Palatal Swelling of Unknown Etiology

•58 yo caucasian male presents with CC:  “ I have had facial swelling, muscle contractions, and clenching issues for 3 weeks, but this morning at 5am my palate swelled up behind my front teeth and it feels like my throat and face swelled too.  10/10 pain.”  pt. self-medicated with benadryl
•Med HX: patient has history of 2 pulmonary embolisms (PEs) approximately 1 year ago and is taking warfarin.  His INR is 3.8 which is really pretty high.  He also has hypertension and is taking Losartan.
•Clinical Findings:  Pt has a 2cmx2cm palatal swelling on the palatal aspect of #8-10 area.  Patient is in so much pain he didn’t want us to turn the lights on and had difficulty speaking.  #8-10 are all quite sensitive to percussion and palpation.  #6-11 all respond to cold with no lingering.   PA number 8-9 reveals a heart-shaped lesion which is splaying the roots of both teeth distally.  All teeth have intact lamina duras. 
Because of the odd presentation I also ordered a CBCT.  CBCT revealed a football shaped lesion that extended from the nasal cavity down to just behind the central incisors.  The palatal swelling appeared to be continuous with the lesion and was exquisitely sensitive to palpation. 
•DX:   Nasopalatine duct cyst with concomitant , non-odontogenic infection.
•TX:  Due to the warfarin use I decided to use my anesthetic for a needle aspiration of the palatal lesion to rule out hemangioma.  This resulted in a purulent exudate.  At this point I made a 2mm incision at the anterior portion of the swelling and proceded to message out the purulent exudate. I was able to drain the lesion to the point that it had a deflated look and the patient expressed notable decrease in the pressure/pain.  Hemostasis was achieved readily and I prescribed: 
–Dexamethazone 4mg, Disp 6tabs, Sig:  take one in the morning and one at noon for three days
–PenVK 500, Disp 30 tabs, Sig:  Take 1q6hrs until gone.
–Ibuprofen 600, Disp 20 tabs, Sig:  Take 1q6hrs prn pain.
•Referral:   Referral to Oral surgery for the next morning to determine source of infection and definitive treatment.  The next day the patient was feeling 90% better so the OS referral scheduled him for a week from now.  His explanation was that the Nasopalatine duct became seeded with bacteria from some unknown reason, but it was clear that it wasn’t from an odontogenic infection based on my testing and the CBCTs revealing the intact lamina dura of all the teeth in the area.

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