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Giant Cystic Lesion in the Floor of Mouth

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 30s presented with a 1-year medical history of a painless, slowly enlarging, midline neck mass without associated dysphagia, odynophagia, weight loss, or history of infection. The mass was soft, mobile, and compressible in midline level IA, measuring 7 cm and posterior-superiorly displacing the tongue. The mass was visible as a clear blue lesion in the floor of the mouth and was nontender. Computed tomographic (CT) scan of the neck with IV contrast was performed (Figure). The patient was taken to the operating room for a successful combined intraoral and transcervical approach to excision.

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B. Epidermoid cyst

Epidermoid cysts (ECs) are classically small, benign, cystic masses with 32% of lesions occurring in the head and neck.1 They usually arise because of failure of primitive epithelial cells to separate from underlying deep tissue during branchial arch formation.2 True ECs are fluid-filled lesions lined by simple squamous epithelium and a layer of keratin. They have been referred to by other terms such as epidermal cysts, epidermal inclusion cysts, sebaceous cysts, and seborrheic cysts. However, the terms “seborrheic cysts” and “sebaceous cysts” are misnomers, not synonymous with epidermoid cysts. Epidermoid cysts are normally close to the skin and can be located anywhere on the face, scalp, and neck. However, in the deep tissue planes, ECs in the head and neck make up only 1.6% to 6.9% of cases in the entire body.3

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Article Information

Corresponding Author: Nicholas Rossi, BA, University of Texas Medical Branch, School of Medicine, 301 University Blvd, Galveston, TX 77550 (narossi@utmb.edu).

Published Online: April 11, 2019. doi:10.1001/jamaoto.2019.0320

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Nigam  JS, Bharti  JN, Nair  V,  et al.  Epidermal cysts: a clinicopathological analysis with emphasis on unusual findings.  Int J Trichology. 2017;9(3):108-112. doi:10.4103/ijt.ijt_16_17PubMedGoogle ScholarCrossref
2.
Shivakumar  MS, Yogesh  TL, Nagaraj  T, Sinha  P.  Epidermoid inclusion cyst of buccal mucosa: a rare case report.  Int J Med Den Case Report. 2015;Article ID 050115:1-3. doi:10.15713/ins.ijmdcr.46.Google Scholar
3.
Teszler  CB, El-Naaj  IA, Emodi  O, Luntz  M, Peled  M.  Dermoid cysts of the lateral floor of the mouth: a comprehensive anatomo-surgical classification of cysts of the oral floor.  J Oral Maxillofac Surg. 2007;65(2):327-332.PubMedGoogle ScholarCrossref
4.
Branham  G, Compton  A, Council  M. Recognition and Treatment of Skin Lesions. 6th ed. In  Cummings Otolaryngology. Mosby Inc; Maryland Heights, Missouri. 2015:286-297.e2.
5.
Fuchshuber  S, Grevers  G, Issing  WJ.  Dermoid cyst of the floor of the mouth—a case report.  Eur Arch Otorhinolaryngol. 2002;259(2):60-62.PubMedGoogle ScholarCrossref
6.
Burger  MF, Holland  P, Napier  B.  Submental midline dermoid cyst in a 25-year-old man.  Ear Nose Throat J. 2006;85(11):752-753.PubMedGoogle ScholarCrossref
7.
Coit  WE, Harnsberger  HR, Osborn  AG, Smoker  WR, Stevens  MH, Lufkin  RB.  Ranulas and their mimics: CT evaluation.  Radiology. 1987;163(1):211-216. doi:10.1148/radiology.163.1.3823437PubMedGoogle ScholarCrossref
8.
Mittal  MK, Malik  A, Sureka  B, Thukral  BB.  Cystic masses of neck: a pictorial review.  Indian J Radiol Imaging. 2012;22(4):334-343. doi:10.4103/0971-3026.111488PubMedGoogle ScholarCrossref
9.
Koca  H, Seckin  T, Sipahi  A, Kazanc  A.  Epidermoid cyst in the floor of the mouth: report of a case.  Quintessence Int. 2007;38(6):473-477.PubMedGoogle Scholar
10.
Kang  SG, Kim  CH, Cho  HK, Park  MY, Lee  YJ, Cho  MK.  Two cases of giant epidermal cyst occurring in the neck.  Ann Dermatol. 2011;23(suppl 1):S135-S138. doi:10.5021/ad.2011.23.S1.S135PubMedGoogle ScholarCrossref
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