Keywords
cysts - nasal obstruction - nasal cavity
Introduction
Nasolabial cysts are also known as nasoalveolar cyst or Klestadt cyst and were described in 1882 by Zuckerkandl.[1]
[2] They are rare,[3] affecting 1.6 per 100,000 persons per year.[2] They occur more frequently in females (4:1), especially among African Americans,
in the fourth and fifth decades of life.[2]
[4]
[5] In 90% of the cases, they are unilateral.[5] Their growth is slow and painless, so they are often underdiagnosed.[1]
[2]
[3]
[6]
Patients typically complain of deformity and nasal obstruction. Signs and symptoms
include nasal obstruction, local pain, swelling, and facial deformity.[1]
[2]
[4]
[7] Usually, there is a fullness of the canine fossa, the nasal ala, and nasal vestibule.
The bulging reaches the nasal cavity beneath the anterior third of the inferior turbinate,
resulting in obliteration of the nasolabial fold and elevation of the alae of the
nose.[2] Because of its close anatomical relation to the nasal cavity and teeth, it may become
infected easily. When it is infected, it grows quickly and may be painful.[1]
A nasolabial cyst is diagnosed by clinical examination and is confirmed by histopathologic
study.[1]
[2] Usually, the nasolabial fold is obliterated. The cysts must be palpated bimanually
with one finger in the floor of the nasal vestibule and another in the labial sulcus.
Imaging tests, like computed tomography (CT) of the paranasal sinuses and nuclear
magnetic resonance (NMR), may be useful.[1]
[8] CT shows a cystic lesion located anterior to the piriform aperture; its contents
may be homogeneous. Cysts are hyperintense on T1 and isointense with cerebrospinal
fluid on T2-weighted images at NMR, without changes after fat suppression.[1]
[8]
Differential diagnosis includes cysts of the nasopalatine duct, periapical inflammatory
lesions (granuloma, cyst, or abscess), and epidermoid or epidermal inclusion cysts.[1]
Complete surgical excision of the nasolabial cyst is the best treatment. The most
used incision is the sublabial.[2]
[3]
[4]
[7] Our aim is to describe the Neumann incision to treat a giant nasolabial cyst.
Case Report
A 37-year-old black man had bilateral nasal obstruction, which improved with saline
nasal lavage and nasal corticosteroids. Two years later, he presented with bulging
of the nasal vestibule, nasal deformity and asymmetry, and worsened nasal obstruction.
Hyposmia, dysgeusia, tenderness, and headache were related.
Puncture of the right nasal vestibule was performed, removing 60 mL of serous liquid,
relieving the symptoms. However, the lesion recurred with worsening of symptoms.
CT was performed and a cyst lesion anterior to the right pyriform aperture, 4 × 4.5 × 5.5
cm wide, was found, pushing the nasal septum to left and bulging the palate ([Fig. 1]).
Fig. 1 Computed tomography (1 and 4) and surgical aspects (2 and 3).
Complete surgical excision of the cyst was performed using the Neumann incision ([Fig. 1]). Histopathologic study revealed squamous and respiratory epithelium with chronic
inflammatory process associated with histiocytic reaction. Culture of the secretion
isolated Streptococcus viridans.
The patient currently has no evidence of recurrent disease at 2 years postoperatively
([Fig. 2]).
Fig. 2 (1) Postoperative aspect. (2 to 4) Three months after the surgery.
Discussion
The origin of nasolabial cysts is controversial. There are two main theories about
its growth. The first suggests that the cysts derive from inclusion cysts, secondary
to mesenchymal cells after the fusion of medial and lateral nasal prominences to the
maxillary prominence during facial skeleton formation. The other theory suggests the
cyst is an epithelial remnant of the nasolacrimal duct, running between lateral nasal
and maxillary prominences.[1]
[2]
The most common histologic type is pseudostratified columnar epithelium, followed
by squamous stratified epithelium and simple cuboidal epithelium.[7] Su et al assessed 10 cysts on electronic microscopy and noticed the cyst had a highly
plicated mucosa and were made of nonciliated stratified columnar epithelium, including
basal and goblet cells, structurally different from the ciliated columnar epithelium
of the paranasal and nasal sinuses and airways.[9]
The treatment of nasolabial cysts consists of complete removal, aiming to prevent
infections, define histologic type, and improve esthetics. Fine needle aspiration
and cauterization are other treatment options available, but these techniques carry
a high recurrence rate.[1] As reported in the case, cyst puncture for pain relief should always be considered.
Endodontists currently use Neumann incision in performing alveoloplasties. It became
popular as an alternative to approaching the maxillary sinus in 1970, replacing Caldwell-Luc
technique.[3] It consists of incision in the free edge of the gingiva in the region of the interdental
papillae, from the medial portion of the lateral incisor to the lateral portion of
the second premolar and first molar, with two vertical extensions, one medial and
other lateral to the gingiva and labia, with subsequent elevation of the flap created,
allowing full access to the pyriform aperture ([Fig. 2]). After the intervention, the mucosal flap is put back into its original position,
and the papillae are sutured with absorbable sutures and atraumatic needle, as well
as the vertical extensions. The incision considers the vessels and nerves in the region;
therefore, the local sensory disturbances such as bleeding are minimal. The potential
complications are facial swelling, insensitive gingiva, teeth numbness, and surgical
site infection.[3]
The patient must be oriented to blow his or her nose and use a toothbrush on the surgical
site. Diet should be reintroduced slowly for the first week. Dental prostheses can
be used immediately after the surgery.[3]
Choi et al described a series of cases in which the cysts varied in size from 1 × 1
cm to 3 × 5 cm.[7] In the case reported, the cyst measured 4 × 4.5 × 5 cm, and during follow-up, no
signs of recurrence or complications were noticed.
Conclusion
Despite its rarity, nasolabial cysts should be considered in differential diagnosis
when there is swelling of the floor of the nasal cavity or vestibule. The Neumann
incision permits good access to the pyriform aperture and the complete cyst excision.
