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Nasolabial cyst – diagnosis and surgical treatment: Case report
MARCOS ANTONIO TORRIANI 1,2 | ÂNGELO NIEMCZEWSKI BOBROWSKI 3,4 | RAFAEL JOBIM RODRIGUES 3,4 | RAQUELE SOARES MATOS 5 | STEFANY RODRIGUES SANTOS 5 | TANIELLEY VIERA MACHADO 5 | CAROLINE KOMMELING CASSAL 3
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ABSTRACT
The nasolabial cyst is an uncommon lesion of soft tissue, with nonodontogenic origin and uncertain pathogenesis. Its occurrence is usually unilateral and has a predilection for female patients (4: 1). Clinically is characterized by a volume increase in the nasolabial area causing elevation of the bridge of the nose and the upper lip projection. In this paper, the authors report the case of a 68-year-old female patient, complaining of swelling in the right nasolabial fold region, approximately 2 years of evolution, without reported episodes of painful symptoms, with clinical features compatible with the nasolabial cyst. Intranasal aspiration of the cystic content was carried out, and immediately performed the injection of radiographic contrast and profile and occlusal radiographs, to locate the lesion. Then, we proceeded to surgical enucleation of the lesion. The diagnosis of nasolabial cyst was confirmed after histopathological examination. After 45 days the patient was discharged, with full clinical recovery without functional and aesthetic complications.
Keywords: Biopsy. Nonodontogenic cysts. Jaw cysts.
1 Universidade Federal de Pelotas, Faculdade de Odontologia, Departamento de Cirurgia e
Traumatologia Bucomaxilofacial (Pelotas/RS, Brazil). 2 Doutor em Cirurgia e Traumatologia Bucomaxilofacial, Pontifícia Universidade Católica do Rio
Grande do Sul (Porto Alegre/RS, Brazil). 3 Universidade Federal de Pelotas, Serviço de Cirurgia e Traumatologia Bucomaximofacial,
Hospital Escola da Universidade Federal de Pelotas (Pelotas/RS, Brazil). 4 Especialista em Cirurgia e Traumatologia Bucomaximofacial, Universidade Federal de Pelotas (Pelotas/RS, Brazil). 5 Universidade Federal de Pelotas, Faculdade de Odontologia (Pelotas/RS, Brazil).
How to cite: Torriani MA, Bobrowski ÂN, Rodrigues RJ, Matos RS, Santos SR, Machado TV, Cassal CK. Nasolabial cyst – diagnosis and surgical treatment: Case report. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):58-63. DOI: https://doi.org/10.14436/2358-2782.5.1.058-063.oar
Submitted: September 28, 2017 - Revised and accepted: February 28, 2018
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
» Patients displayed in this article previously approved the use of their facial and intraoral photo graphs.
Contact address: Rafael Jobim Rodrigues E-mail: rafaeljobim@bol.com.br - raquelesm@yahoo.com.br
INTRODUCTION
The nasolabial cyst is a rare soft tissue lesion of non-odontogenic origin. 1 Its prevalence reaches 0.7% among the maxillary cysts, and its occurrence is usually unilateral, presenting bilaterally in only 10% of cases. 2 The prevalence is been higher in patients of African descent, presenting predilection for females (4:1) 3,4 and higher occurrence between the fourth and fifth decades of life. 5
The first report of a nasolabial cyst is assigned to the Austro-Hungarian anatomist Emil Zuckerkandl 6 . Many names have been used to describe this cyst, including Klestadt cyst, nasoalveolar cyst, buccal nasal cyst, mucous cyst of the nose, nasal ala cyst, maxillary cyst, subalar cyst and nasoglobular cyst. Currently, the term “nasolabial cyst” is the most commonly used. 7,8
The pathogenesis of this lesion is uncertain and, among the various theories for its origin, the most accepted was proposed by Bruggemann in 1920, which suggests that the nasolabial cyst arises from epithelial remnants of the lower anterior part of the nasolacrimal duct, due to histological similarities. 2,7 Other theories assume that it is a fissural cyst or that it originates from deposition of epithelium of the nasolacrimal duct. 9
Upon clinical examination, it is characterized by an increase in volume in the nasolabial region, raising the nasal ala and projecting the upper lip; 10 spontaneous drainage of the cyst into the nasal or oral cavity is responsible for the variation in lesion size. This lesion is located in soft tissues, making the radiographic findings scarce. Radiographic imaging using contrast may aid the diagnosis by showing the lesion size and its proximity to surrounding structures.
Gross examination of an entirely resected nasolabial cyst shows a spherical to oval cyst, colored pink to tan, with soft to firm rubbery texture and smooth surface. The section reveals variable cystic and fibrous areas filled with clear viscous fluid, while necrosis, hemorrhage and purulence are only expected in secondarily infected cysts. 11 The diagnosis is confirmed by histology, and the characteristic histological finding is respiratory columnar pseudostratified ciliated epithelium with goblet cells. 1
CASE REPORT
The 68-year-old female Caucasoid patient attended an Oral and Maxillofacial Surgery and Traumatology Clinic complaining of increase in volume at the right nasolabial fold region, with approximately two years of evolution, without episodes of pain symptomatology.
Extraoral examination revealed a volumetric increase in the right globulomaxillary region, with loss of evidence of the nasolabial fold and increased volume in the intranasal region (Fig 1). The nodule measured approximately 1 cm, was soft and mobile. No changes were observed on intraoral clinical examination. The cystic content was aspired intranasally, followed by immediate injection of non-ionic radiographic contrast Iopamiron 300® (iopamidol 612 mg/ ml) in equal amount into the cavity. Lateral and occlusal radiographs were immediately obtained to locate the lesion (Fig 2) and to observe its relationship with neighboring structures.
Figure 1: Image showing increase in volume on the nasolabial fold, nasal ala and intranasal regions.
The radiographic result by this technique, is an important diagnostic predictor, since it evidences that the lesion affects exclusively soft tissue, and the location and shape were compatible with this type of cyst. Immediately after radiography the lesion was surgically enucleated, with intraoral access under local anesthesia. A semilunar mucosal incision was made in the buccal sulcus, At the anterior region of the right maxilla, followed by posterior divulsion of tissues until complete disclosure and subsequent removal of the lesion (Fig 3). Afterwards, intraoral continuous suture (Catgut 3.0) and extraoral suture (nylon 5.0) were performed, with a small transfixation of the nasal mucosa.
Macroscopic examination revealed a soft tissue fragment measuring 18 x 12 x 2 mm, of fibroelastic texture, brownish color, irregular shape and surfaces. The histological sections revealed a cystic capsule fragment composed of dense fibrous connective tissue, presenting intense vascularization, moderate cellularity and mild, predominantly mononuclear inflammatory infiltrate. The fibrous capsule was lined ciliated cylindrical pseudostratified columnar epithelium, which occasional goblet cells.
The suture was removed after seven days, when the patient presented good intraoral healing. However, the intranasal site ruptured and presented a small secretion of blood clot remnants upon removal.
After 20 days the patient presented significant improvement and was discharged, after 45 days, presenting full clinical recovery, without esthetic or functional disorders.
Figure 3: Surgical technique showing the pre- and post-excision aspect of the surgical wound, aspect and dimensions of cystic capsule, and suture.
A
B
Figure 4: A) Delicate fibrous connective tissue capsule lined by epithelium with few layers (40x magnification). B) lining epithelium varying from stratified pavement to ciliated pseudostratified cylindrical (200x magnification).
DISCUSSION
This case report illustrates the most common characteristics found in the nasolabial cyst; despite the difference in ethnicity predilection, 3 it coincides with the female predilection, 3,4 corroborating previous studies. 2,9 Nasal ala elevation and upper lip projection were clinically observed, which are determinants for the diagnosis of nasolabial cyst, as well as absence of symptoms and history characteristic of infection of dental origin. 10 It should be highlighted that several lesions may occur in soft tissues at this facial site; therefore, the differential diagnosis should be careful. However, only the nasolabial cyst occurs exclusively in this area.
Nasolabial cysts are non-toxic soft tissue lesions and may remain undetected, unless they are infected or associated with facial deformities. For this reason, the patients often delay in searching for treatment because, since they do not present pain symptomatology and exhibit slow evolution, there is no immediate concern, often leading to years before treatment. 12
The nasolabial cyst is asymptomatic, unless there is nasal obstruction, infection or deformity. 7,13,14,15
As reported by El- Din et al 16 nasolabial cysts may range in size from 1 to 5 cm and can lead to erosion of the underlying bone if growing to a large size. Therefore, the sooner the correct diagnosis and treatment, the less trauma to the patient.
The diagnosis of nasolabial cyst is nearly exclusively clinical, and bidigital palpation of the region is fundamental. The diagnosis may be difficult because this is a relatively rare lesion and differential diagnosis may include many other conditions that affect the anterior maxilla, including odontogenic cysts, periapical granulomas, and abscesses. The pulp vitality test of adjacent teeth is essential for adequate diagnosis and should be performed in the first attendance to differentiate from periapical lesions, and teeth in the region should respond positively to the vitality test in the presence of nasolabial cyst. However, this test could not be performed in the present case because the patient was edentulous.
Nasolabial cysts are not obvious on simple radiographs, because their characteristics are not specific, i.e. since it is a soft tissue cyst, the radiographic image does not provide any characteristic findings (without bone erosion), requiring radiograph and utilization of contrast to identify and assess the cyst extent. 17
The utilization of contrast is of an important approach to evaluate the lesion dimensions and its relationship with adjacent structures. Since the nasolabial cyst usually does not show signs on routine radiographic techniques, puncture of the cystic content with immediate contrast injection in the cavity and achievement of radiograph aids the surgical planning, 3 being a low-cost, simple and fast procedure. The spread of bacteria to other facial planes occurs only when the cyst wall breaks, because the volume of contrast injected is greater than the amount of cystic fluid aspirated 18 . This demonstrates the importance of observing the volume of aspirated contents for subsequent injection in equal quantity.
This cystic lesion should always be considered in the diagnosis of soft tissue buccal swelling in the alar region. Thus, after clinical and radiographic examination, the treatment of choice is conservative surgical excision. Histological analysis will confirm the nasolabial cyst, and relapse is rare after proper management of the lesion.
CONCLUDING REMARKS
Knowledge on the clinical and pathological characteristics of the nasolabial cyst is important for the dentist to allow the correct diagnosis, which demands a surgical treatment that is easily accomplished and presents great resolution. Computed tomography, magnetic resonance imaging and simple radiograph are the safest means to correctly diagnose the nasolabial cyst. However, the high cost of computed tomography and magnetic resonance imaging, as well as the electromagnetic and radiation exposure to the patient, make the use of contrast-enhanced plain radiograph, which can be performed in the office, the most viable choice for both dentist and patient. Thus, aspiration of cystic content and immediate injection of an equal amount of contrast for radiographic imaging constitute an important diagnostic aid and surgical guide.
Surgery is mainly done for esthetic reasons and secondary complications, such as infection or bleeding. To our knowledge, malignant transformation of a nasolabial cyst is not reported in the literature. 10 Surgical treatment of the reported case was necessary due to the possible aforementioned complications; in addition, the cyst growth could interfere with adaptation of the maxillary denture used by the patient, causing esthetic and speech disorders and feeding difficulties.
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