From the University of Massachusetts/Dartmouth Health Services (AMT), North Dartmouth, Massachusetts; and the Department of Ophthalmology (DRT), Hasbro Children’s Hospital/Brown University, Providence, Rhode Island.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to David Robbins Tien, MD, 2 Dudley St., Suite 505, Providence, RI 02905.
This is a case report and review of the evaluation and treatment of a patient with acute infection of an orbital dermoid cyst with a communicating sinus tract.
A 10-month-old girl presented in April 2007 with a history of a left upper eyelid mass that had been present since birth. According to the patient’s parents, the mass had always had hair growing from a small, round opening that would leak a whitish material intermittently. Two weeks before presentation, the mass increased in size, with erythema and swelling of the overlying skin to the point at which the eyelid was ptotic (Fig. 1). A more constant discharge from the skin opening in the mass was also present.
Figure 1. Appearance on Presentation, Showing Erythema and Ptosis.
On examination, the patient was found to have a swelling of the left upper eyelid with an underlying nontender, mobile mass. Hairs were observed growing from an associated fistula, and on compression of the mass, a mucopurulent discharge was expressed (Fig. 2). A diagnosis of an infected dermoid cyst with a draining fistula was made, and systemic treatment with amoxicillin and clavulanate (Augmentin; Glaxo-SmithKline, London, UK) was initiated. Orbital imaging studies were not obtained because they are unnecessary for most dermoid cysts. In retrospect, these studies may have been helpful for the current patient, given the atypical presentation.
Figure 2. Fistulous Opening Showing Discharge and Hair.
Because of concerns about potential worsening of the infection, abscess formation, or orbital cellulitis, the patient underwent surgery the next day. The preferred surgical management of orbital dermoid cysts is excision in toto, with care taken to avoid rupture of the cyst. Subtotal excision is prone to extensive orbital inflammation and scarring. The dermoid was completely excised through a superior eyelid crease incision. The fistulous tract was also tied off with a 7-0 polyglactin (Vicryl, Ethicon, Somerville, NJ) suture, then cauterized and cut before the cyst was excised (Fig. 3). Gram stain of the purulent drainage was performed and showed 1+ polymorphonuclear neutrophils, 1+ squamous cells, and 1+ Gram-positive cocci. There was no growth on cultures of the material. Final pathologic examination of the excised mass confirmed a dermoid cyst with acute inflammation.
Figure 3. Bowman Probe Passing Through a Fistulous Tract into the Dermoid.
After surgery, the patient made a complete recovery and had an excellent result (Fig. 4).
Figure 4. Appearance 4 Months Postoperatively.
Dermoid cysts are developmental anomalies that result from trapped germinal epithelium.1–3 They are composed of two germinal layers: ectoderm and mesoderm. Dermoid cysts can occur in all areas of the body, but in the head and neck region, the most common location is in the frontotemporal area or the upper outer quadrant of the orbit,1–4 where they are believed to arise when ectoderm pinches off as the suture lines of the cranium close. Subsequently, this ectoderm develops in an ectopic location, forming a dermoid cyst. Most dermoids contain a mixture of keratin and sebaceous lipid, secreted by the epithelium lining of the cyst.
Orbital dermoids are often evident in infancy, and patients are brought to medical attention as a result of parental concern about a slow-growing periorbital mass or periocular asymmetry. Sometimes the cyst is asymptomatic until later in childhood or adulthood, when enlargement or inflammation occurs. Dermoid cysts are the most common periorbital mass presenting in childhood.
Unlike nasal dermoids, orbital dermoid cysts rarely occur in association with a discharging sinus tract or fistula.1–3 Therefore, preoperative computed tomography scans for nasal dermoids are also performed to document their extent and proximity to orbital structures.
In most cases, imaging studies are not obtained for temporally located dermoids.1 However, in the case of an orbital dermoid cyst associated with a discharging sinus tract or fistula, preoperative computed tomography or magnetic resonance imaging may be advisable to define the extent of the lesion and exclude possible orbital abscess formation.5,6
Therapy for orbitofacial dermoid cysts is complete excision,1,2 which includes removal of the epithelial lining to prevent recurrence, as well as excision of any associated sinus tract or fistula that may be present. Removal is important for cosmetic reasons and to avoid complications, such as inflammation, infection, and malignant change.1
- Hong SW. Deep frontotemporal dermoid cyst presenting as a discharging sinus: a case report and review of literature. Br J Plast Surg. 1998;51:255–257. doi:10.1054/bjps.1997.0236 [CrossRef]
- Honig JF. A de novo discharging sinus of the fronto-orbital suture: a rare presentation of a dermoid cyst. J Craniofacial Surg. 1998;9:536–538.
- Parag P, Prakash PJ, Zachariah N. Temporal dermoid: an unusual presentation. Pediatr Surg Int. 2001;17:77–79. doi:10.1007/s003830000396 [CrossRef]
- Pollard ZF, Calhoun J. Deep orbital dermoid with draining sinus. Am J Ophthal. 1975;79:310–313.
- Shields JA, Kaden IH, Eagle RC Jr, Shields CL. Orbital dermoid cysts: clinicopathologic correlations, classification, and management. The 1997 Josephine E. Schueler Lecture. Ophthal Plast Recontsr Surg. 1997;13:265–276.
- Wells TS, Harris GJ. Orbital dermoid cyst and sinus tract presenting with acute infection. Ophthal Plast Reconstr Surg. 2004;20:465–7. doi:10.1097/01.IOP.0000144789.04263.19 [CrossRef]