Nasolabial Cyst

Introduction

The nasolabial cyst is a developmental soft-tissue cyst that occurs in the upper lip
lateral to the midline (Slootweg, 2015). Nasolabial cysts are benign nonodontogenic masses
that arise in the anterior maxillary region. These cysts account for 0.7% of all
nonodontogenic cysts.1 They are often located submucosally in the anterior nasal floor and
can elevate and medially displace the inferior turbinate (Sheikh,2015 and Yanagisawa, 2002).
This entity was first studied by Emile Zuckerkandl in 1882 and is also referred to in the
literature as Klestadt’s cysts and nasoalveolar cysts (Sheikh,2015 and Klestadt,1953).
Nasolabial cyst known as Klestadt’s cyst) and naso alveolar cyst, is not found within bone,
but is usually described as a rare fissural cyst that may involve bone secondarily
(Shafer,2012).
Two theories have been proposed for its pathogenesis, the first theory suggests that
the lining is derived from epithelium that became entrapped within the lateral portion of the
upper lip during embryologic fusion of the maxillary, medial nasal, and lateral nasal
processes. However, a second more likely theory considers that the epithelial lining is derived
from the lower anterior part of the nasolacrimal duct (Slootweg,2015). It has been thought to
arise at the junction of the globular process, the lateral nasal process, and the maxillary
process as a result of proliferation of entrapped epithelium along the fusion line
(Shafer,2012).
The nasolabial cyst is a rare lesion; data from Shear and Speight show that it
comprises only 0.6 % of all jaw/oral cysts (Slootweg,2015). The prevalence of nasolabial
cysts is cited to be higher in African Americans and has a female preponderance of 4:1 (Van
Bruggen,1985 and Bull,1967). Nasolabial cysts commonly arise on the left side but can be
bilateral in 10% of cases (Marcoviceanu, 2009). From Sheikh systematic review, Gender was
reported in 293 cases; 229 were female and 64 were male, with a female to male ratio of
3.6:1. Nasolabial cysts occurred most frequently on the left side, with 105 patients having
left-sided cysts, 84 patients having right-sided cysts, and 30 patients having bilateral cysts.
The nasolabial cyst presents as a fluctuant swelling in the vestibule of the upper lip
lateral to the midline. As many as 10 % of patients will have bilateral lesions. The swelling
characteristically will elevate the ala of the nose (Slootweg, 2015). The nasoalveolar cyst
may cause a swelling in the mucolabial fold as well as in the floor of the nose, being located
near the attachment of the ala over the maxilla. Superficial erosion of the outer surface of the
maxilla may be produced by pressure of the nasoalveolar cyst, but it should be noted that they
are not primarily central lesions and therefore may not be visible on the radiograph
(Shafer,2012).

Classification

. The swelling characteristically

will elevate the ala of the nose
and can extend into the nasal floor, sometimes
resulting in nasal obstruction. Because the
intraoral swelling often obliterates the depth
of the maxillary vestibule, it may interfere
with the ability of the patient to wear
a denture. Almost 30 % of nasolabial cysts
will be secondarily infected, which can mimic
a dental abscess or acute sinusitis. Infected
cysts may spontaneously drain into the nasal
or oral cavity.

Treatment
The lesion typically is treated by surgical enucleation,
which is accomplished intraorally
through an incision in the labial vestibule
(Fig. 1). Endoscopic marsupialization via
a transnasal approach has also been reported.

• Outcome
Recurrence of the lesion after treatment is
extremely rare.
Macroscopy
On gross examination, the nasolabial cyst will
exhibit a central cavity surrounded by
a thick fibrous capsule (Fig. 2). Mucoid or
yellowish-brown fluid may be found in the cyst
lumen
Microscopy
Most nasolabial cysts are lined by a uniform layer
of pseudostratified columnar epithelium that often
includes goblet cells and cilia (Figs. 3 and 4).Areas
of cuboidal epithelium or squamous metaplasia
also may be seen (Fig. 5). The cyst wall is composed
of fibrous connective tissue that can include
secondary inflammation, if the cyst is infected.
Differential Diagnosis
Because the nasopalatine duct cyst also may be
lined by a combination of pseudostratified
columnar, cuboidal, and stratified squamous
Cyst, Nasolabial, Fig. 1 A saclike lesion is being enucleated
through an incision in the right upper labial vestibule
(Courtesy of Dr. Michael Tabor)

Cyst, Nasolabial, Fig. 3 Medium-power photomicrograph

of a nasolabial cyst that is lined by a uniform layer
of pseudostratified columnar epithelium
Cyst, Nasolabial, Fig. 4 High-power field showing
pseudostratified columnar epithelium with mucinproducing
cells
epithelium, it might be confused with the
nasolabial cyst without an adequate clinical
history. However, the nasopalatine duct cyst
typically occurs as an intrabony lesion within
midline of the maxilla, whereas the nasolabial
cyst develops as a soft-tissue lesion in the
maxillary labial vestibule lateral to the midline.
A salivary duct cyst from a minor salivary gland
also can exhibit a variable combination of
epithelial types. However, most salivary duct
cysts in the upper lip will be located lower
down in the lip proper, and salivary acini should
be found immediately adjacent to the cystic
cavity. (Slootweg, 2015)

Nasoalveolar Cyst (Nasolabial cyst, Klestadt’s cyst)

The nasoalveolar cyst is not found within bone, but is usually
described as a rare fissural cyst that may involve bone
secondarily. It has been thought to arise at the junction of the
globular process, the lateral nasal process, and the maxillary
process as a result of proliferation of entrapped epithelium
along the fusion line.
Clinical Features
The nasoalveolar cyst may cause a swelling in the mucolabial
fold as well as in the floor of the nose, being located near the
attachment of the ala over the maxilla. Superficial erosion of
the outer surface of the maxilla may be produced by pressure
of the nasoalveolar cyst, but it should be noted that they are
not primarily central lesions and therefore may not be visible
on the radiograph. Bilateral cases, such as reported by
Brandao and his associates, are very rare.
Roed-Petersen, in a discussion of this lesion, reviewed 160
reported cases and noted that slightly over 75% of cases
occurred in women. The mean age of occurrence was between
41 and 46 years, although cases have been reported in persons
from 12–75 years of age.
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Excellent reviews of the nasoalveolar cyst, with
recapitulations of its etiology and pathogenesis, have been
published by Moeller and Philipsen and by Campbell and
Burkes. It has been suggested by Roed-Petersen and
emphasized by Christ that this cyst probably originates from
the lower anterior part of the nasolacrimal duct rather than
from epithelium entrapped in the naso-optic furrow.
Histologic Features
Histologically, the nasoalveolar cyst may be lined by
pseudostratified columnar epithelium which is sometimes
ciliated, often with goblet cells, or by stratified squamous
epithelium.
Treatment
The cyst should be surgically excised, although care must be
exercised to prevent perforation and collapse of the lesion.
(Shafers, 2012)

Globulomaxillary Cyst
The globulomaxillary cyst has traditionally been described as
a fissural cyst found within the bone between the maxillary
lateral incisor and canine teeth. Radiographically, it is a
well-defined radiolucency which frequently causes the roots
of the adjacent teeth to diverge. While there can be no doubt
that cyst do occur in this region and that the pulps of the
adjacent teeth
270
may give positive vitality responses, there is now a
considerable body of opinion against the idea that they are
fissural cysts. The evidence against their being fissural cysts
is, in fact, more substantial than the evidence in favor (Shear,
1996).
The WHO classification of cyst of the jaws (1992) considered
this entity under the rubric ‘of debatable origin.’ We have
included here a description of this cyst due to the cited reason.
The globulomaxillary cyst is found within the bone at the
junction of the globular portion of the medial nasal process
and the maxillary process, the globulomaxillary fissure,
usually between the maxillary lateral incisor and cuspid teeth.
However, there are reports of evidence that the cyst actually
forms in the bone suture between the premaxilla and maxilla,
the incisive suture, so that its location may be different from
the cleft ridge and palate. Because of this, Ferenczy has
suggested the term ‘premaxilla-maxillary cyst’ as more
accurately describing its origin. The cause of the proliferation
of epithelium entrapped along this line of fusion is unknown.
Virtanen and Laine have carried out an extensive review and
discussion of the globulomaxillary cyst.
Christ has also thoroughly evaluated the literature dealing
with globulomaxillary cysts and has concluded that,
embryologically, facial processes per se do not exist, and
therefore, ectoderm does not become entrapped in the facial
fissures of the nasomaxillary complex. Thus, he believes that
this cyst should be removed from the category of orofacial
fissural cysts, since modern embryologic concepts do not
support such a view. Instead, he suggests that an odontogenic
origin for this cyst is far more likely, the clinical and
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radiographic appearance being entirely compatible with a
lateral periodontal, lateral dentigerous, or primordial cyst. In
addition, numerous reported cases have had the histologic
features of the odontogenic keratocyst (q.v.), while nests of
odontogenic epithelium in the wall of globulomaxillary cysts
are not rare. Furthermore, there is at least one case, reported
by Aisenberg and Inman, of an ameloblastoma developing in
a globulomaxillary cyst, which suggests an odontogenic
origin.
Clinical Features
The globulomaxillary cyst seldom if ever presents clinical
manifestations. Nearly every recorded case has been
discovered accidentally during routine radiographic
examination. Rarely, the cyst does become infected, and the
patient may complain of local discomfort or pain in the area.
Radiographic Features
This cyst, on the intraoral radiograph, characteristically
appears as an inverted, pear-shaped radiolucent area between
the roots of the lateral incisor and cuspid, usually causing
divergence of the roots of these teeth (Fig. 1-68A).
Interestingly, there are several known cases of bilateral
globulomaxillary cyst (Fig. 1-68B).
Globulomaxillary cyst.
There is a large cyst between the maxillary lateral incisor and
cuspid teeth with a characteristic inverted pear shape (A). The
same type of cyst may occur bilaterally (B). Note the
divergence of the roots of these teeth (Courtesy of Dr Michael
J Freeman and Richard Oliver)
Care must be exercised not to confuse this lesion with an
apical periodontal cyst arising as a result of pulp involvement
or trauma to one of the adjacent teeth. The teeth associated
with a globulomaxillary cyst are vital unless coincidentally
infected.
It has been emphasized recently by Wysocki, reviewing 37
cases of ‘globulomaxillary radiolucencies’ that many different
types of lesions may present radiographically with features
characteristic of a globulomaxillary cyst and that these must
273
be included in any differential diagnosis of such a
radiolucency in this area. He cited as examples such lesions
as the periapical granuloma, apical periodontal cyst, lateral
periodontal cyst, odontogenic keratocyst, central giant cell
granuloma, calcifying odontogenic cyst, and odontogenic
myxoma. He also concluded, in agreement with Christ, that
cysts in the globulomaxillary region are odontogenic rather
than fissural in origin.
Histologic Features
The globulomaxillary cyst classically has been described as
being lined by either stratified squamous or ciliated columnar
epithelium. However, Christ has emphasized that, in the
literature, there is no accepted case of globulomaxillary cyst
that is lined by pseudostratified ciliated columnar epithelium.
The remainder of the wall is made up of fibrous connective
tissue, usually showing inflammatory cell infiltration.
Treatment
This type of cyst should be surgically removed, preserving the
adjacent teeth if possible.

References
Yanagisawa E, Scher DA. Endoscopic view of a nasoalveolar cyst. Ear Nose Throat J
2002;81:137–138.

Klestadt W. Nasal cysts and the facial cleft cyst theory. Ann Otol Rhinol Laryngol
1953;62:84.

Van Bruggen A, Shear M, Du Preez I, Van Wyk D, Beyers D, Leeferink G. Nasolabial cysts.
A report of 10 cases and a review of the literature. J Dent Assoc S Afr 1985;40:15–19.

Bull T, McNeill K, Milner G, Murray S. Naso-alveolar cysts. J Laryngol Otol 1967;81:37–

44.

Marcoviceanu MP, Metzger MC, Deppe H, et al. Report of rare bilateral nasolabial cysts. J
Craniomaxillofac Surg 2009;37:83–86.