What is the recommended treatment for a dermoid cyst in the neck?

Management of Dermoid Cysts in the Neck

Complete surgical excision is the recommended treatment for dermoid cysts in the neck to prevent recurrence and potential complications. 1, 2

Diagnosis and Evaluation

• Dermoid cysts are benign congenital tumors (choristomas) that may contain complex structures like hair, teeth, and cartilage due to their developmental origin 3, 2
• Imaging studies are essential for diagnosis and surgical planning:
  • MRI is preferred as it can show characteristic features including fatty and calciferous content that may be pathognomonic 3, 4
  • Ultrasound typically shows hyperechoic components with acoustic shadowing, hyperechoic lines and dots, and sometimes fluid-fluid levels 3, 2
• A targeted physical examination should be performed for patients with neck masses to rule out malignancy, especially if the mass has been present for ≥2 weeks without fluctuation, is fixed to adjacent tissues, firm in consistency, >1.5 cm, or has ulceration of overlying skin 1

Surgical Management

• Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles 1
• For dermoid cysts in the neck:
  • Complete surgical excision is the treatment of choice to avoid complications and prevent recurrence 5, 6, 7
  • The surgical approach should be planned based on the location and extent of the cyst 3
  • Imaging should be performed prior to surgery to rule out intracranial or intraorbital extension, which occurs in approximately 4% of cases 6

Special Considerations

• Gram stain and culture of pus from inflamed epidermoid cysts are not recommended 1
• Antibiotics are rarely necessary for inflamed cysts unless there are complicating factors such as:
  • Multiple lesions
  • Cutaneous gangrene
  • Severely impaired host defenses
  • Extensive surrounding cellulitis
  • Severe systemic manifestations of infection 2
• In pediatric patients, dermoid cysts are often diagnosed at a median age of 22 months, with periorbital (61%) and neck (18%) being the most common locations 6
• Fine needle aspiration (FNA) should be performed instead of open biopsy for neck masses deemed at increased risk for malignancy when the diagnosis remains uncertain 1

Follow-up and Prognosis

• With complete excision, recurrence is unusual (reported in only 1 out of 49 patients in a pediatric study) 6
• For cystic neck masses, evaluation should continue until a definitive diagnosis is obtained and clinicians should not assume the mass is benign 1
• Patients should be advised of criteria that would trigger the need for additional evaluation, and a plan for follow-up should be documented to assess resolution or final diagnosis 1

Potential Complications

• Untreated dermoid cysts may lead to:
  • Infection
  • Rupture causing inflammation
  • Pressure on adjacent structures
  • Rarely, malignant transformation (more common in older patients) 3, 2
• Large dermoid cysts in the neck can mimic other cystic lesions such as cystic hygromas, making accurate diagnosis crucial for appropriate management 4