Almutairi et al.

BMC Surgery (2020) 20:10

https://doi.org/10.1186/s12893-020-0677-3

CASE REPORT Open Access

Nasolabial cyst: case report and review of

management options
Abdulhakeem Almutairi1, Abeer Alaglan2, Mazyad Alenezi1,3* , Sultan Alanazy1 and Osama Al-Wutayd4

Abstract
Background: Nasolabial cysts are rare, non-odontogenic, soft-tissue cysts that develop between the upper lip and
nasal vestibule with an overall incidence of 0.7% out of all maxillofacial cysts. The predominant presentation of a
nasolabial cyst is a painless localized swelling with varying degrees of nasal obstruction. Several treatment
modalities have described in the management of the nasolabial cyst. In this paper, we present a case of a
nasolabial cyst in a 44 years old man with discussions of the treatment modalities in the lights of the literature.
Case presentation: We present a case of a nasolabial cyst in a 44-year-old man that slowly increased in size
through a period of 3 years, with associated mild pain and nasal obstruction. It had caused a mass effect upon the
maxilla, resulting in scalloping. The cyst was excised entirely with no evidence of recurrence at the two months
follow up.
Conclusions: The nasolabial cyst is a rare soft-tissue cyst. Complete surgical excision using an open approach
performed to our case, which considered with the complete endoscopic removal of the best treatment for the
nasolabial cysts with a rare recurrence rate.
Keywords: Nasolabial, Cyst, Maxillofacial cyst, Otorhinolaryngology

Background painless localized swelling with varying degrees of nasal

Nasolabial cysts are rare soft tissue non-odontogenic cysts obstruction [6]. The location and presentation of these
that develop between the nasal vestibule and upper lip [1]. cysts make them diagnosis nearly clinical exclusively. The
The incidence of nasolabial cysts is 0.7% of all maxillofacial diagnosis tests include nasal scope, CT and MRI. Both CT
cysts. The size measures 1 to 5 cm in diameter [2]. These and MRI are valuable in revealing the origin of the cysts
cysts in 90% of cases are unilateral, and 10% bilateral, they and avoids unnecessary needle aspiration or dental surgery
are commonly seen in the black women in the fourth to [7, 8]. Surgery is equally diagnostic and curative by allowing
fifth decades of life [3]. Zuckerkandl was the first to de- histological examination [9]. In this paper, we present a
scribe the cyst in 1882. It is not uncommon to misdiagnose case of a nasolabial cyst in a 44 years old man.
nasolabial cysts and not treat them appropriately because of
their rarity [4]. The pathogenesis is uncertain with multiple Case presentation
theories. In 1920 Bruggemann proposed the most accept- A 44 years old medically free male began to complain of a
able theory, which suggests that the nasolabial cyst arises right nasal swelling three years ago. It has fluctuated in
from the remnants of the epithelium in the anterior lower size in the previous three years. Recently, it started to
part of the nasolacrimal duct [5]. The origin of the cyst is slowly increase in size with associated mild pain and nasal
developmental, although it does not manifest until adult- obstruction. The patient denied any history of medical dis-
hood, and the typical presentation of a nasolabial cyst is a ease, history of trauma or surgery.
On examination: There was a right nasolabial mass,
* Correspondence: [email protected] 3 × 4 cm, round fluctuating, no discharge, or overlying
1
Department of Otolaryngology, Head and Neck Surgery, Qassim University, skin change (Fig. 1).
Buraydah, Saudi Arabia There was mild tenderness on palpation. The endo-
3
College of Medicine, Qassim University, P.O. Box 6655, Buraidah, Qassim
51452, Saudi Arabia scopic examination showed a mass obstructing most of
Full list of author information is available at the end of the article the right nasal aperture (Fig. 2).
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Almutairi et al. BMC Surgery (2020) 20:10 Page 2 of 6

extraosseous cystic swelling superficial to the anterior

wall of maxilla. The cysts were excised entirely with no
attachment to the underlying bone and were firmly ad-
herent to the floor of the nasal cavity in the mucocuta-
neous junction region. Part of the skin and mucosa
removed in the right nasal cavity as it was part of the
cyst wall. Dead space was packed by iodinated gauze and
removed from the nose after 24 h. The wound closed by
3–0 Vicryl. The histopathological examination showed
respiratory epithelium (ciliated pseudostratified colum-
nar) with goblet cells compatible with nasolabial cysts.
Postoperatively, the patient had mild facial edema with
numbness over the right upper lip and teeth. He was
seen after two weeks to remove stitches and intranasal
cavity wound healed well. Edema had subsided by then,
while the patient still reported numbness in the right
upper lip and teeth. Two months after surgery, he has
seen with an improvement of the previously reported
Fig. 1 Upon initial examination, the patient had a mass in the right numbness and fourteen months follow up showed no
nasolabial area with associated facial asymmetry. There was no recurrence of the mass (Fig. 5).
discharge or overlying skin change
There was no indication for radiological examination
as there were no complications or recurrence of the
CT scan done showed a right inferior nasal alar region lesion.
space-occupying lesion, measuring 3.2 × 2.2 × 2.5cm,
which exhibits isodense to hypodense texture. There was Discussion and conclusions
no enhancement or bone destruction. It was causing a The nasolabial cyst is a rare condition and accounts for
mass effect upon the maxilla, causing scalloping (Fig. 3). about 0.7% of all cases of maxillofacial cysts, and only
A final diagnosis of unilateral nasolabial cysts was 2.5% of the maxillofacial non-odontogenic cysts [4]. It’s
given based on the clinical and CT scan finding. So, no believed that its occurrence is more than that reported
further workup. The cyst excised by the sublabial ap- in the literature; though, indexes are limited owing to
proach (Fig. 4). high rates of misdiagnosis [6]. These cysts are unilateral
They were starting by upper gingivolabial sulcus inci- in 90% of cases and 10% bilateral. Unlike our case, they
sion below the piriform apertures. A round, smooth, are seen commonly in black women in the 4th to 5th
decades of life [3]. Their extra-osseous origin and loca-
tion recognize nasolabial cysts under the alae nasi [10].
It has been given multiple names since, including nasoal-
veolar and Klestadt cyst. Later, in 1951, the term nasola-
bial cyst was introduced by Rao [10]. This term has been
regarded as more accurate since the cysts are situated
wholly within soft tissue, unlike nasoalveolar cysts,
which typically cause a maxillary bone defect [3, 8]. It
has recognized because of the complex discussions of its
pathogenesis, as well as its characteristic clinical presen-
tation [11]. Bruggemann proposed the most acceptable
theory in 1920, which suggests that the nasolabial cyst
arises from the epithelial remnants of the lower anterior
part of the nasolacrimal duct [5]. Although the cyst is
developmental in origin, it typically does not manifest
until adulthood, which was the case in our patient [6].
Characteristically, a patient would present with painless
swelling, mostly in the left side of the upper lip adjacent
to the nasal alae, and very slow-growing nature [12].
Fig. 2 Endoscopy revealed a mass obstructing most of the right
These cysts vary in size from 1 cm to 5 cm, and infre-
nasal aperture
quently erode the underlying bone if they grow to a large
Almutairi et al. BMC Surgery (2020) 20:10 Page 3 of 6

Fig. 3 a, b: CT without contrast showing a right inferior nasal alar region mass measuring 3.2*2.2*2.5 cm exhibiting an isodense to hypodense
texture. There is a mass effect upon the maxilla causing scalloping. No bone destruction. c, d: CT with contrast showing no significant
enhancement within the mass

size [8]. The submucosal location of nasolabial cysts at the fold and the floor of the nasal vestibule, obliteration of the
anterior nasal floor is both distinctive and constant. It was nasolabial fold and elevation of the nasal alae [6, 7]. A well-
described by Bull et al. in 1967 as essentially pathogno- localized fluctuating swelling with a cystic consistency in
monic [13]. Arising from this location, the growth of the the nasolabial sulcus has been reported as a definitive sign
cysts can be possible in three directions: to the nasolabial of a nasolabial cyst by Graamans et al. [8]. In nearly 30% of
fold, the mouth vestibule, and the nasal vestibule [13]. Pa- patients, the initial presentation is an infection. In one series
tients with nasolabial cysts can be asymptomatic; however, done by Kuriloff, half of the patients developed an infection
most have at least one of the three key symptoms: partial [13]. Once infected, the cyst becomes painful and could
or complete nasal obstruction, well-circumscribed swelling, rupture spontaneously to drain into the oral cavity or nose
or localized pain [4]. Each of the key symptoms found in [14]. The presentation of nasolabial cysts is variable, pa-
our patient. The signs of the cysts are rather specific [7]. tients treated by several practitioners, including plastic
Comprising of a fluctuant swelling of the maxillary labial surgeons, otolaryngologists, and others [13]. The differential

Fig. 4 Intraoral approach to excise the nasolabial cyst through a sublabial incision in the upper buccal sulcus
Almutairi et al. BMC Surgery (2020) 20:10 Page 4 of 6

definite diagnosis can reach through histological examin-

ation [4, 7, 13]. Hence, resection of the cyst is both diag-
nostic and curative by allowing histological examination
[9]. Several modalities in the nasolabial cysts management
include endoscopic marsupialization, surgical excision, in-
cision and drainage, injection of sclerotic agents, simple
aspiration and cauterization. Excluding endoscopic marsu-
pialization and complete surgical excision, all the other
modalities have a high recurrence rate [8, 13]. Sheikh et al.
reviewed 79 articles with 311 patients with a nasolabial
cyst and reported no significant recurrence rate found
between the sublabial and transnasal marsupialization ex-
cision [18, 19]. Nearly in all published literature, complete
surgical excision described as the best treatment for the
nasolabial cyst [6, 13]. It is successful with rare recurrence
of the cyst [20]. The indications of surgery are, to establish
a diagnosis, prevent infection of the cyst, and to improve
any cosmetic deformity [13]. The commonest imple-
Fig. 5 Two months postoperatively, there is no facial edema and no mented approach is intraoral enucleation through local
signs of cyst recurrence anesthesia by a sublabial incision in the upper buccal
sulcus, which allows a surgical field to be wider and more
diagnosis of nasolabial cysts is made straightforward by guarantee of an excision completely without tearing the
their extraosseous location. The dentoalveolar abscess nasal mucosa or entering the maxillary sinus [5, 8, 9, 13].
is the most relevant differential, which can be excluded As nasolabial cysts situated near the nasal cavity floor,
easily by testing the affected teeth vitality [4, 14]. It also perforation of the mucosa during excision can happen.
includes the oronasal cysts, especially the commonest This complication is not uncommon, and once it occurs,
non-odontogenic maxillary cystic lesion, nasopalatine should be closed with sutures to avoid oronasal fistula for-
duct cyst [8]. Since, the nasolabial cyst is an extraoss- mation [7]. Some authors advocate that when small perfo-
eous soft tissue mass, and it can easily differentiate rations caused, they can be left untreated with gentle
from the nasopalatine duct cyst with the help of MRIs vestibule packing; however, they must be sutured the lar-
as the latter is an intraosseous cyst [15]. The nasolabial ger one [6, 13]. They are other complications like wound
cyst should be differentiated from dermoid and epi- infection, soft-tissue swelling, and hematoma [21]. In
dermoid cysts, as the color of the mucosa is yellow dis- 1999, an alternative described by Su et alin the means of
coloration, while in nasolabial cysts, the color of the endoscopic trans-nasal marsupialization, which is effective
mucosa is natural pink hue or like blue-tinged. Add- and simple [5]. It is assumed to be an easier approach for
itionally, epidermoid and dermoid cysts are typically in large lesions. Using this approach is especially advanta-
childhood, whereas nasolabial cysts more commonly geous when the cyst extends to the floor of the nose,
seen in an adult [7]. Other differential diagnoses in- which would increase the perforation risk and defects with
clude sebaceous cysts, as well as malignant or benign the conventional sublabial approach [22]. Endoscopic
salivary gland tumors [4]. To a lesser extent, the infec- marsupialization, when compared to the conventional
tion spread from the cysts can mimic acute maxillary incision, is rapid and can be done in an outpatient setting,
sinusitis, periodontal abscess, nasal furunculosis, or fa- with an operative time of approximately 15 min to
cial cellulitis [13]. The tests for diagnosis include nasal complete each procedure [23, 24]. Additionally, intraoper-
scope, CT and MRI [8]. Both CT and MRI are valuable ative bleeding was minimal, and no postoperative pain or
in revealing the origin of the cysts and avoids unwar- edema reported [24]. Since the nasolabial cyst lined with
ranted needle aspiration or dental surgery [3, 7]. ciliated respiratory epithelium, it is converted by marsu-
Ultrasonography could be used in an office-based diag- pialization into a sinus at the anterolateral nasal floor [22].
nostic tool for the nasolabial cyst [16]. Diagnostic CT It is designed to be like a healthy paranasal sinus with
scan is of high significance and relatively low cost. It good drainage and best ventilation functions, without sub-
described as the imaging modality of choice for evalu- sequent mucus accumulation [23]. Nevertheless, if the
ation of the lesion borders is required. Therefore, CT is window created during marsupialization is too small, it
considered essential for the preoperative estimation of leads to shrinking the annular scar around the ostium and
lesion extent and limitation [17]. Cysts located classically followed by accumulation of the mucus in the newly cre-
anteriorly to the piriform aperture [13]. However, a ated sinus or cyst recurrence [23]. Hence, recurrence
Almutairi et al. BMC Surgery (2020) 20:10 Page 5 of 6

reported following this modality in recent reports [5, 17]. Received: 23 January 2019 Accepted: 6 January 2020
Another approach to surgically remove the nasolabial cyst
is the Neumann incision [25, 26]. It is more commonly
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