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Excision of a Preauricular Cyst

Background

Preauricular cysts are a subset of asymptomatic, dome-shaped lesions referred to as epidermoid cysts. Cysts vary in size and have the ability to grow in diameter over time. These cysts can occur anywhere on the body and usually contain keratin. Upon examination of a suspected cyst, different characteristics can specify its type. Dermoid cysts are typically odorous lesions found around the eyes or on the base of the nose. If the cyst did not originate from sebaceous glands, it is not deemed a sebaceous cyst. Typically, surgical intervention is required to fully remove the cyst and prevent further infections or growth.

 Introduction

The video shows an 18-year-old female who presented with a preauricular cyst near her left ear. Upon history and physical examination, the mass was predicted to be a dermoid cyst rather than a sebaceous cyst. Surgical recommendations were given to perform an excisional biopsy of the cyst. The excision is displayed step-wise in the video.

Methods

A 2 cm incision was made just posterior to the lesion with a 15 blade scalpel. Dissection was carried with a sharp hemostat down the level of the parotid fascia. A 1 cm cystic structure was found adherent to the overlying dermis. An elliptical incision was then made over the mass and it was removed with the adherent overlying skin. The wound was then irrigated. Wound was closed in 3 layers. First, the deep layer was closed with 5-0 PDS in interrupted fashion, followed by 5-0 monocryl in running subcuticular fashion, followed by Dermabond

Results

The patient was returned to the care of anesthesia where she was awoken, extubated, and transported to PACU in stable condition. The patient tolerated the procedure well and was discharged the same day.

The specimen was sent for pathological analysis. The pathology report showed that the mass was an epidermal inclusion cyst.

Patient was consented in the preoperative area and brought back to the operating room and placed under general anesthesia. Facial nerve monitoring was used for this procedure due to the proximity of the lesion to the facial nerve. The patient’s left preauricular area was prepped and draped in the standard fashion. A 2 cm incision was made just posterior to the lesion with a 15 blade scalpel. Dissection was carried with a sharp hemostat down the level of the parotid fascia. The facial nerve was not encountered during this dissection. A 1 cm cystic structure was found adherent to the overlying dermis. An elliptical incision was then made over the mass and it was removed with the adherent overlying skin. The specimen was sent for pathological analysis. The wound was then irrigated. Wound was closed in 3 layers. First, the deep layer was closed with 5-0 PDS in interrupted fashion, followed by 5-0 monocryl in running subcuticular fashion, followed by Dermabond. The patient was returned to the care of anesthesia where she was awoken, extubated, and transported to PACU in stable condition. The patient tolerated the procedure well and was discharged the same day. The pathology report showed that the mass was an epidermal inclusion cyst.
Identifiable mass bothersome to the patient/family Recurrent infection requiring many rounds of systemic antibiotic therapy Enlarging or painful mass leading to impingement or invasion of surrounding structures (i.e. cranial nerve 7, parotid gland, mandibular joint range of motion, et cetera) Excision is diagnostic as well as therapeutic
Patients who do not respond well to anesthesia (i.e. malignant hyperthermia) - may consider in-office excision of cyst under local anesthesia Patients with active infection who require anti-inflammatory medications or antibiotics
Patient was placed in the supine position and administered general anesthesia. Sterile technique - drapes, betadine prep, etc. Facial nerve monitoring system Lidocaine for local anesthesia with epinephrine for hemostasis Needles and syringes required for injection of local anesthetic Sterile saline for irrigation Suction set-up Marking pen Scalpel (15 blade) DeBakey forceps Bovie or Bipolar cautery Iris scissors Hemostats Needle driver Adson tissue forceps with teeth Suture scissors 5-0 PDS suture 5-0 monocryl suture Dermabond
Thorough history and physical examination Thorough cranial nerve examination Personal or family history of bleeding disorders History of prior surgery Family history or patient history of prior issues with anesthesia Consideration of imaging (i.e. CT or ultrasound imaging of mass) Consideration of fine needle aspiration of mass May require pre-operative risk stratification prior to surgery if multiple medical comorbidities Hold anticoagulation or anti-platelet medications prior to surgery Consider obtaining pre-operative blood work such as PT, INR, PTT, BMP, and CBC
Parotid Fascia Facial nerve anatomy
Advantages: Removal of undesirable mass Preventing need for recurrent systemic antibiotics Diagnosis of the mass and determining whether further treatment is required Disadvantages: Potential for poor wound healing or scarring Exposure to general anesthesia Excision in the operating room is more costly than under local anesthesia in the office
Complications/Risks Bleeding Infection Violation of cyst capsule Recurrence of lesion post-operatively Injury to branches of the facial nerve
None
Arkansas Children’s Hospital Department of Pediatric Otolaryngology
1. Zuber, T. (2019). Minimal Excision Technique for Epidermoid (Sebaceous) Cysts. [online] Aafp.org. Available at: https://www.aafp.org/afp/2002/0401/p1409.html [Accessed 29 Jul. 2019]. 2. Weir CB, St.Hilaire NJ. Epidermal Inclusion Cyst. [Updated 2019 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532310/ 3. Flint P, Cummings C. Cummings Otolaryngology. Philadelphia, Pa: Elsevier, Saunders; 2015:286-290.

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