A Different Kind of Marble: Sublingual Epidermoid Cyst with the "Sack of Marbles" Sign

Authors

  • Sara Salehi Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester
  • Tubo Shi Department of Radiology, Mayo Clinic, Rochester
  • Alex A. Nagelschneider Department of Radiology, Mayo Clinic, Rochester
  • Bradley J. Erickson Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester

DOI:

https://doi.org/10.3941/jrcr.6047

Abstract

Epidermoid cysts account for approximately 1.6% of oral cavity cysts, with 7% occurring in the head and neck region. The “sack of marbles” appearance on magnetic resonance imaging has traditionally been considered specific for dermoid cysts, where fat globules from sebaceous secretions appear bright on T1-weighted sequences. A 22-year-old male presented with a midline floor-of-mouth mass discovered incidentally after trauma. The lesion enlarged over 18 months, causing mild speech difficulty. Imaging showed a well-circumscribed cyst with multiple bright foci and restricted diffusion, representing free-floating keratin globules. The appearance strongly suggested a dermoid cyst, but histopathology confirmed an epidermoid cyst without dermal appendages. This case demonstrates that epidermoid cysts can exhibit the “sack of marbles” pattern, highlighting that histopathologic correlation is essential for accurate diagnosis.

22-year-old male with epidermoid inclusion cyst in the sublingual space. FINDINGS: CT images in all 3 planes demonstrated a welldefined, homogeneously hypoattenuating, non-enhancing mass measuring 21 × 40 × 39 mm, centered in the midline anterior sublingual space between the tongue and the mylohyoid muscle. TECHNIQUE: CT neck with contrast; 146 mAs,

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Published

2026-04-13

Issue

2026: Articles in Press

Section

General Radiology

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