A dermoid is a tumour containing skin or mucous membrane, occurring in a situation where these tissues are not met under normal conditions.
The skin dermoid, or derma-cyst as it has been called by Askanazy, arises from a portion of epiblast, which has become sequestrated during the process of coalescence of two cutaneous surfaces in development. This form is therefore most frequently met with on the face and neck in the situations which correspond to the various clefts and fissures of the embryo. It occurs also on the trunk in situations where the lateral halves of the body coalesce during development. Such a dermoid usually takes the form of a globular cyst, the wall of which consists of skin, and the contents of turbid fluid containing desquamated epithelium, fat droplets, cholestrol crystals, and detached hairs. Delicate hairs may also be found projecting from the epithelial lining of the cyst.
Faulty coalescence of the cutaneous covering of the back occurs most frequently over the lower sacral vertebrę, giving rise to small congenital recesses, known as post-anal dimples and coccygeal sinuses. These recesses are lined with skin, which is furnished with hairs, sebaceous and sweat glands. If the external orifice becomes occluded, there results a dermoid cyst.
Tubulo-dermoids arise from embryonic ducts and passages that are normally obliterated at birth, for example, lingual dermoids develop in relation to the thyreo-glossal duct; rectal and post-rectal dermoids to the post-anal gut; and branchial dermoids in relation to the branchial clefts. Tubulo-dermoids present the same structure as skin dermoids, save that mucous membrane takes the place of skin in the wall of the cyst, and the contents consist of the pent-up secretion of mucous glands.
Clinical Features.—Although dermoids are of congenital origin, they are rarely evident at birth, and may not give rise to visible tumours until puberty, when the skin and its appendages become more active, or not till adult life. Superficial dermoids, such as those met with at the outer angle of the orbit, form rounded, definitely limited tumours over which the skin is freely movable. They are usually adherent to the deeper parts, and when situated over the skull may be lodged in a depression or actual gap in the bone. Sometimes the cyst becomes infected and suppurates, and finally ruptures on the surface. This may lead to a natural cure, or a persistent sinus may form. Dermoids more deeply placed, such as those within the thorax, or those situated between the rectum and sacrum, give rise to difficulty in diagnosis, even with the help of the X-rays, and their nature is seldom recognised until the escape of the contents—particularly hairs—supplies the clue. The literature of dermoid cysts is full of accounts of puzzling tumours met with in all sorts of situations.
The treatment is to remove the cyst. When it is impossible to remove the whole of the lining membrane by dissection, the portion that is left should be destroyed with the cautery.
Ovarian Dermoids.—Dermoids are not uncommon in the ovary (Fig. 59). They usually take the form of unilocular or multilocular cysts, the wall of which contains skin, mucous membrane, hair follicles, sebaceous, sweat, and mucous glands, nails, teeth, nipples, and mammary glands. The cavity of the cyst usually contains a pultaceous mixture of shed epithelium, fluid fat, and hair. If the cyst ruptures, the epithelial elements are diffused over the peritoneum, and may give rise to secondary dermoids.
The ovarian dermoid appears clinically as an abdominal or pelvic tumour provided with a pedicle; if the pedicle becomes twisted, the tumour undergoes strangulation, an event which is attended with urgent symptoms, not unlike those of strangulated hernia.
The treatment consists in removing the tumour by laparotomy.
Teratoma.—A teratoma is believed to result from partial dichotomy or cleavage of the trunk axis of the embryo, and is found exclusively in connection with the skull and vertebral column. It may take the form of a monstrosity such as conjoined twins or a parasitic fœtus, but more commonly it is met with as an irregularly shaped tumour, usually growing from the sacrum. On dissection, such a tumour is found to contain a curious mixture of tissues—bones, skin, and portions of viscera, such as the intestine or liver. The question of the removal of the tumour requires to be considered in relation to the conditions present in each individual case.