Epidermoid cysts, dermoid cysts and teratoid cysts are cystic malformations lined with squamous epithelium. They present as soft nodular lesions with a sessile base. Their prevalence is 7% in head and neck patients and 1.6% within the oral cavity. The authors present a case series of 21 patients with dermoid and epidermoid cysts who underwent surgical removal. One year of follow-up was carried out without evidence of recurrence. The removal of these cysts is of great concern as it can cause serious social stigma, aesthetic and functional impairment, dysphagia and dysphonia.
Epidermoid, dermoid and teratoid cysts are cystic malformations lined with squamous epithelium and are classified based on whether they are lined with simple squamous epithelium (epidermoid), or skin adnexa are found in the cystic wall (dermoid), or other tissues, such as a muscle, cartilage and bone are present (teratoid).[
Epidermoid cysts occur more frequently in patients between 15 and 35 years but can be seen in all age groups. These are slow growing asymptomatic masses but once they increase in size, they can cause dysphagia, dysphonia and dyspnea.[
Epidermoid cysts are relatively less common in the head and neck region, hence are likely to be misdiagnosed. The aim of this case series is to highlight the presentation of epidermoid and dermoid cysts as a differential diagnosis for head and neck masses, showing various clinical and radiological presentations as well as the surgical outcomes after their removal.
This study included all the patients of dermoid and epidermoid cysts who visited D. Y. Patil Dental College and Hospital, Pune between January 2010 to January 2015. Twenty-one patients (12 females and 9 males) were diagnosed clinically with dermoid/epidermoid cyst and confirmed by fine-needle aspiration cytology. Giant cysts were present on the anterior scalp in 5 patients
Characteristics of patients and the cysts
No. of patients | Age (years) | Gender | Site | Size (cm × cm) | Surgery | Follow-up (months) |
---|---|---|---|---|---|---|
1 | 21 | Male | Intraoral (upper lip) | 2 × 2 | Excision | 13 |
2 | 35 | Male | Anterior scalp | 1.5 × 2 | Excision | 12 |
3 | 23 | Female | Anterior scalp | 3.2 × 2 | Excision | 18 |
4 | 35 | Female | Posterior scalp | 12 × 7 | Excision | 17 |
5 | 57 | Male | Posterior scalp | 5.5 × 4 | Excision | 14 |
6 | 17 | Female | Lat orbital margin | 2.5 × 2 | Excision | 36 |
7 | 16 | Female | Lat orbital margin | 2 × 1.5 | Excision | 25 |
8 | 22 | Female | Lat orbital margin | 2.2 × 2 | Excision | 22 |
9 | 25 | Female | Lat orbital margin | 2.4 × 2.2 | Excision | 30 |
10 | 24 | Male | Lat orbital margin | 2.5 × 2.5 | Excision | 16 |
11 | 32 | Female | Lat orbital margin | 3 × 2.8 | Excision | 14 |
12 | 36 | Male | Anterior scalp | 3.2 × 2.8 | Excision | 19 |
13 | 23 | Female | Lat orbital margin | 2.2 × 2 | Excision | 18 |
14 | 78 | Male | Frontal bone | 8 × 5 | Excision | 20 |
15 | 62 | Female | Frontal bone | 3.8 × 3.5 | Excision | 13 |
16 | 48 | Female | Frontal bone | 3.2 × 3 | Excision | 15 |
17 | 42 | Male | Anterior scalp | 4 × 5 | Excision | 12 |
18 | 40 | Male | Posterior scalp | 5.5 × 4 | Excision | 14 |
19 | 37 | Male | Anterior scalp | 3.5 × 3 | Excision | 14 |
20 | 32 | Female | Lat orbital margin | 2.5 × 2 | Excision | 12 |
21 | 22 | Female | Lat orbital margin | 2.6 × 2.2 | Excision | 18 |
Preoperative (A) and intra-operative (B) view of a dermoid cyst of scalp
Preoperative (A) and intra-operative (B) view of a dermoid cyst of occiput
Preoperative (A) and intra-operative (B) view of a dermoid cyst of lateral orbital margin
Preoperative (A) and intra-operative (B) view of a epidermoid cyst of the upper lip
Dermoid cysts have been classified as true dermoid cysts, epidermoid cysts and teratoid cysts.[
Imaging has an important role in confirming the diagnosis and classifying cysts according to their relation to muscle. Ultrasound is the initial imaging modality. Epidermoid cysts are seen as well-defined cysts with multiple well-defined dependent echogenic nodules within the cyst. Computed tomography scan shows a unilocular cyst with homogenous, hypo-attenuating (0-18 HU) fluid material that contains multiple hypo-attenuating fat density nodules giving a “sack of marbles” appearance; this is a feature virtually pathognomonic for a dermoid cyst. Magnetic resonance imaging (MRI) shows fluid signal due to high protein content, and the areas of fat component will show low signal on fat suppressed images. MRI facilitates visualization of the exact location and extent of cystic lesions in the floor of the mouth and is useful for determining their relationship to the surrounding muscles.[
Pathological features of epidermoid cysts are oily or cheesy, tan, yellow, white material and the cyst wall is a fibrous capsule usually 2-6 mm in thickness.[
In a study of 103 patients with diagnosis of epidermoid and dermoid cyst of the head and neck, 46.6% of these were orbital, 23.3% buccal and submental, 12.3% nasal, 10.7% cervical and 2.9% labial. Various publications also report epidermoid cysts of the oral cavity in the soft palate, the uvula and the sublingual area. However, epidermoid cysts in tonsils are rarely reported.[
The epidermoid cyst rarely discloses malignancy, but isolated cases of premalignant and malignant conditions (Bowen’s disease, Paget’s disease, and squamous cell carcinoma) have been found in their walls. Ozan
In recent literature, we could find no reports related to orbicularis oris muscle fusion defects secondary to epidermoid cysts.[
Dermoid cysts may increase in size, leak and cause inflammation, and thus, it is recommended that even asymptomatic cysts should be removed.[
While dealing with scalp lesions, as well as other cutaneous lesions of the head and neck region, differential diagnosis of keratinous cysts should be kept in mind as these cysts carry certain complications such as cystic rupture, abscess, secondary, and infections, during their treatment. These cysts carry relatively higher risk of recurrence compared to lipomas and certain other benign lesions that mimic these cysts. Therefore, these cysts require thorough histopathological examination and close follow-up due to their potential for malignant transformation.[
None.
There are no conflicts of interest.
All involved patients gave their consent forms.
This study was approved by the Ethical Review Committee of D. Y. Patil Dental College and Hospital.