Nasopalatine Duct Cyst Workup

  • Author: Piotr Kurnatowski, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Feb 13, 2012
 

Imaging Studies

Panoramic, occlusal, and periapical radiographs are standard in the radiographic evaluation of suspected nasopalatine duct cyst.

In some cases, obtaining a 3-dimensional view of the lesion may be necessary.

  • Harris and Brown[35] advocate a second periapical radiograph taken perpendicular to the first, a CT scan (shows imaging information as direct axial or coronal slices or as reformatted coronal or sagittal slices), and linear tomography through the area of interest in an alternative plane.
  • In 2000, Pevsner et al[36] reported CT scan characteristics believed to be unique to nasopalatine duct cysts. These include (1) a midline position of the lesion; (2) pressure erosion of the tooth apices and exclusion of contiguous tooth numbers 8 and 9 rather than incorporation of the apices of these teeth within the cyst; and (3) smooth, noninflammatory bony expansion of the lesion with sclerotic margins. The expansile change of the posterior midline maxilla and smooth elevation of the nasal cavity with tilting of the nasal septum suggest a long-term process that is likely developmental and consistent with a nasopalatine duct cyst.
  • MRIs of nasopalatine duct cysts show homogeneous high-signal intensity on T2-weighted images and intermediate signal intensity on T1-weighted images in the area of the contents of nasopalatine duct cysts (keratin and viscous fluids). MRI is more specific than CT.[1, 20, 29, 37, 38]

Radiographic examination typically discloses a well-defined, ovoid, round or inverted, pear-shaped radiolucency located in the midline of the maxilla, which is inter-radicular and apical to the roots of the maxillary central incisor teeth; larger lesions resorb the surrounding maxillary cortex.[29]

  • The mean radiographic diameter is reported to be 17.1 mm.[17, 23]
  • Superimposition of the nasal spine can impart a heart-shaped appearance to the cyst.
  • Peripheral sclerosis, an indication of a slowly developing growth and intrabony expansion, may or may not be present. The roots of the central incisors may show divergence.
  • Destruction of the floor of the maxillary antrum has been described.[30]
  • In some individuals, a prominent incisive canal can appear as a radiolucent area and mimic nasopalatine duct cyst.
  • Most authors agree that 6 mm should be considered the upper limit for a normal incisive canal. Radiolucencies larger than this should be considered potentially pathologic and merit further investigation.[23]
  • Note the images below.An ovoid radiolucent area between the central inciAn ovoid radiolucent area between the central incisor teeth with a poorly defined sclerotic outline can be suspected to be a cyst. An ovoid, clearly radiolucent area with a sharply An ovoid, clearly radiolucent area with a sharply defined outline and sclerotic margin that has a bearing on the teeth appendix; secondary draw aside of incisor roots. An ovoid radiolucent area with a poorly defined scAn ovoid radiolucent area with a poorly defined sclerotic outline between the central incisor teeth.
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Procedures

Aspiration of pathologic jaw radiolucencies can provide useful information in distinguishing solid processes from cystic processes but is not itself diagnostic of an entity. A clear or straw-colored fluid aspirate is suggestive of nasopalatine duct cyst; however, other cystic processes (eg, lateral radicular cyst, cystic ameloblastoma) cannot be excluded on the basis of this finding alone. Bloody fluid is more indicative of a central hemangioma, a central giant cell lesion, an arteriovenous malformation, or an aneurysmal bone cyst. Negative aspiration indicates a solid process (eg, odontogenic myxoma, solid ameloblastoma).

Tooth vitality testing may be necessary. In the absence of caries, traumatic injury, or other obvious cause of pulpal necrosis, the adjacent maxillary central incisor teeth should be vitality tested to exclude the possibility of a pulpal-periapical inflammatory pathogenesis (eg, lateral radicular cyst, dental granuloma, periapical cyst, periapical abscess).

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Histologic Findings

Histopathologic examination discloses a cavity lined by epithelium and surrounded by a connective tissue wall. A reported about 70% of nasopalatine duct cysts have squamous, columnar, cuboidal, or some combination of these epithelial types; respiratory epithelium is seen in 9.8-32.0%.[17, 23, 26] [32] The type of epithelium depends on the localization of the cyst (see Pathophysiology), and it may also be reflective of the pluripotential character of the embryonic epithelial remnants.[15] Rarely, dendritic melanocytes have been reported within the epithelium.[39] Malignant transformation of the lining epithelium has not been reported.[27]

Often (81% of cases), a chronic inflammatory reaction consisting of lymphocytes and plasma cells is observed in the cyst wall; hemorrhage has been noted in 71% of cases.[22] Also helpful in the microscopic diagnosis of nasopalatine duct cyst are the presence of structural elements in the cyst wall that are native to the nasopalatine canal (eg, moderately sized peripheral nerves, arteries and veins, mucous glands, adipose tissue).

The cyst can be filled by semisolid material, containing erythrocytes, leukocytes, desquamated epithelial cells, tissue debris, and bacteria.[2, 5]

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Contributor Information and Disclosures
Author

Piotr Kurnatowski, MD  Professor, Department of Otolaryngology, Medical University of Lodz, Poland

Disclosure: Nothing to disclose.

Coauthor(s)

Deborah Cleveland, DDS  Director of Oral Pathology, Associate Professor, Department of Oral Pathology, Biology and Diagnostic Sciences, University of Medicine and Dentistry of New Jersey

Deborah Cleveland, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, South Dakota State Medical Association, Southeastern Dermatological Association, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, Southern Medical Association, Southern Orthopaedic Association, Southern Society for Pediatric Research, Southern Thoracic Surgical Association, Southwest Oncology Group, Southwest Pediatric Nephrology Study Group, Southwestern Surgical Congress, Special Operations Medical Association, State Medical Society of Wisconsin, Swedish Medical Association, Sydenham Society, Tennessee Medical Association, Tennessee Radiological Society, Teratology Society, Texas Medical Association, Texas Orthopaedic Association, Texas Pediatric Society, and Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Camila K Janniger, MD  Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Jacek C Szepietowski, MD, PhD  Professor, Vice-Head, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University; Director of the Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Poland

Disclosure: Stiefel GSK Company Salary Employment; Orfagen Consulting fee Consulting; Maruho Consulting fee Consulting; Astellas Consulting fee Consulting; Abbott Consulting fee Consulting; Leo Pharma Consulting fee Consulting

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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An ovoid radiolucent area between the central incisor teeth with a poorly defined sclerotic outline can be suspected to be a cyst.
An ovoid, clearly radiolucent area with a sharply defined outline and sclerotic margin that has a bearing on the teeth appendix; secondary draw aside of incisor roots.
An ovoid radiolucent area with a poorly defined sclerotic outline between the central incisor teeth.
 
 
 
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