Cyst Important Question And Answers

CYST

Question 1. Write a short note on the sebaceous cyst.
Or
Write a short answer on the sebaceous cyst.

Answer. A sebaceous cyst is also called as epidermoid cyst.

• This occurs due to obstruction of sebaceous ducts, resulting in the accumulation of sebaceous material.
• The sebaceous material becomes enlarged due to the retention of its sebum. So it is also called a retention cyst.
• The cyst is lined by squamous epithelium material with an unpleasant smell.
• In the center of the cyst a black spot is found, it is keratin filed punctum.
• Site: Scalp, face, back, scrotum, etc. The sebaceous cyst may occur anywhere in the body where there are sebaceous glands.

Sebaceous Cyst Clinical Features

• It is a painless swelling that is smooth, soft, non-tender, freely mobile, adherent to the skin especially over the summit, fluctuant, and non-transilluminating with punctum over the summit.
• Cyst molds on finger indentation.
• The punctum is present over the summit in 70% of cases because the sebaceous duct opens directly in the skin which gets blocked.
  The punctum is the black-colored spot over the summit of the sebaceous cyst.
• Hair loss over the surface is common because of constant pressure over the roots of the hair follicle.
• The unpleasant odor of sebum content is typical.

Read And Learn More: General Surgery Question And Answers

Sebaceous Cyst Complication

• Infection and abscess formation
• The surface gets ulcerated leading to the formation of a painful fungating mass with discharge known as Cock’s peculiar tumor which resembles epithelioma.
  Cock’s peculiar tumor is not a tumor but a chronic granuloma on the ulcerated surface of the sebaceous cyst.
• Sebaceous horn results from the hardening of slowly discharged sebum through the punctum.

Sebaceous Cyst Treatment

• Excision includes skin adjacent to the punctum using an elliptical incision also known as the dissection method.
• Incision and avulsion of cystic wall.
• If the abscess is formed, then drainage initially and later excision is done.
• If the capsule is not removed properly cyst will recur.

 

Question 2. Describe briefly the sublingual dermoid cyst.

Answer. It is a type of congenital sequestration dermoid cyst.

The cyst is formed by the inclusion of the surface ectoderm at the fusion line of two mandibular arches.

Sublingual Dermoid Cyst Pathology

• The cyst is lined by squamous epithelium.
• The wall of the cyst contains hair follicles, sweat, and sebaceous glands.
• Cyst contains cheesy material.
• It never contains hair.

Sublingual Dermoid Cyst Types

It may be:

• Median variety: It is derived from epithelial cell rests at the level of fusion of two mandibular arches.
  It may be supramylohyoid or infra mylohyoid.
  It is located between two genial muscles, about the mylohyoid muscle.
  It is a midline swelling that is smooth, soft, cystic, nontransilluminant.
• Lateral variety: It develops about the submandibular duct, lingual nerve, and stylohyoid ligament.
  It is derived from the first branchial arch.
  It forms a swelling in the lateral aspect of the floor of the mouth.

It also may be:

• Supra mylohyoid type.
• Infra mylohyoid type.

Sublingual Dermoid Cyst Clinical Features

• It occurs in young children between the ages of 10 to 12 years.
• Congenital, painless, and digitally palpable swelling in the floor of the mouth.
• Swelling is soft and cystic
• The fluctuation test is positive.
• The transillumination test is negative as it contains thick, cheesy, sebaceous material.
• Swelling may often attain a large size presenting both sublingually, intraorally, and midline submentally on the external side.
• Occasionally it can lead to trismus, dysphagia, pain, and odynophagia.

Sublingual Dermoid Cyst Differential Diagnosis

• Ranula: When the sublingual dermoid cyst is in the midline at the floor of the mouth and above the mylohyoid muscle ranula is considered a differential diagnosis.
  Ranula is blue in color and brilliantly translucent.
• Thyroglossal cyst: It is to be taken in the differential diagnosis when the sublingual dermoid cyst is below the mylohyoid muscle.
  The thyroglossal cyst moves up with deglutition whereas the sublingual dermoid cyst does not.

Sublingual Dermoid Cyst Treatment

Excision is done through an intra-oral approach usually; large cystic tending under the geniohyoid muscle may require external approach.

 

Question 3. Write a short note on the thyroglossal cyst.
Or
Describe briefly the thyroglossal cyst.
Or
Write a brief note on the thyroglossal cyst.
Or
Write in short about thyroglossal cyst.
Or
Write about the thyroglossal cyst.

Answer. It is a congenital tubular dermoid cyst.

• It arises from the thyroglossal duct, which extends from the foramen cecum at the base of the tongue to the isthmus of the thyroid gland.
• It is lined by pseudostratified, ciliated, and columnar or squamous epithelium which produces desquamated epithelial cells or mucus at times.

Thyroglossal Cyst Sites

• Subhyoid is the most common site
• At the level of thyroid cartilage
• Suprahyoid: Double chin appears
• At the foramen caecum
• At the level of cricoid cartilage
• At the floor of the mouth.

Thyroglossal Cyst  Clinical Features

• Swelling is present in the midline towards the left side.
• Moves with deglutition as well as with the protrusion of the tongue.
• The patient is asked to open the mouth and keep the lower jaw still.
  The examiner holds the cyst between the thumb and forefinger.
  When the patient is asked to protrude the tongue, a “tugging sensation” can be felt.
• Swelling is smooth, soft, fluctuant (cystic), non-tender, mobile, often transilluminate.
• The thyroid fossa is empty if there is no thyroid in the normal location.
• A thyroglossal cyst can get infected and may form an abscess. The Cyst wall contains lymphatic tissue so infection is common.
• Malignancy can develop in papillary carcinoma.

Thyroglossal Cyst Differential Diagnosis

• Subhyoid bursa
• Pretracheal lymph node
• Dermoid cyst
• Solitary nodule of thyroid
• Submental lymph node
• Collar stud abscess.

Thyroglossal Cyst Investigations

• Radioisotope study
• Ultrasound of neck; T3, T4 and TSH estimation
• FNAC from the cyst.

Thyroglossal Cyst Treatment

Sistrunk operation

Excision of the cyst and also the full tract up to the foramen cecum is done along with the removal of the central part of the hyoid bone as the tract passes through it.

Sistrunk operation Technique

• A thorough transverse neck incision was placed over the cyst, skin flap was raised above along with the platysma. Care should be taken not to open the cyst.
• Cyst with surrounding tissues is dissected up to the hyoid bone. Sternohyoid and thyrohyoid muscles are divided.
• The central part of the hyoid bone of l cm width is resected along with an intact tract within it.
• Geniohyoid and mylohyoid muscles are divided from the hyoid.
• Track with adjacent tissues is dissected above up to the foramen cecum.
• Adjacent tissues also should be removed because of possibility of multiple tracts which otherwise lead to recurrence or fitula formation.
• After this, the anesthetist is asked to apply digital pressure over the base of the tongue near the foramen cecum to facilitate the dissection and to confirm the reach up to the foramen cecum.
• The track is ligated at the foramen caecum and removed.
• If there is no normal thyroid gland after the surgery maintenance dose of L-thyroxine 0.l mg OD is given lifelong.

Sistrunk operation Complications

• Recurrent thyroglossal fistula formation
• Hemorrhage/hematoma formation
• Infection.

 

Question 4. Write a short note on cystic hygroma.
Or
Describe briefly cystic hygroma.
Or
Write a short answer on cystic hygroma.

Answer. It is also called lymphangioma of the neck cavernous lymphangioma or hydrocele of the neck.

It is a congenital cystic swelling, which contains multiple lobules of clear lymph.

• It gets filled up with lymph in the early week of childhood and presents as a large cyst in the lower part of the neck.
• The cyst is not a single cavity but it is a collection of numerous small cysts.
• Their lobules may intercommunicate with one another.
• Each lobule is lined by a single layer of endothelium.
• Cystic hygroma may infitrate into the muscular plane.

Cystic Hygroma Clinical Features

• Swelling is present at birth in the posterior triangle of neck causing obstructed labor.
• Swelling is smooth, soft, fluctuant (cystic), partially compressible, and brilliantly transilluminant. It is not reducible completely.
• During crying swelling often increases in size.
• Disfigurement of the face of the child is a more worrying factor for the parents.
• Swelling may rapidly increase in size causing respiratory obstruction which is a dangerous sign.
• It may get infected forming an abscess which is a tender, warm, soft swelling. It may cause septicemia which may be life-threatening.
• Rupture with lymph ooze can occur.

Cystic Hygroma Complication

• Too much enlargement of cystic hygroma may cause respiratory distress.
• Infection, abscess, septicemia
• Surgery itself may cause torrential hemorrhage
• Chylous fitula, chylothorax
• Recurrence of cysts in 15% of cases.

Cystic Hygroma Treatment

• Aspiration of the cyst is done. Later on, sac and capsule are thickened by fibrous tissue and are excised.
• Meticulous dissection is done across all planes including deeper muscular ones to clear the entire cyst wall. If it is not done properly chances of recurrence are present.
• If respiratory obstruction is present then tracheostomy is done.
• Under antibiotic coverage drainage of the abscess is done and later on sac is excised.
• Preoperative injection of sclerosants is given and later on firosis develops then excision of entire aggregation of cyst is done.
  In past days boiling water injection is given at 7 days intervals.

 

Question 5. Write briefly on ranula.
Or
Write a short note on ranula.
Or
Write in short about ranula.
Or
Write short answer on ranula.

Answer. Ranula is a cystic swelling that occurs in the floor ofthe mouth and involves mainly sublingual salivary glands duct.

• It also arises from accessory salivary glands.
• The word ranula is derived from the resemblance of the swellings to the belly of a frog.

Ranula Etiology

• Ranula occurs due to obstruction to the duct, secreting mucosa.
• Artesia (Obstruction of the duct)
• Stricture of duct due to surgery
• Perforation of duct.

Ranula Types

There are two types of ranulas, i.e.

1.Oral ranula

2.Plunging ranula or cervical ranula.

Oral ranula occurs secondary to mucus extravasation where mucus pools superior to the mylohyoid muscle in plunging ranula mucus extravasation is along the facial planes of the neck.

Ranula Clinical Features

Ranula Oral Ranula

• Seen in young children and adults
• Swelling is typically located in the flor of the mouth to one side of the midline.
• Its surface is smooth with diffuse borders.
• On palpation, it is soft, cystic, non-tender, and fluctuant swelling which gives brilliant transillumination.
• It is covered by thin mucosa containing a clear, serous fluid.
• Hence, it is bluish in color and resembles like a belly offrog.
• The lesion can cross midline when it is large, this makes the offending salivary gland difficult to locate.
• Large oral ranulas displace the tongue and interfere with the functions of the tongue.
• If the mass is located deep, it loses its bluish translucent color.

Ranula Plunging Ranula

• The ranula often extends in the submandibular region through the deep part of the posterior margin of the mylohyoid muscle and is known as the plunging ranula.
• The plunging ranula is also an intra-oral ranula but with cervical extension.
• It remains asymptomatic but enlarges continuously. The overlying skin remains intact.
• The swelling is fluctuant, freely mobile, and non-tender.
• It is digitally palpable.

Ranula Investigations

Ultrasound of the neck or MRI neck should be done.

Ranula Treatment

Oral Ranula

• Marsupialization can be done initially, in marsupialization major part of the cyst along with the mucus membrane of the floor of the mouth is excised.
  Cut edges of cyst wall are sutured to cut mucus membrane and later as the wall of ranula is thickened it should be excised completely.
• If ranula is small, it can be excised without marsupialization.
• Laser ablation and cryosurgery alone or after completion of marsupialization can be done for some patients of oral ranula.

Plunging ranula

• Plunging ranula often requires approach from neck for complete excision.
  Excision of the submandibular and sublingual salivary gland is often needed in plunging ranula.
• For small plunging ranula excision is done orally along with excision of sublingual salivary gland.

Plunging ranula Complications

Rupture for the cyst decreases the size but it can appear at a later date.

When the swelling is big, the tongue is pushed upwards and may cause diffilty in speech and swallowing.

 

Question 6. Write a short note on the dental cyst.
Or
Write in brief about dental cysts.

Answer. A dental cyst is also called a radicular cyst or periapical cyst.

It is the most common type of inflammatory cystic lesion, which occurs about the apex of a non-vital tooth.

In this case, if the involved tooth is extracted the remaining cystic cavity within the bone is known as residual cyst.

Dental cyst Pathogenesis
The radicular cyst develops due to the proliferation and subsequent cystic degeneration of the “epithelial cell rests of Malassez”, in the periapical region of a non-vital tooth.

The process of development of this cyst occurs in various stages:

• Phase of initiation.
• Phase of proliferation.
• Phase of cystifiation.
• Phase of enlargement.
• The phase of initiation: During this phase, the bacterial infection of the dental pulp or direct inflammatory effect of necrotic pulpal tissue, in a non-vital tooth causes stimulation of the “cell rest of Malassez” which are present within the bone near the root apex of teeth.
  The phase of proliferation: The stimulation to the cell rests of Malassez leads to excessive proliferation of these cells, which leads to the formation of a large mass or island of immature proliferating epithelial cells at the periapical region of the affected tooth.
• Phase of cystification: Once a large bulk of the cell rest of Malassez is produced, its peripheral cells get adequate nutritional supply but its centrally located cells are often deprived of proper nutritional supply.
  As a result, the central group of cells undergoes ischemic liquefactive necrosis while the peripheral group of cells survives.
  This eventually gives rise to the formation of a cavity that contains a hollow space or lumen inside the mass of the proliferating cell rest of Malassez and a peripheral lining of epithelial cells around it.
• Phase of enlargement: Once a small cyst is formed, it enlarges gradually by the following mechanisms:

• Higher osmotic tension of the cystic fluid causes progressive increase in the amount of fluid inside its lumen and this causes increased internal hydrostatic tension within the cyst.
  The process results in cyst expansion due to resorption of the surrounding bone.
• The epithelial cells of the cystic lining release some bone resorbing factors like prostaglandins and collagenase, etc. which destroy the bone and facilitate expansion of the cyst.

Dental cyst Clinical Features

• It is common in women around the third and fourth decades.
• Upper anterior teeth are more affected
• The involved tooth shows the presence of caries, fractures, or discoloration.
• Slow enlarging bony hard swelling of the jaw with expansion and distortion of cortical plates.
• Cysts remain asymptomatic if uninfected
• Severe bone destruction by the cystic lesion may produce springiness.
• If the cyst is secondarily infected, it leads to the formation of an abscess then it is called a cyst abscess.

Dental cyst Radiological Features

• It appears as a rounded or pear-shaped radiolucency at the apex of nonsensitive tooth or with nonvital tooth.
• Radiolucency is more than 1.5 cm in diameter but usually less than 3 cm in diameter. It has got well-defied outline with thin hyperostotic borders.
• Margins: In uncomplicated cases margins are smooth, and the cortex is usually well-defied, well-etched, and continuous, except in some cases, there may be window formation.
  There is also a thin white line surrounding the margins of the bone cavity.
  This thin layer of cortical bone is almost always present unless suppuration supervenes in the cyst.
• The image of radiopaque borders is continuous with lamina dura around the associated tooth. Infection may cause the borders to become less distinct.
• Radicular cysts of long duration may cause resorption of roots.
• Adjacent teeth are usually displaced and rarely resorbed.
  There is also buccal expansion involving the maxillary area then displacement of the antrum occurs.

Dental cyst Differential Diagnosis

• Periapical granuloma: If radiolucency which appear on the radiograph is smaller than 1.5 cm, it is considered to be periapical granuloma.
• Periapical scar: It is ruled out on the basis of history and location.
• Lateral periodontal cyst: Radicular cyst originates from the maxillary lateral incisor and is positioned in between the root of the lateral incisor and canine and is confused with the lateral periodontal cyst.
  In this case, tooth vitality should be checked, the tooth associated with a lateral periodontal cyst is vital and a radicular cyst is nonvital.
• Periapical cementoma: In the case of a radicular cyst tooth is nonvital while in the case of periapical cementoma tooth is vital.

Dental cyst Treatment

• Non vital teeth are associated with the cyst can either be extracted or they can be retained by endodontic treatment, i.e. apicoectomy.
• External sinus tracts should always be excised to prevent epithelial ingrowth.
• A commonly employed surgical procedure for radicular cysts is enucleation.
• Very small cysts can be removed through tooth socket.
• Large cysts that encroach upon the maxillary sinus or inferior alveolar neurovascular bundle may be treated by marsupialization.

 

Question 7. Write a short note on the dentigerous cyst.
Or
Write a brief note on the dentigerous cyst.
Or
Write in short about dentigerous cyst.

Answer. It is also known as follicular odontoma.

It is a common odontogenic cyst of epithelial origin, which encloses the crown of an impacted tooth at its neck portion.

The cyst is lined by squamous epithelium, surrounded by connective tissue.

Within the cyst, the tooth lies obliquely or sometimes embedded in the wall of the cyst.

As cyst grows, it displace the teeth deeper and deeper and prevent from eruption.

Dentigerous Cyst Clinical Features

• Age and sex: It is usually found in children, equal in both the sex.
• Site: Most common site is mandibular third molar and maxillary canine which are most commonly impacted.
• Symptoms: Cyst remains asymptomatic, if uninfected. On infection inflammatory signs are present.
• Expansion of mandible: Since the inner table of mandible is strong the expansion mainly occurs in the outer aspect of the mandible.
  The bone gets thinned out resulting in egg shell cracking.
• Blue-domed cyst: When it contains blood then it is called as blue-domed cyst.
• A dentigerous cyst has the potential to become an aggressive lesion with the expansion of bone and subsequent facial asymmetry.
• There is extreme displacement of teeth, severe root resorption of adjacent teeth and pain.

Dentigerous Cyst Radiographic Features

• It is a well-defined radiolucency usually associated with hyperostotic borders unless it is secondarily infected.
• Bony margins are well-defied and sharp.
• It may involve the crown symmetrically; it may expand from the crown.
• Large cysts are confined to the mandible. There may be resorption of roots.

Dentigerous Cyst Differential Diagnosis

• Ameloblastoma or ameloblastic firoma: They are multilocular and not associated with crown of an unerupted teeth.
• Adenomatoid odontogenic tumors: They are rare and occur in the maxillary anterior region.
• Calcifying odontogenic cyst: It occurs as peri coronal radiolucency and contains evidence of calcification.
• Developmental primordial and follicular primordial cyst: It occurs in the crown of the uner updated tooth and super position of the image which may cause cyst-like radiolucency to appear as a dentigerous cyst on the radiograph.

Dentigerous Cyst Treatment

• Treatment via an intraoral approach or extraoral is decided by the size ofcyst, adequate access and whether it desirable to save the involved tooth.
• Marsupialization: It is indicated in children if the cyst is very large in the size and involved tooth/teeth are to be maintained.
  The tooth may erupt in occlusion as the defect heals with normal bone or orthodontic forces may be used to bring the tooth into occlusion.
• Enucleation: Alternatively cyst can be enucleated together with involved tooth in adults as possibility of tooth eruption is low.

 

Question.8. Describe the cysts of jaw and their management.

Answer. Cyst is defied as “A pathological cavity having flid,semiflid or gaseous contents and which is not created by accumulation of pus.” Kramer (1974)

Classification of Cyst of Jaw by Mervin Shear

Cysts of the Jaws:

Epithelial:

Developmental:

Odontogenic

• Gingival cyst of infants
• Odontogenic keratocyst (neoplasm)
• Dentigerous cyst
• Eruption cyst
• Lateral periodontal cyst
• Gingival cyst of adults
• Botryoid odontogenic cyst
• Glandular odontogenic cyst
• Calcifying odontogenic cyst (neoplasm).

Non-odontogenic

• Naso palatine duct cyst
• Nasolabial cyst
• midpalatal raphe cyst of infants
• Median palatine, median alveolar
• Median mandibular cyst
• Globulo maxillary cyst.

Inflammatory:

• Radicular cyst, apical and lateral
• Residual cyst
• Paradental cyst and mandibular infected buccal cyst
• Inflmmatory collateral cyst.

Non epithelial: (Pseudocysts)

• Solitary bone cyst
• Aneurysmal bone cyst.

Cyst associated with maxillary antrum:

• Benign mucosal cyst of the maxillary antrum
• Post operative maxillary cyst.

Cyst of the soft tissues of mouth, face and neck:

• Dermoid and epidermoid cyst
• Lymphoepithelial cyst (Brachial cyst)
• Thyroglossal duct cyst.
• Anterior medial lingual cyst (Intra lingual cyst of foregut origin)
• Oral cyst with gastric or intestinal epithelium
• Cystic hygroma
• Nasopharyngeal cyst
• Thymic cyst
• Cyst of salivary glands: mucous extravasation cyst,mucous retention cyst, ranula, polycystic disease of the parotid.
• Parasitic cyst: hydatid cyst, cysticercus cellulosae,trichinosis.

Management of Cysts of the jaw

It is also known as parts operation.

Cysts of the Jaws Principle

• Marsupialization or decompression, refers to creating a surgical window in the wall of the cyst and evaluation of the cystic contents.
• This process decreases intracystic pressure and promotes shrinkage of the cyst and bone fil.

Cysts of the Jaws Method

• The area is anesthetized with local anesthesia.
• The incision should be long enough to provide good exposure (circular/oval).
• In edentulous patient, incision is given along the crest of ridge and in dentulous patient, the incision is given around the neck of teeth.
• Incision is given bucally or lingually depending on location of cyst.
  Mucoperiosteal flp is raised.
• The character of underlying bone is determined. If this layer of bone is present on cyst, it is carefully peeled of with periosteal elevator.
  If the bone over the cyst is intact, a window is made with a bur/chisel in the postage stamp method.
• Window is enlarged with rongeurs.
• An incision shaped like St Andrew and cross is made on the cyst lining.
• Fluid content of cyst is evaluated with suction.
• Four triangular flps created are turned outwards and sutured with mucoperiosteum.
• The cavity is packed with the gauge in iodoform or white head varnish.
• If the cyst lining is friable as in infected cyst, be sutured with mucoperiosteum the gauge is used to hold the cyst lining and mucoperiosteum together.
• One week later, the gauge is removed. Sutures also, by new union occur between the lining and new periosteum.
• Now a plug is made to maintain the opening of cavity patent and prevent food from entering the cavity.
• The plug is worn continuously but removed after meals.
• The cavity is irrigated with syringe.
• The plug is never made of full cavity depth because it interferes with bone regeneration of the cavity.
• The size of the plug (depth) is decreased gradually as the cavity is filled with bone.
• Finally the mucoperiosteum is closed with sutures.

Cysts of the Jaws Enucleation

Cysts of the Jaws Method

• The area is anesthetized by local anesthesia.
• Incision should be long enough to provide good exposure and at the end of operation flp edge must rest on healthy bone.
• In edentulous patient incision is given along the crest of ridge and in edentulous patient, it is given around the neck of the teeth.
• The incision is given facially or lingually depending on the location of the cyst.
• The mucoperiosteal flap is raised.
• The character ofunderlying bone is determined. Ifthinlayer of bone is present on cyst, it is carefully peeled of with periosteal elevator.
  If the bone over a cystis intact, a window is made with bur or chisel in the postage stamp method.
• The window is enlarged with rongeurs forceps to allow complete enucleation.
• Care is taken not to puncture the cyst wall because the intact cyst is removed easily.
• The cyst lining is gently separated from the cavity wall using the periosteal elevator or curette/Mitchell trimmer/spoon excavator.
  The convex surface of the blade is kept facing the lining of the cyst.
• If the cyst lining is difficult to separate from the cavity wall or nasal or antral lining use H2O2 gauge packing and then perform blunt dissection.
• A plane of cleavage is used to remove the cystic sac in one piece.
• If any tooth or root is involved in a cyst it is either extracted or
• The cavity is cleaned, debrided, irrigated, and inspected.
• Bony margins are smoothened.
• Bleeding is checked and flp is re-positioned.
• Wound is closed with interrupted suture.
• Sutures are removed after 6 to 7 days.
• Routine analgesics and antibiotics are prescribed to prevent postoperatory pain and infection.

Cysts of the Jaws Decompression Followed by enucleation

• Decompression of a cyst relieves the pressure within the cyst and causes it to grow.
• It is performed by making a small opening in the cyst and keeping it open with drain.
• Cyst is kept open initially by medicated gauze pack and an acrylic plug.
• Bone regeneration occur and cavity reduces in size
• This technique is not a defiitive treatment but allows a second stage of enucleation to be undertaken on much smaller lesion which would have been impossible.

 

Question 9. Write note on thyroglossal fitula.
Or
Write short note on thyroglossal sinus.

Answer. Thyroglossal fitula or sinus is never congenital.

It is always acquired due to following reasons:

• Infected thyroglossal cyst rupturing into the skin.
• Inadequate drained infected thyroglossal cyst.
• Incompletely excised thyroglossal cyst.

Thyroglossal fistula Clinical Features

• It occurs during 10 to 20 years.
• Patientgiveshistoryofpreviousswellinginneck(thyroglossal cyst), which becomes infected, burst forms a fitula.
• The fitula or sinus discharges mucus and after sometime fitula closes by itself.
• After few days, it again starts discharging mucus and closes by itself again.
• The normal position of fitula or sinus remains in midline in front of thyroid cartilage.
• Its internal opening is on foramen cecum of tongue.
• If the fistula becomes infected then the surrounding skin becomes red, warm, tender, and full of secret pus.
• A fitulous opening in center of neck which is covered by hood of skin can occur due to increased growth of neck when compared to that of fitula.
  This is known as semilunar sign or hood sign.

Thyroglossal fitula Investigations

Radioisotope study and fitulogram.

Thyroglossal fistula Treatment

Infection is controlled with antibiotics

 

Question 10. What are the different types of cysts in an oral cavity? Describe etiology, pathogenesis, and management.

Answer. Cyst is defied as “A pathological cavity having flid,semiflid or gaseous contents and which is not created by accumulation of pus.” Kramer (1974).

Classification of Cyst in Oral Cavity by Mervin Shear

Cysts of the Jaws:

Epithelial:

Developmental:

Odontogenic

• Gingival cyst of infants
• Odontogenic keratocyst (neoplasm)
• Dentigerous cyst
• Eruption cyst
• Lateral periodontal cyst
• Gingival cyst of adults
• Botryoid odontogenic cyst
• Glandular odontogenic cyst
• Calcifying odontogenic cyst (neoplasm).

Non-odontogenic

• Nasopalatine duct cyst
• Nasolabial cyst
• midpalatal raphe cyst of infants
• Median palatine, median alveolar
• Median mandibular cyst
• Globulomaxillary cyst.

Inflammatory:

• Radicular cyst, apical and lateral
• Residual cyst
• Paradental cystand mandibular infected buccal cyst
• Inflmmatory collateral cyst.

Nonepithelial: (Pseudocysts)

• Solitary bone cyst
• Aneurysmal bone cyst.

Cyst associated with maxillary antrum:

• Benign mucosal cyst of the maxillary antrum
• Postoperative maxillary cyst.

Cyst of the soft tissues of mouth, face, and neck:

• Dermoid and epidermoid cyst
• Lymphoepithelial cyst (Brachial cyst)
• Thyroglossal duct cyst.
• Anterior medial lingual cyst (Intra lingual cyst of foregut origin)
• Oral cyst with gastric or intestinal epithelium
• Cystic hygroma
• Nasopharyngeal cyst
• Thymic cyst
• Cyst of salivary glands: mucous extravasation cyst,mucous retention cyst, ranula, polycystic disease of the parotid.
• Parasitic cyst: hydatid cyst, cysticercus cellulose, trichinosis.

Etiology, Pathogenesis, And Management Of Various Cysts of Oral Cavity

 

Question.11. Write a short note on the branchial cyst.

Answer. This is a cystic neck swelling in the lateral aspect of the neck, which is a result of a persisting cervical sinus formed by the second branchial cleft.

Branchial Cleft Pathogenesis

It arises from

• Epithelial remnant of branchial cleft
• Residual cervical sinus epithelium
• Cystic changes within cervical lymph nodes of epithelial inclusion

Branchial Cleft  Clinical Features

• Swelling is seen in the neck beneath anterior border of upper third of sternomastoid muscle.
• Swelling is smooth, soft, fluctuant, and transilluminate with the sensation of a half-filed double hot water bottle.
• It is seen commonly in late adolescence and during the third decade of life.
• Swelling is painless unless it is infected.
• Mobility of swelling is restricted because of adherence to the sternomastoid muscle.
• It contains cholesterol crystals which is from the lining of the mucus membrane which consists of the sebaceous gland.
  Cheesy toothpaste-like material is typical.

Branchial Cleft Treatment

• Cyst should be excised under general anesthesia.
• A branchial cyst is with carotid, hypoglossal nerve, glossopharyngeal nerve, spinal accessory nerve, posterior belly of digastrics, and pharyngeal wall.
  Medially, it is close to posterior pillar of tonsils.
  During excision all the above structures should be taken care of.
• Sclerotherapy with OK–432 (Picibanil) is effective and is done under ultrasonography guidance.

Branchial Cleft Complications

• Since the wall is rich in lymphatic tissue, it can undergo secondary infection with pain and swelling.
• Recurrent infection.

 

Question.12. Write a short note on plunging ranula.

Answer. When the ranula extends in the submandibular region through the deeper part of the posterior margin of the mylohyoid muscle, it is known as the plunging ranula.

• It is an intraoral ranula with cervical extension.
• It is cross-fluor across mylohyoid.
• It can arise from both the submandibular and sublingual salivary gland as mucus retention cyst that reaches the neck by passing across the mylohyoid muscle presenting as soft, fluctuant, non-tender, dumbbell-shaped swelling in the submandibular region.
• It is digitally palpable.
• Ultrasonography and/or MRI is diagnostic.
• It is treated by surgical excision through the neck approach along with excision of submandibular and sublingual salivary glands.
• Small plunging ranula is often excised orally along with excision of the sublingual salivary gland.

 

Question 13. Write a short note on the cyst.

Answer. Cyst is defined as “A pathological cavity having flid, semifluid or gaseous contents and which is not created by the accumulation of pus.” Kramer (1974)

• True cysts are lined by epithelium while false cysts are not lined by epithelium.

General examination of Cyst

1. Location: Most of the congenital cystic swellings have a typical location wherein diagnosis can be made with fair accuracy.
A few examples are:

• Branchial cyst: Anterior triangle partly covered by the upper one-third of the sternomastoid
• Dermoid cyst: Midline, outer or inner canthus ofthe eye

2. Shape: Majority of the cystic swellings are round or oval.

• For example sub hyoid bursitis: Transverse oval cystic swelling in the midline of the neck
• Thyroglossal cyst: Vertically placed oval swelling in the midline of the neck
• Sebaceous cyst: Hemispherical swelling

3. Surface: Almost all the cystic swellings in the skin and subcutaneous tissue have smooth surface.

4. Consistency: Fluctuation is positive in all cystic swellings.
However, depending on the contents the flctuation may be diffrent, which an experienced surgeon can diagnose.

• Soft cystic: Thyroglossal cyst, meningocele, lymph cyst.
• Tensely cystic: Ganglion.
• Putt or toothpaste: Sebaceous cyst

5. Transillumination Test: Cystic swelling which contains clear flid show positive transillumination.

6. Mobility: Almost all cystic swellings in skin, subcutaneous tissue or in deep plane are freely mobile.
At times, this is not true due to various anatomical factors:

• Branchial cyst: Restricted mobility is due to its adherence to the sternomastoid muscle.
• Thyroglossal cyst: Transverse mobility is absent because cyst is tethered by remnant of thyroglossal duct.

7. Sign of compressibility: Swelling which has communication with the cavity or with tissue spaces gives a positive sign of compressibility.

8. Pulsations: Aneurysms are characterized by expansile pulsations and when the swelling pushes the vessel anteriorly transmission pulsation is obtained.

Complications of Cyst

• Infection: For example sebaceous cyst
• Calcification: For example hematoma, hydatid cyst
• Pressure effects: Ovarian cyst pressing iliac veins
• Hemorrhage: In thyroid cyst.

 

Question 14. Write a short note on the mucous cyst of the lower lip.

Answer. It is also known as a mucocele.

Mucous cyst of lower lip Etiology

• Due to obstruction of salivary duct
• Trauma to secretory acini.

Mucous cyst of lower lip Clinical Features

• They are common and occur on the inner aspect of lower lip. They may also occur on palate, cheek, tongue and flor of the mouth.
• They occur most frequently during the third decade of life.
• The patient complains of painless swelling. The swelling may suddenly develops at meal time and may drain simultaneously at interval.
• The swelling is round, oval, or smooth.
• The superfiial cyst appears as bluish mass and if inflmmed it is flctuant, soft, nodular and dome-shaped elevation.

Mucous cyst of lower lip Treatment

Surgical removal is done by sharp and blunt dissection followed by excision of minor salivary glands.

 

Question 15. Write short note on mucous cysts.

Answer. Mucous cysts are of two types, i.e. mucous extravasation cyst and mucus retention cyst.

Mucous extravasation Cyst

It is the swelling caused by pooling of saliva at injured minor salivary gland.

Mucous cysts Etiology

Trauma to minor salivary gland duct causes extravasation of mucus in connective tissue, due to this there is an accumulation of mucous in connective tissue with continuous pooling of saliva.

Mucous cysts Clinical Features

• They are common and occur on the inner aspect of lower lip. They may also occur on palate, cheek, tongue and flor of the mouth.
• They occur most frequently during third decade of life.
• Patient complains of painless swelling. The swelling may suddenly develops at meal time and may drain simultaneously at interval.
• The swelling is round, oval, or smooth.
• The superficial cyst appears as a bluish mass and if inflamed it is fluctuant, soft, nodular, and dome-shaped elevation.

Mucous cysts Treatment

Surgical removal is done by sharp and blunt dissection followed by excision of minor salivary gland.

Mucous retention Cyst

It is also known as a salivary duct cyst. It is a true cyst.

Mucous retention cyst Etiology

Obstruction to the minor salivary gland leads to retention of saliva, continuous pressure due to retention leads to dilatation of duct and forms a cyst.

Mucous retention cyst Clinical Features

• It more commonly occurs in older individuals.
• The most common site is the parotid gland. Intraorally, it is seen over buccal mucosa, lips, and floor of the mouth.
• It is a slow growing lesion, soft, flctuant swelling which appear bluish in color.

Mucous retention cyst Treatment

Surgical excision is treatment of choice.

 

Question 16. Give classification, clinical features, and complications of cysts.

Answer. Cyst is defined as “A pathological cavity having flid, semifluid or gaseous contents and which is not created by accumulation of pus.”— Kramer (1974)

Classification of Cysts

1. Congenital cyst

• Dermoids: Sequestration dermoid cyst
• Tubulodermoids: Thyroglossal cyst, postanal dermoid, ependymal cyst, urachal cyst
• Cyst of embryonic remnants: cyst from paramesonephric duct and mesonephric duct, cyst of urachus and vitellointestinal duct cyst.

2. Acquired cyst

• Retention cysts: sebaceous cyst, bar tholin’s cyst, parotid cyst, breast cyst.
• Distention cyst: lymph cyst, ovarian cyst, colloid goiter
• Exudation cyst: Dursa, hydrocele, pancreatic pseudocyst

3. Cystic tumors: Dermoid cyst of the ovary, cystadenomas

4. Traumatic cyst: Hematoma, implantation dermoid cyst

5. Degenerative cyst: Tumor necrosis

6. Parasitic cyst: Hydatid cyst, cysticercosis cellulose, trichinosis.

Clinical Features of Cysts

• Hemispherical swelling which is smooth, flctuant, nontender and well localized.
• Some cysts are transilluminate
• Presentation varies depending on anatomical location and pathology
• Cysts can be single or multiple.
• Cysts lead to the compression of adjacent structures
• This leads to infection, sinus formation, hemorrhage, calcification, and cachexia.

Complications of Cysts

• Infection: For example sebaceous cyst
• Calcification: For example hematoma, hydatid cyst
• Pressure effects: Ovarian cyst pressing iliac veins
• Hemorrhage: In thyroid cyst
• Torsion: Ovarian dermoid
• Transformation into malignancy
• Ovarian cachexia.

 

Question.17. Define and describe different features of dermoid cysts and sebaceous cysts.

Answer.

 

Question.18. Name the treatment modalities and differentiating features of ranula and sublingual dermoid.
Or
Describe different features of sublingual dermoid and ranula.

Answer.

 

Question.19. Name the treatment modalities and differentiating features of dental cysts and dentigerous cysts.
Or
Write the difference between a dental cyst and a dentigerous cyst.
Or
Write the difference between periapical cysts and dentigerous cysts.

Answer.

 

Question.20. Name the treatment modalities and differentiating features of the thyroglossal cyst and sub-hyoid bursitis.

Answer.

 

Question 21. Write a short note on sequestration dermoid.

Answer. It occurs at the line of embryonic fusion, due to the inclusion of epithelium beneath the surface which later gets sequestered forming a cystic swelling in the deeper plane.

• It is a congenital type.
• Common sites are:

• Forehead, neck, postauricular dermoid.
• External angular dermoid.
• The root of the nose.
• Sublingual dermoid.
• Anywhere in midline or in the line of fusion.
• Dermoids occurring in the skull may extend into the cranial cavity.
• When it occurs as an external angular dermoid, it extends into the orbital cavity, or it can extend into any cavity about its anatomical location (e.g. thorax, abdomen).

Sequestration Dermoid Types Of Angular Dermoid

• External angular dermoid: lt is a sequestrationdermoid situated over the external angular process of the frontal bone.
  The outer extremity of the eyebrow extend over some part of the swelling.
  This feature diffrentiate it from swelling arising from lacrimal gland.
  It can extend to the orbital cavity also.
• Internal angular dermoid: lt is a sequestration dermoid cyst in the central position near the root of the nose.
  It occurs in frontonasal suture line. It mimics swelling from the lacrimal sac or mucocele of the frontal sinus.
  Mucocele of frontal sinus is due to blockage of frontonasal duct.

Sequestration Dermoid Clinical Features

• Painless swelling in the line of embryonic fusion.
• Seen in second or third decades of life.
• It is smooth, soft, non-tender and fluctuant and non transilluminating
• There is presence of resorption and indentation of bone beneath.
• Impulse on coughing may be present only if there is an intracranial extension.

Sequestration Dermoid Complications

• Infection
• Hemorrhage
• Surface ulceration
• Calcification.

Sequestration Dermoid Investigations

• X-ray skull or part
• CT-scan head or part.

Sequestration Dermoid Treatment

Excision is done under general anesthesia.
Often formal neurosurgical approach is required by raising cranial osteocutaneous flips.

 

Question.22. Enumerate midline swelling of neck. Describe the thyroglossal cyst briefly. 

Answer.

Enumeration of midline swelling of the neck

• Ludwig’s angina
• Enlarged sub-mental lymph node
• Sub-lingual dermoid cyst
• Thyroglossal cyst
• Sub-hyoid bursitis
• Goiter of thyroid, isthmus and pyramidal lobe
• Enlarged lymph node and lipoma in substernal space of burns
• Retrosternal goiter
• Thymic swelling
• Bony swelling arising from the manubrium sterni.