Open Access

Case report
Epidermoid cyst of the tonsil: a rare finding

Rachida Bouatay1,&, Sondos Jellali1, Nouha Abdejelil2, Jamel Koubaa1

1
Department of Otorhinolaryngology and Head and Neck Surgery at "Fattouma Bourguiba" Hospital of Monastir, Tunisia, 2Pathology Department at
"Fattouma Bourguiba" Hospital of Monastir, Tunisia

&
Corresponding author: Rachida Bouatay, Department of Otorhinolaryngology, Head and Neck Surgery at "Fattouma Bourguiba" Hospital of
Monastir, Tunisia

Key words: Epidermoid cyst, tonsil, surgery

Received: 17/01/2019 - Accepted: 15/07/2019 - Published: 02/09/2019

Abstract
Epidermoid cysts (ECs) are benign lesions that can be encountered throughout the body, but with a low incidence in the head and neck (1.6 to 7%).
In oral cavity, the most common affected site is floor of the mouth, but tonsillar location remains extremely rare (less than 0.01%). Here we present
an epidermoid cyst of the right palatine tonsil which was incidentally detected in a patient who consulted for a chronic headache.

Pan African Medical Journal. 2019;34:4. doi:10.11604/pamj.2019.34.4.18193

This article is available online at: http://www.panafrican-med-journal.com/content/article/34/4/full/

© Rachida Bouatay et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

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Introduction are enclosed and lined by stratified squamous epithelium only. If the
wall of the cyst contains skin adnexal structures, they are termed as
"dermoid cyst" and if they include the tissues from ecto, endo or
Epidermoid cysts (ECs), also named epidermal, epithelial, keratinous,
mesoderm like muscle, bone, cartilage or fat, they are called "teratoid
sebaceous, or infundibular cysts are benign lesions developing from
cyst" [5]. They can be of two types: congenital or acquired, which are
abnormal epithelial components of ectodermal tissue formed during
similar both clinically as well as histologically [6]. The etiology of
the fetal period (congenital cysts), or implanted epithelium arising
epidermoid cysts are varied and noted from hormonal influence during
after surgery or trauma (acquired cysts) [1]. They are benign lesions
puberty to abnormal inclusion of cells during surgery/trauma or
that can be encountered throughout the body, but with a low
development from the epithelia remnants isolated during the closure
incidence in the head and neck (1,6 to 7%) [2]. In oral cavity, the
of first and second branchial arches in the midline [7].
most common affected site is floor of the mouth, but tonsillar location
remains extremely rare (less than 0.01%). Treatment of epidermoid
These cysts can be associated with certain hereditary syndromes like
cysts of the head and neck is surgical and can be intraoral or extra
Gardner syndrome caused by mutations in the adenomatous polyposis
oral according to the localization and the size of the lesion [3]. Here
coli gene, or in Lowe syndrome, an X-chromosomal oculo-cerebral-
we report a case of epidermoid cyst arising in the tonsil which was
renal disorder caused by mutations of the OCLR1-gene (Oculo Cerebro
encountered as an incidental finding in the patient.
Renal Lowe syndrome) [1]. They can occur in any age group, starting
from birth (the congenital type) to 72 years. Most patients are in the
range between 15 to 35 years, with male preponderance. Our patient
Patient and observation was a 28- year-old female [4]. In oral cavity, the sites from which ECs
can arise are floor of mouth or the labial, lingual or buccal mucosa [8].
A 28-year-old female with no pathological history, consulted for Oral cavity accounts for about 1,6% [9]. They usually present as
chronic headache without a history of recurrent tonsillitis. On physical asymptomatic painless slow growing mass [4,5]. That was the case
examination the palatine tonsils were hypertrophied and symetric, the for our patient since EC presented as an incidental finding during
throat isthmus was symmetrical. There were no palpable neck masses headache assessment. The differential diagnosis to be considered for
or other findings on head and neck examination. An injected cerebral tonsillar hypertrophy include tumors of parapharyngeal space,
computed tomography performed, showed cystic formation of the infectious etiology, dermoid cyst, lymphoepithelial cyst, papilloma and
right palatine tonsil which enhanced in peripheral with a center of fluid tonsillar carcinoma. Histopathologically we can easily differentiate
density (Figure 1). The patient underwent tonsillectomy under general these entities, hence gross and microscopical examination of every
anesthesia for diagnostic purpose. Histopathologic examination resected tonsillar mass is important. Histopathology is the gold
showed a cystic formation lined by a squamous epithelium standard to rule out malignancy and to confirm the benign nature of
surmounted by parakeratotic hyperkeratosis. It contains neutrophils tonsillar epidermoid cyst [1,7,10].
in exoxtosis and rests on lymphoid tissue (Figure 2). These findings
confirmed the diagnosis of epidermoid cyst of the tonsil. The patient Diagnosis is based on imaging and can be aided by fine needle
was discharged without any postoperative complications; her follow- aspiration in case of symptomatic tonsillar mass, followed by excision
up after 24 months was entirely uneventful. biopsy. Imaging studies can provide some diag¬nostic information
about epidermoid cyst. On CT scan, epidermoid cyst should appear as
a well-circumscribed, low-density, unilocular mass. Typically, it is
predominantly fluid-attenuated. On magnetic resonance imaging, the
Discussion
appearance of EC is variable according to their fluid contents and
protein density. Often, they exhibit a low signal intensity with T1
Epidermoid cysts are defined as benign lesions that are histologically
sequences and a high signal intensity with T2 sequences [11,12].
characterized by cystic spaces lined by squamous epithelium [1].
Treatment for these lesions is surgical excision of the cyst or
Among the different types of cyst which can arise in tonsils, the
tonsillectomy [13]. It should be excised without opening because its
tonsillar retention cyst is the most common type while epidermoid
contents could have an irritating effect on the surrounding
cyst, lymphoepithelial cyst and hydatid cyst are rare causes of tonsillar
fibrovascular tissue. A tonsillectomy was performed in our patient. The
cyst [4]. The cysts in oral cavity are termed as "epidermoid" if they
cyst was excised within its capsule and the follow-up during 24 months

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Conclusion
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Figure 1: axial injected computed tomography section of the oropharynx showed an hypo dense mass of the right palatine tonsil with peripheral
enhancement

Figure 2: cystic cavity within the tonsillar tissue lined with keratinized epithelium HE X 40 (A) and HE X 100 (B)

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