CASE REPORT

Nasopalatine Duct Cyst: A Rare Case Report

1

Chinar Fating , Rolly Gupta , Mekhala Lanjewar Barkha Nayak Anurag Bakshi , Rajkumar
Diwan6
1. Senior Lecturer, Department of Oral Medicine and Radiology, Chhattisgarh Dental College and
Research Institute, Rajnandgaon, Chhattisgarh, India.
2. Senior Lecturer, Department of Oral and Maxillofacial Pathology and Microbiology, Chhattisgarh
Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India
3. Oral Medicine and Radiology(MDS)
4. Senior lecturer, department of oral pathology, Matri dental college, Anjora Durg, CG
5. Post gradute student department of oral medicine and radiology, Matri Dental college Anjora Durg CG
6. Oral medicine and radiology (MDS)
Corresponding Address:
Dr.Chinar Fating, SeniorLecturer, Department of Oral Medicine and Radiology, Chhattisgarh
Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India.
Abstract
There are several developmental cysts derived from embryonic structures or faults in their remnants located in oro-facial region. Nasopalatine duct cyst
(NPDC) is the most common of all the developmental, epithelial and non-odontogenic cysts of the maxilla. This cyst originates from epithelial remnants
from the nasopalatine duct. The cells could be activated spontaneously during life, or are eventually stimulated by the irritating action of various agents
(infection, etc.). Generally, the patients present without clinical signs and symptoms. Therefore, the tentative diagnosis nasopalatine duct cyst is often
based on a coincidental radiological finding on a routine panoramic view or occlusal radiograph. Although NPDC is not rare, it is mostly misdiagnosed.
The definite diagnosis should be based on clinical, radiological and histopathologic findings. We report a case of infected nasopalatine duct cyst in a 35
year old male patient along with briefliterature review.
Key words: Developmental Cyst, Nasopalatine Duct Cyst, Nonodontogenic Cysts.

Introduction
The nasopalatine duct communicates the nasal cavity with
the anterior region of the upper maxilla. It is located on the
midline and palatine to the upper maxilla, above the
retroincisor palatal papilla. During fetal development the
duct gradually narrows until one or two central clefts are
finally formed on the midline of the upper maxilla. The
nasopalatine neurovascular bundle is located within the
duct, and emerges from its intrabony trajectory through the
nasopalatine foramen. Nasopalatine duct cyst (NPDC) was
first described by Meyer in 1914. It is also termed as incisive
canal cyst, arising from embryologic remnants of
nasopalatine duct.
NPDCs are the most common non-odontogenic
cysts of the oral cavity, representing up to 1% of all
maxillary cysts. These lesions are almost three times more
frequent in males than in females. The maximum incidence
is between 40 and 60 years of age.Trauma, infection of the
duct and mucous retention of the adjacent minor salivary
gland have been mentioned as possible etiological factors,
but the role of each have been questioned.
Although
pathogenesis of this lesion is still uncertain, the lesion most
likely represents a spontaneous cystic degeneration of the
remnants of nasopalatine duct. The differential diagnosis is
established with the following conditions: an enlarged
nasopalatine duct, central giant cell granuloma, a central
incisor root cyst or other maxillary cysts, osteitisfistulizing
in the palatine direction, or a bucco-nasal and/or buccosinunasal communication. Treatment in all cases involves
complete surgical removal as soon as possible after
diagnosis. The definite diagnosis of the cyst should be based
on clinical, radiological and histopathologic findings.
Hence, we report a case of nasopalatine duct cyst in a 33
year old male patient, along with a review of literature.
1

Case Report
A 35 year old male patient reported with a chief complaint of
swelling and pus discharge from palatal region of upper
anterior region of the jaw since 2 months. The swelling was
small initially which gradually increased to the present
dimension. Patient gives the history of trauma 4 and half
months back with upper anterior region of the jaw. Patient
initially consulted a local dentist 4 months back.Radiograph
with 11 and 21 was taken and root canal treatment with 11 and
21 was done assuming it as any periapical pathology. But the
patients complaint of swelling was not resolved. Two months
after root canal treatment, the patient experienced pus
discharge with salty taste from the same region. Extraorally
no otherabnormality was noted and no lymphadenopathy was
detected.Intraoral examination revealed asingle,
localised,welldefined and pink coloured swellling, which
was tender, soft in consistency,present in anterior palatal
midline region of maxilla extending from 12 to 22. The size
approximately was 2x2 cm and extended posterior to the
mesial aspect of upper second premolar. (Fig.1)

Fig.1: Photograph showing intraoral presentation of

nasopalatine duct cyst.

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Radiological examination by intraoral periapical

&occlusal radiograph showed a single well circumscribed
oval shaped radiolucency with well corticated borders. Size
was 1x1 cm, location was in midline of anterior maxilla
between the roots of central incisors. (Fig. 2,3) On the basis
of clinical and radiological evidence the provisional
diagnosis ofincisive papilla cyst, nasopalatine duct cyst and
chronic periapical granuloma was given. It was decided to
enucleate the cyst under local anaesthesia. Prior to surgery
all preliminary investigation were done and results were
within normal limits. Palatal mucoperiosteal flap was raised
to expose the cyst (Fig. 4). A friable, haemmorhagic cyst
lining was curetted and sent for histopathological
examination. The flap was sutured back in its original
position. Patient was called for suture removal one week
postoperatively and healing was satisfactory and
uneventful(Fig. 5, 6).

Fig. 6: 1week post operative intraoral periapical radiograph.

Curetted material was further submitted to
histopathological examination. On gross examination,tissue
consisted of multiple bits of tissue, soft to firm in
consistency, resembling thin irregular cystic lining, which
was whitish brown in colour.Microscopic examination
revealed a cystic cavitylined by pseudostratified epithelium
with a fibrous connective tissue wall.The fibrous wall
consisted of neurovascular bundles alongwith dense chronic
inflammatory infiltratesat places mainly comprising of
lymphocytes and plasma cells (Fig 7).The
clinicoradiohistopathologicalcorrelationwas suggestive of
infected nasopalatine duct cyst.

Fig. 2&3: Intraoral periapicaland

occlusalradiographshowing single well circumscribed oval
shaped radiolucency with well corticated borders ofsize
1x1 cm, located in midline of anterior maxilla between the
roots of central incisiors.

Fig. 4: Photograph showing haemorrhagic appearing cyst

after mucoperiosteal flap was raised.

Fig.7:Photomicrograph of Haematoxylin and Eosin stained

section shows: a) Fibrous connective tissue capsule with
inflammatory cell infiltration (Original magnification x40);
b) Fibrous capsule with neurovascular bundle (Original
magnification x100); c) Disturbed pseudoepitheliomatous
epithelial lining with dense chronic inflammatory cell
infiltrate (Original magnification x400).
Discussion
The nasopalatine duct cyst (NPDC) was first describedin
1914 by Meyer. These lesions, also known by other names
such as anterior middle cyst, maxillary midline cyst, anterior
middle palatine cyst, and incisor duct cyst, were regarded as
fissural cysts in the past. At present, according to the
classification of the World Health Organization (WHO),
these lesions are regarded as developmental, epithelial and
non-odontogenic cysts of the maxilla, along with nasolabial
cysts.
The nasopalatine duct cyst is a developmental cyst
derived from proliferation of embryonic epithelial remnants
3

Fig. 5: 1 week post operative intraoral clinical photograph.

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Nasopalatine Duct Cyst: A Rare Case Report

of the nasopalatine duct. It may occur at any age but it is seen

most often in fourth to sixth decades of life. The etiology
underlying these lesions is not clear, though in addition to
the hypothesis of spontaneous proliferation from embryonic
tissue remains, other possible etiologies have been
proposed. Trauma, infection, and mucous retention within
associated salivary gland ducts have all been suggested as
possible pathogenetic factors; however, most believe that
spontaneous cystic degeneration of residual ductal
epithelium is the most likely etiology and some genetic
determinants have been suggested. As far as pathogenesis
isconcerned, it was previously thought that the NPDCs
originatedfrom the trapping of epithelium during fusion of
theembryological processes. This concept has been
discarded,and currently NPDC is thought to develop from
theepithelial remnants of the nasopalatine ducts present
withinthe incisive canals (canals of Stenson).
Nasopalatine duct cysts affect a wide age range, however,
most present in the fourth through sixth decades of life.
There is a slight male predilection. Patients may be
asymptomatic, with the lesion being detected on routine
radiographs, however, many will present with one or more
symptoms. Complaints are often found to be associated with
an infection of a previously asymptomatic nasopalatine duct
cyst and consist primarily of swelling, drainage of pus and
pain. The vitality of nearby teeth is not affected; however, it
is not uncommon to see evidence of endodontic therapy
because the nasopalatine duct cyst has been previously
clinically misdiagnosed as a periapical cyst or granuloma.
In our case, patient came with complaint of swelling and
salty discharge.
The incisive canal is a fusion line that occurs during facial
development. The nasopalatine ducts are small paired
openings in the midline of the anterior palate transmitting
the nasopalatine artery and nerve as well as remnants of the
embryonic nasopalatine duct. The incisive canal is bilateral
on the nasal side and single at the oral side (incisive
foramen). The normal size of the normalforamen is highly
variable, but most authors agree that 6 mm should
beregarded as the upper limit for a normal incisive canal.
Radiolucencies largerthan this diameter should be
considered potentially pathologic and merit
furtherinvestigation. However, the incisive foreman, by
convention, is not expected to exceed 6 mm in diameter,
making the detection of a small nasoplatine duct cyst
difficult. NPDCs are usually central or unilateral with no
prevalence of side occurrence. Radiographically,
nasopalatine ducts cysts are usually well-circumscribed
radiolucencies of the anterior maxilla.The cysts are apical to
the roots of the maxillary incisors and rarely cause root
resorption. Cysts are round, ovoid or some lesions may
appear heart-shaped, either because they become notched
by the nasal septum during their expansion or because the
nasal spine is superimposed on the radiolucent area. Cysts
range in size, with an average diameter of approximately 1.5
cm.
Due to similar signs and symptoms, the NPDC may be
misdiagnosed as a periapical lesion. This is why many
authors believe that its prevalence is actually higher than
presented in the literature. Although a large NPDC might
show the adjacent incisors roots to be within the cystic
cavity, the lamina dura will be intact and the pulp usually
vital whereas a radicular cyst is associated with a pulpless
tooth and involve a portion of the root, usually with loss of
continuity of the lamina dura. In the reported case, adental
3,4

2,6,7

practitionerconsidered it to be a radicular cyst and carried out

the root canal treatment with upper central incisors. Thus, in
establishing a diagnosis of NPDC it is important to attempt to
exclude the possibility of a periapical lesion by performing
the pulp vitality tests of the incisor teeth.
Histologically, the nasopalatine duct cyst is lined by
stratified squamous epithelium alone or in combination with:
pseudostratified columnar epithelium (with or without cilia
and/or goblet cells), simple columnar epithelium, and simple
cuboidal epithelium. The fibrous wall generally contains
nerves, arteries and veins. Additionally, minor salivary gland
tissue and small islands of cartilage may be found. Finally, if
the cyst is infected, acute and chronic inflammatory cells will
be seen throughout the specimen.
The differential diagnosis must be established with other
conditions such as an enlarged nasopalatine duct (less than 6
mm in diameter), central giant cell granuloma, a root cyst
associated to the upper central incisors, a supernumerary
tooth follicular cyst (normally mesiodens), primordial cyst,
nasoalveolar cyst, osteitis with palatal fistulisation, and
bucconasal and/or buccosinusal communication. Other
diagnostic techniques can be used to radiologically assess
lesions of this kind, such as multimodal tomography, which
in addition to exposing the patient to lesser radiation doses
employs crossed and sectional tomographic acquisitions in
the sagittal plane to yield threedimensional images.
Magnetic resonance imaging (MRI) may also prove useful in
establishing the diagnosis, and particularly contrast the
interior of the NPDC with a high signal intensity. Specific
axial T1-weighted imaging reflects the presence of fluid,
viscous and protein material within the cyst, and abundant
keratin at superficial level. Thus, MRI is highly reliable in
diagnosing NPDCs, discarding root cysts or any other cysts
of odontogenicorigin.
The treatment of choice is surgical excision of the cyst,
although some authors propose marsupialization of large
NPDCs. The nasopalatine neurovascular bundle is a delicate
and highly vascularised structure giving rise to profuse
bleeding if inadvertently sectioned during surgery.
Electrocoagulation is required in such cases. Paresthesia of
the anterior palatal zone is a rare complication found in 10%
of the cases, on removal of nerve endings of the nasopalatine
nerve along with the membrane of the cyst.Frequently the
biopsy procedure results in adequate treatment. Recurrence
is rare.
A very rare complication associated with long
standing NPDC is squamous cell carcinomas originating in
maxillary bone. This is due to the metaplasia seen in the
epithelial wall of a cyst or of the epithelial remains that
participated in odontogenesis. Therefore, there are cases in
which NPDC gives rise to squamous cell carcinoma in the
anterior zone of the upper maxilla. This explains the need for
early removal of the NPDC, with the purpose of minimizing
the risks and complications.
9

10

11

1,12

3,9, 13

14

15

CONCLUSION
Nasopalatine duct cysts are the most common
nonodontogenic cyst of the oral cavity seen in the general
population. NPDCs must be distinguished from other
maxillary anterior radiolucencies. In establishing a diagnosis
of NPDC and for avoiding irrational endodontic treatment, it
is important to attempt to exclude the possibility of a
periapical lesion by performing the pulp vitality tests of the
incisor teeth. The final diagnosis could only be performed
after histological analysis.

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AYUSH

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Figure Legends
Figure 1. Photograph showing intraoral presentation of
nasopalatine duct cyst.
Figure 2&3. Occlusal and intraoral periapical
radiographshowing single well circumscribed oval shaped
radiolucency with well corticated borders ofsize 1x1 cm,
located in midline of anterior maxilla between the roots of
central incisiors.
Figure 4. Photograph showing haemorrhagic appearing cyst
after mucoperiosteal flap was raised.
Figure 5. Photomicrograph of Haematoxylin and Eosin
stained section shows: a) Fibrous connective tissue capsule
with inflammatory cell infiltration (Original magnification
x40); b) Fibrous capsule with neurovascular bundle (Original
magnification x100); c) Disturbed pseudoepitheliomatous
epithelial lining with dense chronic inflammatory cell
infiltrate (Original magnification x400).
Figure 5. 1 week post operative intraoral clinical photograph.
Figure 6. 1week post operative intraoral periapical
radiograph.