Home surgery leads to persistent neck mass - Clinical Advisor

Home surgery leads to persistent neck mass

Slideshow

  • CA0811DermClin_2

A man aged 70 years presented with a slightly tender neck mass that had developed in the same location as a pea-sized nodule. The nodule had been present for at least 20 years and caused no problems until the patient tried to squeeze out the contents at home.

The man reported no illness, was afebrile and otherwise felt healthy. Other than the original nodule, he had no history of other similar lesions. The “boil” persisted despite two courses of oral antibiotics (cephalexin [Keflex] and trimethoprim/sulfamethoxazole [Bactrim, Septra]). A culture of the pus produced by the lesion showed mixed flora.
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Epidermal cysts are extremely common, especially in such areas rich in sebaceous glands as the face, neck, and chest. The cysts usually arise from the proliferation of epidermal cells within a circumscribed space in the dermis, the source of which...

Submit your diagnosis to see full explanation.

Epidermal cysts are extremely common, especially in such areas rich in sebaceous glands as the face, neck, and chest. The cysts usually arise from the proliferation of epidermal cells within a circumscribed space in the dermis, the source of which is almost always the follicular infundibulum.

The punctum, which is usually seen on the surface of the cyst, represents the follicle from which it derives. The cheese-like contents of the cyst, liberated by trauma, are chemo­tactic, drawing leukocytes into the area to phagocytize the offending material. The resulting inflammatory response manifests with acute redness, swelling, tenderness, increased warmth and often a tense collection of pus and semisolid material that can be odoriferous.

Similar cysts that result from traumatic implantation of epithelial elements are known as inclusion cysts. These are especially common on the hands but seldom become inflamed.

Since follicular disruption is important in the pathogenesis of epidermal cysts, multiple growths may occur in individuals with a history of significant acne vulgaris.

Gardner syndrome should be suspected in children who present with epidermal cysts or adult patients who develop cysts in such unusual locations as the legs.1 Multiple cysts can also be seen in those afflicted with nevoid basal cell carcinoma syndrome.2

The first-line of treatment for inflamed cysts is incision and drainage to dramatically reduce the associated discomfort. Over time, this treatment also results in steady shrinkage of the lesion, making it more amenable to eventual excision. Histologic examination of excised cysts shows acute and chronic granulomatous inflammatory infiltrate, while the cell type and architecture of its lining and contents confirms its infundibular origin.

Excision of epidermal cysts must be complete to prevent recurrence. Alternative treatment options for smaller inflamed cysts include intralesional steroid injection, which is not curative but does quickly reduce inflammation. In cases in which the cyst does not represent a problem, doing nothing is an acceptable approach, since these growths are completely safe.

Culture of inflamed vs. uninflamed epidermal cysts shows the same kinds and numbers of bacteria (essentially the same as that of normal skin flora).3 The erythema associated with inflamed cysts is limited to the immediate area of the cyst itself. In contrast, true carbuncles demonstrate a wide blush of erythema that extends far beyond the area of fluctuance. The curdy white contents and organized white wall of epidermal cysts are pathognomic for that diagnosis. Even though inflamed cysts do a fair imitation of a carbuncle, they are not the same. Arguably, antibiotics are only occasionally indicated, no matter how compelling their use may seem.

Epidermal cysts are the most commonly encountered type of cyst but not the only cyst of infundibular origin. A lining of stratified squamous epithelium is a key histologic feature of cysts of infundibular origin and is seen with milia, dermoid cysts, pilar cysts (the most common scalp cyst) and pilonidal cysts, among others.

Other types of cysts with a lining of nonstratified squamous epithelium include the hidrocystomas (apocrine and eccrine), bronchogenic, thyroglossal duct and brachial cleft cysts, among others.

Examples of cysts with no epithelial lining include digital mucous cysts, mucoceles, ganglions and auricular pseudocysts.

The term sebaceous cyst is commonly used for any cyst with keratinous contents, but this is inaccurate. The only cyst of truly sebaceous origin is the steatocystoma, which is filled with clear, oily fluid.

Lipomas and a variety of sarcomas are included in the differential diagnosis for subcutaneous firm masses. But epidermal cysts are so common as to be seen virtually every day in a busy dermatology practice. Their fluctuant feel, cheese-like contents, presence of at least one overlying punctum, and location within the sebaceous areas (i.e., face, neck, chest, back, and around the ears) all help to confirm the diagnosis.

In this case, incision and drainage of the patient’s epidermal cyst were carried out, liberating large amounts of semisolid odoriferous material, effectively flattening the lesion and reducing the man’s pain considerably.

Oral antibiotics and packing — both often used with carbuncles — were deemed unnecessary. Time and moist hot packs will almost certainly bring the patient’s cyst down to its previous pea size, at which point the plan is to excise it entirely to avoid a repeat episode.

Joe Monroe, PA-C, is a physician assistant specializing in dermatology at Springer Clinic in Tulsa, Okla. He has no relationships to disclose relating to the content of this article.


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References

1. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, Pa: Mosby; 2004:717.

2. Ho VCY. In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. New York, N.Y.: McGraw-Hill; 1999:884-885.

3. Diven DG, Dozier SE, Meyer DJ, Smith EB. Bacteriology of inflamed and uninflamed epidermal inclusion cysts. Arch Dermatol. 1998;134:49-51.

All electronic documents accessed July 15, 2011


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