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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > Nail Procedures > 34 – Digital Mucous Cyst Removal 34 Digital Mucous Cyst Removal Digital mucous cysts are clear or 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 cyst 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 individuals younger than 40 years of age with the cysts. One longitudinal study found that the cysts occasionally regress spontaneously. Asymptomatic lesions can be observed and may remain stable for years. 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 have also been advocated. Repeated needling of the cyst can provide cure rates up to 70%. 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 steroid has been historically advocated, 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 P.240
15% recurrence rate after cryosurgery. A simple office excision technique also is described in this chapter. Antibiotic ointment and a light gauze dressing are placed after cyst treatments. Some physicians believe immobilization is unnecessary after removal, but an aluminum splint applied 2 to 10 days after the procedures can reduce discomfort and may promote healing. INDICATIONS

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

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PROCEDURE Clean the skin surface with an alcohol wipe, and enter the cyst with a 25-gauge needle. Clear, jelly-like contents will protrude and can be squeezed from the cyst. Multiple needlesticks separated by days may be superior to multiple sticks during one session.

(1) Needling the cyst.

Ablation of the cyst base. After the application of local or digital block anesthesia, shave off the skin and cyst roof using a horizontally held no. 15 scalpel blade (Figure 2A). 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 (Figure 2B). Use the freeze-thaw-freeze technique.

(2) Ablation of the cyst base.

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. P.242
After digital anesthesia, the skin over the cyst is excised, and the cyst is dissected and excised from the surrounding tissues (Figure 3A). Incise a V-shaped base to this circular defect, creating a defect shaped like an ice cream cone. A small, inverted U-shaped rotation flap is incised and undermined from nearby skin on the dorsum of the finger (Figure 3B). The flap is moved over the defect and preferably left to scar to the wound bed (Figure 3C). Not suturing the flap may be preferable, because the larger wound produces scarring that may help to reduce cyst recurrence. 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 (Figure 3D). Antibiotic ointment and splinting are provided after the procedure.

(3) The simple excision technique.

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CODING INFORMATION


CPT® Code Description 2002 Average 50th Percentile Fee

20612 Aspiration or injection of ganglion cyst, any site †
26160 Excision of lesion of tendon sheath or joint capsule (mucous cyst) $700

†No reference fee available because this is a new code in 2003.
CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING A standard office surgery tray, as described in Appendix A, should be available for the excision procedure. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H. 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. Epstein E. A simple technique for managing digital mucous cysts. Arch Dermatol 1979;115:1315–1316. 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. Int J Dermatol 1999;38:531–538. Salasche SJ. Myxoid cysts of the proximal nail fold: a surgical approach. J Dermatol Surg Oncol 1984;10:35–39. Singh D, Osterman AL. Mucous cyst. Emedicine February 21, 2002. Available at http://www.emedicine.com/orthoped/topic520.htm Sonnex TS. Digital myxoid cysts: a review. Cutis 1986;37:89–94. Zuber TJ. Office management of digital mucous cysts. Am Fam Physician 2001;64:1987–1990. Zuber TJ. The illustrated manuals and videotapes of soft-tissue surgery techniques. Kansas City: American Academy of Family Physicians, 1998.

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