}

In external and internal angular dermoids, the skin is incised, the orbicularis muscle is divided along the incision, and then, a blunt submuscular dissection is performed to avoid premature rupture of the cyst.

In deep dermoids, a lazy-S incision is used, the orbicularis muscle is incised along the incision, and the periosteum is incised 2 mm posterior to the orbital rim, dissected from the bone until exposure of the lacrimal fossa.

In all cases after exposure of the anterior portion of the cyst, surgical drapes are applied around the cyst, a small incision is made on the summit of the cyst, the catheter of the suction device is applied through the incision, and all the contents are aspirated [Figure 2]b. After evacuation of the entire contents, the cyst wall is grasped with an artery forceps at the site of the incision and the wall is twisted, dissected, and removed [Figure 2]c and d; 1.0 mm of triamcinolone (40 mg/ml) is applied to the site of the cyst, then the incision is closed with deep polygalactin 5/0 sutures, and the skin is closed with black silk 5/0 sutures. Postoperative systemic antibiotics and analgesic were used for 1 week and silk sutures were removed after 5 days. Patients were followed for 6 months to monitor for postoperative inflammation and recurrence.

 Results



This study included 20 patients, 11 males (55%) and nine females (45%), mean age 6.8 (ranged from 2.5 to 27 years). Ten patients had external angular dermoid (50%), seven patients had internal angular dermoid (35%), and three patients had deep orbital dermoid occurring in the lacrimal gland fossa (15%) [Table 1].{Table 1}

Cases with external and internal angular dermoids (85%) are approached through external and internal sub-brow incisions. Three cases (15%) with deep orbital dermoids were approached by lateral orbitotomy without a bone flap. There was no postoperative recurrence; however, one patient with a deep orbital dermoid (5%) developed recurrent orbital inflammation because this cyst had already ruptured before surgery, and it responded to a local injection of 1.0 mm triamcinolone (40 mg/ml) into the lacrimal gland fossa.

 Discussion



Orbital cystic lesions that can be detected in childhood were classified by Shields and Shields in 2004 [7].

A dermoid cyst is by far the most common orbital cystic lesion in children, accounting for over 40% of all childhood orbital lesions and for 89% of all cystic lesions in childhood that require biopsy or surgical removal [8].

The most common site for a dermoid cyst is superotemporal near the zygomaticofrontal suture [9]. This is in agreement with this study, found in 50% of cases. However, deep orbital dermoids were the least common, representing 15% of cases.

A deep orbital dermoid cyst may remain clinically occult until adulthood, when they enlarge and produce proptosis or displacement of the globe, and may leak material from the cyst into the surrounding tissues, producing inflammation simulating primary orbital inflammation [7]. In the present study, the three patients with deep orbital dermoid presented in adulthood with medial displacement of the globe and in one case (5%), it had leaked into the lacrimal fossa, leading to recurrent postoperative inflammation.

It is generally known that surgical excision of a dermoid cyst is more difficult than that of other periorbital cysts because of the complications that may result from accidental rupture, and if ruptured recurrence and chronic orbital inflammation are unavoidable [10].

Dermoid cysts are usually excised completely using an approach that is appropriate to the location in the orbit. Yuen et al. (2004) used lid crease incision in medial dermoids and some lateral dermoids. Cysts around the brow were excised using incisions below, above, and through the brow. A lynch incision was used in one large medial dermoid [11],[12].

Lateral orbitotomy was used in deep orbital dermoids and is also used commonly for dumbell-shaped dermoids [13].

In the present study, medial and lateral sub-brow incisions were used for excision of internal and external angular dermoids, respectively, and lateral orbitotomy without a bone flap was used for exposure of the lacrimal gland fossa containing the deep dermoid cysts.

Inflammation from preoperative or intraoperative rupture of the cyst can be controlled by prednisolone. The entire cyst must be excised to avoid persistent inflammation, a draining sinus, or recurrence of the cyst. Yuen et al. [13] did not find significant inflammation postoperatively in ruptured cysts, thoroughly washed the area with isotonic saline, and used suction to drain the cyst at the time of rupture.

Total excision of dermoid cysts is mandatory to avoid postoperative inflammation. However, in large or deep orbital dermoids it is wise to aspirate the contents before excision using a 25-G needle [14].

In the present study, the contents of the cysts were aspirated, cyst walls were removed, and triamcinolone was applied at the site of the cysts to decrease postoperative inflammation.

 Conclusion



The possibility of accidental rupture of a dermoid cyst during excision and subsequent complications can be avoided by drainage of the cyst, followed by complete excision of the cyst wall.

 Acknowledgements



Conflicts of interest

There are no conflicts of interest.

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