The Enigma of a Massive Lesion Invading the Maxillary Sinus: A Case Report

Introduction

Radicular cyst is the most common odontogenic cyst. It can be best described as a periapical inflammatory lesion associated with a non-vital tooth. It usually presents as an asymptomatic, slow growing, painless swelling. The aggressive pattern of spread of this cyst is rather uncommon.¹ More often than not, a smaller size radicular cyst can be managed conservatively with root canal treatment without the need for enucleation. However, a larger variant of the same might mandate surgical enucleation.²

Case Presentation

A 55 year old male patient (Figure 1) reported to the Department of Oral and Maxillofacial Surgery, Chhattisgarh Dental College and Research Institute with a chief complaint of pain and swelling in the left upper back tooth region since one week. The pain was continuous in nature and increased at night time. Patient also experienced stuffiness in nose. He gave history of multiple fever episodes in the past two months and extraction of left upper teeth two days back followed by halitosis and faulty taste. No history of any topical balm/heat application was provided. The patient presented with a diffuse extra oral swelling on the left side of the face which was tender on palpation. Intraorally, swelling extended from the left lateral incisor to left first molar involving both the buccal and palatal aspects of the alveolar ridge. Pus discharge was noted from ipsilateral second and third molar extraction sockets. The first molar was noted to have distoproximal caries. Curettage and incisional biopsy from the sockets was done.

Radiographic examination of OPG (Figure 4a) and CT scan revealed a well-defined radiolucency involving left maxilla, and its sinus, crossing the midline up to the opposite side maxillary alveolus and lingual cortex. Impacted mesiodens were also evident. Despite the pathology’s vast extent, teeth vitality and integrity of vital anatomical structures were unviolated.

Surgical Technique

After the pre medical and pre anaesthetic check-up, patient was scheduled for surgery under general anaesthesia. 2% lignocaine with 1:80,000 adrenaline was administered via nerve block and local infiltration. A crevicular incision was placed from 15 to 26 with one releasing incision.

Mucoperiosteal flap was raised (Figure 2) and the thin, weak cortical bone present was removed for the exposure of cystic lining. Careful undermining was performed along the surface of bone to enucleate the cyst in toto. The inflamed maxillary sinus lining was also removed (Figure 3). The two impacted supernumerary teeth and 12, 11, 21, 22 were extracted. After thorough irrigation, primary closure was done using 3-0 silk suture. The enucleated cystic lining along with extracted teeth were sent for histopathological examination (Figure 3).

Hence, the provisional diagnosis of radicular cyst with respect to 26 was made. A surgical treatment plan of enucleation of cyst, removal of inflamed sinus lining along with extraction of involved teeth and impacted mesiodens was proposed.

The surgical site healed completely along with the resolution of symptoms. A three month post-op radiograph revealed good bone healing (Figure 4b). The histopathological evaluation report was suggestive of infected radicular cyst involving right maxillary sinus and maxilla.

Discussion

Radicular cyst is one of the odontogenic inflammatory cysts, with higher prevalence in maxilla (60%) compared to mandible.¹ They can be identified when patients report with complaints such as pain, as was in our case or may present as an accidental finding in radiographs. The epithelium of a radicular cyst is derived from periodontal ligament residue secondary to existing infection.² These cysts are usually slow growing causing root resorption, mobility and displacement of teeth, with accompanied symptoms of pain and swelling if infected.² The cyst has a radiopaque and hyperostotic margin which may be absent in cases of infection. In our case, however, the infected cyst had a well-defined radiopaque border. The differential diagnosis for such a pathology could be other cysts such as odontogenic keratocyst, dentigerous cyst, and odontogenic tumours such as ameloblastoma, cementoma and Pindborg tumour based on the similarities in radiological features. Therefore, it is necessary to differentiate the lesion using histopathologic evaluation. In extensive cases where advanced imaging is done, multilocular nature of the radicular cyst may be evident, as was observed in our case. Histopathologically, non-keratinized stratified squamous epithelium confirmed our diagnosis of radicular cyst.³ Malignant transformation of this cyst into squamous cell carcinoma if not properly treated has been reported in the literature.

The treatment ranges from conservative approach to surgical approach depending on the extent of the lesion.¹ Surgical treatment may include marsupialization or enucleation alongside extraction of involved teeth. However, marsupialization requires prolonged followup and uncomfortable healing period.

A more recent and alternative method is endoscopically assisted enucleation. It has a good conservative approach, providing fine visualization of the cyst and adjacent vital structures.

The post-op complications may include paresthesia, pathologic fractures, wound dehiscence and infections.⁴

In our case, wound dehiscence lead to formation of an oro-antral communication in the left distal most region. In the operation to eliminate this pathologic communication, infection control proved to be a vital step. Considering the site and extent of the cyst, buccal advancement flap and buccal fat pad were chosen. The palatal flap would fail to close the defect due to its labial location in the vestibule. Moreover, the palatal flap is mostly incorporated to close fistulas in premolar region.⁵ The buccal advancement flap is more successful in edentulous ridges with bone loss.^6,7 In this case, the elasticity of the buccal flap was compromised due to lack of periosteum owing to absence of bony structures and hence buccal fat pad was opted for its close proximity and ease of accessibility.^8,9

Enucleation of cyst along with removal of inflamed sinus lining is by far the most accepted and economical method in the management of a giant radicular cyst.

Conflict of Interest

None