Endoscopic removal of a dermoid cyst via scalp incision

Authors

  • Jaiganesh Manickavasagam FRCS (ORL-HNS),

    Corresponding author
    • Department of Paediatric Otorhinolaryngology–Head and Neck Surgery, Sheffield Childrens Hospital, Sheffield Childrens Hospitals NHS Trust, Sheffield, U.K.
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  • James M. W. Robins MB ChB,

    1. Department of Paediatric Otorhinolaryngology–Head and Neck Surgery, Sheffield Childrens Hospital, Sheffield Childrens Hospitals NHS Trust, Sheffield, U.K.
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  • Saurabh Sinha FRCSEd (NeuroSurg),

    1. Department of Paediatric Neurosurgery, Sheffield Childrens Hospital, Sheffield Childrens Hospitals NHS Trust, Sheffield, U.K.
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  • Showkat Mirza FRCS (ORL-HNS)

    1. Department of Paediatric Otorhinolaryngology–Head and Neck Surgery, Sheffield Childrens Hospital, Sheffield Childrens Hospitals NHS Trust, Sheffield, U.K.
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  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Send correspondence to Jaiganesh Manickavasagam, Specialist Registrar Otolaryngology–Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, Royal Hallamshire Hospital, Glossop Rd, Sheffield, S10 2JF, UK jaiganeshkalpana@yahoo.co.uk

Abstract

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar. Laryngoscope, 123:1862–1864, 2013

INTRODUCTION

Nasal dermoid cysts are an important embryologic abnormality responsible for more than 60% of congenital midline lesions.[1]

They typically present as a midline mass, most commonly along the dorsum from the nasoglabellar region to the base of the columella, and may be associated with a sinus opening. Intermittent discharge of sebaceous material and recurrent infection are also common. Hair protruding through a punctum is pathognomonic for a nasal dermoid, but it is present in less than half of patients.[2]

All patients with a dermoid cyst require imaging with high-resolution multiplanar magnetic resonance imaging (MRI) and complementary fine-cut computed tomography to reveal the anatomic extent of the tract and its relationship to the anterior cranial fossa.[3]

Surgical excision is the recommended treatment for nasal dermoids owing to their high risk of infection and negative appearance.[2] There are many described surgical approaches and incisions, including the vertical nasal, transverse nasal, gull wing, bicoronal flap with frontonasal osteotomy, medial canthal (Lynch–Howarth) and external rhinoplasty.[3-5]

In this case, a 2-year-old boy presented with a 1-cm-diameter round subcutaneous midline swelling of the nasion. There was no skin abnormality. MRI axial and sagittal images demonstrated no intracranial component (Fig. 1A and 1B).

Figure 1.

T2-weighted axial (A) and sagittal (B) magnetic resonance images show a well-defined cystic area in the midline at the nasal bridge without intracranial extension consistent with a dermoid.

Technique

We describe a novel method that uses an endoscopic technique via a scalp incision to adequately excise an entirely extracranial nasal dermoid cyst in a 2-year-old boy.

The procedure was carried out by an experienced team consisting of a neurosurgeon and an otorhinolaryngologist using a four-hand technique. The four-hand technique involves one surgeon holding the endoscope with one hand and retracting tissue with the other. The other surgeon is then able to remove the cyst using both hands.

The procedure is described here in conjunction with the images shown in Figure 2. A 2-cm central coronal incision was made with a scalpel blade behind the hairline. Subcutaneous dissection was carried out to the nasion, triangulating at the nasal dermoid. A Killian's nasal speculum was inserted, retracting the forehead flap and enabling a good endoscopic view and ample access to the dermoid. Next, a 0-degree endoscope was used to visualize the dermoid cyst. The cyst was carefully dissected using microlaryngeal instruments and scissors. Hemostasis was achieved using suction bipolar forceps as commonly used endonasally. The dermoid was completely resected.

Figure 2.

(A) A 2-cm horizontal incision is made behind the hairline and marked to show the dissection path to triangulate to the nasal dermoid. (B, C) A Killian nasal speculum is used to raise the brow flap for access to the dermoid, where full operative visualization of the cyst is achieved with an endoscope. Hemostasis is achieved with long cautery, creating a bloodless field maintaining dermoid visualization (D, E). Careful dissection is performed around the cyst with scissors, utilizing traction and countertraction (F). The cyst is removed (G, H).

No drain was inserted. A light head bandage was applied overnight. The patient was discharged home the next day without any complications. At 3-months' follow-up, there was an excellent cosmetic result.

DISCUSSION

Congenital lesions of the nose can be challenging to excise. Surgical access must allow complete excision in all circumstances to prevent recurrence. However, surgical access must be balanced against cosmetic results.[6]

The conventional midline nasal and modified Lynch-Howarth incisions are long-established approaches. They both enable good cyst exposure and thus straightforward dissection and resection. However, they both result in significant and obvious facial scarring, which may progress with age.[7-9]

The external rhinoplasty approach offers excellent access to the nasal dorsum, facilitating gross resection of dermoids. The operative plane created allows a direct line of sight along the nasal dorsum, along which a tract that can be followed if the cyst has an intracranial communication. However, the procedure results in a facial scar on the inferior border of the nasal septum that is frequently justified by its hidden location on casual gaze. Using this approach in a young patient can affect nasal and midface growth, whilst also creating a supratip deformity only apparent postoperatively. These complications may necessitate further rhinoplasty at a later date.[6]

The technique demonstrated in this article is the first documented excision of an entirely extracranial dermoid cyst using a four-hand endoscopic technique with an incision behind the hairline. Previous endoscopic techniques have not used this four-hand method.[10] The technique presented resulted in complete dermoid resection with an excellent cosmetic result that avoided facial scarring. Other benefits of this technique include the magnified operative field afforded by endoscopes which facilitates dissection and with the four-hand technique the main surgeon can concentrate entirely on his dissection of the cyst with a colleague providing a good operative view.

The approach and excision are technically demanding; However, the instruments and techniques used are not dissimilar to those used in transnasal endoscopic surgery. The technique is heavily dependent on the location of the dermoid, in that at the nasion or superior would be suitable but a dermoid localised more inferiorly would be far more challenging. The use of two surgeons for the four-hand technique does result in a greater use of resources, but we believe, however, that the benefits attained make this procedure worthy of consideration.

CONCLUSION

The endoscopic excision of an extracranial dermoid cyst via a scalp incision using a four-hand technique has not been previously described. Although technically challenging, this technique is effective and results in an excellent cosmetic result.

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