To see views enlarged, click on the individual pictures...

You see an 18-month-old boy presented by his mother with a “lump” above his eye. You see this lump as shown in the picture above. The child is described by his mother as “perfectly healthy”. She states that she just noticed this, but in retrospect she thinks that it could have been present for several months at least. Your eye examination confirms that the child’s eyes are normal. The mass is firm to palpation, but can be moved slightly under what appears to be normal skin and is softer than “rock hard”.

1.	The most likely diagnosis is:
	b -- dermoid The most likely diagnosis is a periorbital dermoid. An encapsulated hemangioma with normal overlying skin would be soft to palpation. A lacrimal gland cyst would be behind the orbital rim.  An osteoma would be “rock hard”.
2.	This mass could contain:
	e -- all of the above A dermoid contains hair follicles, sebaceous glands, sweat glands and keratinized epithelium.
3.	Management of this condition is:
	e -- none of the above Observation will only confirm that the mass will not go away, but will likely increase in size, at least some. Irradiation is not indicated. Needle drainage is contraindicated because spilling the contents would be likely to result in lipogranulomatous inflammation.  This lesion intact is not inflammatory and will not respond to warm compresses and antibiotics. The treatment for this type of lesion is surgical excision removing the mass carefully and intact. The best approach is to carry out a curvilinear skin incision extending several millimeters beyond the extent of the mass.  Then carry out meticulous sharp and blunt dissection continuing around the full extent of the cyst until eventually cutting it free from periostium.  These cysts tend to arise from primitive dermal rests at the fetal suture lines of the orbital rim. These cysts can be attached to the suture line, simply adjacent to the suture line and not attached, or they can extend into the orbit presenting both in and out of the orbit, and they can be entirely intraorbital.  These dermoid cysts are not uncommon.  The picture below shows a dermoid persisting in an older patient.  The nasal orbital rim where this mass is found is the second most common site for a dermoid.  These dermoid cysts have different characteristics from limbal dermoids and orbital lipodermoids.