Nasolabial cyst with radiographic contrast medium: report of two cases

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1 Dentomaxillofacial Radiology (2005) 34, 1 5 q 2005 The British Institute of Radiology CASE REPORT Nasolabial cyst with radiographic contrast medium: report of two cases TMP Amaral, JB de Freitas, J de Fátima da Conceição, MCF de Aguiar, LM da Silva Fonseca and RA Mesquita* Department of Oral Surgery and Pathology, School of Dentristy, Minas Gerais Federal University, Belo Horizonte, Minas Gerais, Brazil Two cases are presented of a nasolabial cyst (NC) on which a radiographic contrast medium was used in order to define the real extension of the lesion. Use of contrast is important for visualizing the definite extensions of NC primarily in cases when plain radiographs may not show any detectable changes and CT can not be used. Dentomaxillofacial Radiology (2005) 34, 1 5. doi: /dmfr/ Keywords: nasolabial cyst, image, radiographic contrast medium Case report Case 1 A 42-year-old white woman was referred to the Oral Medicine Clinic of the Dentistry School of Federal University of Minas Gerais (Belo Horizonte, Brazil) for evaluation of an asymptomatic swelling of the right nasolabial region present for 10 years. The patient related that the first treatment for the swelling was endodontic therapy of the upper right lateral incisor, but it was not successful in reducing the swelling. The other anterior teeth presented vitality. The patient also mentioned difficulty in breathing through the right nostril. She was otherwise in good health and her medical history was not contributory. The extraoral examination showed a firm, round, mobile swelling in the region of the right nasolabial fold and a slight elevation on the nasal alae (Figure 1A). On the intraoral examination a swelling measuring 3 cm in the maxillary labial fold in the region of the right lateral incisor and canine teeth was visible. On the occlusal radiographic examination a distortion of the anterior lateral wall of nasal cavity was observed (Figure 1C). Aspiration of 3 ml of cystic fluid was performed with a needle of 0.5 mm and a brown liquid was obtained. Three milli litres of radiographic contrast medium (50% sodium diatrizoat) was injected (Figure 1E). Occlusal and cephalometric radiographs were taken and a 3 cm radiopaque spherical image was observed in these images (Figure 1G, I). In the same clinical session, the lesion was *Correspondence to: Prof. Dr Ricardo Alves Mesquita, Universidade Federal de Minas Gerais, Faculdade de Odontologia, Av.: Antônio Carlos, 6627 sala 3204, Pampulha, , Belo Horizonte, MG, Brasil; ramesquita@ufmg.br Received 24 September 2004; revised 14 February 2005; accepted 7 March 2005 removed surgically via an intraoral approach. The patient has been followed-up for 18 months and no local recurrence has been observed. Case 2 A 64-year-old white woman was referred to the Oral Medicine Clinic of the Dentistry School of Federal University of Minas Gerais with difficulty in wearing the upper denture that she had been using for 12 years. The extraoral examination revealed a firm, round, mobile swelling in the region of the left nasolabial fold and an elevation on the nasal ala (Figure 1B). On the intraoral examination a swelling measuring 2 cm in the maxillary labial fold in the region to the left lateral incisor and canine teeth was visible. On the occlusal radiographic examination a distortion of the anterior lateral wall of nasal cavity was observed (Figure 1D). Aspiration of 2.5 ml of cystic fluid was performed with a needle of 0.5 mm and a brown liquid was obtained. 2:5 ml of radiographic contrast medium (50% sodium diatrizoat) was injected (Figure 1F). A 4 cm radiopaque oval and kidney shaped images were observed in the image with occlusal and cephalometric radiographs (Figure 1H, J), respectively. In the same clinical session, the lesion was removed surgically via an intraoral approach. The patient has been followed-up for 17 months and no local recurrence has been observed. The surgical specimens were sent to the Oral Pathology Laboratory of the Federal University of Minas Gerais, fixed in 10% neutral formalin solution and embedded in paraffin. Sections 5 mm thick were obtained and stained with haematoxylin and eosin. The diagnosis of both lesions was of nasolabial cyst (NC).

2 2 Nasolabial cyst TMP Amaral et al Figure 1 (A) Clinical view of Case 1 with a slight elevation on the right nasal alae. (B) Clinical view of Case 2 with swelling in the region of the left nasolabial fold. Occlusal radiographs with a distortion of the curves of (C) the right and (D) the left anterior lateral wall of nasal cavity (arrow) of Cases 1 and 2, respectively. Clinical manoeuvere of the cystic fluid aspiration and injection of the radiographic contrast medium in Cases (E) 1 and (F) 2. (G, H, I, J.) Radiographic images of the nasolobial cyst with radiographic contrast medium in occlusal and cephalomeric views. A radiopaque oval and kidney shaped image is observed in Cases 1 and 2, respectively Discussion In this report radiographic contrast medium was successfully used in evaluating the extent of nasolabial cysts. Both cases described had clinical features like the other cases described in the literature. 1 3 The nasolabial cyst is a rare soft tissue cyst that occurs as a swelling in the nasolabial fold at the base of the alae of the nose. Its frequency is around 0.7% of cysts of the jaws and 2.5% of the non-odontogenic cyst. 2 The NC affects patients with wide age distribution, but it is more frequent in the fourth and fifth decade, and occurs more in female than in males (ratio of male to female ¼ 1:6.5). 2,4,5 Clinical features of the NC are fluctuant swelling filling of the maxillary labial fold and the floor of the nasal vestibule, obliteration of the nasolabial fold and elevation of the alae of the nose. Some patients may complain about difficulty in nasal breathing. The NC is asymptomatic. 6,7 The NC sometimes does not show signs in routine intraoral radiographs. Aspiration of the cystic fluid and its replacement with radiographic contrast medium and then acquisition of radiographs, preferably two different views at right angles, tangential, posteroanterior or occlusal radiographs, help with diagnosis and surgical planning of the NC. However, only a few authors have described cases Dentomaxillofacial Radiology

3 Nasolabial cyst TMP Amaral et al 3 of the NC with radiographic contrast medium in the literature. 6,7 Routine intraoral periapical radiographs are not diagnostic for NC but assist in excluding other odontogenic or non-odontogenic cysts. 6,8 In accordance with the development time of the NC, three possible radiographic features have been described: (1) increase in radiolucency adjacent to the apex of the lateral incisors observed in periapical radiograph; (2) depression on the labial surface of the maxilla; and (3) distortion of the floor of the nasal vestibule line caused by inferior margin of the anterior bony aperture of the nose because of pressure from the adjacent soft tissue cyst observed in occlusal radiograph. 6 9 We observed the last radiographic feature in both cases. Thus, we think that the clinical-radiograph technique of the radiographic contrast medium in NC is important aid in the diagnosis and surgical planning. The imaging modality of choice in the evaluation of oral maxillofacial cysts and tumours is computed tomography (CT) because it has a high contrast resolution, demonstrates small differences in soft tissue density, provides both good bone detail and good soft tissue definition and shows the soft and bone tissues in the same examination. Unfortunately, there are many countries and dentistry services that do not have access to CT. The CT image of NC was described by Choi as a well-demarcated, lowdensity cystic lesion lateral to the pyriform aperture. 10 Invasion of the adjacent bone was not observed. There is no report in the literature about image with ultrasound in cases of NC. The visualization of NC using radiographic contrast medium injection is a low cost, simple and rapid method. This procedure is precise for visualizing the definite extensions of NC into the upper lip and nasal cavity, mainly in those cases when plain radiographs may not show any detectable changes and where CT can not be accessed. The clinical-radiographic technique with radiographic contrast medium with occlusal and cephalometric radiographs in the NC presented the following features: (1) revealed an oval or kidney shaped radiopaque shadow in the nasoalveolar region of the maxilla; (2) demonstrated the extraosseous nature; (3) helped in differential diagnosis with intraosseous lesions; (4) provided the real extension of the lesion; and (5) helped with surgical planning. 7 The use of radiographic contrast medium and subsequently the taking of radiographs, preferably two different views at right angles to each other, provides information on all three dimensions height, width and depth of the lesion. The radiographic contrast medium does not cause allergy for the patients. While the injection of radiographic contrast medium could rupture the borders confining the cyst and then cause dissemination of bacteria into other facial planes, 11 it can only happen when a different volume of radiographic contrast medium from the liquid aspirated is injected. The technique must be made at the same appointment as the surgery. In conclusion, when CT is not available, it is recommended that the technique of combining radiographic contrast medium with two different imaging views at right angles be used for the diagnosis and management of nasolabial cysts. References 1. Cohen MA, Hertzanu Y. Huge growth potential of the nasolabial cyst. Oral Surg Oral Med Oral Pathol 1985; 59: Vasconcelos RF, Souza PEA, Mesquita RA. Retrospective analysis of 15 cases of nasolabial cyst. Quintessence Int 1999; 30: Waldrep AC, Capodanno JA. Bilateral nasolabial cysts: report of a case. J Oral Surg 1966; 24: Santara E, Ballantyne AJ, Hinds EC. Nasoalveolar cyst. Arch Otolaryngol 1970; 28: Karmody CS. Nasoalveolar cyst. Ann Otol Rhinol Laryngol 1970; 81: Van Bruggen AP, Shear M, Du Preez IJ, Van Wyk DP, Beyers D, Leeferink GA. Nasolabial cyst: a report of 10 cases and a review of the literature. J Dent Assoc S Afr 1985; 40: Crowford W, Korchin L, Greskovich FJ. Nasolabial cysts: report of two cases. J Oral Surg 1968; 26: Chinellato LEM, Damante JH. Contribution of radiographs to the diagnosis of nasoalveolar cyst. Oral Surg Oral Med Oral Pathol 1984; 58: Atterbury RA, Vazirani SJ, McNabb WJ. Nasoalveolar cyst. Oral Surg Oral Med Oral Pathol 1961; 14: Choi JH, Cho JH, Kang HJ, Chae SW, Lee SH, Hwang SJ, et al. Nasolabial cyst: a retrospective analysis of 18 cases. Ear Nose Throat J 2002; 81: Campbell LR, Burkes Jr EJ. Nasolabial cyst: report of case. J Am Dent Assoc 1975; 91: Dentomaxillofacial Radiology

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The nasolabial cyst is an uncommon non-odontogenic

The nasolabial cyst is an uncommon non-odontogenic Rev Bras Otorrinolaringol 2008;74(3): 467-71. case report Nasolabial cyst: presentation of a clinical case with CT and MR images Raphael Navarro Aquilino 1, Vitor José Bazzo 2, Reinaldo José Antônio Faria