OccultTraumaticAvulsionof an Ovarian DermoidCyst ROBERT L. LEVINE, MD,* PAUL E. PEPE, MD,t WILLIAM BLACKSTONE, MD,* JULIUS DANZINGER, JOSEPH VARON, MD” This case report describes a unique presentation involving avulsion of an ovarian dermoid tumor which occurred as the result of blunt trauma secondary to a motor vehicle collision. Despite an unimpressive initial presentation and normal physical examination, the patient subsequently developed symptoms of severe hemorrhage requiring aggressive intravascular volume resuscitation. A ruptured ovarian dermoid tumor was eventually diagnosed by computerized axial tomography. A review of the literature by the authors did not reveal any similar cases of previous reports of this phenomenon. (Am J Emerg Med 1992;10:344-346. Copyright 0 1992 by W.9. Saunders Company) Blunt trauma resulting in an isolated injury to the female reproductive tract with no other accompanying injury is rare. ’ A review of the literature revealed no other previous reports of isolated avulsion of an ovarian dermoid cyst following blunt trauma. In the few cases in which trauma to the pelvic organs has been reported, the physical examination uniformly suggested an acute abdomen, and the diagnosis was made at the time of laparotomy.’ The following case report details the presentation and diagnosis of an avulsed ovarian dermoid cyst which was the lone sequelae of a motor vehicle collision.
CASE REPORT A 2byear-old woman, who was the seat belt-restrained driver of an automobile, was involved in a motor vehicle collision at approximately 4~30 AM. Her vehicle was struck on the driver’s side, specifically involving the driver’s door. However, paramedics reported that there was minimal damage to the patient’s automobile and that the door was opened readily. Her overall condition appeared to be good and she had no specific complaints. She was therefore transported to the nearest community hospital. In the emergency department (ED), the patient only complained of a “gas-like” pain of minimal intensity located diffusely over her abdomen and back. She was awake, alert, and oriented. The odor of alcohol was noted on her breath. Her admission vital sign measurements included a systemic blood pressure of 1lo/82 mm Hg, respirations of 20 breaths/min, pulse rate 88/min, and oral temperature 36.2”C. The general physical examination was unremarkable with the sole exception of the abdomen. Bowel sounds were decreased and mild From *tIlthe Departments of Medicine and TSurgery, Baylor College of Medicine, Waco, TX; Tthe City of Houston, Emergency Medical Services; and the *$Departments of Emergency Medicine and §Radiology, Spring Branch Medical Center, Houston, TX. Manuscript received February 18, 1992; accepted March 6, 1992. Address reprint requests to Dr Levine, 6565 Fannin, MS F-602, Houston, TX 77030. Key Words: Dermoid cyst; ovarian; teratoma; trauma, blunt; injury; avulsion; hemorrhage, shock. Copyright 0 1992 by W.B. Saunders Company 0735-6757/92/l 004-0016$5.00/0 344
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tenderness was noted across the lower abdomen with minimal guarding present. A pelvic and rectal examination were not performed at the time of the initial evaluation. Laboratory tests performed in the ED revealed a hematocrit of 36%, hemoglobin 120 g/L. white blood ceil count 7,200/mm3, serum ethanol 42 mmol/L, and serum amyiase 44 W/L. Arterial blood gas measurements were within normal limits as were the chest, abdomen, and lateral cervical spine radiographs. Serum B-human chorionic gonadotrophin assay was negative and urine analysis was normal. Approximately 35 minutes after her arrival at the ED, while attempting to use the toilet, the patient collapsed. At that time her systolic blood pressure was determined to be 58 mm Hg by palpation. Although the patient’s systemic blood pressure responded initially to rapid infusions of isotonic intravenous fluids, she remained tachycardic. Her abdomen was still minimally tender but was now slightly distended. Her physical examination otherwise remained unchanged. Awaiting the arrival of surgical consultation, a computed axial tomographic scan of the abdomen was performed. This study was performed within 2 hours of admission to the ED. A ruptured epidermoid cyst was demonstrated (Figure 1) with a large amount of accompanying free intraperitoneal blood (Figure 2). A iaparotomy was performed soon thereafter, revealing a large epidermoid cyst in the left ovary. which had been avuised from its vascular pedicie. Massive bleeding was controlled by ligation of the left ovarian blood vessels. A left salpingo-oophorectomy was performed. No other injuries were noted. Postoperatively. the patient had an uneventful course and was discharged home 5 days after admission.
PATHOLOGY Pathologic examination revealed an 8 x 8 x 7-cm cystic mass filled with “cheesy” necrotic material and hair. Typical bone and teeth-like structures were present within the tumor. No malignant changes were noted. The final pathologic diagnosis was benign cystic teratoma of the left ovary. DISCUSSION Although a Babylonian cuneiform papyrus dating from 2,000 years BC may be the first record of a teratoma, Galen, in the first century, is credited with describing the lesion now known as a dermoid cyst.’ In 1863, Rudolf Virchow introduced the name “teratoma” from the Greek word term, meaning monster, because of his impression of the structures contained within the cyst. Today, dermoid cysts are recognized as the second most common type of benign ovarian tumors, and they account for about 15% of all ovarian neoplasms.3.4 This case report presents several unusual aspects of gynecologic trauma diagnosis and management. The vehicular collision occurred with an apparently low-speed impact, resulting in minimal damage to the patient’s automobile while
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FIGURE 1. Computed tomography of the abdomen reveals a large ovarian tumor surrounded by blood. The presence of a tooth is noted in the center of the tumor (arrows).
she was properly restrained. She had no reported symptoms at the scene and she presented without external evidence of trauma. She had only minimal abdominal tenderness on a directed physical examination at the hospital. Nevertheless it appears, in retrospect, that the patient still sustained a significant enough deceleration injury to result in an avulsion of an occult ovarian dermoid cyst. Rupture of ovarian dermoids has occurred spontaneously, or as a result of a minima1 inciting event such as a fall, turning in bed, vomiting, coitus, or an iatrogenic cause.3*5-7 However, previous reports have not described the association between trauma secondary to a vehicular collision and the avulsion of a dermoid cyst, In a S-year review of all female patients with blunt abdominal trauma that underwent laparotomy at the Maryland Institute of Emergency Medical Services System (Baltimore, MD), only 15 cases of gynecologic injury were found.’ All 15 patients were nongravid and 14 had ovarian trauma. Although 13 of these cases were associated with the presence of physiologic ovarian cysts, the hemorrhage was always from an existing corpus luteum. In addition, all of the cases were associated with multiple trauma secondary to a motor vehicle collision. It is likely that our patient did not have symptoms immediately upon admission because of a slow initial hemorrhage and gradual spillage of teratoma contents into the peritoneum. If the entire contents are expelled suddenly, the patient usually presents with a clinical picture of shock and acute abdominal crisis.3 When the patient in this report stood up to use the toilet, the increased intraabdominal pres-
sure may have further stressed the avulsion and resulted in a sudden increase in the rate of hemorrhage and the subsequent hemorrhagic hypotension. It is not certain that earlier performance of a pelvic examination could have led to an earlier diagnosis. Even with a cyst of this dimension, detection by physical examination is not always possible. In addition, there often are logistic and psychologic difficulties in achieving this desirable goal, particularly in a busy ED. Nevertheless, the potential for early detection of an underlying problem by pelvic examination still exists, and the role of early examination should be reemphasized by this report. The treatment of choice when a diagnosis of ruptured dermoid cyst is made or suspected, is surgical removal of the dermoid cyst with lysis of all associated adhesions, The opposite ovary should be carefully inspected as well. Several major points can be derived from this case report. First, though rare, isolated gynecologic injury with significant sequelae can occur in the absence of multiple trauma. Second, such a significant injury can occur in the absence of major symptomatology or signs. Although the person in this case report had ingested ethanol, the serum levels did not reflect a high enough level to significantly obscure the history and physical examination. Third, it confirms the value of continued observation of blunt trauma patients for some period of time, even when the mechanism of injury and apparent physical findings appear minor. Fourth, this case also emphasizes a lower threshold for performing early rectal and pelvic examinations in victims of blunt trauma.
346
FIGURE 2. (arrows).
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of the abdomen at the level of the liver and spleen. A large amount of blood is noted with no other injuries
In conclusion, community ED physicians and other members of trauma teams need to be aware of the potential for isolated gynecologic injury from low-speed motor vehicle collisions. In addition, if necessary, the computed axial tomographic scan can be used to diagnose an avulsed dermoid cyst. Finally, early rectal and pelvic examinations should be emphasized in blunt trauma patients, especially with nonspecific and minor abdominal symptoms. REFERENCES 1. Stone NN, Antes IG, Brotman S: Gynecologic injury in the nongravid female during blunt abdominal trauma. J Trauma 1984;24(7):626-627
2. Pantoja E, Noy MA, Axtmayer RW, et al: Ovarian dermoids and their complications: Comprehensive historical review. Obstet Gynecol Surg 1975;30(1):1-18 3. Abitbol MM, Pomerance W, Mackles A: Spontaneous intraperitoneal rupture of benign cystic teratomas. Review of the literature and report of two cases. Obstet Gynecol 1959;13(2): 198-202 4. Wynn RM: Ovary. In Obstetrics and Gynecology: The Clinical Core. Philadelphia, P, Lea & Febiger, 1988, pp 272-294 5. Stein IF, Kaye BM: Granulomatous peritonitis secondary to perforation of dermoid cyst. Am J Obstet Gynecol 1954:67(l): 155-157 6. Ranney B: latrogenic spillage from benign cystic teratoma causing severe peritoneal granulomas and adhesions. Obstet Gynecol 1970;35(4):562-564 7. Piper MC: Traumatic rupture of dermoid cysts of the ovary. Proc Staff Meet Mayo Clinic 1941;16:349-352
CASE REPORT A 2byear-old woman, who was the seat belt-restrained driver of an automobile, was involved in a motor vehicle collision at approximately 4~30 AM. Her vehicle was struck on the driver’s side, specifically involving the driver’s door. However, paramedics reported that there was minimal damage to the patient’s automobile and that the door was opened readily. Her overall condition appeared to be good and she had no specific complaints. She was therefore transported to the nearest community hospital. In the emergency department (ED), the patient only complained of a “gas-like” pain of minimal intensity located diffusely over her abdomen and back. She was awake, alert, and oriented. The odor of alcohol was noted on her breath. Her admission vital sign measurements included a systemic blood pressure of 1lo/82 mm Hg, respirations of 20 breaths/min, pulse rate 88/min, and oral temperature 36.2”C. The general physical examination was unremarkable with the sole exception of the abdomen. Bowel sounds were decreased and mild From *tIlthe Departments of Medicine and TSurgery, Baylor College of Medicine, Waco, TX; Tthe City of Houston, Emergency Medical Services; and the *$Departments of Emergency Medicine and §Radiology, Spring Branch Medical Center, Houston, TX. Manuscript received February 18, 1992; accepted March 6, 1992. Address reprint requests to Dr Levine, 6565 Fannin, MS F-602, Houston, TX 77030. Key Words: Dermoid cyst; ovarian; teratoma; trauma, blunt; injury; avulsion; hemorrhage, shock. Copyright 0 1992 by W.B. Saunders Company 0735-6757/92/l 004-0016$5.00/0 344
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tenderness was noted across the lower abdomen with minimal guarding present. A pelvic and rectal examination were not performed at the time of the initial evaluation. Laboratory tests performed in the ED revealed a hematocrit of 36%, hemoglobin 120 g/L. white blood ceil count 7,200/mm3, serum ethanol 42 mmol/L, and serum amyiase 44 W/L. Arterial blood gas measurements were within normal limits as were the chest, abdomen, and lateral cervical spine radiographs. Serum B-human chorionic gonadotrophin assay was negative and urine analysis was normal. Approximately 35 minutes after her arrival at the ED, while attempting to use the toilet, the patient collapsed. At that time her systolic blood pressure was determined to be 58 mm Hg by palpation. Although the patient’s systemic blood pressure responded initially to rapid infusions of isotonic intravenous fluids, she remained tachycardic. Her abdomen was still minimally tender but was now slightly distended. Her physical examination otherwise remained unchanged. Awaiting the arrival of surgical consultation, a computed axial tomographic scan of the abdomen was performed. This study was performed within 2 hours of admission to the ED. A ruptured epidermoid cyst was demonstrated (Figure 1) with a large amount of accompanying free intraperitoneal blood (Figure 2). A iaparotomy was performed soon thereafter, revealing a large epidermoid cyst in the left ovary. which had been avuised from its vascular pedicie. Massive bleeding was controlled by ligation of the left ovarian blood vessels. A left salpingo-oophorectomy was performed. No other injuries were noted. Postoperatively. the patient had an uneventful course and was discharged home 5 days after admission.
PATHOLOGY Pathologic examination revealed an 8 x 8 x 7-cm cystic mass filled with “cheesy” necrotic material and hair. Typical bone and teeth-like structures were present within the tumor. No malignant changes were noted. The final pathologic diagnosis was benign cystic teratoma of the left ovary. DISCUSSION Although a Babylonian cuneiform papyrus dating from 2,000 years BC may be the first record of a teratoma, Galen, in the first century, is credited with describing the lesion now known as a dermoid cyst.’ In 1863, Rudolf Virchow introduced the name “teratoma” from the Greek word term, meaning monster, because of his impression of the structures contained within the cyst. Today, dermoid cysts are recognized as the second most common type of benign ovarian tumors, and they account for about 15% of all ovarian neoplasms.3.4 This case report presents several unusual aspects of gynecologic trauma diagnosis and management. The vehicular collision occurred with an apparently low-speed impact, resulting in minimal damage to the patient’s automobile while
LEVINE ET AL n TRAUMATIC
AVULSION
OF AN OVARIAN
CYST
345
FIGURE 1. Computed tomography of the abdomen reveals a large ovarian tumor surrounded by blood. The presence of a tooth is noted in the center of the tumor (arrows).
she was properly restrained. She had no reported symptoms at the scene and she presented without external evidence of trauma. She had only minimal abdominal tenderness on a directed physical examination at the hospital. Nevertheless it appears, in retrospect, that the patient still sustained a significant enough deceleration injury to result in an avulsion of an occult ovarian dermoid cyst. Rupture of ovarian dermoids has occurred spontaneously, or as a result of a minima1 inciting event such as a fall, turning in bed, vomiting, coitus, or an iatrogenic cause.3*5-7 However, previous reports have not described the association between trauma secondary to a vehicular collision and the avulsion of a dermoid cyst, In a S-year review of all female patients with blunt abdominal trauma that underwent laparotomy at the Maryland Institute of Emergency Medical Services System (Baltimore, MD), only 15 cases of gynecologic injury were found.’ All 15 patients were nongravid and 14 had ovarian trauma. Although 13 of these cases were associated with the presence of physiologic ovarian cysts, the hemorrhage was always from an existing corpus luteum. In addition, all of the cases were associated with multiple trauma secondary to a motor vehicle collision. It is likely that our patient did not have symptoms immediately upon admission because of a slow initial hemorrhage and gradual spillage of teratoma contents into the peritoneum. If the entire contents are expelled suddenly, the patient usually presents with a clinical picture of shock and acute abdominal crisis.3 When the patient in this report stood up to use the toilet, the increased intraabdominal pres-
sure may have further stressed the avulsion and resulted in a sudden increase in the rate of hemorrhage and the subsequent hemorrhagic hypotension. It is not certain that earlier performance of a pelvic examination could have led to an earlier diagnosis. Even with a cyst of this dimension, detection by physical examination is not always possible. In addition, there often are logistic and psychologic difficulties in achieving this desirable goal, particularly in a busy ED. Nevertheless, the potential for early detection of an underlying problem by pelvic examination still exists, and the role of early examination should be reemphasized by this report. The treatment of choice when a diagnosis of ruptured dermoid cyst is made or suspected, is surgical removal of the dermoid cyst with lysis of all associated adhesions, The opposite ovary should be carefully inspected as well. Several major points can be derived from this case report. First, though rare, isolated gynecologic injury with significant sequelae can occur in the absence of multiple trauma. Second, such a significant injury can occur in the absence of major symptomatology or signs. Although the person in this case report had ingested ethanol, the serum levels did not reflect a high enough level to significantly obscure the history and physical examination. Third, it confirms the value of continued observation of blunt trauma patients for some period of time, even when the mechanism of injury and apparent physical findings appear minor. Fourth, this case also emphasizes a lower threshold for performing early rectal and pelvic examinations in victims of blunt trauma.
346
FIGURE 2. (arrows).
AMERICAN
Computed tomography
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of the abdomen at the level of the liver and spleen. A large amount of blood is noted with no other injuries
In conclusion, community ED physicians and other members of trauma teams need to be aware of the potential for isolated gynecologic injury from low-speed motor vehicle collisions. In addition, if necessary, the computed axial tomographic scan can be used to diagnose an avulsed dermoid cyst. Finally, early rectal and pelvic examinations should be emphasized in blunt trauma patients, especially with nonspecific and minor abdominal symptoms. REFERENCES 1. Stone NN, Antes IG, Brotman S: Gynecologic injury in the nongravid female during blunt abdominal trauma. J Trauma 1984;24(7):626-627
2. Pantoja E, Noy MA, Axtmayer RW, et al: Ovarian dermoids and their complications: Comprehensive historical review. Obstet Gynecol Surg 1975;30(1):1-18 3. Abitbol MM, Pomerance W, Mackles A: Spontaneous intraperitoneal rupture of benign cystic teratomas. Review of the literature and report of two cases. Obstet Gynecol 1959;13(2): 198-202 4. Wynn RM: Ovary. In Obstetrics and Gynecology: The Clinical Core. Philadelphia, P, Lea & Febiger, 1988, pp 272-294 5. Stein IF, Kaye BM: Granulomatous peritonitis secondary to perforation of dermoid cyst. Am J Obstet Gynecol 1954:67(l): 155-157 6. Ranney B: latrogenic spillage from benign cystic teratoma causing severe peritoneal granulomas and adhesions. Obstet Gynecol 1970;35(4):562-564 7. Piper MC: Traumatic rupture of dermoid cysts of the ovary. Proc Staff Meet Mayo Clinic 1941;16:349-352
