Indian J Otolaryngol Head Neck Surg

(Oct–Dec 2013) 65(4):385–388; DOI 10.1007/s12070-011-0242-6

CLINICAL REPORT

Nasopalatine Duct Cyst: Report of a Case with Review

of Literature
S. Shylaja • K. Balaji • A. Krishna

Received: 1 January 2010 / Accepted: 13 June 2010 / Published online: 11 April 2011
Ó Association of Otolaryngologists of India 2011

Abstract The nasopalatine duct cyst is the most common palatal aspect in midline of maxilla; above the retroincisor
non-odontogenic developmental cysts. Nasopalatine duct palatal papilla. During fetal development the ducts gradu-
cyst also termed as incisive canal cyst, arises from ally narrow until 1 or 2 central clefts are finally formed on
embryologic remnants of nasopalatine duct. Most of these the midline of the upper maxilla. The nasopalatine neuro-
cysts develop in the midline of anterior maxilla near the vascular bundle is located within the duct, and emerges
incisive foramen. This article reports a case and review of from its intrabony trajectory through the nasopalatine
literature with respect to epidemiology, etiology, clinical foramen. There can be as many as six different foramina,
presentation, radiographic and pathological findings, though there are usually only two, with independent neu-
treatment and recurrence rates. rovascular bundles (right and left) the vascular and neural
elements can emerge separately; in this sense, foramina
Keywords Nasopalatine duct cyst
Non-odontogenic containing exclusively vascular elements are known as
cyst
Incisive canal cyst
Median palatine cyst Scarpa’s Foramina (Figs. 1, 2) [1].
The nasopalatine duct cyst (NPDC) was first described
by Meyer in 1914 [2]. It is also know by other names
Introduction such as anterior midline cyst, maxillary midline cyst,
anterior middle palatine cyst, and incisive duct cyst were
The nasopalatine ducts communicates with the nasal cavity regarded as fissural cyst in the past [3]. At present
in the anterior region of the maxilla. It is located on the according to the classification of the World Health
Organization (WHO) it is regarded as developmental,
epithelial, non-odontogenic cysts of the maxilla along
S. Shylaja
with nasolabial cysts. It is considered to be the most
Department of Oral & Maxillofacial Pathology,
SVS Institute of Dental Sciences, Mahabubnagar, common of the non-odontogenic cysts, occurring in about
Hyderabad, Andhra Pradesh, India 1% of the population. The majority of cases occur
between 4th and 6th decade of life. It is slightly more
K. Balaji
common in males than in females. These cysts are usually
Department of Pedodontics & Preventive Dentistry,
SVS Institute of Dental Sciences, Mahabubnagar, asymptomatic. On occasion, they may present as soft
Hyderabad, Andhra Pradesh, India tissue mass (Figs. 3, 4, 5) [1].

A. Krishna
Department of Oral & Maxillofacial Pathology,
SVS Institute of Dental Sciences, Mahabubnagar, Case Report
Hyderabad, Andhra Pradesh, India
The case presented here is that of a 36 year old woman
S. Shylaja (&)
with a swelling in the anterior part of the palate for past
MIG 276, 4th Road, KPHB Colony, Kukatpally,
Hyderabad 500 072, Andhra Pradesh, India 6 months. The swelling gradually increased to the present
e-mail: [email protected] size. Extra orally no abnormality was detected.

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Fig. 3 Post-surgical photograph showing cystic cavity

Fig. 1 Radiograph showing well-defined round radiolucent area

between the roots of maxillary central incisors

Fig. 4 Photomicrograph of H&E stained section showing well-

defined cystic lumen lined by pseudostratified ciliated columnar
epithelium along with mucous glands in the CT wall (04 9 10). Inset
showing photomicrographic high-power view of pseudostratified
ciliated columnar epithelium (40 9 10)

Fig. 2 Surgical picture showing the cystic area in the anterior part of
the palate

Intra oral examination revealed a well defined swelling

approximately 20 mm 9 30 mm located posterior to the
palatine papilla. On palpation the swelling was fluctuant
and non tender. Occlusal radiograph showed well circum- Fig. 5 Photomicrograph of H&E stained section showing neurovas-
scribed oval shaped radiolucency in the midline of anterior cular elements in the deeper areas of CT (10 9 10)
maxilla between the roots of central incisors. No evidence
of resorption of the tooth roots. On the basis of clinical and Histopathological Examination
radiographic evidence a provisional diagnosis of Nasopal-
atine duct cyst was made. The specimen was excised under Microscopic examination revealed fibrous wall lined by
local anesthesia adapting the usual palatal approach and pseudostratified ciliated columnar epithelium and partly by
sent for histopathological examination fixed in 10% stratified squamous epithelium. Few nerve bundles, blood
formalin. vessels and mucous cells were seen in the cyst wall.

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Discussion discharge with a salty taste. Displacement of teeth is a rare

finding [1].
The NPDC is the most common developmental, non-neo- Radiographically it appears as a round or ovoid radio-
plastic, non-odontogenic cysts of the oral cavity, occurring lucency between the roots of the central incisors. Due to
in about 1% of population [1]. They are believed to superimposition of the nasal spine, a heart shaped
develop from remnants of paired embryonic nasopalatine appearance may be seen. Most of the lesions have a well
ducts [3]. NPDC is one of the many pathologic processes defined sclerotic border [1, 5]. In some individuals, a
that may occur within the jaw bones, but is unique in that it prominent incisive canal can appear as a radiolucent area
develops in only a single location, which is the midline of and mimic NPDC. Most authors agree that 6 mm should
the anterior maxilla [4]. It can arise at any age, but is seen be considered the upper limit for normal incisive canal
most often in patients between 30 and 60 years of age [2, radiolucencies larger than this should be considered
5] though there have been reports of NPDCS in pediatric potentially pathologic and merit further investigation [1].
patients up to 8 years of age [1]. It is slightly more com- The differential diagnosis should be established with the
mon in males than in females; the ratio being 3:1 which following conditions:
could be because women typically seek dental help sooner Odontogenic cysts (e.g., lateral radicular cyst, lateral
than men [2]. Due to a lack of representative studies, it is periodontal cyst, odontogenic keratocyst).
not fully clear whether NPDCS are more common in Odontogenic tumors (e.g., ameloblastoma, odontogenic
Caucasians, Negroes or Asians [6]. myxoma).
Nasopalatine ducts ordinarily undergoes progressive Non-odontogenic tumors (e.g., central giant tumor, brown
degeneration however, the persistence of the epithelial tumor of hyperparathyroidism, central hemangioma) [1].
remnants may later become the source of epithelia that gives A through differential diagnosis must be established in
rise to NPDC, from either spontaneous proliferation [7] or order to avoid unnecessary treatments such as endodontic
proliferation following trauma(e.g. removable dentures), procedures in vital permanent upper central incisors [5]. A
bacterial infection or mucous retention [6]. Genetic factors correct tentative diagnosis should be based on positive
have also been suggested [1, 5]. The mucous glands present dental vitality testing and negative percussion findings of
among the proliferating epithelium can contribute to sec- the permanent upper central incisors provided these teeth
ondary cyst formation by secreting mucin within the do not have pulp or periodontal problems. Radiological
enclosed structure [8]. The etiology is not clear, though in exploration is essential for diagnosing NPDCs, and in
addition to the hypothesis of spontaneous proliferation from addition o panoramic X-rays, other complimentary tech-
embryonic tissue remains. However few authors consider an niques are advised, such as periapical and occlusal radio-
unknown etiology or spontaneous proliferation to be the graphs and computed tomography. The latter technique
most plausible explanation, based on studies reporting cystic offers maximum guarantees in establishing a tentative
degeneration phenomena in the incisal duct and on the diagnosis, since it generates a great detail of the structures
midline of the palate in human fetuses, in which the above (normally intact) adjacent to the lesion [1].
mentioned circumstances are unable to have occurred [1]. Histopathological examination reveals a cavity lined by
There have even been exceptional reports such as the epithelium and surrounded by connective tissue wall. A
casual diagnosis of NPDC 9 months after rapid surgical reported 71.8% of NPDCs have squamous, columnar,
palatal expansion or NPDC associated to the presence of cuboidal or some combination of these epithelial types;
two bilateral mesiodens [1]. NPDC can form within the respiratory epithelium is seen in 9.8% [5]. The type of
incisive canal which is located in the palatine bone and epithelia that line the nasopalatine duct is highly variable,
behind the alveolar process of the maxillary central inci- depending upon the relative proximity of the nasal and oral
sors, or in the soft tissue of the palate that overlies the cavities. The most superior part of the duct is characterized
foramen, called the cyst of the incisive papilla [5]. by a respiratory type of epithelial lining and moving
These cysts are usually asymptomatic and discovered on downwards the lining changes to cuboidal epithelium. In
routine radiographs. The most common presenting symp- the most inferior portion closest to the oral cavity, squa-
toms are swelling of the anterior palate, drainage and pain. mous epithelium is the usual type [1].
Rarely a large cyst may produce a ‘‘through-and-through’’ The cyst wall may contain a chronic inflammatory reac-
fluctuant expansion involving the anterior palate and labial tion consisting of lymphocytes and plasma cells. Also
mucosa. If the cyst is near the surface the swelling will be helpful in the diagnosis of NPDC are the presence of neu-
fluctuant with a bluish hue. Deeper cysts are covered by rovascular bundles, mucous glands and adipose tissue [1].
normal mucosa, unless it is ulcerated. Burning sensation The hypekeratotic feature noted in Odontogenic Kera-
and numbness may be experienced due to pressure on the tocyst can also be found in NPDC and is associated with a
nasopalatine nerve. Occasionally they cause intermittent poorer prognosis, since the relapse rate is higher (close to

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30%) [9]. Squamous cell carcinomas originating in max- References

illary bone are mainly due to the metaplasia experienced by
the epitheial wall of a cyst or of the epithelial remains that 1. Francoli JS, Marques NA, Aytis LB, Escoda CG (2008) Naso-
palatine duct: report of 22 cases and review of literature. Med
participate in odontogenesis therefore there are cases in Oral Patol Oral Cir Bucal 13(7):E438–E443
which NPDC gives rise to squamous cell carcinoma in the 2. Vasconcelos R, De Aguair MF, Castrow De, Araujo VC, Mesq-
anterior zone of the upper maxilla [10]. uita R (1999) Retrospective analysis of 31 cases of nasopalatine
The treatment of choice is surgical excision of the cyst, duct cyst. Oral Dis 5(1):325–328
3. Robertson H, Palacios E (2004) Nasopalatine duct cyst. Ear Nose
although some authors propose marsupalization of large Throat J 83(5):313
cysts. The neurovascular bundle is a delicate and highly 4. Kly N, Sheehy EC, Mc Donald F (2001) Nasopalatine duct cyst: a
vascularized structure giving rise to profuse bleeding if case report. Int J Paediatr Dent 11(2):135–137
inadvertently sectioned during surgery. Electrocoagulation 5. Gnanasekhar JD, Walvekar SV, Al-kandari AM, Al-Duwairi Y
(1995) Misdiagnosis and mismanagement of nasopalatine duct
is required in such cases. In squamous cell carcinoma cyst and its corrective therapy. A case report. Oral Surg Oral Med
radical en block resection of the anterior region of upper Oral Pathol Oral Radiol Endod 80(1):465–470
maxilla is required [1]. 6. Swanson KS, Kaugars GE, Gunsolley JC (1991) Nasopalatine
duct cyst: an analysis of 334 cases. J Oral Maxillofac Surg
49(3):268–271
7. Mermer Rw, Rider CA, Cleveland DB (1995) Nasopalatine duct
Conclusion cyst: a rare sequelae of surgical rapid palatal expansion. Oral
Surg Oral Med Oral Pathol Oral Radiol Endodon 80(6):620
NPDC occurs in approximately 1% of the population. 8. Regezi JA, Sciubba JJ, Jordan RCK (2003) Oral pathology:
clinical pathology correlations. Saunders, St. Louis, pp 256–257
Presentation may be asymptomatic or include swelling, 9. Yih WY, Krump JL (2005) Odontogenic keratocyst in the
pain and drainage from the hard palate. A well circum- nasopalatine duct associated with mural cartilaginous metaplasia.
scribed, round, ovoid or heart shaped radiolucency is seen J Oral Maxillofac Surg 63(9):1382–1384
on radiograph. Histopathological findings reveal squamous 10. Takagi R, Ohashi Y, Suzuki M (1996) Squamous cell carcinoma
in the maxilla probably originating from Nasopalatine duct cyst:
or respiratory cell types, or a combination of these, infil- report of case. J Oral Maxillofac Surg 54(1):112–115
trated by inflammatory cells. Enucleation is the preferred
treatment with low recurrence rate.

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