Endoscopic view of a nasoalveolar cyst. (Rhinoscopic Clinic).

A 46-year-old black woman complained of a lump in her right nostril, which she said had been present for as long as she could remember. The mass was painless, but the patient had experienced increasing difficulty in nasal breathing through her nostril when she had an upper respiratory tract infection. She denied drainage from the nasal and oral cavities.

On physical examination, a 2.5cm smooth cystic mass was palpated at the right nasal vestibule (figure, A). A 4-mm, 0[degrees] telescopic examination showed that the mass extended posteriorly beneath the inferior meatus and displaced the inferior turbinate superiorly. This was confirmed by computed tomography and by magnetic resonance imaging (MRI) (figure, A). Cranial function, including facial sensation, was intact. Examination of the oral cavity revealed vital teeth.

The patient was taken to the operating room, where she underwent excision of the mass via a modified lateral rhinotomy approach (figure, B). During the procedure, it was difficult to remove the cyst from its attachment, so intraoperative decompression with a 20-gauge needle was performed, and it yielded a thick, yellowish fluid (figure, C). The cyst and its lining were then removed en bloc. Pathology identified a benign cystic mass with chronic inflammation and squamous metaplasia, which were consistent with a nasoalveolar cyst.

Postoperatively, the patient did well and was without breathing difficulty. At the 5-year follow-up, her facial and nasal incisions were well healed and not visible. There was no evidence of recurrence (figure, D).

Zuckerandl first characterized a nasoalveolar cyst in 1892. (1) These cysts have been characterized as relatively rare lesions of the soft tissue of the nasal alar region of the face. They occupy a submucosal position in the anterior nasal floor, often elevating and medially displacing the inferior turbinate. (1) Remaining extraosseous, they expand into and in front of the piriform aperture, downward into the gingivolabial sulcus, and laterally into the soft tissue of the face. (1) Because of their position in the facial soft tissues rather than in the alveolar process, the term nasolabial cyst has been preferred. (2)

Nasolabial cysts are usually unilateral, more common in women, usually present during the fourth and fifth decades of life, and have a predilection for the black population. (3) They are usually painless and asymptomatic, and they are recognized only when they are acutely inflamed or large enough to cause nasal obstruction. Sometimes their size will cause flattening of the nasolabial fold. They are generally thought to be of embryonic origin, arising where nasal epithelium became trapped in the cleft formed by the fusion of the maxillary, lateral, and medial nasal processes. (1-3)

The differential diagnosis includes other midline cysts, odontogenic cysts, abscesses from anterior maxillary teeth, and furuncles or neoplasms of the nasal vestibule. Diagnosis usually can be made by a thorough history and physical examination. Vitality testing of the teeth and radiographs showing a nonodontogenic origin are also helpful.

Treatment options for nasolabial cysts include needle aspiration, injection of sclerosing agents, cautery destruction, and incision and drainage. (1) Recently, transnasal endoscopic marsupialization has been reported. (4) However, complete surgical excision via a sublabial approach is the treatment of choice because of its low incidence of recurrence. (1,3) Because the mass in our patient had extended into the inferior meatus, we took another surgical option. The final result was cosmetically pleasing and functionally excellent, and there has been no evidence of recurrence. This case demonstrates that a modified lateral rhinotomy is a viable option in cases of difficult dissection.

References

(1.) Kuriloff DB. The nasolabial cyst-nasal hamartoma, Otolaryngol Head Neck Surg 1987;96;268-72.

(2.) Fishman RA. Pathologic quiz case 2: Nasolabial (nasoalveolar) cyst. Arch Otolaryngol 1983;109:348-9, 351.

(3.) Karmody CS, Gallagher JC. Nasoalveolar cysts. Ann Otol Rhinol Laryngol 1972;81:278-83.

(4.) Su CY, Chien CY, Hwang CF. A new transnasal approach to endoscopic marsupialization of the nasolabial cyst. Laryngoscope 1999;109:1116-8.

From the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa and Dr. Scher); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, and the Section of Otolaryngology, Hospital of St. Raphael, New Haven (Dr. Yanagisawa).