Globulomaxillary cyst invading the maxillary sinus

GLOBULOMAXILLARY

CYST INVADING

THE MAXILLARY

SINUS

Report of Two Cases

FREQUENCY

ASD

OCCURRENCE

cysts arc rare. Approximately 135 cases appear to be reliterature. Among 300 maxillary cysts operated on in the Dcpartrncnt of Surgcr’y of the Royal School of Dentistry in Stockholm from 1955 to 1960, only two (0.6 per cent) have been globulomaxillar? cysts. In each of these cases the cyst, invaded a major part of the maxillar!. sinus. LOBULOMAXILLSRY

G corded in the available

PATHOGENESIS

The globulomaxillary cyst, develops in the alveolar process of the maxilla between the root,s of the lateral incisor and the canine. Heredity has been mcntioned in one case reported by Thomal and is considered R “good possibility” by Sayer and Scully.:’ PATHOLOGY

The cystic sac in the globulomaxillar~ cyst is gencrnlly thick, tough, and firmly attached to the alveolar margin between the teeth, a feature which is characteristic of all the so-called fissural cysts. Microscopically, the wall consists of a dense conncctivc t,issuc mcmbranc lined with a stratified squamous epitheliurn which has deep projections into the underlying tissue. In the case reported by Robinson and his colleagues,” areas lined by ciliar columnar epithelium were also observed. SYMPTOXS

The globulomaxillary cyst, may remain unrecognized for a long tzime. It, develops as a nontender, expanding process in the bone and cause the> I+oots ol’ the canine and lateral incisor to diverge. This divcrgencc~ is an early s)-mptoul ant1 may constitute the first clinical indication of the presence of SIIC+ 21cayst. By its expansion, the cyst extends beyond the apices of the adjoining troth. In som(~ *Head Sweden.

of

Department

of

Surgery,

Royal 392

School

of

Dentistty,

Stockholm

and

Umeb.

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CYST

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cases incision of the cyst has resulted in the discharge of a clear fluid. A vitality test of the adjacent teeth normally elicits a positive response. The roentgenogram establishes a radiolueent, well-defined, and often more or less pear-shaped area between the roots of the canine and lateral incisor, with a well-demarcated periodontal space upon both. Treatment consists of surgical removal, which may be difficult because of the firm attachment to the alveolar margin. Cases have been recorded in which the expanding process has encroached upon the maxillary sinus.4 Since this complication is rare, I feel justified in reporting two cases that have come under my observation. CASE REPORTS CASE 1.--A 26-year-old woman was referred by a dentist who found a pathologic process in the region of the upper left lateral incisor and canine during a routine roentgpnographic examination. The process had presented no symptoms, and the patient was feeling perfectly well. A firm swelling of moderate size was found on the alveolar process in the region from the upper left canine to the upper left second molar on both the vestibular and the palatal sides. On the vestibular side there was an opening from which pus was discharged. There was no tenderness. Routine examination was essentially negative. A roentgenogram revealed a well-defined radiolucent cystic area, the size of a prune (Fig. 1). The cyst occupied a major part of the maxillary sinus and caused a displacement of the nasal cavity as well as of the sinus. Injection of a contrast medium through the opening demonstrated no communication with the maxillary sinus (Figs. 2 and 3). Treatme&-An operation was performed through an anterior incision. A mucoperiosteal flap was detached from the capsule of the cyst. The cyst, which was only covered by bone from the region of the lateral incisor to the first and second molars, was bluntly isolated and removed without leakage into th(s nose or maxillary sinus. Thr roots of the upper left lateral incisor and cani’ne were amputated. The wound was closed with sutures. Pathologic Eeport.-The cystic wall was polypoidal and thick. Microscopic examination revealed a cystic membrane of dense fibrous connective tissue covered by a squamous-cell epithelium and presenting pronounced inflammation. The diagnosis was globulomaxillary cyst with extension into the maxillary sinus. O&corns.-The postoperative course was uneventful, and the patient was discharged feeling well. At a follow-up examination four yrars later the patient presented no symptoms; there WAS no facial disfigurement, and no swelling was found in the vestibule. A roentgenogram revealed that bony tissue had grown and filled all hut a small part of the cavity. CASE 2.--A 22.year-old man sought medical advice bule corresponding to the right nasolabial furrow. The patient was a child, and it had grown steadily. Two viously, the last time because a cyst originating from suspected, but the swelling had persisted. The patient

concerning a swelling in the vestiswelling was first noticed when the operations had been performed prethe upper right lateral incisor was had no pain, and there had been no

acute symptoms. Examination revealed a soft, nontender swelling, the size of a hazelnut, in the vestibular region. The lip and the ala nasi were elevated. The swelling was firmly attached to the underlying tissue. Roentgenographic examination revealed a radiolucent area, the size of a bean, beside the root of the lateral incisor u-hich had been operated upon previously. He-rxamioatioo of the roentgenograms taken three years earlier revealed a well-defined radiolucent area, the size of a prune, which occupied a major part of the right maxillary sinus (Figs. 4 and 5). The area did not reach the alveolar process, and it did not involve the adjacclnt structures of the teeth.

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GLOBULOMAXILLARY

Volume 16 Number 4

Treatment.-A Ac zyst was found ma1,gin. Although

IFig 3.-&w

Fig.

395

surgical procedure was performed through an incision in the vestib #tie. strongly adherent to the adjacent structures, particularly to the alvel alar it leaked at the isolation and a thick, broxynish fluid was discharged, the

1. Globulornaxillary

,l.-Case

CYST

cyst

2. Globulomaxillary

encroaching upon has been injected.

cyst

encroaching

the maxillary

sinus.

upon

maxillary

the

Contrast

med ium

sinus.

diss #e&ion was carried out successfully and the entire cyst,, which occupied a major part Of the sinus, was removed. The mucous membrane of tbe sinus was seen in the floor of the camrity but was not perforated. The air test was negative, and the bony walls were clear. The WOIund was closed.

I’rctholo,qic ~~po”t.-l\lic~lc)~~~~~li(~ t~xittuillilt ion r~~vc~:tlt~~lp;lrls of a. cystic* wall cwnsistillg of a fil,rous hyalinv conncc~tiw tissue. .kt donit~ plawq tlie \\a11 was covc~rrtl 1)~ :I well-demarcated thin c~pitholiurn of a metaplastic type, with one or more layers of cells with small, shrinking nuclei. Scattered t,hroughout \WI’C a slight cdcnn~, l~lwtling, and filninoi~l necrosis. Only a slight inflammatory iufiltrntion was f’ouncl. cyst with extension into the maxillary simw. The tliagnosiS was glolmlonmsillar~ O~tconrr.-The postoperative course was uneventful, and the patient was tlischargetl, feeling well, six days after the surgical procedure. At follow-up examination three years later, the patieut presented no symptoms. There war 110 discharge through the nope. no facial Ilisfigurement, anll no cvidencv of a fistula.

Two cast53 of microscopically verified globulomaxillar~ cyst which invaded a major part of the maxillary sinus arc: reported. Surgical removal was snwesst’nl in both wses, with no complications from the masillary sinus. REFERESCES 1. Hare,

0. (‘.: ORAL

An Ideal RTRC.,

ORAL

Result MED.

in the Entlodontic & ORAL PATH.

Approach

8: 865-866,

to the Glolmlomaxillar~

Cyst,

1955.

L?. Robinson, H. B. G., Koch, W. E., and jasper, L. H.: lnfectetl Am. J. Orthodontics & Oral Surg. 29: 608-611. 194X 3. Saver, B.. and Sculls. .T. B.: Fissural (‘ysts, Am. .r. Orthodontics

Globulomaxillar,v

Cyst,

8: Oral Surg. 29: X0-