This is a case of an 8 month old with a midline nasal mass present since birth. Preoperative physical exam and imaging was consistent with a nasal dermoid cyst with no evidence of intracranial extension.
An elliptical skin incision overlying the cyst is made and 1% lidocaine with epinephrine is injected into the skin. A 15 blade is then used to make the overlying incision through the epidermis and dermis. Blunt and sharp dissection using a hemostat and scissors is used to follow the tract down to the level of the nasal bones. Care should be taken to ensure the entire tract is isolated to its termination. If the tract is disrupting the nasal bones, an osteotome can be used to carefully lateralize the overlying nasal bones allowing for complete dissection of the cyst and its tract. A dissector (such as a cottle or rhoton) can be used to dissect the cyst off the surrounding tissues. Once you are confident you have completely released the cyst from the tissues, the deep aspect can be transected which is often fibrous tissue. The wound is irrigated and then sutures may be used to re-approximate the nasal bones in a simple interrupted fashion. If a large bony defect is present, bone material can be used to fill the space. The wound is then closed in layers.
Nasal dermoid cysts in the midline which have been proven to show no intradural extension of glial components can be removed with this technique. Although at an early age the lesion may not cause significant cosmetic consequences, as the patient grows, the lesion can also grow causing further mass effect on the nasal bones and nasal architecture and can become infected leading to a more complicated course.
Encephalocele, nasal glioma. If less than 1 year of age and asymptomatic, observation with later excision is recommended.
General anesthesia is necessary in children. The entire nose should be visible to ensure proper anatomical positioning and for achieving a cosmetic closure. The patient should be placed supine, draped, and the skin prepped with betadine.
Midline nasal masses are present due to erroneous closure of embryologic spaces which can lead to trapped neural or epithelial elements. Because these masses could involve neural tissue, such as a glioma or encephalocele and up to 19%  have been seen to have intracranial extension, it is crucial to ensure a complete work up. Work up for these patients includes a thorough history and physical exam to access for progression and other notable lesions the patient might have. Depending on the age of the patient, it also might be appropriate to perform a fiberoptic flexible endoscopy to see if the extent in the nasal cavity, assess for CSF leak or see if the mass appears to trans illuminate. Finally, MRI is essential to evaluate for intracranial connection. CT scans can also be useful to assess the extent of involvement of the nasal bones and skull base, however it may not be necessary as there is a small risk with radiation exposure.
This surgical approach allows for direct access and visualization of the cyst and any tracts it may have which would be much more difficult it an endoscopic approach. It also allows for small osteotomies to easily be made if the cyst is deep to the nasal bones. While a disadvantage is potential poor cosmetic outcome and possible scarring, as long as care is taken to properly close the incision, this risk is small which might be avoided endoscopically.
Open roof deformity, saddle nose deformity, possible intradural extension which was not apparent on imaging, infection, seroma, poor cosmetic outcome, and recurrence.
None to disclose.
Herrington H, Adil E, Moritz E, et al. Update on current evaluation and management of pediatric nasal dermoid. Laryngoscope. 2016;126(9):2151–2160. https://pubmed.ncbi.nlm.nih.gov/26891409/