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Special Feature |

Radiological Case of the Month FREE

[+] Author Affiliations

Section Editor: Beverly P. Wood, MD

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Arch Pediatr Adolesc Med. 1998;152(5):504. doi:.
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Published online

DENOUEMENT AND DISCUSSION: TORSED OVARY WITH A DERMOID CYST

Figure 1. Abdominal radiograph showing a calcification in the lower quadrant that is a tooth in the dermoid cyst.

Figure 2. Left, Ultrasonographic scan shows an adnexal mass with cystic and solid components. Right, The same mass showing an echogenic structure with shadowing (tooth).

Ovarian torsion usually occurs in women during their reproductive years,1 but it may occur prenatally or in women after menopause.2,3 Patients older than neonates present with acute localized pain and vomiting or fever.1,4 Of girls 3 to 11 years of age, one third present with diffuse pain.5 The pain is proportionate to the degree of circulatory compromise from torsion, and if torsion is complete, the pain is acute and severe and is accompanied by nausea and vomiting.6,7 Spontaneous detorsion may occur and the pain will subside. Right ovarian torsion is slightly more common than left ovarian torsion. Bilateral torsion is rare, and even more infrequently observed is sequential torsion of the other ovary.8,9 The nonspecific nature of the presenting symptoms may result in a delay in the diagnosis.4,10

Risk factors for ovarian torsion include pregnancy and ovarian abnormality. The most common risk factor associated with torsion is the presence of a dermoid cyst (32%).1 These cysts are usually benign as are most ovarian masses that may cause torsion. Torsion may also occur in a normal ovary.4,11,12

On physical examination, the most consistent finding is a palpable mass felt 50% to 80% of the time.1,13 Radiographs of the abdomen may show calcification or a mass in the pelvic area indicating a dermoid cyst (68%).14 This patient's pelvic calcification and left-sided symptoms reflect the left ovary being positioned in the midline after torsion. The diagnostic procedure of choice is an ultrasonographic scan, which will demonstrate an enlarged ovary with multiple peripheral follicles and congested veins.15,16 In this patient, the ultrasonographic scan showed a large heterogeneous mass without visualization of the left ovary. Color flow sonography is useful in determining abnormal blood flow to the ovary and venous drainage.17

Treatment of a torsed ovary with a dermoid cyst or other abnormality requires detorsion of the ovary and removal of the cysts if the ovary is viable; a nonviable ovary will need to be removed.10,18,19 The procedure can be done by laparoscopy or laparotomy. This patient had a laparotomy with detorsion and an ovarian cystectomy with preservation of a viable ovary. Pathologic examination of the cysts revealed a 14-cm mature teratoma containing 250 mL of fluid, a tuft of hair, and a tooth.

Accepted for publication February 27, 1997.

Reprints: Gary Schwartz, MD, Vanderbilt University Medical Center, Nashville, TN 37232-4700

Lee  CHRaman  SSivanesaratnam  V Torsion of ovarian tumors: a clinicopathological study. Int J Gynaecol Obstet. 1989;2821- 25
Link to Article
Anteby  EYMoshe  RRevel  A  et al.  Germ cell tumors of the ovary arising after dermoid cyst resection: a long-term follow-up study. Obstet Gynecol. 1994;83605- 608
Link to Article
Croitoru  DPAaron  LELaberge  JM  et al.  Management of complex ovarian cysts presenting in the first year of life. J Pediatr Surg. 1991;261366- 1368
Link to Article
Mordehai  JMares  AJBarki  Y  et al.  Torsion of uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg. 1991;261195- 1199
Link to Article
Meyer  JSHarmon  CMHarty  MP  et al.  Ovarian torsion: clinical and imaging presentation in children. J Pediatr Surg. 1995;301433- 1436
Link to Article
Nichols  DHJulian  PJ Torsion of the adnexa. Clin Obstet Gynecol. 1985;28375- 380
Link to Article
Warnock  NGBrown  BPBarloom  TJHermann  LS Spontaneous detorsion of the ovary demonstrated by ultrasonography. J Ultrasound Med. 1994;1357- 59
Buss  JGLee  RA Sequential torsion of the uterine adnexa. Mayo Clin Proc. 1987;62623- 625
Link to Article
Davis  AJFeins  NR Subsequent asynchronous torsion of normal adnexa in children. J Pediatr Surg. 1990;25687- 689
Link to Article
Shalev  EPeleg  D Laparoscopic treatment of adnexal torsion. Surg Gynecol Obstet. 1993;176448- 450
Ward  MJFrazier  TG Torsion of normal uterine adnexa in childhood: case report. Pediatrics. 1978;61573- 574
Porvost  RW Torsion of the normal fallopian tube. Obstet Gynecol. 1972;3980- 82
Bower  RJAdkins  JC Surgical ovarian lesions in children. Am Surg. 1981;47474- 478
Siegel  MJMcAlister  WHShackelford  GD Radiographic findings in ovarian teratomas in children. AJR Am J Roentgenol. 1978;131613
Link to Article
Graif  MItzchak  Not Available Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR Am J Roentgenol. 1988;150647- 649
Link to Article
Graif  MShalev  JStrauss  Not Available  et al.  Torsion of the ovary: sonographic features. AJR Am J Roentgenol. 1984;1431331- 1334
Link to Article
Fleischer  ACStein  SMCullinan  Not Available  et al.  Color Doppler sonography of adnexal torsion. J Ultrasound Med. 1995;14523- 528
Chapron  CDubuisson  JBSamouh  N  et al.  Treatment of ovarian dermoid cysts. Surg Endosc. 1994;81092- 1095
Link to Article
Zweizig  SPerron  JGrubb  D  et al.  Conservative management of adnexal torsion. Am J Obstet Gynecol. 1993;1681791- 1795
Link to Article

Tables

References

Lee  CHRaman  SSivanesaratnam  V Torsion of ovarian tumors: a clinicopathological study. Int J Gynaecol Obstet. 1989;2821- 25
Link to Article
Anteby  EYMoshe  RRevel  A  et al.  Germ cell tumors of the ovary arising after dermoid cyst resection: a long-term follow-up study. Obstet Gynecol. 1994;83605- 608
Link to Article
Croitoru  DPAaron  LELaberge  JM  et al.  Management of complex ovarian cysts presenting in the first year of life. J Pediatr Surg. 1991;261366- 1368
Link to Article
Mordehai  JMares  AJBarki  Y  et al.  Torsion of uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg. 1991;261195- 1199
Link to Article
Meyer  JSHarmon  CMHarty  MP  et al.  Ovarian torsion: clinical and imaging presentation in children. J Pediatr Surg. 1995;301433- 1436
Link to Article
Nichols  DHJulian  PJ Torsion of the adnexa. Clin Obstet Gynecol. 1985;28375- 380
Link to Article
Warnock  NGBrown  BPBarloom  TJHermann  LS Spontaneous detorsion of the ovary demonstrated by ultrasonography. J Ultrasound Med. 1994;1357- 59
Buss  JGLee  RA Sequential torsion of the uterine adnexa. Mayo Clin Proc. 1987;62623- 625
Link to Article
Davis  AJFeins  NR Subsequent asynchronous torsion of normal adnexa in children. J Pediatr Surg. 1990;25687- 689
Link to Article
Shalev  EPeleg  D Laparoscopic treatment of adnexal torsion. Surg Gynecol Obstet. 1993;176448- 450
Ward  MJFrazier  TG Torsion of normal uterine adnexa in childhood: case report. Pediatrics. 1978;61573- 574
Porvost  RW Torsion of the normal fallopian tube. Obstet Gynecol. 1972;3980- 82
Bower  RJAdkins  JC Surgical ovarian lesions in children. Am Surg. 1981;47474- 478
Siegel  MJMcAlister  WHShackelford  GD Radiographic findings in ovarian teratomas in children. AJR Am J Roentgenol. 1978;131613
Link to Article
Graif  MItzchak  Not Available Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR Am J Roentgenol. 1988;150647- 649
Link to Article
Graif  MShalev  JStrauss  Not Available  et al.  Torsion of the ovary: sonographic features. AJR Am J Roentgenol. 1984;1431331- 1334
Link to Article
Fleischer  ACStein  SMCullinan  Not Available  et al.  Color Doppler sonography of adnexal torsion. J Ultrasound Med. 1995;14523- 528
Chapron  CDubuisson  JBSamouh  N  et al.  Treatment of ovarian dermoid cysts. Surg Endosc. 1994;81092- 1095
Link to Article
Zweizig  SPerron  JGrubb  D  et al.  Conservative management of adnexal torsion. Am J Obstet Gynecol. 1993;1681791- 1795
Link to Article

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