Our Experience at Tertiary Medical College: Excision with Sublabial Approach Versus Marsupialization with Transnasal Endoscopic Approach in Patients with Nasolabial Cyst

Abstract

Rare non-odontogenic cysts of the soft tissue of the midface that form between the nasal vestibule and upper lip are known as nasolabial cysts. Treatment can be accomplished by surgical removal, injection of sclerosing material into the cyst, and endoscopic marsupialization. The aim of this study is to compare the effectiveness of Excision with sublabial approach versus Marsupialization with Transnasal Endoscopic approach in patients with Nasolabial cyst in terms of operating time, recurrence rate, postoperative pain and complications. Our study was Duration based prospective observational study with a Duration of four years from August 2018 till July 2022 with study population inclusive of 30 patients aged between 20 and 70 years who were diagnosed with a unilateral nasolabial cyst on the basis of clinical presentation, anatomical location, and computed tomography (CT) findings at ENT Department of our Tertiary Institution. The study used a randomized, single blind, parallel design with a total of 30 patients, which were randomly allocated to undergo Excision with sublabial approach (group A) in 15 patients (15 nasolabial cysts) and Marsupialization with Transnasal Endoscopic approach (Group B) in 15 patients (15 Nasolabial cysts). In the sublabial approach group, the mean operating time was 91.28 ± 3.1 min, whereas in the transnasal marsupialization group, it was 29.7 ± 3.2 min. These differences were statistically significant (P = 0.003). In the excision with sublabial approach and transnasal endoscopic marsupialization groups, the visual analogue scale (VAS) for postoperative pain was 5.9 ± 1.4 and 3.2 ± 0.6, respectively (P = 0.001). Ten patients in the sublabial approach group and five patients in the transnasal marsupialization group had one or more problems during the follow-up period which disappeared spontaneously within 4 weeks without long lasting issues. There were no recurrence lesions or obstructions of the marsupialized cyst opening in either group, according to physical, endoscopic and computed tomography examinations. Nasolabial cysts can be marsupialized transnasally, which offers many advantages over the more traditional sublabial excision method. Transnasal endoscopic marsupialization has the benefits of a shorter operating time, less postoperative pain, and a low complication rate. Therefore, we propose that Transnasal Endoscopic marsupialization be the treatment of choice for nasolabial cyst, replacing the conventional Excision with sublabial approach.

Introduction

Rare non-odontogenic cysts of the soft tissue of the midface that form between the nasal vestibule and upper lip are known as nasolabial cysts [1, 2]. The most tenable idea regarding the pathophysiology of nasolabial cysts was offered by Bruggemann in 1920 and contends that the remnants of the epithelium in the anterior lower portion of the nasolacrimal duct give rise to the nasolabial cyst [3]. Although it doesn't appear until adulthood, the cyst's origin is developmental. A nasolabial cyst typically presents as a painless, localized swelling in the nasolabial fold that causes the upper lip to project and the alar nose to elevate along with varying degrees of nasal obstruction over the course of several years [4].

Treatment can be accomplished by surgical removal, injection of sclerosing material into the cyst, and endoscopic marsupialization [5]. According to numerous reports, surgical excision of nasolabial cysts via a sublabial technique is the standard treatment [3, 5, 6]. The procedure's side effects include swelling of the face, gingival numbness, wound infection, and diminished tooth feeling [4, 7]. Transnasal Endoscopic Marsupialization, first performed in 1999, is a minimally invasive, simple and successful surgical treatment for nasolabial cysts. It has several benefits over the traditional sublabial excision treatment. The postoperative endoscopic and radiological findings showed that the cyst was replaced by an air containing sinus with a persistent opening on the anterior or anterolateral nasal floor without evidence of accumulation of mucus in the newly created sinus or recurrence of the cyst [4, 8].

There is very little literature comparing these two surgical techniques,so we have done the same with the aim to compare the effectiveness of Excision with sublabial approach versus Marsupialization with Transnasal Endoscopic approach in patients with Nasolabial cyst in terms of Operating time, Recurrence rate, Postoperative pain and Complications.

Material and Methods

Our study was Duration based prospective observational study with a Duration of 4 years from August 2018 till july 2022 with study population inclusive of 30 patients aged between 20 and 70 years who were diagnosed with a unilateral nasolabial cyst on the basis of clinical presentation, anatomical location, and computed tomography (CT) findings at ENT Department of our Tertiary Institution.The study used a randomized, single blind, parallel design with a total of 30 patients,which were randomly allocated to undergo Excision with sublabial approach (group A) in 15 patients (15 nasolabial cysts) and Marsupialization with Transnasal Endoscopic approach (Group B) in 15 patients (15 Nasolabial cysts).The Patients were administered an informed consent and written consent was obtained from those who agreed to participate in the study.A case record (Proforma) form was filled by the patient.

Surgical techniques and follow-up: Both procedures such as Excision with sublabial approach (group A) and Marsupialization with Transnasal Endoscopic approach (Group B) were performed under general anaesthesia in all of the cases.The excision with sublabial approach (group A) involved sublabial incision at the upper gingivobuccal sulcus just below the pyriform aperture (Fig. 1a) after infiltration with 2% lidocaine containing 1:100,000 epinephrine and blunt dissection of the tissues until the exposure of the smooth, well defined cystic lesion is noted (Fig. 1b). The cyst was completely extraosseous in each of our cases, with no attachment to the underlying bone. In some situations, the cyst could be readily separated from the soft tissues around it, but in other individuals, tearing or rupture of the cyst happened, and part of the nasal floor mucosa was removed along with the cyst due to the challenging dissection between them. In all cases, the cyst was completely removed without any remaining cystic wall or epithelium (Fig. 1c). However, the nasal floor mucosa defect was not a severe issue because the bleeding was easily managed and the nasal mucosa quickly recovered by re-epithelialization. To lessen soft tissue edema, a compression dressing was used after the wound was sealed with 3–0 Vicryl material. After the operation, patients were discharged two days later. The nasal cavity was anesthetized topically and decongested using cotton pledgets soaked in a solution of 2% lidocaine and 0.1% epinephrine in the Transnasal Endoscopic marsupialization group (group B).The anterior nasal cavity, vestibular area, and mucosal surface over the cyst were infiltrated locally with 2% lidocaine containing 1:100,000 epinephrine. Over the cyst's roof, an elliptical incision was made under the guidance of rigid, straight, 4 mm diameter 0 and 30 degree nasal endoscopes using 15 number blade (Fig. 2a), leading to gush of clear fluid with opened nasolabial cyst (Fig. 2b). With a microdebrider straight blade, trimming of the cyst margins were done to make surface smooth (Fig. 3a) the cyst's opening was widened to at least 10 by 10 mm in size (Fig. 3b). Gentle packing of the postoperative widened cystic cavity done with Bismuth iodoform paraffin paste gauze pack and After the operation, patients were discharged on second postoperative day. Each group's patients had follow-up appointments once per week for four weeks, and then they came in for check-ups three, six, and twelve months after the treatment. During the 1-year follow-up period, there were no patients who were dropped from the study. Each group's surgical procedure's length, postoperative pain, complications, and recurrence were assessed, and comparisons were conducted between them for the same factors. The induction and recovery times for anaesthesia were not included in the measurement of the operating time.

Fig.1.

Intraoperative photograph showing (a) Right sublabial incison with visualization of cyst wall (b) Smooth well defined cystic lesion after blunt dissection (c) Postoperative surgical site after excision of the nasolabial cyst using sublabial approach

Fig. 2.

Intraoperative Zero Degree Endoscopic photograph showing (a) Elliptical incision over the roof of the nasolabial cyst in right nasal cavity using 15 number blade (b) opened nasolabial cyst with gush of clear fluid from inside

Fig. 3.

Intraoperative Zero Degree Endoscopic photograph showing (a) Trimming of the margins of the nasolabial cyst using straight blade of microdebrider to make smooth surface (b) widening of the Nasolabial cyst's opening to at least 10 by 10 mm in size using microdebrider straight blade (c) Decrease in the size of the marsupialized cyst at 1 year follow-up without any obstruction of its opening

Using a visual analogue scale (VAS), where a score of zero indicated no pain and a score of ten indicated intense pain, patients in each group were questioned regarding the severity of postoperative pain. The patients were questioned about their post-procedure experiences of cheek swelling, face pain, facial bruising, facial tingling, facial numbness, numbness of the teeth or gingiva, and nasal bleeding during the follow-up period. Patients who had any of the symptoms were further questioned about how long they had been experiencing them. Recurrence was assessed in light of the patient's symptoms and postoperative CT results during one year after the surgery.

Statistical Analysis

The Statistical Package for the Social Sciences (SPSS) version 13 was used to statistically evaluate the data that were gathered. Cross-tabulations of the study participants were performed, and treatment groups were matched based on characteristics including age and gender using the chi squared test of association. Significant differences between the two groups were determined using the X2 Test and Fisher Exact Test. In order to assess group differences, the t test for continuous variables was used. The cut off point for analytical significance was P < 0.05. Using the descriptive approach in SPSS, descriptive statistics like mean age and standard error of mean age were computed.

Results

The Study involved 30 patients (30 nasolabial cysts) in the age group 20–70 years age group with the highest number of cases (i.e., 21) occurring in the 41–50 year age group, which made up around 70% of the study population. Among the 30 patients in the study, 27 (90%) were female. Female to male patients ratio was 9:1, with 3 patients (10%) being male. (Table 1) The lesions were unilateral in all of our cases. The most common presenting symptom was swelling around the nose (15 patients, 50%), followed by pain (9 patients, 30%), and nasal obstruction (6 patients, 20%). In the sublabial approach group, the mean operating time was 91.28 ± 3.1 min, whereas in the transnasal marsupialization group, it was 29.7 ± 3.2 min. These differences were statistically significant (P = 0.003). In the excision with sublabial approach and transnasal endoscopic marsupialization groups, the VAS for postoperative pain was 5.9 ± 1.4 and 3.2 ± 0.6, respectively (P = 0.001). The response was carefully assessed at each meeting to ascertain whether problems or recurrence had emerged. Ten patients in the sublabial approach group had one or more problems during the follow-up period, including facial swelling, facial pain, facial bruising, and gingival and tooth numbness. Mild facial swelling occurred in five patients in the transnasal marsupialization group. Within 4 weeks of the surgery, all of these side effects spontaneously disappeared, and no long-lasting issues developed. No patients experienced any further negative side effects, such as facial tingling, nasal haemorrhage, hematomas, or wound infections. No patient reported experiencing recurring symptoms throughout the 1-year follow-up period. There were no recurrence of lesions or obstructions of the marsupialized cyst opening in either group, according to physical, endoscopic, and CT examinations. Histopathology in all of our cases shown nasolabial cyst with Pseudostratified columnar epithelium (blue arrow) with intermittent goblet like mucin-producing cells (yellow arrow), and non-specific chronic inflammatory infiltration in the stroma (Fig. 4).

Table 1.

Demographic features of the study population

Age in years	Excision with sublabial approach (GROUP A)		Marsupialization with Transnasal endoscopic Approach (GROUP B)		Total
	Number	Percentage	Number	Percentage	Number	Percentage
21–30 years	01	6.67%	01	6.67%	02	6.67%	X2 = 0.381 P = 0.984006
31–40 years	01	6.67%	02	13.33%	03	10%
41–50 years	11	73.33%	10	66.67%	21	70%
51–60 years	01	6.67%	01	6.67%	02	6.67%
61–70 years	01	6.67%	01	6.67%	02	6.67%
Total	15	100%	15	100%	30	100%
Mean age ± SE	49.52 ± 14.07		48.64 ± 12.05
Minimum age	22		21		21
Maximum age	68		70		70
Sex
Males	01	6.67%	02	13.33%	03	10%	X2 = 0.3704 P = 0.542802
Females	14	93.33%	13	86.67%	27	90%
Total	15	100%	15	100%	30	100%

Fig. 4.

Histopathological photomicrograph showing nasolabial cyst with Pseudostratified columnar epithelium (blue arrow) with intermittent goblet like mucin-producing cells (yellow arrow)

Discussion

Zuckerkandl published the first description of nasolabial cysts in 1892. The maxillofacial region can be seen with non odontogenic masses by these lesions. The lesions are given names in the literature as Klesdadts tumour, nasolabial cyst, and nasoalveolar cyst [9]. The extraosseous, submucosal lesion enlarges and extends all of the soft tissues through the gingivobuccal sulcus outwards. The cysts typically appear between the fourth and fifth decade over a lifetime. Literature shown that 10% of cases of nasolabial cysts are bilateral [10]. Our study shown that the highest number of cases were in the 41–50 year age group with female preponderance and the lesions were unilateral in all of our cases. The differential diagnosis of the cyst must include periapical cysts, periapical abscesses, periapical granulomas, maxillary cysts, central line cysts, and odontogenic cysts, a cystic epidermal inclusion, nose-base furunculosis as well as nose-base tumours [3].The clinical and radiologic methods and histopathology analysis can be used to diagnose the lesion [11].

The treatment can be made by surgical excision, injection of sclerozing materials in the cyst, and endoscopic marsupialization methods [3]. The preferred method of treating nasolabial cysts is typically excision using a sublabial technique [3, 5, 6]. However, a novel transnasal marsupialization technique was used by Su et al. [4] in 17 cases, with no recurrences, and other studies have documented case series utilizing this procedure [2]. Recently, Chen et al. [8] described endoscopic marsupialization of the nasolabial cyst using microdebrider assistance. The sublabial method (10 cases), traditional transnasal marsupialization (13 cases), and microdebrider-assisted marsupialization (8 cases) were all compared. When compared to the outcomes of our study, the surgical procedures and outcomes were comparable. However, their study was retrospective in nature, and randomization was not done, which would be a study limitation.

Although some authors have claimed that transnasal marsupialization is superior to the traditional method, no prospective study has directly contrasted these two surgical approaches. Because it required longer to elevate the gingival flap and separate the cyst from the surrounding structures using the sublabial method, transnasal marsupialization was significantly simpler and quicker from a surgical procedure and operating time standpoint. The length of the procedure was extended by the need to control bleeding. In contrast, transnasal marsupialization only required a small amount of cyst roof widening with a microdebrider while using direct endoscopic vision, and the mucosal surface bleeding was effectively controlled with Bismuth iodoform paraffin paste gauze pack.

The transnasal marsupialization group also demonstrated superior postoperative pain as assessed by the VAS. The mucosal incision and retraction of the upper lip during the procedure may inflict more discomfort and soft tissue swelling than transnasal marsupialization in the sublabial approach group. Ten patients in the sublabial approach group had one or more problems during the follow-up period, including facial swelling, facial pain, facial bruising, and gingival and tooth numbness. Mild facial swelling occurred in five patients in the transnasal marsupialization group. Within 4 weeks of the surgery, all of these side effects spontaneously disappeared, and no long-lasting issues developed. No patient in either group had a recurrence of the lesion. Therefore, in terms of the surgical outcome, the transnasal marsupialization and the sublabial approach are both useful techniques for treating nasolabial cysts.

Because the cut edges of the nasal mucous membrane and the cyst lining were so closely matched after marsupialization, fast epithelialization and a persistent opening were established [4]. However, if a window is formed in the cyst that is too small, the annular scar around the ostium will quickly contract, and either mucus may gather in the pocket or the cyst may return. In order to prevent recurrence, a wide opening should be formed [2, 4]. No occlusion of the opening was seen in any of the patients in this investigation, despite the fact that the size of the marsupialized cyst and opening shrank during the follow-up period in patients of the transnasal marsupialization group (Fig. 3c).

A nasolabial cyst is a true cyst from the histopathological perspective and has an inner lining of ciliated respiratory epithelium [3–5, 12, 13]. It is thought that marsupialization transforms a nasolabial cyst into an air-containing sinus covered in respiratory epithelium with cilia, much like the mucosa of the paranasal sinuses and nasal cavity, which might perform ventilation and drainage duties like a typical paranasal sinus, which would prevent mucus buildup [4].

In this study, the expected side effects of transnasal marsupialization that is mucus buildup and cyst recurrence were not noted during the observation period. Despite the fact that both techniques resulted in successful surgical outcomes, we think that transnasal endoscopic marsupialization is a better method for treating nasolabial cysts than the traditional excision with sublabial approach because it has fewer complications, less postoperative pain, and a shorter operating time. The minimal number of patients included in each group was a drawback of our study. Nasolabial cysts make up just 0.7% of all maxillary and mandibular cysts, making them very uncommon [3]. We believe that our study has importance in illustrating the advantages of transnasal marsupialization in the random prospective manner because of availability of limited literature for comparing the efficacy of transnasal marsupialization with the traditional sublabial procedure.

Conclusion

Nasolabial cysts can be marsupialized transnasally under endoscopic guidance, which offers many advantages over the more traditional excision with sublabial approach method. Transnasal endoscopic marsupialization has the benefits of a shorter operating time, less postoperative pain, and a low complication rate. Therefore, we propose that Transnasal Endoscopic marsupialization be the treatment of choice for nasolabial cyst, replacing the conventional Excision with sublabial approach.

Funding

Not applicable.

Declarations

Conflict of interest

All the authors declare that they have not any conflict of interest.

Ethical Approval

Ethical approval taken from institutional ethical committee of Ashwini Rural Medical College & Hospital Solapur as per ICMR guidelines.

Human Participants and Animals

All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration.

Informed Consent

Informed consent was obtained from all individual participants involved in the study.