Local Examination of a Suspected Dermoid Cyst
The proper local examination of a suspected dermoid cyst should focus on assessing size, mobility, consistency, location, and signs of complexity or inflammation to guide surgical planning and rule out malignancy. 1, 2
Key Physical Examination Features
Essential Characteristics to Document
Size and volume: Measure the maximum dimension of the mass, as cysts >10 cm require surgical intervention and larger cysts may indicate increased complexity 3, 4
Mobility assessment: Test whether the cyst is mobile or fixed to adjacent tissues—immobility is present in all complex dermoids and suggests deeper extension or complications 4, 1
Consistency: Palpate for firmness versus fluctuance; dermoid cysts typically feel firm due to their keratinous and fatty content, unlike simple fluid-filled cysts 2, 5
Location specificity: Document the precise anatomic location, as this determines surgical approach and risk of complications 1, 5
Red Flags Requiring Urgent Evaluation
Fixed mass to adjacent tissues: This finding warrants immediate imaging as it may indicate malignancy or complex extension 1
Overlying skin changes: Look for ulceration, erythema, or warmth suggesting inflammation, rupture, or rarely malignant transformation 1, 2
Size >1.5 cm with firm consistency: Masses meeting these criteria require evaluation to rule out malignancy, especially if present ≥2 weeks 1
Orbital signs (for head/neck dermoids): Proptosis, diplopia, or restricted eye movement indicate complex dermoid requiring preoperative imaging 4
Location-Specific Examination Considerations
Head and Neck Dermoids
Frontonasal dermoids: May appear innocuous like pimples or comedones; attempt to express contents—sebaceous or creamy fluid suggests dermoid, while clear CSF drainage indicates intracranial extension 6
Parieto-occipital dermoids: Look for surrounding hair whorls ("horse collar" pattern) and palpate for underlying bony defects 6
Oral cavity dermoids: Assess impact on deglutition and airway patency, as floor-of-mouth dermoids can cause respiratory obstruction 5
Ovarian/Pelvic Dermoids
Bimanual pelvic examination: Assess adnexal masses for size, mobility, and tenderness; however, ultrasound is superior and should follow immediately 6
Abdominal examination: Palpate for masses extending above the pelvis, which may indicate cysts >10 cm requiring surgical intervention 3
Critical Pitfalls to Avoid
Do not assume benignity: Continue evaluation until definitive diagnosis is obtained, as malignant transformation can occur, particularly in postmenopausal patients 1, 3
Do not perform open biopsy: If malignancy risk is elevated, fine needle aspiration is preferred over open biopsy to avoid potential seeding 1
Do not overlook inflamed cysts: Inflammation typically results from cyst wall rupture rather than infection; gram stain and culture are not recommended for routine inflamed epidermoid cysts 6, 2
Do not delay imaging for complex features: Any dermoid with immobility, orbital signs, or concerning features requires imaging before surgical planning 1, 4
When Antibiotics Are Indicated
Systemic antibiotics are rarely necessary for inflamed dermoid cysts unless specific complications exist: 6, 2
- Multiple lesions
- Cutaneous gangrene
- Severely impaired host defenses
- Extensive surrounding cellulitis
- Severe systemic manifestations (high fever, sepsis)
Documentation Requirements
Record all examination findings systematically: Size, location, mobility, consistency, overlying skin condition, and any associated symptoms 1
Document criteria triggering additional evaluation: Establish a follow-up plan to assess resolution or obtain final diagnosis 1
Note any changing characteristics: Changing morphology or developing vascular components indicate need for surgical intervention 3