Dermoid cyst – eyelid diseases – central lakes medical

INTRODUCTION Dermoid cysts are congenital choristomas containing components of both the epidermis and skin appendages. They account for 15-20% of all eyelid lesions in childhood. These cysts can occur as superficial, subcutaneous, or deep eyelid and orbital lesions. They presumably result from entrapment of skin along embryonic closure lines. Attachment to underlying bony sutures often is present and most commonly involves the frontozygomatic suture. Lesions may extend posteriorly into the orbit and into soft tissues such as the lacrimal gland. Erosion or remodeling of bone can occur. Dermoid cysts of conjunctival origin are usually located in the medial conjunctiva, caruncle, or orbit and appear to represent sequestration of epithelium destined to become caruncle.

CLINICAL PRESENTATION Superficial lesions usually are recognized in early childhood and present as somewhat fluctuant round, slowly enlarging, non-tender masses beneath the skin of the upper eyelid. Most commonly they are seen in the lateral upper eyelid and brow region, but can be seen medially as well. Very rarely, they may be bilateral. Deeper orbital dermoids may not become clinically evident until adulthood. Eyelid dermoid cysts are usually freely movable, but can be more firmly adherent to the underlying periosteum. They may become irritated and inflamed with repeated manipulation causing eyelid edema. They range in size from less than one, to several centimeters and rarely can be sufficiently large to partially close the lid or press on the globe resulting in amblyopia. Less commonly, the clinical presentation may be orbital inflammation, incited by leakage of oil and keratin from the cyst.

HISTOPATHOLOGY These cysts are lined by keratinized, stratified squamous epithelium, identical to that of the epidermis, with adnexal structures including sebaceous and eccrine glands and hair follicles. The cyst cavity contains keratin, hair shafts, and sebaceous secretions. If the cyst ruptures, it incites an intense granulomatous inflammatory response. Occasional specimens submitted for histopatho-logical analysis will show only keratin debris, hair fragments, and a granulomatous reaction.

TREATMENT These lesions are benign and when small can safely be observed. In most cases, however, cosmetic issues warrant treatment. Management is with complete surgical excision which can usually be accomplished through an upper eyelid crease incision, even for lesions under and above the brow. Preoperative orbital imaging is indicated if the entire cyst cannot be palpated or if they are fixed to periosteum and orbital extension is suspected. The surgeon must be prepared to manage an occult extension into the orbit or into the intracranial cavity. Recurrences are rare, but can occur if the lesion is rupture during removal.

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