Digital Mucous Cyst Removal

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Digital mucous (myxoid) cysts are flesh-colored nodules that appear on fingers between the distal interphalangeal (DIP) joint and the proximal nail fold. Also known as digital myxoid cysts, the lesions are usually 3 to 12 mm in diameter, solitary, and more common on the dominant hand. The cysts typically appear just lateral to the midline. The lesions are more common in middle-aged to older adults and rarely are encountered on the toes. Women are affected twice as often as men. The lesions would be better described as pseudocysts because they lack a true epithelial lining. 
Two different types of cysts have been identified. One type is associated with degenerative arthritis of the DIP joint and can appear similar to ganglions or synovial cysts. These lesions often have an identifiable stalk that can be traced back to the joint. The second type is independent of the joint and arises from metabolic derangement of the soft tissue fibroblasts. These lesions are associated with the localized production of hyaluronic acid. 
Patients may be asymptomatic or report pain, tenderness, or nail deformity associated with the lesion. Nail ridging is observed in up to one third of patients; a prior history of trauma may be reported by those younger than 40 years of age. One longitudinal study found that the cysts occasionally regress spontaneously. 
Asymptomatic lesions may remain stable for years and can be observed without treatment. Many different treatment regimens have been suggested for symptomatic digital mucous cysts. Aggressive surgery with removal of the cyst and underlying osteophytes may produce the fewest recurrences. Osteophyte removal alone (without cyst removal) also appears effective. Osteophyte removal has been associated with higher cost and complications of joint stiffness, loss of motion, and nail deformity. 
Simpler treatment interventions also have been advocated. Repeated needling of the cyst can provide cure rates in up to 70% of cases. At least two to five punctures appear to be necessary for cyst resolution, and patients can be provided with sterile needles for home treatment. Aspiration and injection of an equal mixture of 0.2 mL of 1% lidocaine (Xylocaine) and 0.2 mL of triamcinolone acetonide (Kenalog, 10 mg/mL) has been advocated historically, but the high rate of recurrence limits this technique. 
Cryosurgical, chemical, or electrosurgical ablation of the cyst base is effective in eradicating the cyst. If freezing is employed, repeated freeze–thaw–freeze technique appears superior to a single freeze. Even with proper cryosurgical technique, there is a 10% to 15% recurrence rate. Carbon dioxide lasers also are being used to ablate the cyst base. A simple office excision technique is described in this chapter. Because infection is a common complication of mucous cyst treatments, some providers recommend prophylactic antibiotics for 3 days postoperatively. 
Historically, sclerotherapy was considered an appropriate method of treatment. However, sclerotherapy is now considered a dangerous approach because of the potential for extravasation of the chemical into the joint or tendon sheath with resultant scarring. 

Equipment

  • A standard office surgery tray, as described in Appendix G, should be available for the excision procedure.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

Indications

  • Symptomatic nodules on the dorsum of the finger between the DIP joint and proximal nail fold

Contraindications (Relative)

  • Uncooperative patient

  • Presence of cellulitis, bacteremia, or active infection

  • Heavy smokers and insulin-dependent diabetics (increased risk of complications)

The Procedure

Needling

Step 1
Clean the skin surface with an alcohol wipe, and enter the cyst with a 25-gauge needle. Pass the needle through the wall of the cyst 5 to 10 times. Multiple needle sticks separated by days may be superior to multiple sticks during one session. The patient may be trained to repeat the procedure at home. 
Step 2
Clear, jelly-like contents will protrude and can be squeezed from the cyst. 
Step 2

Courtesy of Dr. Scott Bergeaux.

Step 2

Courtesy of Dr. Scott Bergeaux.

Ablation of the Cyst Base

Step 1
After the application of local or digital block anesthesia (see Local Anesthesia Administration and Digital Nerve Block Anesthesia), shave off the skin and cyst roof using a horizontally held no. 15 scalpel blade. Apply the cryosurgery probe to the cyst base, and create an ice ball that extends outward onto 2 to 3 mm of the normal-appearing surrounding skin. Alternatively, spray the base with a liquid nitrogen sprayer to the same diameter. Use the freeze–thaw–freeze technique. 
  • PITFALL: Avoid prolonged freezing of the tissues, because notching of the proximal nail fold may develop. The length of the freeze is based on the observed size of the ice ball.

Excision

Step 2
After digital anesthesia, the skin over the cyst is excised, and the cyst is dissected and excised from the surrounding tissues. 
Step 3
Incise a V-shaped base to this circular defect, creating a defect shaped like an ice cream cone. 
Step 4
A small, inverted U-shaped rotation flap is incised and undermined from nearby skin on the dorsum of the finger. 
Step 5
The flap may be moved over the defect and preferably left to heal to the wound bed. Note that suturing the flap may be preferable, because the larger wound produces scarring that may help to reduce cyst recurrence. 
Step 6
Often, the flap does not center over the wound, or excessive bleeding may occur. A single stitch on one or both sides of the flap can help alleviate these problems. Antibiotic ointment and splinting are provided after the procedure. 

Complications

  • Notching of the proximal nail fold

  • Cyst recurrence

  • Scarring of the nail matrix with nail dystrophy

  • Local depigmentation after steroid injection

  • Radial or ulnar deviation of the DIP joint

  • Tendon injury

  • DIP septic arthritis

  • Persistent swelling

  • Pain or numbness

Pediatric Considerations

Digital mucous cysts are rare in childhood. 

Postprocedure Instructions

Antibiotic ointment and a light gauze dressing are placed after cyst treatments. Gentle active range of motion is allowed, and sutures usually are removed after 2 weeks. 

Coding Information and Supply Sources

Instrument and Materials Ordering

  • A standard office surgery tray, as described in Appendix G, should be available for the excision procedure.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation recommendations appear in Appendix E.

Bibliography

Bennett RG. Fundamentals of Cutaneous Surgery . St. Louis: CV Mosby;  1988:754–756.
Dodge LD, Brown RL, Niebauer JJ, et al. The treatment of mucous cysts: long-term follow-up in sixty-two cases. J Hand Surg Am.  1984;9:901–904. [View Abstract]
Epstein E. A simple technique for managing digital mucous cysts. Arch Dermatol.  1979;115:1315–1316. [View Abstract]
Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br.  1997;22:225–225.
Haneke E, Baran R. Nails: surgical aspects. In: Parish LC, Lask GP, eds. Aesthetic Dermatology . New York: McGraw-Hill;  1991:236–241.
Hernandez-Lugo AM, Dominguez-Cherit J, Vega-Memije AE. Digital mucoid cyst: the ganglion type. Intl Dermatol .  1999;38:531–538.
Salasche SJ. Myxoid cysts of the proximal nail fold: a surgical approach. J Dermatol Surg Oncol .  1984;1035–1039.
Singh D, Osterman AL. Mucous cyst. E-medicine. Available at http://www.emedicine.com/orthoped/topic520.htm. Accessed February 21, 2002.
Sonnex TS. Digital myxoid cysts: a review. Cutis .  1986;37:89–94. [View Abstract]
Zuber TJ. Office management of digital mucous cysts. Am Fam Physician.  2001;64:1987–1990. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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