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Clinical Note |

Apocrine Hidrocystoma Masquerading as a Posttraumatic Cerebrospinal Fluid Leak:  Case Report and Literature Review

Yash Patil, MD; Marci J. Neidich, MD; Qihui Zhai, MD
Arch Otolaryngol Head Neck Surg. 2011;137(10):1031-1034. doi:10.1001/archoto.2011.152.
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Otolaryngologists frequently care for patients with injuries that violate multiple aspects of the facial skeleton and skull base. Cerebrospinal fluid (CSF) leak is a common complication after skull base trauma. Two percent of head injuries and 12% to 30% of all basilar skull fractures result in CSF leak.1 In a retrospective review2 of 820 fractured temporal bones, 122 CSF fistulae were noted. Posttraumatic CSF leaks originate most commonly from frontal or ethmoid sinus fractures or appear after longitudinal temporal bone fracture.3 Typically, CSF leak presents as clear nasal drainage or meningitis. We describe a case of swelling in the midface under a radial forearm fasciocutaneous free flap that was used to reconstruct the palate, midface, and skull base. Initial evaluation of this painless, slow induration 1 year after enucleation of orbital remnants was highly suspicious for a skull base CSF leak, mucocele, or encephalocele. Surgical exploration and final pathologic analysis revealed an unusual presentation of a dermatologic entity: apocrine hidrocystoma.

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Figure 1. Axial (A) and coronal (B) computed tomographic scans demonstrating facial and skull-base injuries.

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Figure 2. The defect before free-flap reconstruction.

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Figure 3. Axial (A) and coronal (B) computed tomographic scans demonstrating fluid collection under the flap.

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Figure 4. Photomicrographs of the resected lesion. The cystic wall and pseudopapillae are lined by 2 rows of cells forming a luminal epithelium with apocrine differentiation and a basal myoepithelium. Note the lack of nuclear atypia and mitotic figures in the luminal epithelium (hematoxylin-eosin, original magnification ×20 [A] and ×40 [B]).

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