Oral Surgery ISSN 1752-2471

CASE REPORT

Nasolabial cyst: a case report

I. Zografos1, L. Podaropoulos1 , E. Malliou2 & K. I. Tosios3
1
Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
2
Private Practice, Athens, Greece
3
Department of Oral Pathology, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece

Key words: Abstract

Klestadt cyst, nasoalveolar cyst, nasolabial
cyst, non-odontogenic cyst Nasolabial cysts are rare non-odontogenic cysts of soft tissue that usually
present as asymptomatic swellings beneath the ala of the nose. Their
Correspondence to: pathogenesis is uncertain. The presence of the lesion is perceived
I Zografos clinically and by the aid of radiological imaging. The usual treatment is
Department of Oral and Maxillofacial Surgery
surgical excision. Nasolabial cysts, when infected, are painful and
School of Dentistry
mistreated occasionally as odontogenic defects. This article reports a case
National and Kapodistrian University of
Athens of a nasolabial cyst that was initially diagnosed and treated as a
Aggelidou 10-12 periapical abscess, which lead to the loss of a tooth. Complete
P. Faliro 17561 enucleation of the cyst was performed under local anaesthesia and its
Athens identity was confirmed by histopathology. Follow-up over a year
Greece revealed no evidence of recurrence.
Tel: +302109828103
Fax: +302107461267
email: ioannis_zografos@hotmail.com

Accepted: 22 April 2018

doi:10.1111/ors.12365

Introduction cause facial asymmetry and deformity8,10. It mea-

The nasolabial cyst is an uncommon, non-odonto-
genic developmental cyst with an incidence esti-
mated to 0.7% of all maxillary and mandibular
cysts1,2. It is located in the soft tissues of the upper
lip, inferior to the nasal alar region3. Its first descrip-
tion is credited to Emil Zuckerkandl in 18934. Naso-
labial cyst is, also, referred as nasoalveolar cyst, but
this name should be abandoned as it is a soft tissue
cyst and the alveolus is not involved. Less common
names used in the past are nasovestibular cyst,
nasoglobular cyst, subalar cyst and Klestadt’s cyst5,6.
Nasolabial cysts shows a female preponderance of
a ratio ranging between 2.7:1 and 3.7:11,7,8. They
are mostly unilateral, equally affecting both sides1,8,
but bilateral occurrence is reported in slightly more
than 10%1,8,9. Clinically, the nasolabial cyst presents
as a slow-growing painless soft tissue swelling of the
upper lip elevating the ala of the nose that may
sures 1 to 5 cm in diameter11. Nasal obstruction may
ensue, and pain follows infection of the cyst12,13.
Diagnosis is established by microscopical examina-
tion. A combination of pseudostratified squamous,
stratified squamous, respiratory and cuboidal epithe-
lium may be seen, and inflammatory cells are pre-
sent8. Goblet cells are found in 55.6%2 to 67%14 of
cases.
We present a case of an infected nasolabial cyst in
a 60-year old male that was initially diagnosed and
treated as a periapical abscess.
Case report
A 60-year old male presented to the general dentist
with a chief complaint of a painful swelling in the
upper lip. He stated that the lesion was present for
at least one year and did not give a history of
trauma, infection or surgical operation in the area.

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Nasolabial cyst Zografos et al.

His medical history was non-contributory. The asso-

ciated teeth were not sensitive to percussion, but the
left upper canine had negative reaction to thermal
vitality tests. An intraoral radiograph did not reveal
any pathologic signs. The case was misdiagnosed as
periapical infection associated with a non-vital upper
left canine, therefore apicectomy with simultaneous
endodontic treatment was performed. During the
procedure pulp necrosis of the tooth was confirmed,
as tissues in the root canal presented with a charac-
teristic black appearance and odour of a necrotic
pulp. Amoxicillin (1000 mg) and metronidazole
(500 mg) were prescribed twice daily for 8 days. This
broad spectrum antibiotic regimen was prescribed by
the referring general dental practitioner due to the
severity and persistence of the symptoms. However,
the patient was not relieved from his symptoms and
the relevant canine was extracted, since it was con-
sidered responsible for the persistence symptoms. As
no improvement followed patient’s condition he was
Figure 2 Intra-oral pre-operative view of the lesion: a reddish mucosa
referred to our team for further investigation.
is detected in the buccal area of the extraction site of the upper left
Clinical examination confirmed the presence of a canine.
slight facial asymmetry and a deformity in the left
nasolabial region (Fig. 1). On extraoral palpation a
round, tender and diffuse swelling was located conventional CT of the maxilla was performed
underneath the left ala of the nose. Intraorally, the revealing a homogeneous, well circumscribed round
swelling was covered by reddish mucosa and was soft tissue mass left to the midline, below the alar
soft (Fig. 2). base, protruding and narrowing the entrance of the
The region was radiographically examined by cone left nasal cavity (Fig. 4). The lesion measured
beam computed tomography (CBCT) scan, but 3.4 cm 9 3.0 cm.
no areas of pathology were detected (Fig. 3). A Periapical abcess or radicular cyst was excluded
from the differential diagnosis spectrum as no rele-
vant teeth were left and involved in the region.
Odontogenic cyst of non-inflammatory type was
considered, however, no radiolucency on the radio-
graphs was detected. Clinical diagnosis was directed
to either a soft tissue cyst – such as dermoid, epider-
moid or nasolabial cyst – or a soft tissue neoplasm.
Surgical treatment under local anaesthesia and
intraoral approach was decided (Fig. 5). A sublabial
incision was performed and after the elevation of a
mucoperiosteal flap the cyst was completely removed
without perforating the nasal mucosa, however, the
cystic sac was ruptured. The defect was closed by pri-
mary intention and properly sutured using resorb-
able 3/0 vicryl sutures (MonocrylTM, Ethicon,
Somerville, NJ, USA). A cystic sac, approximately
4 9 1.5 9 0.5 cm was fixed in a 10% neutral buf-
fered formalin solution and submitted for pathologic
examination.
Microscopic examination of 5 lm thick tissue
sections stained with haematoxylin and eosin
Figure 1 Extra-oral pre-operative view of the lesion. showed that the wall of the sac consisted of cellular

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Zografos et al.
Figure 3 Dental CT of the area of the extracted upper left canine showing no evidence of bone pathology in the alveolar ridge.
Figure 4 Conventional CT revealed a circumscribed mass in contact
to the left nasal cavity (red arrows).
and vascular connective tissue, lined by ciliated,
pseudostratified columnar epithelium (Fig. 6). No
goblet cells were found. The connective tissue pre-
sented focal inflammatory infiltration by plasmacytes
and lymphocytes, mostly subepithelial, as well as
haemorrhagic infiltration (Fig. 7). The final diagnosis
was nasolabial cyst.
Post-operative healing course was uneventful
while follow-up at 1 year with conventional CT
showed no evidence of recurrence (Fig. 8).
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Nasolabial cyst
Figure 5 Full thickness mucoperiostal flap extending from the right
canine to the left first molar exposing the lesion.
Discussion
Searching the MEDLINE/Pubmed database under
the terms “Nasolabial cyst”, “Nasoalveolar cyst”,
“Nasovestibular cyst” and “Klestadt’s cyst” resulted
in 94 published case reports. These case reports fol-
low different methodologies in imaging, diagnosis
and treatment modalities. Nevertheless, the final
diagnosis and confirmation of the nature of a lesion
should be performed by histological analysis.
In the case presented herein, the clinical, radio-
graphic and microscopic features were consistent
with nasolabial cyst. The patient noticed the lesion
for least a year before presentation, however, he
asked for medical advice only after it became
53
Nasolabial cyst
Figure 6 The wall of the sac consisted of cellular and vascular connective
tissue, lined by ciliated, pseudostartified columnar epithelium.
Figure 7 The connective tissue presented focal inflammatory infiltra-
tion, mostly subepithelial.
painful. Following the case from its onset, it is not
clear if the nasolabial cyst caused the loss of the
vitality of the upper left canine, since no pathology
was detected at the periapical bone in the intraoral
radiograph, or it was infected from the adjacent
canine. This commonly ensues in nasolabial cyst9,13
and may mislead clinician towards a diagnosis of
periapical abscess or an odontogenic cyst, that in our
case lead to the loss of a tooth.
Differential diagnosis may include nasopalatine
duct cyst or globulomaxillary cyst, however, the
extraosseous location of the nasopalatine cyst aids
diagnosis. The diagnostic spectrum will encompass,
as well, soft tissue cysts, such as dermoid or epider-
moid cyst, furunculosis of the base of the nose,
benign tumours, soft tissue and salivary gland
54
Zografos et al.
Figure 8 Medical CT one year post-operatively. No pathology
detected.
tumours. Malignant tumours, in particular mucoepi-
dermoid carcinoma, should also be considered.
Intraoral or panoramic radiographs are not usually
informative in the diagnosis of nasolabial cyst, but
help in excluding intra-osseous lesions. Conventional
CT is the most commonly used imaging tool to detect
a suspected nasolabial cyst and preferred to magnetic
resonance imaging (MRI) due to its lower cost8. In
our case, the CBCT also failed to detect the cyst, as it
depicts only the hard tissues, but it was revealed in
the conventional CT. In general, intraoral and
panoramic radigraphs as well as CBCT should not be
considered the imaging method of choice for depict-
ing a nasolabial cyst since they are hard tissue imag-
ing modalities. In case conventional CT fails to detect
the lesion, an MRI should be considered. In both
conventional CT and MRI nasolabial cyst presents
as a non-odontogenic homogeneous circumscribed
mass, with varying intensity, with or without bony
erosion2,15,16. Usually conventional CT is preferred
due to its lower cost, however, MRI does not expose
the patient to ionising radiation. Ultrasonography
(USG) is a method often used for detecting soft tissue
lesions, which may be used intraorally as well. In a
case report Acar et al.17 concluded that USG was use-
ful and adequate when nasolabial cyst is suspected.
USG is fast becoming the modality of choice in
depicting oral soft tissue lesions due to its inexpen-
sive and non-ionising nature, giving it an advantage
over conventional CT or MRI. On the other hand is
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Zografos et al.
an operator dependent method and its interpretation
is determined by the experience of the user18,19.
The etiopathogenesis of nasolabial cysts is debat-
able. Initially, it was considered as a fissural cyst
derived by epithelial cells entrapped at the fusion
area of the medial and lateral nasal processes and
the maxillary process5,6. Currently, an origin from
embryonic remnants of the nasolacrimal duct tissue
is considered more probable and supported by bilat-
eral occurrence of some cysts2,13,20. However, some
cysts may develop due to surgical treatments and
chronic inflammation21.
Therapeutically, injection of sclerozing materials,
simple aspiration and destruction by cautery13 have
been tried, but show a high recurrence rate2,10,13,22,23.
The most common and effective treatment is complete
surgical excision of the cyst, usually performed intrao-
rally via a gingivolabial incision, under local or general
anaesthesia8. A transnasal approach of endoscopic
marsupialisation of nasolabial cysts is described10 that
according to some8,13,24, but not all25,26 studies shows
good therapeutic results. In a prospective randomised
study27 it was concluded that both methods are effec-
tive. The transnasal marsupialisation has many benefits
over the conventional intraoral approach, but there is
no difference with regard to post-operative swelling,
pain, or overall recurrence rate. Therefore, more stud-
ies with longer follow-up periods are needed to esti-
mate in depth the two different techniques8. A
modification of the above mentioned method that is
suggested is to firstly aspirate the cyst before enucle-
ation which, according to the authors, exhibits lower
recurrence rates5. Cryosurgery has also been applied as
an alternative treatment method on nasolabial cysts.
Janardhan et al.28 performed cryosurgery, after a sub-
labial incision, in four patients. The authors suggest
that the application of a cryo probe to the bed of the
cyst after excision is beneficial, especially in cases when
complete cyst wall removal is not a certainty. Further-
more, no complications or recurrence has been
reported with this method.
Care should be taken during surgical excision, as
the tight attachment of the cyst to the nasal mucosa
may lead to perforation of the floor of the nose.
However, in some cases this may be required to
ensure the complete removal of the cyst, followed
by suturing. Complications following surgery of
nasolabial cysts include facial/perinasal swelling,
pain, toothache, facial numbness and tooth loss8.
Recurrence is not common2 and is associated with
intraoperative rupture of the cyst13. Sheikh et al.8
analysed 79 articles with 311 patient nasolabial cyst
cases and reported a recurrence rate of 1.63% in
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Nasolabial cyst
cases where the lesion was surgically excised and a
recurrence rate of 2.53% in cases where the transna-
sal marsupialisation approach was used. Authors
conclude that overall recurrence rate seems to be
irrelevant of the surgical technique involved8. In the
case presented, the nasal mucosa was not perforated,
but the cyst was not removed intact. However, no
recurrence was found in the 1 year follow-up.
Sheikh et al.8 in a recent literature review reported 79
articles including 311 patients with diagnosed and con-
firmed nasolabial cysts. Several variables, which were
not consistent in all articles, were included. However,
an effort was made to categorise the data based upon
patient demographics, location of the cyst, aetiology,
radiological imaging, histology, management and out-
come. Authors concluded that nasolabial cysts are rare,
are best defined in conventional CT and MRI and the
rates of post-operative swelling, pain and recurrences
are similar in the sublabial and transnasal approach.
However, they report inconsistencies between articles
in the reporting of presentation, cyst characteristics,
management and complication and they add that the
heterogeneity of their data may subject their study to
institutional, geographical and selection bias.
In conclusion, nasolabial cyst, although rare,
should be included in the differential diagnosis in
cases of sublabial swelling with facial deformity.
Panoramic radiography and CBCT do not give sub-
stantial information, therefore, conventional CT or
MRI should be preferred and USG considered. Trans-
nasal marsupialisation or surgical enucleation seems
to be equally successful in its treatment.
Conflict of interest
The authors confirm that there are no conflicts of
interest.
Ethical approval
None required.
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