Nodular Fasciitis Mimicking a Dermoid Cyst

It is easy to get lulled into thinking that all superior medial masses in young children are dermoid cysts.  In this case, the patient was initially thought to have a dermoid cyst, but at follow up had induced astigmatism from the mass, which is not typical for a dermoid cyst.  The mass proved to be nodular fasciitis with complete excision.  Evaluation by the medical oncology service showed no spread. 

This is Richard Allen at oculosurg.com.  This patient originally presented at 5-months with a mass in the superior medial orbit.  This is a typical location of a medial dermoid cyst and was given this preliminary diagnosis with a 6-month follow-up.  At the follow up, the patient had induced astigmatism and surgery was scheduled.  A lid crease incision is made with the 15 blade.  The needle tip cautery is then used to dissect through the orbicularis muscle to the underlying orbital septum.  The orbital septum is opened with Westcott scissors.  The mass is then exposed and engaged with forceps.  The mass is able to be prolapsed relatively easily anteriorly.  Often, dermoid cysts will have some firm attachment to the periosteum.  Dissection is then carried out around the mass to attain complete excision.  Although the mass has some characteristics suggestive of a dermoid cyst, on closer inspection it appears to be soft tissue, rather than a cyst.  Pathology results proved the lesion to be nodular fasciitis.  Hemostasis is obtained with the needle tip cautery.  The upper eyelid incision is then closed with interrupted 5-0 fast absorbing sutures.  Antibiotic ointment will be placed over the sutures and the patient will follow up in approximately one week.