ORIGINAL ARTICLE

Management of Nasolabial Cysts by Transnasal

Endoscopic Marsupialization
Wei-Chieh Chao, MD; Chi-Che Huang, MD; Po-Hong Chang, MD;
Ying-Lin Chen, MD; Chiang-Wen Chen, MD; Ta-Jen Lee, MD

Objective: To evaluate hospitalization rates and dura- Main Outcome Measures: History, clinical presen-
tion of surgery associated with transnasal endoscopic mar- tation, preoperative condition, histopathologic find-
supialization compared with sublabial excision in treat- ings, treatment, complications, and outcomes.
ing nasolabial cysts.
Results: The mean duration of surgery was 91.3 min-
utes in the sublabial group and 29.5 minutes in the trans-
Design: Retrospective clinical series. nasal group (P =.003). The hospitalization rate was 100%
(23 of 23) in the sublabial group and 59% (20 of 34) in
Setting: Large urban community hospital. the transnasal group (P 1 .001). The medical costs were
significantly lower in the transnasal group than in the
Patients: Consecutive sample of 57 patients with na- sublabial group (P =.002). The follow-up period ranged
solabial cysts treated from January 1, 2000, to February from 6 to 85 months. Neither group of patients experi-
29, 2008. enced any major complications or recurrences during the
follow-up period.
Interventions : Sublabial excision in 23 patients Conclusion: Transnasal endoscopic marsupialization is
(sublabial group) and transnasal endoscopic marsupi- an effective treatment for nasolabial cysts, is less costly,
alization in 34 patients (transnasal group). Among 57 and has fewer complications than sublabial excision.
patients, 47 underwent preoperative computed tomog-
raphy. Arch Otolaryngol Head Neck Surg. 2009;135(9):932-935

ASOLABIALCYSTS ARE A matoma, soft-tissue swelling, wound infec-

rare disorder observed tion, and oronasal fistula.2-5 Su et al6 de-
primarily among per- scribed the use of transnasal endoscopic
marsupialization as an option in managing

N
nasolabial cysts. Although the procedure has
been performed easily and safely in pa-
tients, to our knowledge, no large-scale stud-
ies of this technique have been conducted.
The objective of this study was to compare
soni n theofWestrnAfrican ancestryworld.
traditional sublabial excision with transna-
Most patients are women aged 40 to 60 sal endoscopic marsupialization in the man-
years.1 Diagnosis is made on the basis of agement of nasolabial cysts. Our study rep-
clinical features such as midfacial asym- resents the largest series of patients with
metric swelling and nasal obstruction. The nasolabial cysts among the Chinese popu-
painless cysts develop slowly, but pa- lation to date. It is also the first study to de-
tients may be seen with an acutely pain- fine the cost-effectiveness and efficiency of
Author Affiliations: Division of ful swelling if the cyst becomes infected. transnasal endoscopic marsupialization for
Rhinology, Department of In some patients, facial cellulites may de- the treatment of nasolabial cysts.
Otolaryngology, Chang Gung velop after expansion of a secondary in-
Memorial Hospital (Drs Chao,
fection. 2-5 Clinically, the cysts appear as
Huang, Chang, Y.-L. Chen, METHODS
C.-W. Chen, and Lee), and
smooth fluctuant soft-tissue masses be-
Graduate Institute of Clinical tween the upper lip and nasal aperture,
Medical Sciences (Drs Huang with obliteration of the nasolabial fold and This study was approved by the Institutional
and Chang), Chang Gung elevation of the nasal ala. Review Board of Chang Gung Memorial Hos-
University, Taoyuan, Taiwan. Thus far, surgical excision through a sub- pital. Sixty patients diagnosed as having naso-
labial approach has been the most popular
and well-established procedure for the man-
agement of nasolabial cysts. Although prom-
ising results with low recurrence rates have
been reported, complications include he-
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labial cysts were treated at the Department of Otolaryngology,
Chang Gung Memorial Hospital in Taiwan from January 1, 2000, Table 1. Characteristics of Patients
to February 29, 2008. Three patients were excluded from the Having Nasolabial Cysts
study because of additional sinus surgery. Clinical medical rec- Treated With Sublabial Excision vs
Transnasal
ords of the remaining 57 patients were reviewed for history,
Endoscopic Marsupialization
clinical presentation, preoperative condition, histopathologic
findings, treatment, complications, and outcomes. Surgical speci-
Sublabial Transnasal
mens from all patients were reviewed by a pathologist.
Group Group
Diagnosis was made on the basis of anatomic location, ra-
Characteristic (n=23) (n=34) P Value
diologic findings, and histopathologic examination. The 57 pa-
Male to female ratio 6:17 9:25 .78
Age, mean (SD), y 49.3 (12.7) 48.6 (13.3) .45
tients had 59 nasolabial cysts (2 bilateral cases). Patients were Left side to right 12:11 12:20 (2 Bilateral) .96
divided into 2 groups according to whether they underwent sub- side ratio
labial excision (sublabial group) or transnasal endoscopic mar- Maximum cyst 14.7 (6.4) 21.2 (6.2) .001
supialization (transnasal group). A total of 47 patients (82%) diameter, mean
underwent preoperative computed tomography (CT). (SD), mm
Duration of surgery, 91.3 (36.9) 29.5 (9.6) .003
We performed transnasal endoscopic marsupialization as
mean (SD), min
documented by Su et al.6 The nasal cavity was shrunk with ir-
Hospitalization 23 (100) 20 (59) 1.001
rigated gauzes (Bosmin; Daiichi Pharmaceutical Inc, Tokyo, Ja- rate,
pan) for 5 minutes. Under endoscopic guidance, an incision No. (%) 23 955 (8328) 16 933 (6255) .002
was made along the anterior border of the protruding cyst. The Medical cost, mean
roof of the cyst wall and the nasal mucosa above it were ex- (SD), NT$
cised. The opening of the cyst was widened. Meanwhile, the
edges of the nasal mucosa and the cyst lining were trimmed
smooth. Loose nasal packing was then applied.
Statistical analysis was performed using commercially avail-
able software (SPSS, version 13.0; SPSS Inc, Chicago,
Illinois).
32 Test and Fisher exact test were used to calculate significant
differences between the 2 groups. Group differences were ana-
lyzed using the t test for continuous variables. The level of sig-
nificance for analysis was P 1 .05.

RESULTS

The transnasal group comprised 9 men and 25 women with

a mean age of 48.6 years; the sublabial group comprised
6 men and 17 women with a mean age of 49.3 years. Most
patients had a history of intermittent swelling over the na-
solabial area, usually characterized as a painless lump lo-
cated beneath the unilateral ala of the nose. In some pa-
tients, the lump protruded from the upper lip or effaced
the nasolabial fold, resulting in minor discomfort.
Cyst diameter varied from 6 to 40 mm as estimated
by CT. The maximum cyst diameter in the transnasal
Figure 1. Postoperative sinus computed tomogram of
group was significantly larger than that in the sublabial a right nasolabial cyst.
group (P =.001) (Table 1 ). Three years after transnasal endoscopic marsupialization, sinus-containing
The follow-up period ranged from 6 to 85 months. Both air has replaced the previous cyst with a patent stoma at the anteronasal
floor (arrowhead).
operations were successful in all patients. There were no
major complications in either group of patients.
Operations for 14 of 34 patients in the transnasal group sal floor even 3 years after surgery ( Figure 1 and
were performed on an outpatient basis. In the sublabial Figure 2 ). In the sublabial group, the wounds healed
group, all patients were hospitalized for the operation. The within 2 to 3 weeks, and postoperative sequelae in-
duration of surgery for patients in the transnasal group was cluded toothache, numbness of the perinasal area, and
significantly shorter than that for patients in the subla- swelling sensations of the upper lip. In the transnasal
bial group. The medical costs in the transnasal group were group, a patient experienced a nasal clicking sound when
significantly less than those in the sublabial group (Table 1). she compressed the alar area (Table 2 ). Endoscopy re-
The medical costs included all expenses incurred from the vealed a stricture orifice of marsupialized cavity with mu-
operation and postoperative hospitalization. cus retention. The patient refused further treatment be-
There was no evidence of recurrence among 57 pa- cause there were no obvious discomforts.
tients followed up for at least 6 months. Within 3 to 4
weeks after marsupialization, endoscopy revealed com-
COMMENT
plete epithelialization over the edge of the new opening.
Postoperative endoscopy and CT showed that the naso-
labial cyst was replaced by a ventilated sinus with a well- Nasolabial cysts account for only 0.7% of all maxillary
and mandibular cysts.7,8 Biologist Emile Zuckerkandl first
epithelialized ostium at the anterior or anterolateral na- described a nasolabial cyst in 1882.2 These cysts are most

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 neous nonenhancing cystic mass anterior to the pyri-
form aperture, showing no erosion or separation of the
underlying maxilla on CT and readily distinguishable from
vestibular or odontogenic abscesses, odontogenic cysts,
or other nonodontogenic maxillary cysts that occur in
identical locations. 10 Therefore, CT is a useful tool for
diagnosis and determination of the surgical approach. 11
Indications for surgery include prevention of second-
ary infection and correction of facial deformity. Previ-
ously, the most commonly used surgical method of sub-
labial excision had a low rate of recurrence but often
caused defects of the nasal floor, although most heal
quickly. Su et al 6 initially reported transnasal endo-
scopic marsupialization for nasolabial cysts in 1999, de-
scribing the procedure as a simple, effective, and less in-
vasive operation. They compared the 2 procedures in a
bilateral case, demonstrating shorter duration of sur-
Figure 2. A well-epithelialized ostium gery and less blood loss with transnasal endoscopic mar-
at the anterior or anterolateral nasal
floor persisting 3 years after marsupialization (arrow). supialization. In recent years, transnasal endoscopic mar-
supialization has been performed frequently in Taiwan.
To our knowledge, this study is the first attempt to con-
Table 2. Comparison of Numbers trast the 2 procedures using a statistical evaluation in a
of Postsurgical large group. In our study, the transnasal group ben-
Complications in the Patient Groups efited from a significantly shorter duration of surgery, a
reduced hospitalization rate, and lower medical costs. The
Sublabial Transnasal medical costs were significantly lower in the transnasal
Group Group
group mainly because of their lower hospitalization rate
Complication (n=23) (n=34) P Value
and shorter duration of surgery. As summarized in Table 1,
Facial swelling 6 1 .005 transnasal endoscopic marsupialization is a cost-
Facial numbness 4 0 .008
effective procedure for the treatment of nasolabial cysts.
Toothache 5 0 .002
Nasal clicking sound 0 1 .44 In our experience managing nasal sinus mucocele with
endoscopic marsupialization, one does not need to re-
move the lining mucosa of nasolabial cysts. A patent stoma
commonly seen among adults, with peak prevalence in is similar to a newly created paranasal sinus with cili-
the fourth and fifth decades of life, as was also seen in ated nasal mucosa. Ciliated respiratory epithelium is the
our series. The literature describes nasolabial cysts as rare, most common cell type in nasolabial cysts,1 and the lin-
but they seem to be frequently diagnosed among Asians. ing of most of these cysts typically features many goblet
Yuen et al9 reported a 5-year series of 18 patients. Our cells. However, Su et al12 observed no tufts of cilia over
series represents a large-scale study of nasolabial cysts the nasolabial cyst epithelial cells during scanning elec-
treated in a single institute for more than 8 years. tron microscopy. Instead, the luminal surfaces of all su-
There are 2 main hypotheses for formation of naso- perficial epithelial cells demonstrated numerous short
labial cysts. One theory presumes that the cysts origi- wide microvilli. In our study using only light micros-
nate from entrapped embryonic nasal respiratory epithe- copy, all specimens showed respiratory epithelium with
lium in a facial cleft formed by the merging maxillary, ciliated pseudostratified columnar and goblet cells. Fur-
medial, and lateral nasal processes. Hence, nasolabial cysts ther electron microscopic examination may be needed
are also classified as fissural cysts.2 Another theory pos- to reveal more detail. However, ciliated respiratory epi-
tulates that the cysts may emanate from misplaced epi- thelium or microvilli-like surface epithelium can help
thelium of the nasolacrimal duct because their location transport and prevent retention of mucus when the cre-
and histologic findings are identical.1 ated orifice is sufficiently large. As a consequence, a well-
The differential diagnoses for a painless vestibular soft- marsupialized nasolabial cyst could be integrated into a
tissue swelling within the anteromaxillary-alar region in- part of the nasal cavity, with acceptable physiologic func-
clude odontogenic, developmental, and neoplastic le- tion. We suggest that creating a sufficiently large stoma
sions.2 Because they are located in the same area, cysts is crucial to preventing the accumulation of mucus or re-
of the nasopalatine duct or incisive canal are often con- currence of the disease after transnasal endoscopic mar-
fused with nasolabial cysts. These odontogenic cysts are supialization.
usually intraosseous, and the extraosseous locations of Su et al6 reported that the transnasal endoscopic mar-
nasolabial cysts should render the differential diagnosis supialization technique is much easier to perform on larger
straightforward. 9 cysts. In our patients, protrusion of the cyst in the nasal
Smaller cysts can be difficult to detect. In our study, cavity was the main consideration in selecting an appro-
some smaller cysts were found incidentally during an priate surgical approach. Creating a sufficiently large
imaging evaluation for sinusitis. Nasolabial cysts may be stoma for drainage is facilitated by performing transna-
elusive with radiography, but CT allows a definite diag- sal endoscopic marsupialization in larger protrusive cases.
nosis. Nasolabial cysts are characterized by a homoge-

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With smaller lesions, it is difficult to find the cyst in the the surgical treatment of nasolabial cysts compared with
nasal cavity using an endoscope. We further found that sublabial excision, especially for patients with large le-
the size of the cyst closely parallels that of the protrud- sions. Transnasal endoscopic marsupialization can be per-
ing part in the nasal cavity (mostly in the nasal floor). In formed in an outpatient setting, with fewer postsurgical
the present study, the mean cyst diameter was signifi- sequelae than those associated with sublabial excision.
cantly larger in the transnasal group than in the subla-
bial group (P =.001). Therefore, the size of the cyst and Submitted for Publication: December 30, 2008; final re-
the related protruding part in the nasal cavity were im- vision received March 8, 2009; accepted March 18, 2009.
portant considerations when making decisions about an Correspondence: Ta-Jen Lee, MD, Division of Rhinol-
appropriate surgical approach. Based on this, sublabial ogy, Department of Otolaryngology, Chang Gung Memo-
excision may be a better choice of operation in patients rial Hospital, Chang Gung University, 5 Fu Hsing St, Kuei
with smaller lesions. Shan, Taoyuan, Taiwan (entlee@adm.cgmh.org.tw).
Transnasal endoscopic marsupialization can be per- Author Contributions: All authors had full access to all
formed safely in an outpatient setting. Nasal packing was the data in the study and take responsibility for the in-
not required in our patients. Minimal blood loss during tegrity of the data and the accuracy of the data analysis.
surgery was noted, and no postoperative bleeding was Study concept and design: Huang, C.-W. Chen, and Lee.
encountered. Nevertheless, as a safety precaution, we ini- Acquisition of data: Huang, Y.-L. Chen, and C.-W. Chen.
tially admitted most of our earlier patients undergoing Analysis and interpretation of data: Chao, Chang, and Y.-L.
transnasal endoscopic marsupialization into the hospi- Chen. Drafting of the manuscript: Chao and Y.-L. Chen.
tal, and only 14 patients in this group were treated in an Critical revision of the manuscript for important intellec-
outpatient surgery setting. tual content: Huang, Chang, C.-W. Chen, and Lee. Sta-
The mean duration of surgery for transnasal endo- tistical analysis: Huang, Y.-L. Chen, and C.-W.
scopic marsupialization was longer in our study than in Chen. Ad-
the study by Su et al.6 This may be because the cyst mu- ministrative, technical, and material support:Chao, Huang,
cosal lining was removed as much as possible to mini- Chang, Y.-L. Chen, and Lee. Study supervision: C.-W.
mize recurrence in our earlier patients, resulting in a Chen.
longer duration of surgery. Financial Disclosure: None reported.
Complications of sublabial excision of nasolabial cysts
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