Ganglia and Myxoid Cysts Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Ganglia and myxoid (mucous) cysts in adults age 18+

This guidance does not cover:

  • Symptomatic soft tissue masses in children

Assessment

Signs and Symptoms

  • Ganglia of the hand and wrist are common benign lesions
  • Ganglia less commonly present at the foot and ankle
  • They most frequently arise adjacent to joints and tendons, but may also be intratendinous or intraosseous

History and Examination

  • Digital myxoid or mucoid cysts typically occur at the distal interphalangeal joints and can be associated with osteoarthritic joints. They can intermittently become inflamed but are rarely truly infected
  • Both ganglia and myxoid cysts may be cosmetically noticeable (the latter can also cause disruption of nail growth). They can sometimes be painful or cause limitation of function

Differential Diagnoses

  • Referrers should be aware that certain pathology do not turn out to be ganglia but can present in a similar way. The following conditions fall into this category:
    • Osteoarthritic changes in a joint
    • Gouty tophi, rheumatoid nodules or synovitis
    • Giant cell tumours
    • Lipomas and other benign lesions
    • Plantar fibromas
    • Malignancy (rare): see Red Flag section for more information regarding 2ww criteria
  • The majority of these lesions do not require onward referral and can be observed in primary care.

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • The majority of ganglia occur in the upper limbs. For lower limbs in particular, diagnostic uncertainty should prompt consideration of further imaging
  • Soft tissue sarcomas are rare and account for approximately 1% of all malignant tumours. The age standardised incidence rate for soft tissue sarcoma for England is 44.9 cases per 1million population
  • If aspiration of the lesion has not been possible (usually ganglia exude a thick clear gel when aspirated with a wide gauge needle under local anaesthetic) this should prompt the possibility of the lesion being a solid tumour
  • The 2ww criteria for referral to the liposarcoma service include any of the following:
    • Measurement exceeds 4cm
    • Significant persistent pain that is not solely pressure related
    • Rapid growth over a short period of time
    • Deep fixity to muscle or fascia (the mass becomes less obvious on muscle contraction)
    • Prior malignancy other than basal cell carcinoma

Investigation

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Ultrasonography can be useful to evaluate superficial lumps of diagnostic uncertainty especially if examination findings are equivocal.
  • The National Institute for Health and Care Excellence (NICE) recommends urgent ultrasonography for all unexplained lumps increasing in size
  • Aspiration of a thick clear gel from a suspected ganglion can help confirm diagnosis

Management

  • These are common presentations. Observation and primary care assessment and management are appropriate for the majority of cases. Complications are rare and settle without the need for further intervention
  • Most ganglia can be managed in primary care. Patients can be reassured that approximately 60% of ganglia resolve spontaneously therefore a simple watch and wait approach is often appropriate
  • Options for primary care management include:
    • Simple splint immobilization for upper limb ganglia
    • Analgesia
    • Aspiration or lancing with sterile wide gauge needle under local anaesthetic – may need repeated treatments.
    • Steroid injections *
  • Ganglia frequently recur, but this is also true following surgical treatments

Notes:

  • For ganglia of the wrist and hand, the cure rate following aspiration increases with 3 week splinting post procedure
  • *Steroid injections work best for preventing recurrence in volar retinacular (flexor tendon sheath) ganglia when combined with transverse massage, but should be avoided for volar radial ganglia due to the proximity of the radial artery.

Referral

Referral Criteria

  • Red Flags
  • All North Kirklees referrals (excluding red flags) should be made to CONNECT COMMUNITY MSK who will undertake clinical assessment and triage and refer on as appropriate.

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 04.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2019
  • Ref No: MSK10 - 04.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

Home > Care Pathways > Musculoskeletal (MSK)* > Ganglia and Myxoid Cysts Care Pathway