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Giant neck cyst not only a surgical concern

Molina, Gabriel A; García, Cristhian R; De La Torre, Diego X; Gonzalez, Daniela A

doi: 10.4103/ijssr.ijssr_11_18
Case Report

Epidermoid cysts are slow-growing, usually benign lesions that derive from an abnormally located ectodermal tissue. Epidermoid cysts can appear anywhere on the body; they are usually small and frequently asymptomatic. Giant cysts are rare, with few cases ever described. We report a case of a 66-year-old male, with a giant mass in the neck that developed over the last 10 years. Due to geographic limitations and lack of access to health care, he allowed the mass to grow to giant proportions. Surgical treatment was decided, and the patient underwent full recovery. Giant epidermoid neck cyst was the final diagnosis.

PGY3 General Surgery Program, P.U.C.E, Quito-, Ecuador

Head and Neck Surgery Department at Hospital Eugenio Espejo, Quito-, Ecuador

General Practitioner at Hospital Eugenio Espejo, Quito-, Ecuador

PGY2 Anesthesiology Program U.C.E, Quito-, Ecuador

Address for correspondence:Gabriel Molina, PGY3 General Surgery Program, P.U.C.E, Quito, Ecuador

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Epidermoid cysts are usually benign lesions, characterized by cystic spaces lined by simple squamous epithelium. 1 They appear in hair-bearing skin areas, including the scalp, face, neck, and trunk. 2 They are typically slow-growing lesions that grow to 1–5 cm in diameter and are usually asymptomatic. 3 Unusual symptoms such as headaches, infections, or even psychological alterations have also been reported. 2 , 4 Lesions over 5 cm in size are rare, with few cases ever reported. 1 , 4 Treatment is surgical, and complete excision is recommended. 2 , 3 We report a case of a 66-year-old patient with a giant cystic mass on the neck; surgery was decided and he underwent full recovery. Giant epidermoid neck cyst was the final diagnosis.

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Case Report

The patient is an illiterate 66-year-old male without any medical history other than a neck reconstructive surgery due to a neck and upper chest gasoline burn during infancy.

He presented to the doctor's office referred by a primary care physician because of a giant cervical mass. The patient initially became aware of the mass in the midline of the neck just above his burn scars, 5 years after his reconstructive surgery.

He remarked to us that the mass had been growing in size over the last 10 years; however, during the last year, he noticed that the weight of the mass caused severe headaches. Moreover, the patient revealed depression and had developed social anxiety as a result of the cosmetic difficulties caused by the mass. Furthermore, due to lack of sufficient access to health care because of his geographic location and the fact that he was ashamed of the mass, he did not search any medical attention.

Clinical examination revealed a large superficial (10 cm × 10 cm) movable and well-defined cervical mass in the midline of the neck Figure 1a and Figure 2a; he had mild pain when the lesion was pressed. No signs of dysphagia or respiratory distress were evident.

Figure 1

Figure 1

Figure 2

Figure 2

Contrast-enhanced computed tomography revealed an 11 cm × 10 cm × 8 cm cystic tumor located below the platysma in the midline of the neck. The tumor was near the major vessels of the neck; however, no infiltration or lymph nodes were evident Figure 3a.

Figure 3

Figure 3

Due to the size mass, a head-and-neck surgeon consultation was required, and surgery was planned.

At surgery, a 10.5 cm × 10 cm × 7.5 cm subplatysmal cystic mass was identified. It had an elastic texture and was attached to the strap muscles without invading them. No lymph nodes were evident. Complete excision was achieved, and a drain was left in place Figure 1b.

Pathology revealed a cystic tumor with an encapsulated reddish surface; at cut, the yellowish liquid was evidenced; the wall thickness was 0.1–0.2 cm and was lined by a keratinized stratified squamous epithelium. Epidermoid cyst was the final diagnosis Figure 2b.

The postoperative course of the patient was uneventful; due to the low and serous production of the cervical drain, it was removed on the 4 thpostoperative day Figure 3b. After this, the patient was discharged without any complications. Postoperative instructions were simple: keep wound clean and contact immediately if there is any bleeding or pain. After 2 months on follow-up controls, the patient is well. Wound seemed fine without signs of infection, and no other neck lesion was evident. He told us that after his successful surgery, he had overcome his shame and no longer had depression.

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Cystic lesions are usually benign lesions, characterized by cystic spaces lined by simple squamous epithelium (epidermoid cyst), containing skin adnexa (dermoid cyst) or tissues of all three germ layers (teratoid cyst). 5 When they occur in the head or neck, they are usually benign and can appear in the scalp (34%), neck (18%), periorbital area (17%), cheeks (16%), periauricular area (9%), and nasal area (6%). 1

The epidermoid cyst is a lesion, filled with keratin and imprisoned by stratified squamous epithelium similar to the skin. 3 It can be divided into a congenital and acquired type. 4 Congenital is derived from the entrapment of surface epithelium, and the acquired type is believed to originate through implantation of epithelium by either surgical or accidental trauma into deeper mesenchymal tissues. 4 Due to patient burns, and previous surgery, the acquired type was suspected in our case. Epidermoid cysts are usually slow-growing lesions that grow to 1–5 cm in diameter and are usually asymptomatic. Due to this, the patient usually cannot associate the lesion with a possible suffered trauma. 3 They clinically present as a flabby mass over the face or neck. They appear to be more frequent in the third decade, 3 and males are usually more affected. 1 , 3

Epidermoid cysts with a diameter ≥5 cm are rare, with few cases ever reported. 2 , 3 A lesion >5 cm in size could be locally aggressive and may potentially harbor a malignant tumor. However, this is extremely rare. 1 , 4 Nevertheless, when they do grow, they are easier to rupture, and this may induce infection and also they may compress adjacent organs, including major arteries, veins, and nerves. 3 , 5 Furthermore, giant masses may cause cosmetic or even depression and anxiety due to the high visibility of the head and neck. 2 Unusual manifestations such as a headache, obstructive sialadenitis, and facial asymmetry have also been reported. 4

Our patient had severe headaches, and expressed depression and social anxiety because of the growing mass; in addition, due to limited health care access, the mass continued to grow over the past 10 years.

Diagnosis is mostly made by image. It can differentiate cystic masses from solid lesions and assess their luminal content. 4 Cysts can also be punctured by fine-needle aspiration or excision biopsy. 5 However, regardless of the location of the cystic mass, surgical intervention is necessary. It is recommended to remove as much of the capsule of the cystic contents to prevent any recurrences. 1 , 3 , 4 Histologically, they have a cystic wall lined with keratinized stratified squamous epithelium. Epidermoid cysts have a shiny, smooth, waxy keratinous content. Unlike dermoid cyst, they exhibit no adnexal structures such as hair follicle, sebaceous glands, and sweat glands. 6 Microscopic examination remains the primary means of diagnosing epidermoid cysts. 4 Due to the size of the mass and clinical condition of our patient, surgery was decided, and treatment was straightforward. Complete excision was achieved and the patient fully recovered. Not only were the headaches resolved but also his mental health and behavior with his social environment improved considerably.

Learning points

Even if it is rare, neck epidermoid cyst size can compromise any patient's mental health and social behavior. Timely detection could avoid all these scenarios and all its social, affective, and physical ramifications. In addition, in a unique way, it proves that cystic neck masses can grow to gigantic proportions if left untreated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest

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6. Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP, et al The SCARE statement: Consensus-based surgical case report guidelines Int J Surg. 2016;34:180–6
7. . .;:

    Epidermoid cyst; giant cyst; neck

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