Imaging and surgical approach of nasal dermoids,☆☆

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Abstract

Objective: Determine the most accurate and cost effective radiographic evaluation for nasal dermoids. Determine the best surgical approach for excision of nasal dermoids. Design: Retrospective chart review. Setting: Division of Pediatric Otolaryngology, Children's Hospital and Health Center, San Diego, California. Participants: All patients with nasal dermoids evaluated and treated from 1990 to 2000. Intervention: Preoperative radiographic evaluation and surgical excision. Outcome measures: Accuracy of CT and MRI correlated with surgical findings and results. Results: Ten patients were identified with the diagnosis of nasal dermoid. The age at diagnosis ranged from 0 to 24 months, with a mean of 3 months. Six children presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. Six children underwent a computed tomogram with contrast of the head. Seven children underwent a MRI study of the head. Three children underwent an initial CT followed by MRI. Twenty percent of children were found to have intracranial extension. CT scan accurately diagnosed intracranial extension in one case, was indeterminate in a second case and falsely positive in a third case. MRI correctly diagnosed intracranial extension in two cases and had no false positive or false negative results. No children were found to have associated intracranial anomalies. In the early years of the review, a simple excision was made over the mass with blunt and sharp dissection for removal. (An external rhinoplasty incision is now used with better exposure and improved cosmetic results.) In cases with intracranial communication, a combined approach of external rhinoplasty and craniotomy was used. Conclusions: MRI alone is the most cost effective and accurate means of evaluating nasal dermoids and is essential for preoperative planning. The surgical approach of choice is external rhinoplasty for both cosmetic reasons and exposure of nasal dermoids with and without intracranial extension.

Introduction

Midline congenital lesions of the nose are rare. The incidence of encephaloceles, gliomas and nasal dermoids is estimated at 1 in 20,000–40,000 births [1], [2], [3], [4]. Nasal dermoids are the most frequently encountered of these congenital midline lesions. Nasal dermoids account for 1–3% of all dermoid cysts and 4–12% of cervicofacial dermoids [1], [5]. The potential for intracranial extension is a major concern in these anomalies.

Nasal dermoids, gliomas and encephaloceles are congenital malformations of ectopic neuroectoderm. In the midface, it is believed that failure of the fonticulous frontalis to fuse, or failure of the foramen cecum at the base of the frontal bones to obliterate, leaves a pathway for neural tissue to extend into the prenasal space. Persistence of neural tissue results in nasal gliomas and encephaloceles. Retraction of neural tissue as the fetus develops may cause involution of ectoderm leading to dermoid sinuses and cysts with the potential for intracranial extension [4].

Nasal dermoid sinuses and cysts may present as midline pits, fenestrae or discrete masses. Dermoids may appear anywhere from the glabella, along the bridge of the nose, to the base of the columella. They are non-compressible, non-pulsatile, do not transilluminate and frequently have hair protruding from an ostium. These lesions do not enlarge when the patient cries, and the Furstenberg test (enlargement with compression of the jugular veins) is negative. There may be intermittent discharge of sebaceous material and/or pus, intermittent inflammation, osteomyelitis, local abscess, broadening of the nasal root or bridge and intracranial complications. Potential intracranial complications include meningitis, cerebral abscess, cavernous sinus thrombosis and periorbital cellulitis [1], [2], [3], [4], [5].

This retrospective study evaluates the clinical presentation, computed tomography (CT), magnetic resonance imaging (MRI) and surgical findings of 10 nasal dermoids treated in the Division of Pediatric Otolaryngology, Children's Hospital San Diego from 1990 to 2000. Specifically, the contribution of CT and MRI in determining intracranial extension for preoperative surgical planning was evaluated.

Section snippets

Materials and methods

A retrospective review of all patients with nasal dermoids treated in the Division of Pediatric Otolaryngology, Children's Hospital and Health Center, San Diego, California during the 10-year period from 1990 to 2000 was performed. Ten cases were identified by the international code of diseases-9 (ICD 9). After obtaining IRB approval, a standardized data sheet was used to retrieve the following information from the charts: sex, age at diagnosis, history, physical examination, imaging diagnostic

Results

A total of 10 patients were identified with the diagnosis of nasal dermoid, including five boys and five girls (Table 1). The age at diagnosis ranged from 0 to 24 months of age, with a mean of 3 months. Seven children were diagnosed at birth. Six patients presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. All lesions were soft, non-tender, non-inflammatory subcutaneous masses that were

Discussion

Nasal dermoid sinuses and cysts should be surgically removed as early as possible to avoid bony atrophy and/or distortion of the nasal bones and cartilage that may occur from expansion of the mass. Early excision also decreases the risks for local infection and intracranial complications. Complete excision as early as 6 months of age has been advocated [12].

The diagnosis of nasal dermoid mandates preoperative radiographic imaging in all cases. Imaging may suggest or eliminate the diagnosis of

Conclusion

In conclusion, nasal dermoids are uncommon congenital midline lesions presenting with nasal swelling or a sinus tract opening to the skin. External rhinoplasty approach is the current treatment of choice for most lesions. It provides good exposure, allows complete excision of the lesion and has excellent cosmetic results. External rhinoplasty can be combined with craniotomy when intracranial extension is found on preoperative imaging. MRI alone is a cost effective and accurate means of

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Presented at the 16th Annual Navy Academic Research Competition, Naval Medical Center San Diego, San Diego, CA, USA, April 2001. Presented at the Annual Society of Pediatric Otolaryngology, Scottsdale, AZ, USA, May 2001.

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The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

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