Endoscopic-assisted, closed rhinoplasty approach for excision of nasoglabellar dermoid cysts

Authors

  • Justin H. Turner MD, PhD,

    1. Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.
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  • David E. Tunkel MD,

    1. Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.
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  • D. Kofi Boahene MD

    Corresponding author
    1. Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.
    • Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 6th Floor, 601 N. Caroline Street, Baltimore, MD 21287
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  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

Objective/Hypothesis:

To report the feasibility and early results of a new surgical technique for excision of nasoglabellar dermoid cysts.

Study Design:

Retrospective case series.

Methods:

Patients with nasoglabellar dermoid cysts without intracranial communication were treated with the endoscopic-assisted, closed rhinoplasty approach. Data pertaining to patient characteristics, surgical outcome, and cosmetic results were obtained by retrospectively reviewing medical records.

Results:

Three patients were included in the study. The endoscopic-assisted, closed rhinoplasty approach was utilized in all patients. In each case, complete excision was achieved without violation of the cyst wall. All patients had satisfactory cosmetic results as assessed by subjective evaluation by the parent(s) and surgeon.

Conclusions:

The endoscopic-assisted, closed rhinoplasty approach allows for safe and complete excision of uncomplicated nasoglabellar dermoid cysts. This new surgical technique should be considered in children with benign, midline nasal, and forehead masses due to its ease and excellent cosmetic results. Laryngoscope, 2010

INTRODUCTION

Midline congenital nasal masses are rare, occurring in one out of every 20,000 to 40,000 births. Of these lesions, dermoid cysts and sinus tracts are the most common. Dermoid cysts result from failed regression of embryonic neuroectoderm during development causing sequestration of skin appendages into the prenasal space. Dermoid cysts and sinuses are composed of epithelium, sebaceous tissue, and sometimes hair and other adnexal tissues, surrounded by a discrete cyst wall. Nasoglabellar dermoids present as slow-growing, midline masses, often with a discrete midline skin pit, which are usually soft and noncompressible. Complete excision is the treatment of choice, with recurrence rates of up to 50% to 100% noted in cases of incomplete removal.1

A variety of approaches for removal of nasoglabellar dermoid cysts and sinuses have been described. Classically, dermoid cysts have been excised via a vertical skin incision directly over the mass or encompassing the sinus tract opening. Other external approaches include the inverted U, transverse, medial brow, and lateral rhinotomy incisions, all of which generally provide adequate access for complete cyst removal.2–4 Unfortunately, the prominent location of these lesions sometimes produces a scar with unfavorable cosmesis, particularly in infants who have yet to develop glabellar rhytids. Other external approaches, such as the bicoronal technique, avoid incisions over the expressive face, but still require large frontal hairline incisions, wide undermining, and can result in complications such as hematoma, alopecia, and nerve damage. The increased use of endoscopic surgical procedures, particularly the endoscopic browlift technique, has provided yet another approach for the removal of dermoid cysts that are near the brow or high in the glabellar area. As first reported by Lin and colleagues, one or more incisions behind the frontal hairline can be used to establish access for instruments and an endoscope.5 This allows for subsequent approach and removal of dermoid cysts through a subperiosteal and subgaleal plain. Although this approach generally provides good cosmetic results, it nonetheless requires extended exposure over the forehead that risks injury to neurovascular structures, can disrupt the definition of the nasofrontal angle, and might be difficult when the dermoid is located lower along the mid-nasal vault. The open rhinoplasty approach has also been successfully used to access nasal dermoids. This technique requires a small columellar incision and produces excellent cosmetic results. However, some authors have expressed concern that the wide undermining of the nasal tip and dorsum could potentially affect subsequent nasal growth and development in young children.6, 7

We report our experience with an endoscopic-assisted, closed rhinoplasty approach for the removal of nasoglabellar dermoid cysts. This novel technique requires no external skin incisions and allows for excellent exposure and complete removal of these midline lesions.

MATERIALS AND METHODS

Subjects

Patients who presented to the senior author with midline nasoglabellar dermoid cysts were selected for the endoscopic-assisted closed rhinoplasty approach. All patients were evaluated by magnetic resonance imaging (MRI) to rule-out communicating tracts and/or intracranial communication. Patients underwent the approach between May 2008 and February 2010. Data pertaining to patient characteristics, surgical outcome, and cosmetic results were obtained by retrospectively reviewing medical records. This study was exempt from institutional review board review at the Johns Hopkins Hospital.

Surgical Procedure

The procedure is performed under general anesthesia with an oral endotracheal tube. The nose is decongested with oxymetazoline-soaked pledgets, and the soft tissues are infiltrated with lidocaine and epinephrine. A hemitransfixion incision is made and joined with a one-sided intercartilaginous incision. A soft tissue envelope is elevated over the upper lateral cartilage and over the nasal bone. Using a periosteal elevator, the envelope is further elevated up to the frontal bone after transitioning into a subperiosteal plane. A wide cavity is then created with a self-retaining nasal speculum (Fig. 1A), and hemostasis is achieved with oxymetazoline-soaked pledgets. A 0-degree rigid nasal endoscope is then used to visualize the cyst (Fig. 1B), and pediatric endoscopic instruments are used to dissect the cyst from surrounding soft tissues, including the adjacent procerus and corrugator muscle (Fig. 2A). We find that small endoscopic sinus scissors allow for spreading of surrounding tissues as well as sharp dissection of the cyst from the surgical cavity. The cyst is then removed, taking care to avoid disturbing the cyst wall. The surgical cavity is then irrigated and reexamined for any sinus tracts or undissected tissue (Fig. 2B). At this point, the soft tissue envelopes are repositioned and the hemitransfixion and intercartilaginous incisions are closed with 5-0 fast-absorbing sutures. In some cases, the dermoid cyst can cause a deformity in the upper lateral cartilages and nasal bone, resulting in a depression of the nasal dorsum after removal. In these instances, an onlay cartilage graft is used to augment the nasal dorsum, usually using conchal cartilage or Alloderm tissue matrix (LifeCell Corp., Branchburg, NJ). An annotated video detailing the procedure is available as online supporting information.

Figure 1.

Closed rhinoplasty approach. (A) After making hemitransfixion and intercartilaginous incisions, the soft tissue envelope is raised and a self-retaining nasal speculum is placed within the cavity. (B) The cyst is apparent after closed rhinoplasty approach surrounded by soft tissue and muscle. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 2.

Microdissection of nasoglabellar cyst using a rigid nasal endoscope. (A) Optical cavity for endoscopic access and microdissection. The dermoid cyst, with intact cyst wall, is easily visible (arrow). Note small hairs emanating from the cyst wall. (B) Surgical field after complete removal of dermoid cyst. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

RESULTS

Three patients underwent the previously described approach, including two males and one female. All patients had preoperative imaging, including MRI, that was consistent with a dermoid cyst (Fig. 3). Patient demographics, dermoid sizes, and other details are provided in Table I. All patients underwent the above-mentioned procedure without complication. Patients 1 and 2 underwent augmentation of the nasal dorsum with auricular cartilage and Alloderm, respectively, due to nasal dorsum depression apparent after removal of the cyst. All patients had satisfactory cosmetic results as assessed by subjective evaluation by the parent(s) and surgeon. There have been no signs of recurrence to date.

Figure 3.

Nasoglabellar dermoid cyst. T1-weighted sagittal magnetic resonance imaging showing lesion within the midline subcutaneous tissues along the nasal bridge consistent with a nasoglabellar dermoid cyst.

Table I. Summary of Patients Treated with Endoscopic-Assisted, Closed Rhinoplasty Approach
PatientAge, moSexSize, cmFollow-up, mo
125Male1.65
232Male0.822
328Female0.63

DISCUSSION

Nasoglabellar dermoid cysts and sinuses are benign masses that can be excised with a variety of approaches. Endoscopic techniques have replaced or supplemented open surgical approaches through the range of otolaryngology–head and neck surgery. We detail an endoscopic-assisted, closed rhinoplasty approach for the excision of nasoglabellar dermoid cysts. This technique avoids external skin incisions entirely, while minimizing dissection of nasal soft tissues. Improved visualization with the endoscopes allowed complete excision in these cases.

The technique utilized in the current study combines a rhinoplasty approach with the use of endoscopic techniques for improved visualization. The use of the external, or open rhinoplasty approach, has been advocated by several authors with reasonable results.8–11 Although it provides good access, the open rhinoplasty approach provides limited exposure of masses high along the nasal bone or within the glabellar region. This technique also requires wide undermining of the soft tissues of the nasal tip and dorsum, which has the potential to alter subsequent nasal growth and development. Over the last decade, many surgeons of different specialties have used the endoscopic browlift technique to approach nasoglabellar dermoids.5, 12, 13 Nonetheless, this technique still requires up to five incisions within the frontal hairline, as well as wide undermining with resultant risk to neurovascular structures. To our knowledge, this is the first description of a closed rhinoplasty approach in combination with endoscopy for the excision of nasoglabellar dermoid cysts.

CONCLUSION

The endoscopic-assisted, closed rhinoplasty approach is a useful technique for excision of nasoglabellar dermoid cysts and perhaps other benign, midline masses in select patients. This technique allows for complete cyst removal with minimal morbidity and excellent cosmetic results.

Ancillary