DERMATOLOGY

Nasal Dermoid Cyst

March 7, 2018

Authors:

Sarah Utz, BA
Icahn School of Medicine at Mount Sinai, New York, New York

Lauren Geller, MD
Departments of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York

Citation:

Utz S, Geller L. Nasal dermoid cyst [published online March 5, 2018]. Consultant for Pediatricians.

 

An 8-year-old boy presented to a pediatric dermatology office with an asymptomatic bump on his nose. His parents had first noticed it when the patient was approximately 1 year old, but over the past year, the lesion had increased in size. The boy denied headaches, nausea, dizziness, or discharge from the lesion.

Physical examination. Upon physical examination, the patient had a 1.7-cm skin-colored nodule on the midline nasal tip (Figure). There was no erythema, crust, or discharge.

 

dermoid cyst
Figure. Skin-colored nodule on the midline nasal tip

 

Diagnostic testing. An ultrasonogram showed an avascular ovoid hypoechoic lesion, suggesting a cyst. A magnetic resonance imaging (MRI) scan showed a hyperintense nodule within the midline tip of the nose, extending posteriorly, and a small defect of the midline frontal bone reaching at least the level of the dura, consistent with a dermal sinus tract with possible intracranial connection. The patient underwent successful neurosurgical removal of the lesion and has not had a recurrence of the cyst or further complications.

Discussion. Midline congenital nasal anomalies such as dermoid cysts are rare, with an estimated prevalence of 1 in 20,000 to 1 in 40,000 births.1 Of all midline congenital nasal lesions, the dermoid cyst is thought to be the most common.2 Dermoid cysts most commonly occur at the lateral eyebrow but can also present as midline nasal lesions. They can appear as a subtle dimple, pit, or, as in our case, a firm raised papule that is neither compressible nor pulsatile and does not transilluminate.3 The first step in management is ultrasonography to determine the nature of the lesion. If the results of the scan suggest a dermoid cyst, T1- or T2-weighted MRI should be ordered to assess for intracranial extension. Surgical excision is the mainstay of treatment to prevent local or intracranial infection.

Differential diagnosis. The differential diagnosis of congenital midline nasal lesions includes nasal gliomas, encephaloceles, and hemangiomas. Nasal gliomas are benign masses composed of ectopic neural tissue.3,4 They often present as well circumscribed, firm, noncompressible, bluish or purple masses that, like dermoid cysts, do not transilluminate. There is no intracranial connection and therefore no fluctuation in size with changing intracranial pressure. Encephaloceles are caused by a defect in the closure of the skull and dura with resulting herniation of the brain. They appear as large, soft, bluish frontal masses, often resulting in broadening of the nasal bridge. Unlike dermoid cysts and nasal gliomas, encephaloceles have a patent intracranial extension and therefore tend to compress, transilluminate, and increase in size with change in intracranial pressure.3,4 Infantile hemangiomas are benign vascular tumors that can also appear as bluish subcutaneous masses when they involve the nasal tip. They follow a predictable natural history, initially undergoing a period of proliferation and then, after 1 year, slowly involute, which was not the case with our patient.

It is important to recognize and differentiate these midline nasal anomalies, because they can be associated with significant morbidity. While management of these lesions generally requires referral to a dermatologist, a neurosurgeon, and/or a plastic surgeon, the pediatrician is often the first to see the patient and is essential in the initial diagnosis.

References:

  1. Zapata S, Kearns DB. Nasal dermoids. Curr Opin Otolaryngol Head Neck Surg. 2006;14(6):406-411.
  2. Ramos SD, Mukerji SS, Riascos-Castaneda R. A nasal mass. Nasal dermoid ND cyst. JAMA Otolaryngol Head Neck Surg. 2013;139(7):745-746.
  3. Paller AS, Pensler JM, Tomita T. Nasal midline masses in infants and children: dermoids, encephaloceles, and gliomas. Arch Dermatol. 1991;127(3):362-366.
  4. Hedlund G. Congenital frontonasal masses: developmental anatomy, malformations, and MR imaging. Pediatr Radiol. 2006;36(7):647-662.