Klestadt's cyst

Abstract

The nasolabial cyst is a rare nonodontogenic cyst originating in maxillofacial soft tissues. In the previous reports and literature, it is mentioned that nasolabial cyst clinical features of an asymptomatic swelling beneath the ala of nose and characteristic lip swelling are diagnostic. This is a case report of a 36-year-old male, who reported to our department with the chief complaint of swelling lateral to right ala of nose since 4 months. Characteristic lip swelling was missing. The reason for this unusual finding is not documented in the literature.

INTRODUCTION

The nasolabial cyst is a rare nonodontogenic cyst originating in maxillofacial soft tissues.[1] It was first described in 1882 by Zuckerkandl.[2] Earlier, the cyst was referred by many names, e.g., nasoalveolar cyst, nasal vestibule cyst, nasal wing cyst, and mucoid cyst of the nose.[3] Rao revised the nomenclature and defined nasolabial cysts as lesions located entirely within soft tissue, different from nasoalveolar cysts, which cause maxillary bone erosion.[4]

Previous reports suggest an adult onset, higher incidence among women and preponderance on left side.[5] It usually presents as an asymptomatic swelling beneath the ala of nose.[6] In the previous reports and literature, it was mentioned that nasolabial cyst clinical features of an asymptomatic swelling beneath the ala of nose and characteristic lip swelling are diagnostic.

However, this case report describes a 36-year-old male, who reported to our department with the chief complaint of swelling lateral to right ala of nose since 4 months.

CASE REPORT

A 36-year-old male patient, reported to our department with the chief complaint of swelling lateral to right ala of nose since 4 months. Swelling was progressively increasing in size. There was mild pain and associated white watery discharge intraorally from the swelling on pressure application. Patient gave no history of trauma, previous infections, or surgery.

Extra oral examination revealed an ovoid swelling measuring 4 × 3 cm, lateral to right ala of nose [Figure 1]. Swelling was soft, fluctuant, movable with diffuse margins with slight local rise in temperature. Overlying skin was smooth. Intraorally, the swelling was soft, extending from canine to first molar and overlying mucosa was normal. There was no associated discharge. All the associated teeth were vital.

Figure 1.

Clinical picture.

Radiographic investigations included OPG [Figure 2] and Water's view [Figure 3] which revealed no significant findings. On aspiration, a straw colored fluid was present.

Figure 2.

OPG.

Figure 3.

Water's view.

Differential diagnosis included canine Space infections, salivary gland cyst and tumors, lipoma, epidermoid inclusion cysts and sebaceous cysts.

Microscopic examination [Figure 4] revealed epithelial lining of varied thickness showing cuboidal to polyhedral cells arranged in a stratified manner. Goblet cells and mucous cells could be seen. Connective tissue just beneath the epithelium showed hemorrhagic areas. Enucleation of the cyst was done.

Figure 4.

Microscopic picture at 10X and 45X magnification showing epithelial lining and capsule

DISCUSSION

Nasolabial cysts represent about 0.7% of all cysts in the maxillofacial region,[8] and 2.5% of non odontogenic cysts.[1] Many authors believe that its prevalence is actually higher than presented in the literature; however, due to misdiagnosis, indexes remain low.[1]

Nasolabial cysts are usually unilateral, but bilateral cases have been also reported. Swelling in this case was also unilateral. There is a sex predilection of incidence in females (3.7:1) and age predilection in 2^nd to 7^th decade though it frequently occurs during middle age.[1] This case report was present in a male of 36 years of age.

Pathogenesis of nasolabial cyst is still uncertain. Two main theories of pathogenesis have been proposed. Some authors suggest that lesion arises from misplaced epithelium of nasolacrimal rod or duct remnants and others suggest that it is a fissural cyst arising from epithelial remnants entrapped in the developmental fissures between the lateral nasal, globular, and maxillary processes.[2] Because of the location of the cyst in this case, the second theory seems to be more acceptable. The case report also suggests that there may be some unknown pathogenetic basis.

Extraorally, patients usually complain of a swelling adjacent to the nose, and sometimes the cyst may be observed on routine examination. Intraorally, swelling is usually present in the maxillary labial sulcus but may reach great dimensions and extend to the buccal sulcus, causing discomfort with the use of dentures, breathing obstruction and facial asymmetry.[1] Swelling in this case was present little posterior to usual findings. Characteristic lip swelling was missing. The reason for this unusual finding is not documented in literature.

Cyst lies in soft tissues with usually no radiographic findings, but it can sometimes cause erosion of the underlying maxillary bone which may be observed in radiographic examination. Because nasolabial cyst is a soft-tissue mass, MR imaging is most helpful for a differential diagnosis.[7] Radiographic investigations (OPG, Water's view) revealed no significant findings.

Histologically, the cyst may be lined by pseudostratified columnar epithelium which is sometimes ciliated often with goblet cells and mucous cells, or by stratified squamous epithelium.[9] The lining in this case was also stratified squamous with goblet cells and mucous cells.

Treatment of choice is enucleation which has low recurrence rate.[2] The cyst in this case was also enucleated with no recurrence.

This case is unique in that respect as none of the earlier case report has mentioned a similar location of the entity. The unusual location in this case imply that nasolabial cyst may manifest in a location different from its common position beneath the ala of nasi or some unrecognized entity exists in a lateral location with features similar to nasolabial cyst.