Cutaneous Cysts of the Head and Neck
Taiseer Hussain Al-Khateeb, BDS, MScD, FDSRCSEd, FFDRCSI,*
Nidal M. Al-Masri, MD,† and Firas Al-Zoubi, MBBS, FRRC‡
Purpose: A retrospective study on the features of cutaneous cysts of the head and neck as seen in a North Jordanian population.
Patients and Methods: The records of the Department of Pathology at Jordan University of Science and Technology were reviewed for patients with cutaneous cysts of the head and neck during the 12-year period extending between 1991 and 2002. Applicable records were retrieved, reviewed, and analyzed.
Primary analysis outcome measures included patient age, gender, location of the cyst, type, clinical presentation, and treatment. The records of 488 patients were available for analysis.
Results: Epidermoid cyst was the most frequent lesion (49%) followed by pilar cysts (27%), and dermoid cysts (22%). The site affected most frequently was the scalp (34%), predominantly with pilar cysts (96%).
Epidermoid cyst was the most frequent lesion in the neck (68%), cheeks (77%), periauricular area (70%), and the nasal area (55%). Dermoid cyst was the most frequent lesion in the periorbital area (52%). Females represented 51% of the patients and males accounted for 49%. The peak of age distribution for patients with dermoid cysts was at the first decade, and both of epidermoid and pilar cysts peaked at the third decade.
Infection presented in 2.5% of cases. All cysts were enucleated surgically.
Conclusion: Maxillofacial surgeons often encounter cutaneous cysts of the head and neck, and they must be familiar with the clinicopathologic characteristics of these lesions.
©2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:52-57, 2009
Cutaneous cysts are frequently benign head and neck lesions. The most common cutaneous cysts are reten- tion cysts from skin appendages, with developmental or embryonic cysts presenting much less routinely.1 Cysts of skin appendages are labeled as sebaceous cysts commonly. The sebaceous cyst is preferably described as either an epidermal cyst or trichilemmal (pilar) cyst.2Sweat gland elements may also produce cysts classified as hidrocystomas.1
Dermoid and epidermoid cysts are developmental cysts that occur in the head and neck with an inci-
dence ranging from 1.6% to 6.9%.3 They represent less than 0.01% of all cysts of the oral cavity.4 An epidermal cyst is derived from epidermis, and is formed by cystic enclosure of epithelium within the dermis that becomes filled with keratin and lipid-rich debris.5It occurs in young to middle-age adults. It is usually solitary and connects with the surface by ker- atin-filled pores. Dermoid cysts lack any entry port and have a predilection for lines of embryonic fu- sion.6Younger patients predominate for dermoid cyst presentation. Histologically, pilosebaceous structures may be noted within the wall of a dermoid cyst.5
According to Fitzpatrick,5a pilar cyst is seen most often on the scalp in middle-age females. It occurs frequently as multiple smooth, firm, dome-shaped nodules that are not connected to the epidermis. The usually thick cyst wall is composed of stratified squa- mous epithelium with a palisaded outer layer resem- bling that of the outer root sheath of hair follicles, and an inner corrugated layer. The cyst contains very dense keratin; it is often calcified, with cholesterol clefts. If the cyst ruptures, it may be inflamed and very painful.
Cutaneous cysts are diagnosed and treated by max- illofacial surgeons around the world on an almost regular basis. Nevertheless, there is a notable paucity of comprehensive studies in the literature on the various lesions encountered in clinical practice. This
*Associate Professor, Division of Maxillofacial Surgery, Jordan University of Science and Technology and King Abdullah University Hospital, Irbid, Jordan.
†Associate Professor, Department of Pathology and Microbiol- ogy, Jordan University of Science and Technology and King Abdul- lah Teaching Hospital, Irbid, Jordan.
‡Assistant Professor, Division of Otorinolaryngology, Jordan Uni- versity of Science and Technology and King Abdullah Teaching Hospital, Irbid, Jordan.
Address correspondence and reprint requests to Dr Al-Khateeb:
Department of Oral & Maxillofacial Surgery, Jordan University of Science & Technology, Irbid, PO BOX 3030, Jordan; e-mail:
©2009 American Association of Oral and Maxillofacial Surgeons 0278-2391/09/6701-0009$34.00/0
study focuses on some of the features of cutaneous cysts of the head and neck as seen in a North Jorda- nian population.
Patients and Methods
Data included in this retrospective study were collected from the records of the Department of Pathology at Jordan University of Science and Tech- nology. The Department of Pathology receives all biopsy specimens from all hospitals in the northern part of Jordan, serving approximately 30% of the Jordanian population living in 4 different governor- ates. The records of patients with cutaneous cysts of the head and neck received during the 12-year period extending between 1991 and 2002, were retrieved, reviewed, and analyzed. The main analy- sis outcome measures were patient age, gender, and cyst location, type, clinical presentation, and treatment. The records of 488 patients were avail- able for analysis.
TYPE AND SITE
Epidermoid cyst was the most frequent lesion (49%) followed by pilar cysts (27%) and dermoid cysts (22%), in a descending order. Other cyst types com- prised 2% of cases (Table 1). These consisted of hidro- cystoma (5 cases) and hydatid cyst (3 cases). As shown in Table 1, the head and neck sites affected most frequently with cutaneous cysts were the scalp (34%) followed by the neck (18%), periorbital area (17%), cheeks (including lips; 16%), auricular area (9%), and nasal area (including forehead; 6%).
The predominant cyst type in the scalp was the pilar cysts (96%); the distribution of other scalp cysts is shown inTable 1. The neck exhibited epidermoid cysts (68%) mostly; other cyst types were dermoid, pilar, lymphoepithelial, and a single hidrocystoma (Table 1). The periorbital area presented dermoid cysts (52%), epidermoid cyst (42%), and hidrocysto- mas, in a descending order (Table 1). The cheek (including lips) was involved predominately by epi- dermoid cyst (77%); dermoid and pilar cysts were of
Table 1. TYPE AND SITE DISTRIBUTION OF CUTANEOUS CYSTS OF THE HEAD AND NECK (Nⴝ 488)
Cyst Type (%)
Epidermoid Pilar Dermoid Hidrocystoma Hydatid Total % Total
Preauricular 4 2 0 6 1
Auricle 14 2 16 3
Postauricular 13 9 22 5
Total 31 (70) 2 (5) 11 (25) 0 0 44 (100) 9
Cheek 61 (77) 9 (11) 9 (11) 79 16
Submandibular 4 1 3 8 2
Lateral (ONS) 4 1 1 6 1
Sublingual 4 4 8 2
Submental 2 5 7 1
Midline (ONS) 6 6 1
Not specified 39 1 8 1 3 52 11
Total 59 (68) 3 (3) 21 (24) 1 (1) 3 (3) 87 (100) 18
Nasal complex 17 (55) 4 (13) 9 (29) 1 (3) 31 (100) 6
Eyebrow 7 15 22 5
Eyelid 16 1 17 34 7
Canthus 8 2 2 12 2
Supraorbital 1 0 4 0 5 1
Not specified 3 5 2 10 2
Total 35 (42) 3 (4) 43 (52) 2 (2) 0 83 (100) 17
Occipital 1 4 5 1
Temporal 1 3 4 1
Not specified 32 109 13 1 155 32
Total 34 (21) 113 (69) 16 (10) 1 (1) 0 164 (100) 34
Total 237 (49) 134 (27) 109 (22) 5 (1) 3 (1) 488 (100) 100
Abbreviation: ONS, otherwise not specified.
Al-Khateeb, Al-Masri, and Al-Zoubi. Cutaneous Cysts. J Oral Maxillofac Surg 2009.
equal frequency (11%). The periauricular area exhib- ited mostly epidermoid cysts (70%), but dermoid and pilar cysts were also present (Table 1). The nasal area (including forehead) mostly presented with epider- moid cysts (55%), dermoid cysts (29%), and pilar cysts (13%).
AGE AND GENDER
Among the 488 patients with cutaneous cysts of the head and neck an almost equal distribution between males and females was found, with females represent- ing 51% of the patients and males 49% (Table 2). The average age at the time of surgical excision was 29.14 years. As depicted inFigure 1, the peak age distribu- tion for patients with dermoid cysts was at the first decade, with a sharp drop afterward. On the other hand, both epidermoid and pilar cysts peaked at the third decade with a steady decline afterward. Age and gender distribution of individual cyst types is shown inTable 2.
The chief complaint in all cases was that of a mass lesion of varying duration. Pain was reported in 12 cases (2.5%). The majority of lesions were provision-
ally diagnosed as cysts; few cases (23; 4.7%) were misdiagnosed as other mass lesions. Multiple scalp pilar cysts were reported in 5 cases. Infection pre- sented in 12 cases (2.5%; 8 epidermoid cysts, 3 dermal cysts, 1 pilar cyst).
Histopathologic findings were classical in all cyst types. Dystrophic calcification was observed in 12 pilar cysts, but the diagnosis of other trichilemmal lesions such as pilomatricoma was excluded. Giant cell reaction was reported in 48 cases (31 epider- moid, 10 pilar, 7 dermoid cysts). Two cases of epider- moid cysts showed extensive mural fibrosis.
Small superficial epidermoid cysts were excised around the base. Deeper epidermal cysts were re- moved via an elliptical incision along the axis of a skin crease around the punctum of the cyst. This was followed by deep dissection around the cyst periph- erally ending in complete cyst enucleation with the attached skin carrying the punctum. Other types of cysts, notably dermoid and pilar cysts were enucle- ated via a small incision in a resting skin tension line or hidden behind the hairline, followed by dissection around the cyst.
Table 2. AGE AND GENDER DISTRIBUTION OF CUTANEOUS CYSTS OF THE HEAD AND NECK (Nⴝ 488)
Cyst Type Number (%)
Age (Yr) Gender (%)
Range Mean Female Male
Epidermoid 237 (49) 0.25-80 28.3 100 (42) 137 (58)
Pilar 134 (27) 1.5-80 37.9 92 (69) 42 (31)
Dermoid 109 (22) 0.25-65 17.9 49 (45) 60 (55)
Hidrocystoma 5 (1) 39-60 49.4 3 (60) 2 (40)
Hydatid 3 (1) 39-70 30.1 3 (100) 0
Total 488 (100) 247 (51) 241 (49)
Al-Khateeb, Al-Masri, and Al-Zoubi. Cutaneous Cysts. J Oral Maxillofac Surg 2009.
FIGURE 1. Age distribution of common cutaneous cysts of the head and neck in North Jordanians.
Al-Khateeb, Al-Masri, and Al-Zoubi. Cutaneous Cysts. J Oral Maxillofac Surg 2009.
Sublingual dermoid cysts were removed via a trans- verse submental incision and the anterior bellies of the digastric muscles separated. The deep fascia was entered to show the well-encapsulated cystic mass.
The entire cyst was removed with blunt dissection.
The head and neck sites affected most frequently with cutaneous cysts were the scalp (34%), neck (18%), periorbital area (17%), cheeks (including lips;
16%), periauricular area (9%), and nasal area (includ- ing forehead; 6%). This differs from findings of a previous series2that showed that the cheeks (includ- ing upper lips) were the most common location for cysts, accounting for 36% of the total. The difference is probably related to a referral bias because their patients were referred for a facial lesion clinic. Our results were obtained from the record of a regional pathology facility receiving specimens from different specialties in different hospitals.
In our series, epidermoid cyst was the most fre- quent lesion (49%) followed by pilar cysts (27%) and dermoid cysts (22%), in a descending order. Golden and Zide5found a similar pattern although their fre- quency of individual types of cutaneous cysts differs markedly from our findings. They found that 79% of their lesions were epidermoid cysts, 9% were pilar cysts, and only 3% were dermoid cysts. Epidermoid cysts may occur anywhere in the body. About 7% of them are found in the head and neck region and only 1.6% are located within the oral cavity.7 Malignant change, although extremely rare, have been reported in epidermoid cysts.8Although it is stated commonly that epidermoid cysts are congenital in origin, trauma could be a major factor in their etiology.9Our finding that epidermoid cysts were most frequent among pa- tients in their third decade supports a reactive causa- tion for these cysts.
Dermoid cysts are relatively rare lesions, with only 1% to 3.5% affecting the head and neck region.10 These cysts have been reported to involve a wide range of head and neck structures including the fron- totemporal-lateral brow area,11 midline nasal re- gion,12the oral cavity,4,13,14nasopharynx, and lateral neck.15 In our series, the most frequent location for dermoid cysts was the periorbital area followed by the neck, scalp, periauricular, nasal and cheek areas, in a descending order. A similar distribution was re- ported by a previous series.16 Dermoid cysts have been reported to have no obvious gender predilec- tion.2,10,17Our results showed only a very slight ex- cess of these cysts among males. This agrees generally with previous findings.2,10,17
It has been stated that although dermoid cysts are considered congenital lesions, that may present in a
wide age range.17These cysts are postulated to arise from ectodermic elements entrapped during the mid- line fusion of the first and second branchial arches between the third and fourth weeks of intrauterine life.18Alternatively, they may arise from the tubercu- lum impar of His which, with each mandibular arch, forms the floor of the mouth and the body of the tongue.19 Another theory suggests that midline der- moid (and epidermoid) cysts may be a variant of the thyroglossal duct cyst with ectodermal elements pre- dominating.20Our results showed a relatively young mean age of patients with dermoid cysts (17 years).
This finding supports a congenital origin of this le- sion.
Dermoid cysts of the floor of the mouth are rela- tively rare. In our series they comprised 8.3% of all dermoid cysts of the head and neck. In a review of 541 cases of dermoid cysts (from the whole body) seen at Mayo Clinic, 6.5% were located in the floor of the mouth.17Their low incidence is also confirmed by recent literature.21,22Cystic lesions developing above the mylohyoid muscle have the potential to displace the tongue toward the palate and subsequently create difficulty with mastication, speech, and possibly breathing.23Cystic lesions developing below the my- lohyoid often produce a submental or submandibular swelling. Regardless of the location of the cystic mass, surgical intervention is necessary eventually. Depend- ing on the extent and location of the cyst, removal can be achieved through an extraoral or a transoral approach.
The predominant scalp cutaneous cyst was the pi- lar cysts; a similar finding was reported in a previous series 2. Our results contrast with those of others,24 however, who found that dermoid cyst was the most common. A possible cause for this contrast is a selec- tion bias because the lesions reported by Cummings et al24were referred for neurosurgical intervention. It is worth stressing the point that surgeons must be cautious about swellings of the scalp that clinically seem to be attached to the skull. These should be investigated by radiographs and preferably by com- puted tomography (CT) before surgical intervention because of the possibility of intracranial extension.25 We found 3 (0.6%) cases of hydatid cysts of the head and neck. This disease is caused by the parasitic tapeworm, Echinococcus. These cysts present as slowly growing benign tumors.26The clinical course depends on the site of involvement, the size of the cyst, and the pressure caused by the enlarged cyst.27 Although hydatid cysts of the liver and lung are not unusual, they are rare in the head and neck region.
Few cases have been reported in the pterygopalatine fossa,27maxillary area,28parotid region,29infratempo- ral fossa,30 and nasopharynx.31 Surgical removal of the hydatid cyst is the most effective treatment.27The
surgeon must be careful to remove the cyst, totally avoiding spilling its contents.32 Fatal anaphylaxis on spilling the contents of the cyst has been reported.27 The surgical strategy varies widely between radical clearance followed by lavage and simple instillation of scolicide. Supplementary chemotherapy, such as me- bendazole or albendazole, can also be used.
The periorbital area presented mostly with dermoid cysts. This agrees with the majority of published lit- erature.16,33-35 Orbital dermoid cysts have been clas- sified as either exophytic or endophytic, according to their site of attachment in relation to the orbital rims.33 The exophytic cysts grow externally and are discovered in childhood, whereas the endophytic ones are discovered later in life when they produce bone damage, with or without invasion of the adja- cent structures.
The nasal area (including forehead) mostly pre- sented with epidermoid cysts. A similar finding was reported by Golden and Zide.2The next in frequency was dermoid cysts. Nasal dermoid cysts are rare le- sions that present most frequently in young patients.
Curative treatment is surgical. However, CT or mag- netic resonance imaging (MRI) is advisable to delin- eate deep tissue involvement and to exclude a possi- ble associated intracranial extension, before surgical excision. A 27.5%, risk of intracranial extension has been reported, especially in men with a dermal si- nus.36
Among the 488 patients with cutaneous cysts of the head and neck, an almost equal distribution between males (49%) and females (51%) was found. Identical gender distribution was reported previously.2 The average age at the time of surgical excision was 29.14 years. This is lower than the average age of 44.1 reported previously.2
We found infection to be present in 2.5% of cases.
This is lower than the 7% reported by Abou-Rayyah et al37and the 30% reported by Westphal and Reil,38 but close to the 4% reported by Pryor et al.16 In a study of dermoid cysts,37 it has been found that al- though clinical signs of inflammation are relatively few, about two thirds of the excised cysts showed histopathologic evidence of chronic infection. It has been found that aerobic isolates from infected neck cyst were predominantly Staphylococcus aureus and Streptococcus pyogenes. Pigmented Prevotella, Por- phyromonas, and Peptostreptococcus species, all part of the oral flora, were the predominant anaerobes.39 Infected cutaneous cysts may be mistaken for odon- togenic abscesses, infected atheromas, furuncles, su- perinfected tumors, and other inflammatory condi- tions.
All cysts in this series were removed by a form of surgical enucleation with or without the overlying skin. In a study comparing punch and elliptical inci-
sions for the treatment of epidermoid cyst,40 it has been concluded that the punch incision produces a superior cosmetic result while keeping a low recur- rence rate of cysts. It has been recommended that epidermoid cysts measuring 1 to 2 cm that are located on the face or in an area of cosmetic concern are best treated with punch incisions.40 A minimal excision technique for epidermoid cyst removal has also been reported.41 This technique involves making a 2 to 3 mm incision, expressing the cyst contents through compression, and extracting the cyst wall through the incision.
The clinical diagnosis of cutaneous cysts is con- firmed easily at surgery by the typical appearance of a cystic formation filled with a creamy fluid. It is fre- quent therefore, for “typical” lesions to escape histo- logic investigation after removal. This poor clinical practice must be abandoned as some more sinister lesions such as basal cell carcinoma and pilomatrix carcinoma can mimic cutaneous cysts.42Remote pos- sible diagnoses must always be kept in the mind of maxillofacial surgeons and should be included in the differential diagnosis of these lesions especially in cases with atypical clinical presentation. Maxillofacial surgeons often encounter cutaneous cysts of the head and neck, and they must be familiar with the clinico- pathologic characteristics of these lesions.
1. Weedon D, Strutton G: Cysts and Sinuses in Skin Pathology (ed 2). Edinburgh, Churchill Livingstone, 2002, p 246
2. Golden BA, Zide MF: Cutaneous cysts of the head and neck.
J Oral Maxillofac Surg 63:1613, 2005
3. Gibson WS Jr, Fenton NA: Congenital sublingual dermoid cysts.
Arch Otolaryngol 108:745, 1982
4. Rajayogeswaran V, Evenson JW: Epidermoid cyst of the buccal mucosa. Oral Surg Oral Med Oral Pathol 67:181, 1989 5. Fitzpatrick TB: Fitzpatrick’s Color Atlas and Synopsis of Clinical
Dermatology (ed 5). New York, McGraw-Hill, 2005
6. Silver S, Ho V: Epidermal and appendageal tumors, in Freed- berg I, Eisen A, Wolff K (eds): Fitzpatrick’s Dermatology in General Medicine (ed 6). New York, McGraw Hill, 2003 7. Turetschek K, Hospodka H, Steiner E: Case report: Epidermoid
cyst of the floor of the mouth: Diagnostic imaging by sonogra- phy, computed tomography and magnetic resonance imaging.
Br J Radiol 68:205, 1995
8. Debaize S, Gebhart M, Fourrez T, et al: Squamous cell carci- noma arising in a giant epidermal cyst: A case report. Acta Chir Belg 102:196, 2002
9. Özera E, Kanlıkamaa M, Bayazıta YA, et al: A unique case of an epidermoid cyst of the pterygopalatine fossa and its manage- ment. Int J Pediatr Otorhinolaryngol 67:1259, 2003
10. Guarisco JL: Congenital head and neck masses in infants and children. Ear Nose Throat J 70:75, 1991
11. Scolozzi P, Lombardi T, Jaques B: Congenital intracranial fron- totemporal dermoid cyst presenting as a cutaneous fistula.
Head Neck 27:429, 2005
12. Nocini PF, Barbaglio A, Dolci M, et al: Dermoid cyst of the nose: A case report and review of the literature. J Oral Maxil- lofac Surg 54:357, 1996
13. King RC, Smith BR, Burk JL: Dermoid cyst in the floor of the mouth: Review of the literature and case reports. Oral Surg Oral Med Oral Pathol 78:567, 1994
14. Kormanik KE, Bersu ET, Bentz ML: Dermoid sinus and cyst of the lip. J Craniofac Surg 17:162, 2006
15. Gorur K, Talas DU, Ozcan C: An unusual presentation of neck dermoid cyst. Eur Arch Otorhinolaryngol 262:353, 2005 16. Pryor SG, Lewis JE, Weaver AL, et al: Pediatric dermoid cysts of
the head and neck. Otolaryngol Head Neck Surg 132:938, 2005 17. Taylor BW, Erich JB, Dockerty MB: Dermoids of the head and
neck. Minn Med 49:1535, 1966
18. Walstad WR, Solemon JM, Schow SR, et al: Midline cystic lesions of the floor of the mouth. J Oral Maxillofac Surg 56:70, 1998
19. Howell CJT: The sublingual dermoid cyst: Report of five cases and review of the literature. Oral Surg Oral Med Oral Pathol 59:578, 1985
20. Demello D, Lima J, Liapis H: Midline cervical cyst in children:
Thyroglossal anomalies. Arch Otolaryngol Head Neck Surg 113:
21. De Ponte FS, Brunelli A, Marchetti E, et al: Sublingual epider- moid cyst. J Craniofac Surg 13:308, 2002
22. Longo F, Maremonti P, Mangone GM, et al: Midline (dermoid) cysts of the floor of the mouth: Report of 16 cases and review of surgical techniques. Plast Reconstr Surg 112:1560, 2003 23. DeMattei R, Aubertin M: Dental hygiene screening reveals
childhood neck mass. J Dent Hyg 70:225, 1996
24. Cummings TJ, George TM, Fuchs HE, et al: The pathology of extracranial scalp and skull masses in young children. Clin Neuropathol 23:34, 2004
25. Sudhakar N, Stephenson GC: Swelling on the head-a forgotten lesson: A case report of an intradiploic epidermal cyst with an iatrogenic complication. Br J Oral Maxillofac Surg 42:155, 2004 26. Fradis M, Podoshin L, Goldstein Y, et al: Cervical echinococcal
hydatid cyst. J Laryngol Otol 103:435, 1989
27. Gangopadhyay K, Abuzeid MO, Kfoury H: Hydatid cyst of the pterygopalatine-infratemporal fossa. J Laryngol Otol 110:978, 1996
28. Ataoglu H, Uckan S, Oz G, et al: Maxillofacial hydatid cyst.
J Oral Maxillofac Surg 60:454, 2002
29. Karahatay S, Akcam T, Kocaoglu M, et al: A rare cause of parotid swelling: Primary hydatid cyst. Auris Nasus Larynx 33:227, 2006
30. Pasaoglu E, Damgaci L, Tokoglu F, et al: CT findings of hydatid cyst with unusual location: Infratemporal fossa. Eur Radiol 8:1570, 1998
31. El Kohen A, Benjelloun A, El Quessar A, et al: Multiple hydatid cysts of the neck, the nasopharynx and the skull base revealing cervical vertebral hydatid disease. Int J Pediatr Otorhinolaryn- gol 67:655, 2003
32. Paksoy Y, Odev K, Sahin M, et al: Percutaneous treatment of liver hydatid cysts: Comparison of direct injection of albenda- zole and hypertonic saline solution. AJR Am J Roentgenol 185:727, 2005
33. Bonavolonta G, Tranfa F, de Conciliis C, et al: Dermoid cysts:
16-year survey. Ophthal Plast Reconstr Surg 11:187, 1995 34. Steele MH, Suskind DL, Moses M, et al: Orbitofacial masses in
children: An endoscopic approach. Arch Otolaryngol Head Neck Surg 128:409, 2002
35. Guerrissi JO: Endoscopic excision of frontozygomatic dermoid cysts J Craniofac Surg 15:618, 2004
36. Vaghela HM, Bradley PJ: Nasal dermoid sinus cysts in adults.
J Laryngol Otol 118:955, 2004
37. Abou-Rayyah Y, Rose GE, Konrad H, et al: Clinical, radiological and pathological examination of periocular dermoid cysts: Ev- idence of inflammation from an early age. Eye 16:507, 2002 38. Westphal D, Reil B: Infected dermoid and epidermoid cysts in
the maxillofacial region. Differential diagnosis and therapy.
Dtsch Zahnarztl Z 33:804, 1978
39. Brook I: Microbiology and management of infected neck cysts.
J Oral Maxillofac Surg 63:392, 2005
40. Lee HE, Yang CH, Chen CH, et al: Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: A prospective, randomized study.
Dermatol Surg 32:520, 2006
41. Zuber TJ: Minimal excision technique for epidermoid (seba- ceous) cysts. Am Fam Physician 65:1409, 2002
42. Vandeweyer E, Renard N: Cutaneous cysts: A plea for system- atic analysis. Acta Chir Belg 103:507, 2003