Troublesome cyst on dorsum of Hallux

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I have just seen a patient with the above for the 3rd time. She is a healthy active(runs 6miles/week) 60yr old with no s/s of PAD.

Visit 1 - Tense cyst 10mm diam - pierced with sterile needle and paste extruded

Visit 2 (10 weeks later) Pt reported that cyst had "settled down" but was concerned about the blood blister that had formed over it. I debrided the 10mm lesion to reveal extravasated paste. Sample taken for C&S. Hardened silver nitrate applied to base of cyst.

Visit 3 (5 weeks later). "It's not uncomfortable any more, but I would just like it to go". Now 6mm diam, shallow lesion debrided to reveal healthy base which is still extruding some paste from a 2mm central area. C&S from visit 2 revealed only skin flora. I applied hardened silver nitrate again.

If this doesn't resolve it I'm thinking a spot of phenol under a ring block would probably do the trick. Has anyone else experience in treating this kind of lesion? I've been prone to cysts myself and know what a nuisance/worry they can be.

 

I would think of two things. Firstly a mucoid cyst- as name suggests sticky exudate usually associated with distal IPJ. Tends to recur- I would look at excision. Less likely is a gouty tophus but the grainy nature you describe could be significant. Again excision would be good. Worry with phenol would be the burn particularly if involving a joint. Hope this helps. Lyndon

 

Hi,

If this is outside your area of expertise, please refer on to a Pod Surgeon.
A "spot of phenol may do the trick" suggests you are trying things out, rather than presenting a known remedy.

 

I agree, sounds like a myxoid/mucoid cyst. Got a few pts with them and have given them your details, Lyndon.

:welcome: to the Arena, BTW. We need more pod surgeons input here :drinks

Cheers,
Bel

 

Thanks Lyndon
IMO it is a mucoid cyst (possibly incurred by well-meaning advice from a friend to toe strike when running, but that's another story:craig. As phenol has been documented as a medical t/t for both mucoid and mucous cysts I thought it would be worth trying a tiny amount very carefully applied, before referring on for a more complex, more costly and more scarring procedure such as excision.
To be fair I've also read that hitting it with a heavy book(this was done to me for a wrist ganglion - it actually worked, but recurred a year or so later!!) and placing onion or garlic over it are also quoted as possible treatments::wacko:

No such species up here David! It's also classed as a 'remote and rural' area so we have to be pretty self reliant. I read about the phenol, makes sense to me as a possible treatment and I use it every other day to cauterize nail beds. Whilst I take your point about expertise, we all encounter situations in clinic that are not routine. When does a treatment become 'a known remedy' - when people try it, and it works?

Thanks for all your comments - if I do decide to go ahead with the smallapplication of phenol, does anyone reckon I'll actually need a ring block - they don't use it for dental T/t of mucous cysts, and she has found application of moistened silver nitrate stick a bit nippy but tolerable.

 

Can you please reference the sources for the phenol treatment? Also the accredited medical sources for the garlic, onion and 'hitting with a heavy book' treatments?

I agree completely with Belinda, David and Lyndon and would suggest that you take their informed advice.

A 'known remedy' is when an accepted double blinded trial of a statistically significant numbers of patients has taken place having previously been approved by an appropriate ethical committee, and has been published in a peer reviewed publication. Of course, there is nothing to prevent you trying out your idea except the possibility of action against you by a) the patient in court b) the HPCP and c) the ethical committee of your own professional body. It is not possible for an ethical practitioner to advise you concerning L.A. (except that as a generality the vast majority of your colleagues do not use ring blocks anyway) because one of them might be engaged by a court to comment on your actions.

Sorry to be negative, but please do not go ahead as you suggest.

Bill Liggins

 

In addition to what Bill has mentioned, you shouldn't even be considering application of phenol when you are unsure of what you are treating. Once you have a diagnosis then you know or should know what the treatment options are. I would suggest maybe posting a photo if possible. Failing that, ask the GP to refer for an ultrasound scan if it cannot be diagnosed clinically.

Also, to help colleagues here give a potentially more informed opinion of what this 'cyst' actually is, you way wish to provide further detail.

For example, where on the hallux is the lesion other than just dorsal? MTPJ level, over the IPJ ect.
What is paste? What colour/consistency is the exudate? Histopathology may be more useful than C&S to aid diagnosis.

I have encountered and excised plenty of mucoid cysts but never seen one on a hallux. DIPJ arthroplasty with excision of the cyst is my treatment of choice. I wouldn't be performing an arthroplasty or more likely an arthrodesis of the hallux IPJ for something that is essential not particularly troublesome though (assuming that this is indeed a mucoid cyst).

Under no circumstances would I be using phenol for this.

Regards,
Ryan

 

I had a think about this one yesterday Mo.

It may seem a bit harsh that we are advising you not to treat, or not to treat with phenol.

A little bit of historical perspective.
40 years ago your gung-ho attitude would have been applauded. Without it we wouldn't have had the introduction of local anaesthesia, skin surgery, or, to take it to it's logical progression, Consultant Pod Surgeons.
At that time there was a lot of pushing boundaries, not all of it good or well thought-out (although most of it was). I had just qualified and it was a VERY interesting time to be a young and enthusiastic chiropodist.

Nowadays though, things are different. Our hard-won clinical rights (and they were hard-won) cannot be taken away from us, provided we are sensible. We have NHS Pod Surgeons working at a high level within the NHS, and we have degree-level training, one or the other of which should obviate the need for experimentation without supervision. Unfortunately, or fortunately, depending on your point of view, with clinical freedom comes clinical responsibility - you can't have one without the other.

To be constructive, may I suggest you find your nearest NHS Pod Surgeon and talk with them. Even in the Highland and Islands you aren't too far from civilisation in the 21st century. Ask the Pod Surgeon if you can accompany your patient for the day to see how the problem toe should be tackled. Most of the one's I've met are only too willing to help a colleague if the problem is explained.

I hope this helps.

 

Hi over the years I have only come across 1 mucoid cyst. "2nd PIPJ?"
This has largely been symptomatic and client happy not to treat.
Over 5 + years it has cycled through: bursting after shower/pool/sleep. Antiseptic applied the cyst would then develop and again burst without intervention.
There has been no signs or symptoms for the last 12 months.

Cheers

Heather

 

My goodness, I feel like a naughty child! I have no wish to bring the good name of podiatry into disrepute - haven't in the last 20 years and hopefully will not in the forseeable future.

Thanks to all who shared their experience, and/or concerns here. I thought it was a reasonable question to pose and your answers have indeed given me food for thought as I hoped it would.

BTW David, you are quite wrong about one thing: the Highland and Islands of Scotland is 'civilisation', it's the rest of you who are savages