Postoperative Maxillary cyst (POMC)

Diego Gonzalez

Dr. Diego Gonzalez

A postoperative maxillary cyst (POMC) is a benign lesion arising from trauma or surgery involving the midface, specifically the maxillary antrum, as a late complication. It is usually locally aggressive, and accounts for approximately 20% of the lesions seen in Japanese patients undergoing extensive maxillary sinus surgery.

According to the available literature, the insertion of mucosal cells between the bony edges of a fracture or osteotomy may result in the cystic degeneration that precedes this type of lesion (1).
The clinical and histological characteristics of a POMC are often mixed, with fibrous connective and myofibroblastic tissue in the surrounding anatomy, which could make the diagnosis difficult or misleading

A POMC is also called a surgical ciliated cyst, postoperative paranasal cyst, or respiratory implantation cyst (2) (3). It is a well-known pathological entity, commonly associated with corrective, reconstructive, or trauma surgery. A POMC usually develops unilaterally as a solitary lesion, with a bilateral appearance being very rare (3) (4). The current American literature shows only a few reports of cases involving unilateral POMCs, but no bilateral cases. The largest report of POMCs known to date consists of 71 patients (5), while the most relevant literature regarding this entity has been published by different Japanese and Korean groups (6). This lesion appears less frequently in the Western literature likely due to misdiagnoses (6) and a lack of publication; therefore, we encourage the reporting of such a pathology. Moreover, a retrospective study is necessary to determine the incidence of this lesion in the American population.

Some reports have suggested two possible etiologies for POMCs: the closure of the natural ostium and intranasal opening, along with the entrapment of the sinus mucosa, and the retention of tissue fluid/blood after a surgical procedure (2) (7). These cysts are usually lined by pseudostratified columnar ciliated epithelium of the respiratory type, which may be focally replaced by squamous, cuboidal, or columnar epithelium (8), with surrounding fibrous connective tissue (9). Radiographically, it appears as a well-defined unilocular radiolucency in the maxillary sinus, capable of eroding the surrounding bony structures if not treated. Its appearance can vary from between 3 and 60 years after the traumatic event occurs (10), with a good long term prognosis once the lesion is removed and normal sinus draining is achieved (3) (10) (11).

The diagnosis of a POMC can be completed using a biopsy alone, but we decided to perform an immunohistochemical analysis of the extracted tissue to determine the most common markers (Table 1). Actin, desmin, and S-100 are among the most common markers in either normal or pathological fibrous connective tissue, and as expected, POMCs possess similar markers due to their mixed cellular components.

A POMC is a benign pathology that could appear up to 60 years after a maxillary trauma, without evidence in the literature of any malignant transformation (6). However, it should be treated promptly, in order to prevent complications associated with the surrounding anatomical structures, and to ease the course of treatment. This will result in a less traumatizing experience for the patient.

In order to determine the extent of the lesion, a maxillofacial CT (12) is important to outline the characteristics of a POMC, which will become very important when planning surgery (13) (14). This pathology is usually misdiagnosed due to the common fibrous findings in a traumatized maxillary sinus, along with a poor clinical description and/or lack of corresponding imaging. The histology of a POMC could be potentially confusing because of the extensive fibrous repair of a previous trauma, and could render the diagnosis difficult (11) (15)since the presence of respiratory
epithelium is a mandatory finding in the maxillary sinus. Other lesions of the maxillary sinus that must be considered in the diagnosis of a POMC are mucous retention cysts and maxillary pseudocysts (16) (17) (18). According to Gardner (19), histologically, these lesions share pseudostratified columnar epithelium (15) (20) (21); however, they do not usually follow an aggressive pattern, displacing or reabsorbing the surrounding bony structures, when compared to POMCs (4).
We have reported this case here because this disease requires more attention in order to obtain an adequate rate of incidence in the Western population. Therefore, we encourage other researchers to conduct a retrospective study of the American literature for a further evaluation of this pathology.

 

Bibliography

1. Surgical ciliated cyst: a delayed complication in a case of maxillary orthognathic surgery. Hayhurst DL,
et al. s.l. : Med Oral Patol Oral Cir Bucal., 2009, Vols. 4 (7):E361-4. .
2. A buccal cyst occurred after radical operation of the maxillary sinus. Kubo I, et al. 1927, Zeitschrift fur
Oto-Rhino-und-laryngologie., Vol. 1, p. 896.
3. Bilateral postoperative maxillary cysts after orthognathic surgery: A case report. Lee JH, et al. Seoul,
Korea : Imaging Science in Dentistry, 2014, Vols. 44(4): 321–324.
4. Postoperative maxillary cysts: Magnetic resonance imaging compare with computer tomography.
Chindasombatjaroen J., et al. 2009, Oral Surg Oral Med Oral Pathol Oral Radiol Endod, Vol. 107(5), pp.
e38-e44.
5. The postoperative maxillary cyst: report of 71 cases. Kaneshiro S, et al. s.l. : J Oral Surg., 1981, J Oral
Surgery, Vols. 39(3):191-8, pp. 191-199.
6. Bilateral Postoperative Cyst after Maxillary Sinus Surgery: Report of a Case and Systematic Review of
the Literature. B. M. Niederquell, et al. 6263248, s.l. : Hindawi Publishing Corporation Case Reports in
Dentistry, 2016, Vol. 2016.
7. Problems relating to postoperative maxillary cyst. Mohri M., et al. 1977, Journal of Otolaryngology,
Vols. 80(4):326-33., p. 326.
8. Cyst of the oral regions. Shear M., et al. 1976, Bristol: Jhon Wright and Sons, pp. 129-130.
9. Clinicopathologic study of the postoperative maxillary cyst. Yamamoto H., et al. 1986, Oral Surg Oral
med Oral Pathol, pp. 544-548.
10. Surgical ciliated cyst of the maxilla. Clinical case. Cano J., et al. 2009, Med Oral Patol Oral Cir Bucal.,
Vol. 14(7), pp. 361-364.
11. The post-operative maxillary cyst; experience with 23 cases. Basu M.K., et al. 1988, Int. J. Oral and
Maxillofac.l Surg., Vol. (5), pp. 282-284.
12. A comparative study of the radiological diagnosis of postoperative maxillary cyst. Heo M.S., et al.
2000, Dentomaxillofacial Radiology, Vols. (6):347-51, pp. 347-351.
13. Cystic Expansile Masses of the Maxilla: Differential Diagnosis with CT and MR. Han M.H., et al. 1995,
American journal of Neuroradiology, Vol. (2), pp. 333-338.
14. Effective treatment of the postoperative maxillary cyst by marsupialization. Yoshikawa Y, et al. 1982,
J Oral Maxillofac Surg, Vols. 40(8):487-91, p. 487.
15. Surgical Ciliated Cysts May Mimic Radicular Cysts or Residual Cysts of Maxilla: Report of 3 Cases.
Leung Y., et al. 2012, J Oral Maxillofac Surg, Vol. 70(4), pp. e1-e6.
16. Surgical Ciliated Cyst After Maxillary Orthognathic Surgery: Report of a Case. Amin M., et al. 2003, J
Oral Maxillofac Surg, Vol. 61(1), pp. 138-141.
17. PostoperativeMaxillary Cyst: A Case Report. Asiye S., et al. 2010, Pathology Research International.
18. Post operative maxillary cyst: Report of an unusual presentation. Shakib K., et al. 2009, British J. of
Oral and Maxillofac.l Surg, Vol. 47(5), pp. 419-421.
19. Pseudocyst and retention cyst of the maxillary sinus. Gardner, D. 1984, Oral Surg Oral Med Oral
Pathol, Vol. 58(5), pp. 561-567.
20. Maxillary sinus mucocele presenting as a late complication of a maxillary advancement procedure.
Thio D., et al. 2003, The Journal of Laryngology and Otology, Vol. 117(5), p. 402.
21. Surgical ciliated (postoperative maxillary) cyst following mid-face osteotomies. Sugar A.W., et al.
1989, British J. of Oral and maxillofac. Surg., Vol. 28(4), pp. 264-267.

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