Background <p>Median palatine cysts are uncommon nonodontogenic lesions found in the midline of the hard palate with only 22 cases reported in literature hitherto. Often asymptomatic, they are frequently discovered incidentally during routine clinical examination. We report a case of large median palatine cyst with a novel technique to mitigate the risk of oronasal fistula and give a brief review on the current literature on the entity.</p> Case Presentation <p>A 29-year-old male presented with recurrent purulent nasal discharge, right-sided nasal obstruction, fever, and headaches persisting for six months. Clinical examination revealed a mucosa-covered bulge obstructing the right nasal cavity and partially affecting the left. Intraoral examination identified a soft, fluctuant midline palatal swelling communicating with the nasal cavity. Computed tomography revealed a well-circumscribed midline opacity involving the hard palate and nasal cavity. Surgical excision was performed using a U-shaped mucoperiosteal flap. Intraoperatively, a breach in the nasal mucosa was noted, necessitating reconstruction with a buccal fat pad to prevent oronasal fistula formation.</p> Result <p>Histopathological examination confirmed the diagnosis of median palatine cyst, characterised by a fibro-collagenous cyst wall lined by stratified squamous epithelium. Postoperatively, the patient exhibited wound contracture with intact mucosa over the palate.</p> Conclusions <p>This case highlights the importance of timely diagnosis and appropriate surgical management of median palatine cysts to prevent complications such as oronasal fistula. The described surgical approach effectively addressed the cyst while minimizing the risk of postoperative complications, highlighting its efficacy in managing this rare entity. Long-term follow-up is essential to monitor for recurrence and ensure favourable outcomes.</p>