Surgical Ciliatedcyst of the Maxilla

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C A S E R E P O R T

Surgical ciliated cyst of themaxilla followingmaxillaryosteotomy:a case reportC.A. Koo Min Chee1, D.J. Brierley2,K.D.Hunter2,C.Pace1 & A.J. McKechnie3

1Departmentof Oraland MaxillofacialSurgery,ChesterfieldRoyalHospital,Calow2AcademicUnit of Oraland Maxillofacial Pathology, The Schoolof Clinical Dentistry,Sheffield3Departmentof Oraland MaxillofacialSurgery,The Charles Clifford DentalHospital, Sheffield,UK

Keywords:

dental cyst, orthognathicsurgery,post-operative

maxillary cyst, surgicalciliatedcyst

Correspondenceto:

MrAJMcKechnie

Departmentof Oraland Maxillofacial SurgeryTheCharles Clifford Dental Hospital

WellesleyRoad

Sheffield S10 2SZ

UK

Tel.:+01142717804

Fax:+01142717863

email: [email protected]

Accepted:12April2013

doi:10.1111/ors.12041

Abstract

A healthy 42-year-old male presented with a 1-week history of pain asso-

ciated with a swelling localised to the upper right quadrant of his mouth.

The patient had undergone a bimaxillary osteotomy 20 years previously. An

initial clinical diagnosis included an inflammatory or developmental odon-

togenic cyst leading to enucleation of the lesion. Post-operative histopa-thology revealed a diagnosis of surgical ciliated cyst of the maxilla. This case

highlights the need for awareness of this cyst to ensure appropriate patient

management.

Case report

A 42-year-old man who had undergone a bimaxillary

osteotomy 20 years ago presented with a 1-week

history of throbbing pain associated with a swelling

localised to the upper right quadrant of his mouth. He

also reported a persistent headache.

Extraoral examination showed a soft, non-fluctuant,

tender swelling just beneath the right zygoma. There

was no cervical lymphadenopathy or neurological

signs, but mild trismus was noted. Intraorally, there

was a well-defined, tender, mucosa-coloured swelling

in the upper right buccal sulcus adjacent to the maxil-lary molars. There was no evidence of bony expansion.

None of the teeth in this quadrant were tender to per-

cussion; however, the upper right second molar had a

7 mm periodontal pocket, and was unresponsive to

ethyl chloride and electric pulp testing. A straw-

coloured discharge was also noted distal to the upper

right second molar.

A sectional panoramic radiograph revealed an

unerupted upper right third molar associated with a

well-defined periapical radiolucency extending distallyto involve the maxillary tuberosity. The teeth showed

no evidence of caries. An L-shaped metal plate from the

previous osteotomy was also evident (Fig. 1).

A cone beam computerised tomography scan con-

firmed the radiolucency but showed an opacity in the

right maxillary sinus associated with erosion of the

lateral antral wall. The sagittal views showed a line of

cortication within the soft tissues filling the right max-

illary sinus, suggesting that the lesion was cystic in

nature (Fig. 2).

Cyst enucleation was performed under general

anaesthesia. A mucoperiosteal flap was raised bymaking a crevicular incision around the upper right

second and third molar. Once exposed, a cystic lesion

was evident extending through the lateral maxillary

wall of the sinus into the antrum. True bony destruc-

tion was difficult to ascertain as it was unclear whether

the lesion had extended through an iatrogenic bone

defect caused by previous orthognathic surgery. The

upper right wisdom tooth was extracted and the cyst

lining sent for histopathological examination. The

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wound was closed primarily, and the patient was dis-charged with post-operative antibiotics, analgesia and a

decongestant. Recovery was uneventful and the

patient is currently under review with no signs of

recurrence.

Histopathological examination showed chronically

inflamed granulation tissue, lined by ciliated columnar

epithelium (Fig. 3). A thick fibrous wall comprising

variably dense fibrovascular connective tissue sur-

rounded the granulation tissue. Focally, the fibrous

tissue was dense, acellular and hyalinised. The features

were described as being consistent with a surgical cili-

ated cyst of the maxilla.

Discussion

Surgical ciliated cysts (also known as post-operative

maxillary cyst, post-operative paranasal cyst or

mucocele, respiratory implantation cyst and surgical

implantation cyst), first described by Kubo in 19271, are

reportedly more common in the Japanese populationcompared with other populations2. They occur in up to

20% of Japanese patients following radical maxillary

sinus surgery3. The reported UK incidence is much

lower. Fewer cases have been reported in the UK with

the majority occurring following sinus surgery and a

small number following orthognathic procedures46.

The surgical ciliated cyst has a slight male predilec-

tion2. There is a wide presenting age range from 21 to

80 years, and it is reported to occur 361 years follow-

ing maxillary sinus surgery2.

Surgical ciliated cysts may share some features seen

in cysts of odontogenic or glandular origin. Both den-tigerous and radicular cysts can show respiratory dif-

ferentiation, but it is rarely the only type of epithelium

present. The panoramic radiograph and surgical

removal of the lesion showed that the cyst did not

appear to originate from the amelocemental junction

or apex of any tooth. The upper right second molar

was unresponsive to vitality testing but had no evi-

dence of caries or restoration. A previous report sug-

gested that surgical ciliated cysts can interfere with the

Figure 1 Sectional panoramic radiograph showing radiolucency associ-

atedwith theuneruptedupperright thirdmolar.

Figure 2 Cone beam computerised tomography (CT) showing soft tissue

masswithinthe rightmaxillarysinus withevidenceof cortication.

Figure 3 Histology showing granulation tissue lined by ciliated columnar

epithelium(10 magnification).

Surgicalciliated cystmaxilla KooMinChee et al.

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neurovascular supply of nearby teeth7. Antral pseu-

docysts, retention cysts and mucoceles of the maxil-

lary antrum related to obstruction of the sinus ostium

should also be considered when faced with a cystic

lesion in this region. However, the patients past

history, radiology and histology were most consistent

with a surgical ciliated cyst.The most widely accepted pathogenesis of the surgi-

cal ciliated cyst is thought to be due to the entrapment

of sinus mucosa in the wound following surgery

(traumatic theory)3.

Definitive diagnosis is made by histological exami-

nation of the cyst lining. However, biochemical analysis

of the fluid aspirate to determine the levels of gly-

cosaminoglycans may assist with reaching a diagnosis

in the earlier stages of presentation8.

It has been suggested that recurrences of surgical

ciliated cyst are rare, but could happen if the cystic

lining is incompletely removed, and that if cysts are

large and complete enucleation is not guaranteed,

marsupialisation should be performed first9.

Although a rare complication following orthognathic

or other sinus surgery, an increased alertness to surgical

ciliated cysts will ensure timely referrals, and avoid

delays in diagnosis and treatment. This case also high-

lights the importance of meticulous surgical technique

to avoid entrapment of sino-nasal mucosa, which could

lead to cyst formation.

Acknowledgements

There are no conflicts of interests.There are no financial disclosures to declare.

References

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KooMinChee et al. Surgicalciliated cystmaxilla

41OralSurgery 7 (2014) 3941.


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Surgical Ciliatedcyst of the Maxilla