Presentation of cystic lesions

GANGLION: Ganglia occur in relation to a joint or tendon sheath and are most commonly seen on the dorsum of the hand, wrist or ankle. Ganglia occur at any age but most commonly appear between the teenage years and the 40s. They are often symptomless, but occasionally ache. They usually develop slowly and can vary in size or disappear. On examination, the gel-filled swelling is fluctuant and transilluminates. The gel is thought to be derived from synovial fluid. The ganglion can be aspirated or dispersed by a blow or pressure. However, recurrence is common. Surgical removal has better results. 

MYXOID CYST: Myxoid cysts occur as a result of a degeneration of the connective tissue at the end of the finger. They may connect with the joint. The cyst is filled with thick, sticky, mucoid material. The shiny, smooth surfaced swelling overlies the nail matrix, causing the nail to develop a longitudinal furrow in it. Recurrence after treatment is common. Treatment options include firm pressure on the cyst to express the contents through a hole made with a sterile needle, cryotherapy, steroid or sclerosant injection or surgical removal.

TRICHOLEMMAL CYST: A tricholemmal cyst derives from the outer root sheath of the hair follicle. It occurs in hair-bearing areas such as the scalp. The cyst is more common in middle-aged women. It is mobile within the dermis or as a small warty flesh-coloured papule. Occasionally they may rupture and discharge. A single lesion may be mistaken for a cystic basal cell carcinoma. The cyst may be excised. Multiple tricholemmal cysts may be associated with the autosomal dominant Cowden's syndrome, a rare condition in which the patient develops a cobblestone appearance in the mouth as a result to oral papillomatosis, which may be a marker for carcinoma of the breast, pancreas or thyroid.

APOCRINE HIDROCYSTOMA: Apocrine hidrocystoma or cystadenoma is a benign tumour of the apocrine glands. It usually presents on the face in middle age and is most commonly seen around the eyes. It develops slowly and is seen as a dome shaped cystic, bluish swelling. Excision is the best treatment.

BARTHOLIN'S CYST: Bartholin's cyst is a common benign lesion of the vulva in which there is dilatation of the duct of Bartholin's gland. The patient presents with an asymptomatic, unilateral swelling on the postero-lateral aspect of the introitus. It may vary in size between 2-8cm and is filled with sterile mucous. The cyst may become infected. The patient will then complain of acute, severe pain and the cyst will be swollen and inflamed. The abscess may rupture spontaneously and/or require surgical intervention, with marsupialisation to allow for drainage. The infection is usually due to a staphylococcal, streptococcal or E coli infection, or occasionally by a gonococcal infection.

GARTNER'S DUCT CYST: Gartner's duct is active during foetal development but usually disappears after birth. It most commonly lies in the side walls of the vagina and in some patients fluid may collect in the duct, resulting in a cyst in that area in later life. A Gartner's cyst is usually symptomless, but patients may sometimes be aware of the swelling or complain of dyspareunia. Other complications are rare. On examination the cyst can be seen and will feel hard and solid. A biopsy should be carried out to exclude malignancy. If troublesome the cyst can be excised.

CYST OF MOLL: Cyst of Moll or marginal cyst may develop in blocked lipid and sweat secreting glands in the margins of the eyelids. On examination the cyst is dome shaped and there is no inflammation. The cyst is filled with clear fluid. Marginal cysts occur most commonly in the lower lid near the lachrymal punctum but may be anywhere on the eyelid. If the cyst is not causing any problems for the patient, no treatment is required but if necessary or for cosmetic reasons, the cyst can be excised under local anaesthetic.

MEIBOMIAN CYST: Meibomian cyst or chalazion is a granuloma of the lipid-secreting meibomian glands of the eyelid. It is probably caused by a blocked duct. The patient might complain of a painless lump in the eyelid that gradually enlarges. It usually occurs on the conjunctival surface of the lid. Occasionally pressure from the swelling can lead to astigmatism and blurred vision. If there is discomfort or inflammation, warm compresses and topical antibiotic cream such as fusidic acid should be used. About one third of cases will resolve spontaneously. Most cysts will reabsorb within two years. However, if necessary the tarsal gland can be incised, followed by curettage.

- Contributed by Dr Jean Watkins, a GP in Ringwood, Hampshire.

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