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Dhabarde et al. UJMDS 2015, 03 (02): Page 44-46 ISSN 2347-5579 Unique Journal of Medical and Dental Sciences Available online: www.ujconline.net Case Report RARE CASE OF LARGE ORBITAL SEBACEOUS CYST WITH FISTULOUS TRACT NEAR LACRIMAL SAC AREA Dhabarde Kavita A1*, Deshmukh MR2 , Bodalkar VP3 1 2 Assistant Professor, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India Associate Professor, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India 3 Post Graduate, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India Received: 26-04-2015; Revised: 24-05-2015; Accepted: 22-06-2015 *Corresponding Author: Dhabarde Kavita A Assistant Professor, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India, Mobile No. 09423105181 ABSTRACT A 55 year old male presented with a large gradually increasing swelling over left lacrimal sac area with thick cheesy toothpaste like material coming out from skin over sac area on pressure since 2 years. On examination obvious roughly 3cm x 3 cm swelling with external fistula was present on sac area which was raised above the surface, slightly tender with no redness or increased temperature on it and attached to overlying skin. Material on culture and sensitivity showed no growth. On histopathological examination , cheesy material with few leucocytes and red blood cells were seen, malignant cells were absent. ELISA for HIV was nonreactive. Patient was given systemic and local antibiotics and anti-inflammatory drugs with daily expression of material from cyst. Removal of cyst with fistulectomy was done and sebaceous cyst was confirmed on histopathological examination. Keywords: Large Orbital Sebaceous Cyst, Fistula Near Lacrimal Sac Area, Cheesy Discharge INTRODUCTION Diseases of the orbit create some of the most complex and perplexing problems in ophthalmology1. Sebaceous cyst are small lumps just under the skin that contain keratin. (Keratin – a pasty or cheesy looking protein that often has a foul odour).They are usually painless, slowly growing occurring often as a result of swollen hair follicles or skin trauma, diagnosed easily by appearance2. Most common areas are armpits, groin, bikini line, inner legs and anywhere that sweats and rubs against clothing. Stress is a big inducer.2 Sebaceous cyst in lacrimal sac area is very rare. Reported prevalence of sebaceous cyst is 5 per 1000 ie approx.1 in 200 or 1.4 million people in USA. Present case is a very rare case of large orbital sebaceous cyst with fistulous tract near lacrimal sac area. CASE REPORT A 55 years old male, slum dweller, rickshaw-puller by occupation presented with gradually increasing swelling over left lacrimal sac area with thick cheesy toothpaste like material coming out from skin over sac area on pressure since 2 years. The thick discharge material was slightly blood tinged with no foul smell. Patient had no complaint of pain, redness over the swelling or watering from the eye. He was non-diabetic and chronic alcoholic since 20 years. There was no history of contact. On examination, his visual acuity was 20/20 in right eye and 20/60 with no improvement with pinhole in left eye. Right eye was normal except a small 1 cm x 1cm nontender swelling n sac area. In left eye, lids were edematous with mechanical ptosis. Eyelashes were matted with discharge. Rest of anterior segment was normal in right eye .The left eyeball was displaced laterally by 4 mm. A large round obvious roughly 3cm x 3 cm swellng with external fistula was present on sac area .The swelling was raised above the surface for about ½ cm with punctum over it and was attached to overlying skin. Continuous discharge of thick pultacious cheesy looking initially white and then blood stained material was present on pressure over sac area .The swelling was slightly tender with no redness or increased temperature of the skin over selling . Culture and sensitivity of thick discharge material showed no growth of organisms. Plain X-ray left orbit (lateral view) showed soft tissue density lesion anterior to ethmoidal sinus. CT scan of left orbit demonstrated an irregular lesion involving left lacrimal fossa . ENT examination did not reveal any nasal pathology. Skin specialists opinion was suggestive of long standing sebaceous cyst with fistula over sac area. Syringing of right eye was patent and of left eye could not be done. Blood sugar levels were within normal limits. Elisa for HIV was non- reactive. Histopathological examination of Unique Journal of Medical and Dental Sciences 03 (02), April-June 2015 44 Dhabarde et al. UJMDS 2015, 03 (02): Page 44-46 discharge revealed cheesy keratin material with few leucocytes and red blood cells. Malignant cells we were absent. Patient was administered systemic (Cefotaxime, Gentamycin, Metronidazole) and local antibiotics and anti anti-inflammatory drugs with daily expression of thick discharge from the cyst. Removal of cyst with fistulectomy was done with the help of oculoplasty oplasty surgeon and cyst was sent for histopathological examination. The cyst was lined by stratified squamous epithelium and was filled with keratinous material. CLINICAL PHOTOGRAPHS OF THE PATIENT Sebacious Cyst with cheesy thick pultaceous, slightly blood stained discharge Cyst showing umblication, with gross lid oedema and thick cheesy discharge with fistula in sac area DISCUSSION A sebaceous cyst is a type of cyst that forms in the epidermis, the outermost layer of the skin. Sebaceous cysts are common, noncancerous, and are generally not a serious condition3. It also sometimes called an epidermal cyst, forms when keratin, a protein that makes of the epidermis, blocks a sebaceous gland2. This creates a contained sac that fills with a fatty white substance secreted by the sebaceous gland called sebum. The contents of the sebaceous cyst are often referred tto as resembling cottage cheese. Sebaceous cysts can be caused by skin trauma, swollen hair follicles, high levels of testosterone, and some hereditary syndromes4. Sometimes they grow large enough that may interfere with everyday life. Sometimes even lasting ng for weeks or months, they can tunnel under skin and spread. They can become infected and can form painful abscesses. Often a sebaceous cyst requires no treatment, and it may disappear by itself. If the cyst is small injection of steroids with antibiotics ics can be tried. In cases of large cyst, surgical removal is indicated. If incompletely removed, can recur2. CONCLUSION Sebaceous cyst in lacrimal sac area is very rare. The above reported case of large orbital sebaceous retention cyst with fistula near lacrimal sac area of long duration is a very rare case. It can very well mimic chronic dacryocystitis (large mucocele), adenocarcinoma of lacrimal sac, pseudo tumor of orbit and orbital cellulitis. We recommend considering it in the differential diagnosis of swelling over lacrimal sac area5. Unique Journal of Medical and Dental Sciences 03 (02), April-June 2015 201 45 Dhabarde et al. UJMDS 2015, 03 (02): Page 44-46 4. REFERENCES 1. 2. 3. Levine RA, Putterman AM, Macrae DW.Orbital and Adnexal Tumors.In:Peyman GA,editor. Principles and Practice of Ophthalmology,1st Indian ed. New Delhi: Jaypee publishers; 1987.p.2149-204. Tracee Cornforth. Sebaceous cyst. Sebaceous cysts are pasty filled bumps and lumps below the skin. http://www.nlm.nih.gov/medlineplus/ency/article/000 842.htm.Accessed 08/26/09 Updated Aug 13 , 2014 .Available from 2014About.com PubMed Health A.D.A.M Medical Encyclopedia. Sebaceous cyst. Epidermal cyst; Keratin cyst;Epidermoid cyst; Epidermal inclusion cyst / Habif TP. Clinical dermatology: A colour guide to diagnosis and Therapy.Philadelphia,Pa:Elsevier Mosby;2009: chap 20. Last reviewed May 15, 2013.Reviewed by Kevin Burman. 5. 6. Lydia Krause. What’s causing this sebaceous cyst ? Healthline medically reviewed by George Krucik .Epidermoid cysts(sebaceous cysts).(2011)Mayo clinic . Retrieved July 24 ,2012 from http://www.mayoclinic.com/health/sebaceous cysts/DS00979/ www.mayoclinic.org/diseases-conditions /sebaceous cyst resources/CON 20031599. Mayo foundation for medical education and research 1998-2014 Book : Mayo clinic family health book,4th edition Goldberg BG et al . Overview of benign lesions of the skin . http://www.uptodate.com/home Accessed Jan 20,2014 Jacob Pe’er, Hidayat AA, Ilsar M, Landau L, Stefanyszyn. Glandular tumors of the lacrimal sac. Their histopathologic patterns and possible origins. Ophthalmology 103;10:1601-05 Source of support: Nil, Conflict of interest: None Declared Unique Journal of Medical and Dental Sciences 03 (02), April-June 2015 46