Pediatric nasopalatine vs. median palatine cysts: differential diagnosis and endoscopic management – a comparative case report

Abstract

Background

Median palatine cysts (MPCs) and nasopalatine duct cysts (NPDCs) are rare non-odontogenic cystic lesions in the pediatric population. Due to their low incidence and often asymptomatic nature in children, these cysts are frequently overlooked or misdiagnosed. To the best of our knowledge, few comparative pediatric cases have been reported. The novelty lies in the detailed histopathological differentiation and the analysis of their impact on maxillofacial development, providing a crucial clinical reference for early intervention.

Case presentation

In this report, two pediatric patients presented with similar clinical manifestations and obvious dental malalignment. Initial imaging suggested NPDCs in both cases. Both patients underwent complete cyst removal via endoscopic nasal surgery. Postoperative histopathological examination confirmed the distinct diagnoses: one as an MPC and the other as an NPDC. The primary histopathological differentiator was the composition of the fibrous cyst wall; the NPDC contained specialized structures (blood vessels, nerves, and mucous glands), which were absent in the MPC. At the two-year follow-up, both patients showed favorable maxillofacial development and no signs of recurrence.

Conclusions

These cases illustrate that while MPCs and NPDCs may share clinical similarities, they possess distinct histopathological characteristics. The endoscopic approach appears to be a feasible surgical option in these cases. Early and accurate differential diagnosis can aid in surgical planning and may help mitigate potential impacts on pediatric maxillofacial development, offering useful insights for otolaryngologists and pediatric dentists.

Background

A wide variety of cystic lesions can occur in the anterior midline region of the maxilla. In addition to odontogenic lesions that should be routinely excluded, this area is a classic predilection site for non-odontogenic developmental cysts [1]. Among these lesions, the NPDC is relatively common [2, 3], whereas the MPC represents a comparatively rare clinical entity [4–6]. Nasopalatine duct cysts (NPDCs), also known as incisional duct cysts, are a developmental cyst originating from the epithelial remnant tissue of the nasopalatine duct [3]. In contrast to MPCs, NPDCs are the most common non-odontogenic cysts of the maxilla, accounting for approximately 1% of the general population [3, 7, 8]. The average age of onset is 42.5 years [9]. The incidence in men is significantly higher than in women, but it is rare in children [9, 10]. They are often diagnosed clinically based on clinical manifestations, physical examination, imaging features, and histopathological examination of the cyst. However, histopathological examination remains the gold standard for definitive diagnosis of this disease. Microscopically, the cyst wall has one or more of the following histopathological features: blood vessels, nerves, mucous glands, salivary glands, hyaline cartilage islands [9, 11]. Histologically, the epithelial lining of nasopalatine duct cysts is diverse, with the type of cystic epithelium varying according to the anatomical site of involvement (palatal, intermediate, or nasal). Clinically, squamous epithelium is predominant, but ciliated respiratory epithelium can be observed when the lesion is located more higher or closer to the nasal cavity [12, 13].

Median palatine cysts (MPCs) are rare non-odontogenic facial cleft cysts, accounting for only 7.14% of all non-odontogenic jaw cysts [4–6]. These cysts originate from epithelial remnants entrapped during embryonic palatal fusion [4]. Male patients are more common, with a male to female ratio of 4:1, and the average age of diagnosis is between 20 and 50 years old [4]. It is rarely reported in children [14]. In the case of MPC, histological characteristics and intraoperative findings serve as the essential basis for this differentiation, confirming that the cyst neither involves the incisive canal nor is associated with non-vital teeth [4]. There is no usually histologic evidence of hyaline cartilage, large vessel spaces, nerve trunks, or accessory salivary gland tissue on the cyst wall [4]. However, whether the MPC exists as an independent entity remains controversial. In traditional embryological theories, the MPC was once classified as an independent entity. Nevertheless, in the second revised edition of Histological Typing of Odontogenic Tumors, published by the World Health Organization (WHO) in 1992, the MPC is no longer recognized as an independent cystic entity. Instead, it is now widely considered to be the result of a posterior extension of a nasopalatine duct cyst into the hard palate region [15–17]. From a histopathological perspective, it is precisely this posterior anatomical displacement away from the incisive canal region. Consequently, the cyst wall naturally cannot enclose the neurovascular bundles and glands characteristic of the incisive canal. Furthermore, being far from the nasal floor, its epithelial lining often presents as stratified squamous epithelium, thereby creating the histological illusion of an independent disease entity. We acknowledge the World Health Organization (WHO) classification; however, as noted in much of the recent literature, the traditional terminology “MPC” is still frequently used in current research for clarity of clinical anatomical localization [18]. Therefore, we retain this terminology when describing the specific cases in this report.

In the pediatric population, these two types of cysts present complex, multifaceted diagnostic challenges. First, the insidious and asymptomatic nature of early lesions can easily lead to a delayed diagnosis, thereby affecting the development of the dentition and maxillofacial skeleton [10]. Second, their clinical presentations are easily confused with those of odontogenic lesions (such as radicular cysts, dentigerous cysts, and ameloblastomas) and other non-odontogenic diseases (such as enlarged nasopalatine ducts and central giant cell granulomas) [12, 13, 19, 20]. Therefore, incorporating a comprehensive dental evaluation may provide valuable diagnostic evidence to help differentiate between an odontogenic and non-odontogenic origin. Finally, due to the histological overlap in their epithelial linings, further definitive differentiation between NPDCs and MPCs remains highly challenging, relying on key histological clues within the cyst wall, such as the presence of nerves, blood vessels, or mucous glands. Given that the existing epidemiological data are primarily based on adults, clinical data regarding such anterior maxillary midline lesions in the pediatric population remain relatively limited, and delayed diagnosis is frequently encountered. Furthermore, although current pathological consensus tends to regard the NPDC and MPC as the same disease entity, few studies have directly compared their histopathological variations within different anatomical microenvironments. Therefore, through a comparative analysis of two pediatric cases occurring in the anterior midline region of the maxilla, this report focuses on the following three main aspects: First, we aim to supplement the currently limited clinical and radiological data available for this relatively uncommon pediatric population and highlight the associated diagnostic challenges. Second, through direct comparison, we explore the specific histopathological differences of the same disease entity arising in different spatial locations and emphasize the core value of cyst wall characteristics in differential diagnosis. Finally, considering that children are in a critical period of maxillofacial skeletal and dental development, this study aims to preliminarily investigate the feasibility and potential clinical advantages of an endoscopic endonasal minimally invasive approach in preserving the structural integrity of the maxilla and reducing local tissue injury.

Case presentation

Case 1: median palatine cyst

Case information

A 13-year-old boy was incidentally found to have a cystic lesion in the midline of the maxilla during an orthodontic examination for malocclusion (Fig. 1). The child had no nasal congestion, runny nose, loose teeth, or pain. A mucosal mass was seen in the right nasal cavity, with a wide base, soft texture, and cystic feel. There was no bleeding or obvious tenderness when touched. Computed tomography (CT) examination of maxilla showed that, at the level of the upper incisive canal, an enlargement of the maxilla could be seen on the right side of the midline. Its diameter was about 1.4 cm and its height was about 1.9 cm, accompanied by local bone destruction, which protruded into the right inferior nasal meatus and common nasal meatus (Fig. 2a, b, c).

Fig. 1.

The yellow arrow indicates the malalignment of the child’s maxillary incisors. (This image shows the localized lesion site.)

Fig. 2.

The yellow arrows indicate a median palatine cyst in the (a) axial, (b) coronal, and (c) sagittal views

During the initial evaluation, pulp vitality testing was not performed because the patient first presented to the Department of Otolaryngology-Head and Neck Surgery. However, preoperative high-resolution CT demonstrated that the lesion was located in the anterior palatal region, with an intact bony separation between the lesion and the apices of the adjacent incisors. The absence of widened periodontal spaces or periapical bone destruction preliminarily ruled out the possibility of an odontogenic lesion.

Treatment plan

Considering that the patient’s maxillofacial skeleton and dentition were still undergoing growth and development, and the lesion was not causing obvious clinical symptoms, the primary focus of the preoperative assessment was how to adequately preserve the developing anatomical structures while achieving complete lesion removal. Therefore, an endoscopic endonasal cyst excision was selected. During surgery, the mucosa was incised along the anterior margin of the mass down to the nasal floor for preliminary unroofing, revealing an outflow of brown cystic fluid (Fig. 3). Subsequently, the cystic tissue was completely excised and submitted for histopathological examination.

Fig. 3.

Cystic fluid can be seen in the cyst indicated by the yellow arrow, IT is the inferior turbinate, and NS is the nasal septum

The results showed that the cyst was partially lined with ciliated columnar epithelium, and most of it was covered with squamous epithelium. The area beneath the epithelium was fibrous tissue, and the local area showed mucinous degeneration. A small number of lymphocytes and eosinophils infiltrated in the cyst, and a large amount of cholesterol crystals formed locally in the cyst, as well as small focal calcifications and patchy hemorrhage. Therefore, based on the clinical and histopathological features, the postoperative diagnosis was established as a cyst consistent with MPC phenotype (Fig. 4).

Fig. 4.

Photomicrograph of the cyst wall showing various epithelial components (hematoxylin and eosin [H&E] stain, original magnification ×40). The yellow arrow indicates pseudostratified columnar ciliated epithelium, and the black arrow indicates squamous epithelium. No glands are observed beneath the epithelial layer

Case 2: nasopalatine duct cyst

Case information

A 10-year-old girl presented to the hospital with mouth breathing and hypoplastic dentition. The patient had no symptoms such as nasal congestion, nasal discharge, snoring, toothache, or loose teeth (Fig. 5). Her fiberoptic nasopharyngoscopy showed that the bulging nasal base in bilateral nasal cavities and the adenoids were not large. Her maxillary CT examination results showed that a round-like soft tissue density mass was visible in the midline area of the maxilla, approximately 4.3 × 2.4 × 3.5cm³ in size, with intact edges. The mass was located behind the tooth root and had a significant mass effect. The left nasal cavity was completely blocked, and the right nasal cavity was partially blocked. In the local hard palate, we could see bone destruction, the nasal septum was compressed by the mass and deviated to the right, the bone was discontinuous, and the roof wall of the oral cavity was compressed and arc-shaped concave (Fig. 6a, b, c).

Fig. 5.

The yellow arrow indicates the malalignment of the child’s maxillary incisors. (This image shows the localized lesion site.)

Fig. 6.

The yellow arrows indicate a nasopalatine duct cyst in the (a) axial, (b) coronal, and (c) sagittal views

Similarly, pulp vitality testing was not performed during the initial evaluation of Case 2. However, high-resolution CT also demonstrated that the lesion was primarily located in the maxillary region, with an intact bony separation between the lesion and the adjacent tooth apices, and no obvious signs of periodontal or periapical involvement (Fig. 6). Based on these findings, an odontogenic origin was preliminarily excluded.

Treatment plan

Considering the patient’s age and the characteristics of the lesion, the patient underwent endoscopic endonasal cyst excision under general anesthesia, similar to Case 1. Histopathological examination of the completely excised specimen revealed that the cyst wall was lined by pseudostratified ciliated columnar epithelium, with abundant salivary glands identified within the cyst wall. Based on the clinical and histopathological features, the final diagnosis was a nasopalatine duct cyst (Figs. 7 and 8).

Fig. 7.

Photomicrograph of the cyst wall showing various epithelial components (H&E stain, ×200). The black arrow indicates pseudostratified columnar ciliated epithelium, the black triangle indicates salivary glands, and the orange triangle indicates small blood vessels

Fig. 8.

Photomicrograph of the cyst wall showing various epithelial components (H&E stain, ×40). The black arrow indicates pseudostratified columnar ciliated epithelium; the orange triangle indicates salivary glands; the orange five-pointed star indicates small blood vessels; the black triangle indicates a nerve trunk

Follow-up

Postoperatively, neither patient developed fever, wound infection, or obvious maxillofacial swelling and numbness. To effectively prevent infection, both patients routinely received oral antibiotic therapy for 3 days postoperatively. In addition, based on the healing of the surgical cavity and individual recovery status, adjunctive treatments including nasal irrigation, topical intranasal corticosteroid sprays, and mucolytic agents were administered to effectively promote the resolution of local mucosal edema, control inflammation, and accelerate the stabilization of the surgical cavity mucosa. At the 3-month postoperative follow-up, the mucosa at the surgical site had healed well, crusting at the margins of the surgical cavity had resolved, and the wound surface appeared flat and smooth. Both patients were followed for 2 years, during which no evidence of cyst recurrence was observed (Figs. 9 and 10). The overall treatment timeline is illustrated in Fig. 11. This case report was prepared in accordance with the CARE guidelines.

Fig. 9.

Two-year postoperative endoscopic view of the child with MPC, showing a small amount of mucoid secretions and smooth, well-healed mucosa at the surgical site (IT: inferior turbinate)

Fig. 10.

Two-year postoperative endoscopic view of the child with NPDC, showing smooth and well-healed mucosa at the surgical site (MT: middle turbinate)

Fig. 11.

The timeline of the entire treatment

Discussion

To our knowledge, current research on NPDCs and MPCs primarily focuses on adults, while discussions on their specific manifestations and characteristics in pediatric patients remain relatively limited. By conducting a direct comparative analysis of these two lesions within a pediatric cohort, this study aims to contribute additional clinical data to the field. Given that these two types of anterior maxillary midline lesions occasionally overlap in clinical and radiological presentations, we hope that these comparative findings will provide valuable references for clinicians in evaluating, differentiating, and managing similar pediatric cases.

Median palatine cysts (MPCs) and nasopalatine duct cysts (NPDCs) have no special symptoms in the early stage and are mostly discovered accidentally during routine physical examination or oral examination. As the cyst increases in size and protrudes into the nasal cavity, it can cause nasal congestion and numbness. After infection, swelling and pain in the hard palate may occur [3, 4, 9]. The imaging manifestations of the two are also very similar, with round or oval soft tissue density shadows. Although the two patients in this article had similar clinical manifestations, the postoperative pathological results showed that there were significant differences in the composition of the cyst wall between the two, thus confirming the diagnosis.

The asymptomatic presentation of oral and maxillofacial cysts in their early stages often delays diagnosis and treatment, leading to aggressive growth of the cyst and destruction of adjacent anatomical structures (such as the maxillary sinus and mandibular nerve) [21–23]. These factors can also have adverse aesthetic and functional effects on maxillofacial and dental structures [24]. For instance, NPDCs are frequently misdiagnosed as periapical lesions in clinical practice, potentially leading to inappropriate endodontic treatment or even unnecessary tooth extraction, while the pathological condition remains unresolved [25, 26]. Therefore, accurate diagnosis and appropriate treatment strategies are very important to reduce the risk of misdiagnosis, inappropriate treatment, and complications.

The management of cysts in the anterior midline region of the maxilla is determined by their etiology and anatomical location, with the primary goals being complete eradication of the lesion, maximal preservation of functional structures, and prevention of recurrence or malignant transformation. The preferred treatment for NPDCs is surgical excision and curettage, and the specific surgical approach depends on the size and location of the cyst (palatal or labial) [9]. Nasopalatine duct cysts carry a potential for malignant transformation. Traditional treatment usually involves complete resection of the lesion via a transpalatal or nasal vestibule approach [27, 28]. In current reports, most NPDCs are managed by surgical excision, and common postoperative complications include: nasal floor perforation, oronasal communication, fistula formation, adjacent dentition damage, infection, hemorrhage, and paresthesia in the anterior palatal region [12, 29, 30]. A case report described successful treatment of an NPDC using unilateral transnasal endoscopic marsupialization, demonstrating that endoscopic marsupialization can effectively reduce the risk of oronasal fistula formation [31]. The recurrence rate for NPDCs is relatively low, about 2% to 11% [11]. The surgical treatment of MPCs has gone through three stages: the combined palatal and upper labial sulcus approach, the upper labial sulcus approach alone, and the endoscopic fenestration technique [32]. In recent years, with the advancement of endoscopic techniques, endoscopic-guided fenestration and drainage has emerged as the predominant treatment modality. This transnasal approach emphasizes maintaining surgical cavity patency, effectively avoiding damage to adjacent critical structures caused by complete cyst removal, effectively reducing cyst recurrence, improving the quality of life of patients, and shortening the healing time [13, 19, 31, 33, 34]. Although procedures such as cyst enucleation, marsupialization, and traditional resections via transpalatal or upper labial sulcus approaches possess definitive clinical efficacy, conventional open surgeries are associated with greater surgical trauma and carry the risk of inducing severe postoperative complications such as dental root damage, paresthesia of the anterior palate, and oronasal fistula formation. In contrast, endoscope-assisted surgery appears to offer potential advantages in preserving local nerves and blood vessels, maintaining anatomical integrity, and potentially minimizing the aforementioned complications [13, 19, 31]. The minimally invasive benefits of the endoscopic approach are particularly prominent when managing large lesions with a pronounced mass effect. For instance, one NPDC patient in this study presented with a massive lesion measuring approximately 4.3 × 2.4 × 3.5 cm³, exhibiting a pronounced mass effect. For such cases, the endoscopic endonasal approach not only facilitates adequate exposure and complete removal of the lesion but also maximally prevents the structural damage to the hard palate and anterior dentition region associated with traditional extensive resections. Consequently, based on a comprehensive consideration of minimizing complication risks, reducing surgical trauma, and optimizing postoperative outcomes, all cases in this group ultimately opted for endoscope-assisted surgical approach.

In this report, as the main portion of the cysts in both cases was located closer to the nasal cavity, the surgery was performed via an endoscopic endonasal nasal floor approach, with the incision extending laterally from the inferior aspect of the nasal septum. The procedure was initiated with fenestration and unroofing of the cyst to achieve adequate exposure of the cystic cavity. Subsequently, under the guidance of the preoperative maxillary CT-defined lesion extent, low-temperature plasma radiofrequency ablation (LTP-RFA) was used for ablation and excision of the residual cyst wall. The application of LTP-RFA facilitated surgical margin control and intraoperative hemostasis while enabling effective removal of cystic tissue, thereby potentially reducing the risk of postoperative recurrence. No complex local flap reconstruction was required postoperatively, and the surgical wound was allowed to heal naturally. During the two-year postoperative follow-up, neither case showed cyst recurrence. Endoscopic fenestration may be a promising option for potentially reducing complications such as oroantral fistula formation and dental root injury [13, 31, 35]. Literature indicates that low-temperature plasma radiofrequency ablation (LTP-RFA) offers the technical advantages of minimal tissue damage and excellent local hemostasis in minimally invasive surgery [36, 37]. In the two cases reported in this study, the application of LTP-RFA as an adjunct to endoscopic surgery proceeded smoothly, with minimal intraoperative blood loss, and both patients recovered well in the early postoperative period without any significant complications. These preliminary clinical observations suggest that this combined technique appears feasible and may be a promising option for our group of pediatric patients. However, its long-term recurrence rates and definitive advantages over conventional surgical modalities still require validation in larger cohorts through future large-scale, long-term, prospective comparative studies.

In addition, children are still in the growth and development stage. Since nasopalatine cysts grow expansively and compress the surrounding bone, if they are discovered late, they may have a potential impact on the development of teeth, the nasal cavity, and the maxillofacial area. Therefore, they should be of greater concern to otolaryngologists and dentists. The effect of nasopalatine cysts on children’s teeth depends mainly on the size and location of the cyst. Nasopalatine cysts are usually located near the midline of the maxilla, close to the central incisors. When they grow, they will occupy the space in the midline of the maxilla, pushing or compressing the surrounding teeth, causing the teeth to displace, tilt, and even become loose. Not only that, but cysts may also interfere with the normal development of permanent teeth, resulting in delayed or abnormal eruption of permanent teeth. Recently, some scholars reported an NPDC in an 11-year-old child. Due to the large size of the cyst, severe bone loss caused by its expansion led to the loss of support of the incisor bones and even the distal displacement of the incisor root, which in turn severely affected the development of the central incisors, suggesting that NPDCs in children can lead to maxillary deformity [38]. Similarly, case 2 in this article had a long course of disease, a large cyst, and displacement of the root of the incisor (Fig. 5). In addition to the impact on the development of dentition, the impact of nasopalatine cysts on children’s nasal development and sleep cannot be ignored: as the cysts continue to grow, the bottom of the nasal cavity and nasal septum are compressed and deformed, resulting in partial or complete obstruction of the nasal cavity or deviation of the nasal septum, causing poor ventilation [39]. Patients are prone to symptoms such as nasal congestion, snoring, mouth breathing, and poor sleep quality. Not only that, but the expansile growth of cysts and bone destruction may cause irreversible damage or even deformity to the hard palate and nasal floor. Because early symptoms of such lesions are not obvious and children’s teeth and maxillofacial region are still in the developmental stage, regular oral and otolaryngological examinations are important. Nasopalatine cysts are usually removed surgically, having a good prognosis and are less likely to recur. However, larger nasopalatine cysts are more likely to develop oronasal fistula after surgery [14]. Therefore, early diagnosis and early treatment are very important. Most children can return to normal tooth development and oral function after surgery. At the same time, doctors and family members should pay attention to post-operative care and orthodontic treatment of cysts to prevent subsequent adverse effects.

Although NPDC and MPC are widely documented in adults, pediatric cases remain relatively limited [38, 40]. Furthermore, there is a significant disparity in the number of reports between these two cysts, with NPDC being reported far more frequently than MPC. Based on the present cases and a review of the literature, we summarize a systematic diagnostic framework and several key clinical considerations for pediatric practice regarding these lesions. First, unlike adult patients, who often present with localized swelling or pain, pediatric patients are often asymptomatic in the early stages [10]. Routine CT imaging performed before orthodontic treatment may therefore provide an important opportunity for early detection of such lesions, which is consistent with the clinical presentations of our cases. When a well-defined radiolucent lesion is incidentally detected in the anterior midline region of the maxilla on imaging, clinicians should maintain a high index of suspicion for non-odontogenic developmental cysts such as NPDC or MPC. Second, CT imaging not only aids in the preliminary identification of the anatomical origin of the lesion by evaluating its spatial relationship with the incisive canal, nasal floor, and palatal bone, but also provides important guidance for determining lesion extent and surgical planning. In particular, accurate assessment of the anatomical distance between the lesion and adjacent developing permanent teeth can help surgeons achieve complete lesion removal while better preserving the developing dentition and maxillofacial skeletal structures in pediatric patients. In earlier reports, traditional open surgical excision via a sublabial or palatal approach was considered the mainstream treatment method [27, 32]. However, in pediatric patients, preservation of the developing maxillofacial structures and dentition is the primary concern. The endoscopic endonasal approach utilized in this report provides excellent illumination and a magnified field of view, allowing clear exposure of the lesion and enabling more precise cyst excision, thereby reducing injury to the surrounding tissues. In addition, the application of LTP-RFA provides effective hemostasis and aids in surgical margin control, facilitating thorough removal of cystic tissue and thereby helping to reduce the risk of postoperative recurrence [36, 37]. Based on the preliminary experience from these two cases, this minimally invasive strategy combining endoscopic surgery with LTP-RFA appears to be a feasible and promising treatment option for such lesions in pediatric patients. Nevertheless, histopathological evaluation remains essential for accurate diagnosis, and the long-term efficacy of this surgical strategy still requires validation in larger cohort studies. Finally, in terms of definitive histopathological classification, the epithelial lining types of the two cysts may exhibit histological overlap, which likely stems from their similar embryological origins [15, 17]. Therefore, epithelial features should not be used as independent diagnostic criteria. The key distinction between the two lesions lies in the characteristic components within the cyst wall. Because NPDC originates from remnants of the nasopalatine duct, its cyst wall commonly contains one or more accessory structures, including blood vessels, nerves, mucous glands, minor salivary glands, or even hyaline cartilage islands. Conversely, MPC, as a developmental cyst of non-ductal origin, usually presents a relatively simple cyst wall that characteristically lacks these specific components (Table 1). Therefore, although the epithelial phenotypes may be similar, differences in anatomical location and subtle variations in cyst wall composition may provide valuable references for clinically distinguishing between these two phenotypes.

Table 1.

Differential diagnosis between Median Palatine Cyst (MPC) and Nasopalatine Duct Cyst (NPDC)

Features	Median palatine cyst (MPC)	Nasopalatine duct cyst (NPDC)
Origin	Epithelial remnants entrapped during embryonic palatal fusion	Epithelial remnant tissue of the nasopalatine duct
Relationship to the Palatine Papilla	behind the palatine papilla	in front of the palatine papilla
Anatomical Location	Symmetrically distributed along the midline of the hard palate; no communication with the incisive canal	Distributed along the midline of the palate or on one side of it; associated with the incisive canal
Radiographic Features	Round or oval radiolucency	Round, oval, or characteristic heart-shaped radiolucency
Histopathology of the Cyst Wall	Absence of large nerve trunks, blood vessels, hyaline cartilage, or salivary gland tissue	the cyst wall has one or more of the following histopathological features: blood vessels, nerves, mucous glands, salivary glands, hyaline cartilage islands

Limitations

This study has certain limitations. First and foremost, the major limitations are the small sample size (n = 2) and the retrospective nature of this report, which inevitably limit the generalizability of our findings. Second, because the pediatric patients initially presented to the otolaryngology head and neck surgery department, specialized dental examinations such as dental vitality testing, formal orthodontic evaluation, and complementary dental examinations were not conducted during the initial clinical assessment, despite their significant diagnostic reference value. We acknowledge this as a limitation in the clinical awareness of pediatric otolaryngologists during the diagnostic and therapeutic process. Accordingly, we carefully evaluated the preoperative high-resolution CT images to help exclude an odontogenic etiology. The imaging finding showed that the lesion was located in the anterior midline region of the maxilla, with a clear and intact bony separation between the lesion margin and the root apices of the adjacent incisors. No widening of the periodontal ligament space or typical signs of periapical bone destruction were observed. Ultimately, histopathological examination of the cyst wall revealed no odontogenic epithelial components, thereby ruling out odontogenic lesions and establishing the definitive diagnosis. In retrospect, we believe that a multidisciplinary team (MDT) approach involving both otolaryngology and stomatology is particularly important in the management of anterior palatal cystic lesions. A more comprehensive clinical evaluation may further reduce the risk of misdiagnosis or overlooked lesions. Third, there is a lack of a comparator group in this study, precluding a direct comparison between the endoscopic endonasal approach and traditional open surgical techniques (such as the upper labial sulcus approach). Although our preliminary clinical observations suggest that the endoscopic technique appears feasible and may be a promising option for these pediatric patients, current evidence remains insufficient to draw generalized conclusions regarding its absolute superiority over traditional modalities. These preliminary findings require validation in larger cohorts, and future large-sample, prospective controlled studies are still needed to further establish the long-term clinical advantages and definitive recurrence rates of the endoscopic approach.

Conclusion

Endoscopic management appears to be a feasible minimally invasive option. However, its application should not be generalized; surgeons must consider the three-dimensional anatomical characteristics of the lesion and its adjacent relationships, strictly adhering to appropriate surgical indications. Furthermore, histopathological evaluation remains essential for accurate diagnosis and the differentiation of NPDCs from MPCs, particularly through the detection of characteristic nerves, blood vessels, and minor salivary glands within the cyst wall. Given the complexity of disease classification within this anatomical junction region, a multidisciplinary team (MDT) approach involving otolaryngology head and neck surgery and dental specialties may be beneficial to optimize preoperative assessment and individualized therapeutic strategies. Finally, larger studies are required to validate these clinical observations.

Abbreviations

MPC

Median palatine cyst

NPDC

Nasopalatine duct cyst

CT

Computed tomography

WHO

World Health Organization

LTP-RA

Low-temperature plasma radiofrequency ablation

MDT

Multidisciplinary team

H&E

Hematoxylin and Eosin

Authors’contributions

WXP was responsible for formulating writing ideas and writing the manuscript. WJ, LC, WPP and XX were responsible for collecting information. GWT and HY were responsible for revising the manuscript and guiding the writing of the manuscript. Each author has made an important scientific contribution to the study and is thoroughly familiar with the primary data. All authors approved the version to be published and all agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

This work was supported by Capital’s Funds for Health Improvement and Research (2024-2-2098), Respiratory Research Project of National Clinical Research Center for Respiratory Diseases (HXZX-202109), Capital’s Funds for Health Improvement and Research (2024-1-2093), Beijing Natural Science Foundation (7242052), Training Fund for Open Projects at Clinical Institutes and Departments of Capital Medical University (CCMU2023ZKYXY001).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Beijing Children’s Hospital affiliated with Capital Medical University and the committee’s reference number is [2025-E-003-R]. All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from the parents of the patients for publication of this case report.

Consent for publication

Written informed consent was obtained from the child’s parents for publication of this case report and accompanying images.

Competing interests

The authors declare no competing interests.