85 Scalp Lesions
Daniel Sciubba

♦ Preoperative

• Cranial sinus tracts:
  
  
  
  
  • An epithelium-lined tract that extends from the skin surface at variable depths into tissues (Fig. 85.1)
    
  • A persistent attachment that probably forms when cutaneous ectoderm does not separate completely from neuroectoderm during neural tube formation
    
  • Found in either the midline nasal or occipital regions
    
  • Associated with a variety of cutaneous findings: hair, hemangioma, dimple, or lipoma
    
  • Occipital cysts are midline and extend subcutaneously in a caudal direction
    
  • Those penetrating the calvarium enter the bone inferior to the torcula
    
  • Dermoid or epidermoid cysts may be found anywhere along the sinus tract
    
  • Often discovered following bouts of recurrent sterile (chemical) or bacterial meningitis
    
  • Tracts should never be probed during physical examination to avoid introducing infectious materials intracranially
    
  • Magnetic resonance imaging is best to visualize the sinus tract and level of extension, and to determine presence of intracranial abnormality such as a dermoid cyst
    
  • Goal of surgery is elective total excision of the entire sinus and cyst (when present) prior to possible infectious complication

Equipment

• Major craniotomy tray
  
• Mayfield head holder
  
• High-speed drill

Operating Room Set-up

• Headlight
  
• Loupes
  
• Bovie cautery and bipolar cautery

Fig. 85.1 Different layers of the scalp and skull that may be traversed by dermal sinus tracts.

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