Indian Journal of Dental ResearchIndian Journal of Dental ResearchIndian Journal of Dental Research
HOME | ABOUT US | EDITORIAL BOARD | AHEAD OF PRINT | CURRENT ISSUE | ARCHIVES | INSTRUCTIONS | SUBSCRIBE | ADVERTISE | CONTACT
Indian Journal of Dental Research   Login   |  Users online: 923

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size         

 


 
Table of Contents   
CASE REPORT  
Year : 2020  |  Volume : 31  |  Issue : 1  |  Page : 157-159
Postoperative maxillary cyst


1 Department of Dentistry, Government Medical College and General Hospital, Dhule, Maharashtra, India
2 Department of Oral Pathology and Microbiology, Government Dental College and Hospital, Mumbai, Maharashtra, India
3 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India
4 Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Mumbai, Maharashtra, India

Click here for correspondence address and email

Date of Submission24-Mar-2018
Date of Acceptance06-Aug-2018
Date of Web Publication02-Apr-2020
 

   Abstract 


Cysts of the oral cavity are among the most commonly encountered biopsy specimen in histopathology. Shear categorized the cysts associated with maxillary antrum under four subheadings – mucocoele, retention cyst, pseudocyst, and postoperative maxillary cyst (PMC). PMC is also known as surgical ciliated cyst, postoperative paranasal cyst, or respiratory implantation cyst. Although it constitutes 20% of oral cysts in Japan, it is quite rare in the other parts of the world. Herewith, we report a case of a 65-year-old female who presented with the complaint of palatal swelling and having a history of maxillary sinus surgery 30 years ago.

Keywords: Maxillary antrum, postoperative maxillary cyst, surgical ciliated cyst

How to cite this article:
Siwach P, Joy T, Gaikwad S, Meshram V. Postoperative maxillary cyst. Indian J Dent Res 2020;31:157-9

How to cite this URL:
Siwach P, Joy T, Gaikwad S, Meshram V. Postoperative maxillary cyst. Indian J Dent Res [serial online] 2020 [cited 2021 May 11];31:157-9. Available from: https://www.ijdr.in/text.asp?2020/31/1/157/281805



   Introduction Top


Cysts of the oral cavity are among the most commonly encountered biopsy specimen in histopathology, but when it comes to cysts associated with the maxillary sinus, our knowledge seems to be very limited. Shear categorized the cysts associated with maxillary antrum under four subheadings – mucocoele, retention cyst, pseudocyst, and postoperative maxillary cyst (PMC).[1] PMC, also known as surgical ciliated cyst, postoperative paranasal cyst, or respiratory implantation cyst, was first described by Kubo in 1927. It may occur within a span of 49 years after the surgery associated with maxillary sinuses.[2] Although it constitutes 20% of oral cysts in Japan,[3] it is quite rare in the other parts of the world. In the University of the Witswatersrand, only five cases have been diagnosed over a 32-year period representing 0.1% of 3498 jaw cysts.[1] However, the only report suggesting that the lesion may not be rare outside Japan is by Basu et al. from the University of Birmingham Dental School, where 23 cases were diagnosed over a period of 3 years.[4]

Gregory and Shafer suggested that cysts are derived from the epithelial lining of the maxillary sinus which is trapped in the wound during closure of the Caldwell–Luc incision, and subsequently begin to proliferate.[4] Herewith, we report a case of a 65-year-old female who presented with complaint of palatal swelling, having a history of maxillary sinus surgery 30 years ago.


   Case Report Top


A 65-year-old female presented with complaint of a swelling on the right side of the face since one year. The patient gave history of surgery for chronic sinusitis in the labial vestibule (Caldwell–Luc operation), 30 years ago. On extraoral examination, there was a diffuse swelling on the right side of the face, extending superiorly from the inferior orbital margin to 1 cm below the corner of the mouth and anteriorly from ala of nose to lateral canthus of eye; obliterating the nasolabial fold [Figure 1]a. It was hard and nontender on palpation.
Figure 1: (a) Extraoral examination revealing a diffuse swelling on the right side of the face and (b) intraoral examination revealed a soft, smooth-surfaced, fluctuant, dome-shaped swelling

Click here to view


Intraoral examination revealed a soft, fluctuant, nontender, and dome-shaped swelling. The overlying mucosa was smooth, bluish-pink in color with prominent blood vessels on the surface [Figure 1]b. Swelling was extending from the right canine region to maxillary tuberosity, obliterating buccal vestibule and not crossing the midline of the palate. Provisional diagnosis of benign cystic lesion was considered, and in differential diagnosis, residual cyst, mucocoele, and pleomorphic adenoma were included.

Due to overlapping structures in the maxillary region, the extent of lesion was not appreciable on orthopantomography, and therefore, cone-beam computerized tomography (CBCT) was advised. CBCT showed a corticated isodense lesion, pushing the maxillary sinus upward, decreasing the size and volume of sinus. Furthermore, massive expansion and perforation of buccal and palatal cortical plates along with deviation of the nasal cavity were noted on other sections of CBCT [Figure 2]a and [Figure 2]b.
Figure 2: (a) Cone-beam computed tomography showing a well-corticated isodense lesion pushing the right maxillary sinus upward and (b) cone-beam computed tomography showing the lesion causing massive expansion and perforation of buccal and palatal cortical plates

Click here to view


Aspiration yielded dirty mud colored, viscous fluid which showed numerous inflammatory cells in a background of red blood cells and few cholesterol crystals. Incisional biopsy only revealed a cystic lumen lined by fibrocellular connective tissue devoid of epithelium, suggestive of a cystic lesion. Considering it to be a benign cystic lesion, it was completely enucleated.

The microscopic examination of the excised specimen revealed a cystic lumen lined predominantly by pseudostratified ciliated columnar epithelium [Figure 3]a,[Figure 3]b,[Figure 3]c, with few areas exhibiting one to two cell layers of nonkeratinized stratified squamous epithelium [Figure 3]d. The connective tissue capsule was loose, fibrocellular with few hyaline or mucoid-like areas adjacent to the epithelium. Diffuse areas of mild chronic inflammatory cell infiltrates with few cholesterol clefts and peripheral bony trabeculae were also noted.
Figure 3: (a) (H and E, ×4) stained section showing a cystic lumen lined by pseudostratified ciliated columnar epithelium, (b) (H and E, ×10) stained section showing a cystic lumen lined by pseudostratified ciliated columnar epithelium with loose fibrocellular connective tissue capsule, (c) (H and E, ×40) stained section showing pseudostratified ciliated columnar epithelium having goblet cells, and (d) (H and E, ×10) stained section showing one to two cell layers of nonkeratinized stratified squamous epithelium

Click here to view


Among the differential diagnosis, pseudocysts do not have an epithelial lining, while mucoceles of maxillary sinus are rare and commonly involve frontal sinus. Radicular cysts can expand to the maxillary sinuses but are lined by stratified squamous epithelium and are associated with infected tooth.[2],[5],[6] Antral polyp may also present as dome-shaped lesion on maxillary sinus floor but are often multiple, pendulous, and irregular in shape.

The final diagnosis, on the basis of clinicoradiohistopathological features along with the history of maxillary sinus surgery, was given as postoperative maxillary cyst.


   Discussion Top


Different pathologic conditions can affect the maxillary sinuses and are frequently confused and misinterpreted.[5] There could be either intrinsic pathologies, that is, which originate primarily from tissues of sinus such as sinusitis, antral polyp, and mucocele, or extrinsic pathologies, that is, which originate outside but impinge or infiltrate the maxillary sinus such as odontogenic cysts or tumors.[7]

The term “postoperative maxillary cyst” or “surgical ciliated cyst” is derived from the fact that it is a delayed complication arising years after surgery involving the maxillary sinus.[1] It is most commonly associated with history of operation for maxillary sinusitis, particularly Caldwell–Luc procedure, but may also result from gunshot injuries, fractures of the malar–maxillary complex, and mid-face osteotomies. Even cases have been reported after orthognathic surgery and traumatic tooth extraction in mandible.[3],[8],[9]

The majority of the patients are in the fourth and fifth decades, with age ranging from 21 to 72 years. The patients may complain of pain, discomfort, or swelling in the cheek or face, or intraorally in the palate or alveolus. There can be presence of pus discharge.[2]

Radiographs reveal a well-defined radiolucent area closely related to the maxillary sinus. In early lesions, no destruction of bone is evident, but as they enlarge the sinus wall becomes thinned and eventually perforated (Gardner and Gullane, 1986) and may resemble a malignant neoplasm (Basu et al., 1985). Gradually, the cyst expands beyond the original boundaries of the sinus, as also seen in our case.[1]

Histologically, the cysts are lined by pseudostratified ciliated columnar epithelium, with squamous metaplasia in chronically inflamed areas. Combinations of ciliated, cuboidal, and squamous epithelium with varying numbers of mucous cells may be seen. The underlying connective tissue may be cellular or fibrotic (Gardner and Gullane, 1986). Foam cells, cholesterin clefts, hemosiderin, and foci of calcification may be present.[1]

Sugar et al. (1990) have suggested that in most cases enucleation through an approach appropriate to the site is the treatment of choice. Marsupialization for unilocular cysts with a thin wall and extensive bony perforation is also proposed by Yoshikawaet al. (1982).[9]


   Conclusion Top


A comprehensive patient history, which is most often lacking, can be very helpful in guiding toward the final diagnosis, as it played a significant role in diagnosis of our case. Due to complications of Caldwell–Luc operation, it is largely replaced by endoscopic nasal antrostomy, but prevalence of postoperative maxillary cysts might increase because of the rapidly increasing number of the cases of orthognathic surgery for cosmetic purposes. Hence, this entity should always be considered in differential diagnosis of oral lesions in patients having history of surgery involving maxillary sinus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Shear M, Speight P. Cysts of the Oral and Maxillofacial Regions. 4th ed. Oxford: Blackwell Munksgaard; 2007. p. 167-70.  Back to cited text no. 1
    
2.
Bulut AŞ, Sehlaver C, Perçin AK. Postoperative maxillary Cyst: A case report. Patholog Res Int 2010;2010:810835.  Back to cited text no. 2
    
3.
Nishioka M, Pittella F, Hamagaki M, Okada N, Takagi M. Prevalence of postoperative maxillary cyst significantly higher in Japan. Oral Med Pathol 2005;10:9-13.  Back to cited text no. 3
    
4.
Basu MK, Rout PG, Ripple JW, Smith AJ. The post-operative maxillary cyst experience with 23 cases. Int J Oral Maxillofac Surg 1988;17:282-4.  Back to cited text no. 4
    
5.
Araujo RZ, Gomez RS, Castro WH, Lehman LF. Differential diagnosis of antral pseudocyst, surgical ciliated cyst, and mucocele of the maxillary sinus. Ann Oral Maxillofac Surg 2014;2:10-6.  Back to cited text no. 5
    
6.
Ragsdale BD, Laurent JL, Janette AJ, Epker BN. Respiratory implantation cyst of the mandible following orthognathic surgery. J Oral Maxillofac Pathol 2009;13:30-4.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
White SC, Pharoah MJ. Oral Radiology-Principles and Interpretation. 1st ed. South Asia, India: Elsevier; 2014. p. 473-4.  Back to cited text no. 7
    
8.
Lee JH, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC, et al. Bilateral postoperative maxillary cysts after orthognathic surgery: A case report. Imaging Sci Dent 2014;44:321-4.  Back to cited text no. 8
    
9.
Yashikawa Y, Nakajima, Kaneshiro, Sakaguchi M. Effective treatment of post-operative maxillary cyst by marsupialization. J Oral Maxillofac Surgery 1982;40:487-91.  Back to cited text no. 9
    

Top
Correspondence Address:
Pooja Siwach
Department of Dentistry, Government Medical College and General Hospital, Dhule, Mumbai - 424 001, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_259_18

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed1208    
    Printed20    
    Emailed0    
    PDF Downloaded31    
    Comments [Add]    

Recommend this journal