Abstract
A cutaneous sinus tract due to periapical cyst being very rare may easily be misdiagnosed, leading to incorrect treatment. Identifying the etiology is difficult, but it is the key to effective therapy. The case presented here is a cutaneous sinus tract in the nasolabial region of odontogenic origin. After surgery and extraction of the tooth, the sinus tract healed remarkably (Belmehdi et al. in Contemp Clin Dent 9:314–318, 2018; Latifa et al. in Clin Case Rep 10:e05333, 2022).
Keywords: Cutaneous sinus tract, Periapical cyst, Odontogenic sinus tract
Introduction
Due to its unusual frequency and lack of distinctive symptoms, a cutaneous sinus tract of odontogenic pathology is relatively uncommon and is frequently misinterpreted [3]. It consists of the tract that emerges from a confined region of infection or inflammation and travels to the cutaneous surface of the neck or face [4]. Swelling or pain is frequently absent as the periradicular lesion drains continuously from the sinus opening [5]. Cutaneous sinus tract usually results after the invasion of bacteria in the dental pulp. As the infection spreads into the periarticular region, necrotic impacted teeth present with apical periodontitis. Byproducts of purulent infection prefer the route with the least resistance, which is between facial planes, and form the draining cutaneous sinus tract opening [6].
This study aimed to provide an unusual case of a cutaneous sinus tract associated with an infected periapical cyst misdiagnosed and incorrectly treated for more than one year without any recovery. The sinus opening and the tract healed only after surgical removal of the cutaneous tract and the involved tooth.
Case Report
A 56-year-old healthy male patient presented himself to the Otorhinolaryngology department of this hospital. The patient came with a primary complaint of sinus opening in the right nasolabial fold. The patient reported a 1-year history of intermittent purulent discharge from the sinus opening that was previously treated with on and off antibiotics without any improvement. The patient had no past history of any toothache or dental infection. No intra oral swelling was present. Dental caries were observed with poor oral hygiene. On examination there was a presence of a crusty sinus orifice on right side cheek in nasolabial region which was around 0.6 cm in diameter. Light pressure in the surrounding area resulted in purulent discharge from the sinus opening. Contrast enhanced Computed tomography (CT) scan with sinogram was done. Sagittal and axial sections confirmed the diagnosis of sinus tract with its proximal part opening in right nasolabial fold showing tortuous course and its distal part ending up in periapical cyst at base of right upper lateral incisor tooth. These clinical and radiological interpretations made the diagnosis of cutaneous sinus tract in the nasolabial fold on right side, caused by a chronic periapical cyst.
Intraoperative tracing of the sinus tract was done by injecting methylene blue from the sinus opening. An elliptical incision was made around the sinus opening, and complete excision of the sinus tract was done. Dental extraction was done to prevent recurrence. External wound was closed in layers. The patient was given one week prescription of antibiotic medications (amoxicillin–clavulanic acid) along with anti-inflammatory medications and antiseptic mouth wash. Postoperative histopathological evaluation of the specimen confirmed the diagnosis of periapical cyst. Patient was reviewed after 7 days and then after 1 month which showed completely healed sinus tract (Figs. 1 and 2).
Fig. 1.
Pre-op images. a CT showing sinus tract b cutaneous sinus tract opening
Fig. 2.
Post-op images. a External b Intraoral
Discussion
Sinus tracts are abnormal connections between an infected site and an epithelial surface. Odontogenic sinus tract openings can be found anywhere extraorally or intraorally. Intraorally, the opening is usually located on the buccal gingiva or in the vestibule. Whereas extraorally the odontogenic sinus tract opening can be anywhere on the face and neck. Although rare lesions, odontogenic cutaneous sinus tract has been thoroughly recorded in the literature [3, 5]. However, inaccurate diagnosis and futile treatment is frequently seen [3]. Due to their site on the head-and-neck region, various medical specialties are interested in the cutaneous sinus tract [7]. Extraoral drainage is influenced by the position of the diseased tooth, as well as other elements like the virulence of the pathogen, patient’s immunity, and the relationship between facial muscle attachments and anatomy. The clinical presentation and appearance of these tracts frequently resemble other skin lesions [8]. Most of the times general practitioners and dermatologists are the primary health care professionals consulted by patients [7]. During the course of a year, our patient consulted and one dermatologist and three general practitioners, receiving various topical treatments, including antibiotics, without any remission. Similar to this, odontogenic cutaneous sinus tract rarely present with any obvious dental symptoms and might advance slowly without the patient becoming concerned [8]. A comprehensive intraoral examination should be done to identify whether there is a odontogenic cause [5]. Such odontogenic cutaneous sinus tract frequently develop as a result of chronic apical lesion caused by pulp degeneration or necrosis. If untreated, the apical infection may easily spread across the narrow space and perforate the cortical alveolar bone. In soft tissue, the infection follows the path with least minimum resistance between facial planes until exiting cutaneously [8].
The odontogenic cutaneous sinus tract is anticipated to disappear within 1–2 weeks, if correctly diagnosed and treated. It has been noted that systemic antibiotic medications will temporarily lessen the discharge and result in apparent healing [3]. However, unless the infection's source is found and treated, the sinus tract will return when antibiotic therapy is over [3]. Contrary to intraoral sinus tracts, extraoral tracts cause cutaneous scarring that heals with granulation tissue [5]. Patient may possibly require a revision scar surgery. The surgical revision is frequently uneventful and improves the cosmetic appearance.
In summary, determining the cause of the chronic draining sinus tract of the face may be exigent but is the secret to effective therapy. Cutaneous sinus tracts are not easy for diagnosis. The aperture of the sinus tract is far away from where it starts, so the treating physician should consider the likelihood of its dental origin to make an accurate diagnosis. With the help of radiological investigations, early diagnosis of a periapical root infection can be done. Unnecessary antibiotic medications can be avoided if accurate diagnosis is made. When the lesion results from extension of periapical cyst, surgery is the treatment of choice, and it will result in predictable and fast healing, reduce the probability of further complications like osteomyelitis and sepsis.
Funding
Non funded.
Declarations
Conflict of interest
Author Prasanna Moon and author Sanika Kalambe declare that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from the patient included in the case report study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
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