Osteomyelitis of frontal sinus, zygomatic bone and maxilla

Abstract

A 52-year male patient reported with loosening of right upper jaw. He has no pain or discharge, or any acute symptoms and systemic disease. Intraoral examination reveals necrosed maxillary bone. He also has no sickle cell disease, hepatitis, HIV or tuberculosis. 3D CT scan reveals destruction of maxilla, maxillary sinus, lateral nasal wall, superior and inferior orbital wall, zygoma and frontal bone(outer table). The clinical diagnosis of osteomyelitis was made. Under general anaesthesia, sequestrectomy was done with the help of Weber-Ferguson incision with infraorbital extension for maxilla, maxillary sinus, zygomatic bone, lateral nasal wall and infraorbital and medial wall of orbit. Frontal sinus region sequestrectomy was done via bicoronal flap. The patient was completely diseased free after 4 years follow-up.

Background

Osteomyelitis (OML) of maxilla is very rare due to its rich collateral blood supply, thin cortical plates.¹ It is caused most commonly by Staphylococcus aureus, epidermidis, Actinomyces and Escherichia coli.² In the literature, the OML of malar bone is only 1.42% and OML of frontal sinus is extremely rare.³ We here in describe a case with OML of right maxilla extending to maxillary sinus, lateral nasal wall, zygomatic bone and inferior and medial orbital wall up to frontal sinus. The extension of OML to frontal sinus and zygomatic bone via maxillary bone is very rare; the present case described the successful management and early intervention. The patient also comes to us after consultation from various doctors at the local village; he also gives the history of multiple antibiotic course therapy that was given to him for many years for teeth pain. Multiple antibiotics for longer time also play a major role in the extension of OML of maxilla to the frontal sinus.

Case presentation

A 52-year male hardware vendor patient reported with chief complaint of loosening of right upper jaw. He has no pain or discharge, or any acute symptoms and systemic disease. Intraoral examination reveals necrosed maxillary bone and presence of few mobile teeth (figure 1). His complete blood count, packed cell volume, liver and kidney function test, fasting and post meal blood sugar were within normal limits. He has no sickle cell disease, hepatitis, human immuno deficiency virus (HIV) or tuberculosis. He gave the history of multiple antibiotic course therapy that was given to him for many years for teeth pain. No history of similar disease was found in the family of the patient. The history reveals the chronic nature of the pathology.

Figure 1.

Intraoral view of necrosed maxillary bone.

Investigations

A CT scan was done showing necrosis of supraorbital rim and lateral wall of frontal sinus (figure 2A), necrosis of frontal bone (figure 2B) along with a digital volume tomography scan (figure 2C), which showed necrotic bone.

Figure 2.

(A) CT scan showing necrosis of supraorbital rim and lateral wall of frontal sinus. (B) CT scan showing necrosis of frontal bone. (C) 3D CT scan showing necrosis of maxilla, infraorbital and supraorbital RIMs, and frontal bone.

Cone beam CT (CBCT) demonstrated severe bone lose around teeth resulting in loosening of teeth, necrosed maxillary bone and progression of disease involving maxillary sinus, nasal cavity, orbital bones and cavity in association with the frontal sinus (figure 3A–C).

Figure 3.

(A) CBCT scan showing necrosed maxillary bone and disease progression to maxillary sinus. (B) CBCT scan showing necrosed maxillary bone. (C) CBCT scan showing progression of the disease to nasal cavity and orbit.

Differential diagnosis

Necrosed bone without any nodal involvement and the chronic nature of disease helps us to reach the diagnosis of chronic OML of maxilla extending up to the frontal sinus.

Treatment

Under general anaesthesia, sequestrectomy was done with the help of Weber-Ferguson incision with infraorbital extension for maxilla, maxillary sinus, zygomatic bone, lateral nasal wall, infraorbital and medial wall of orbit (figure 4). A modified Weber-Ferguson incision with Borle’s extension⁴ was kept as a part of treatment plan if reconstruction was planned with extended temporalis myofascial flap.⁵

Figure 4.

Exposure through Weber-Fergusson incision with infraorbital extension, showing necrosed bones.

Frontal sinus region sequestrectomy was done via bicoronal approach (figure 5). Incisions over scalp often bleed a lot, hence a scalp tourniquet was used to control excessive haemmorrhage.⁶ Bone mapping was done in order to replace the healthy bone following complete currettage.⁷ The sequestrum was removed, bone curettage done and fresh bleeding created from the margins of bone (figure 6). In the present case, the posterior table was intact and thus preserved. Irrigation of the surgical site was done with the help of a solution containing hydrogen peroxide, povidone iodine and normal saline. No healthy bone was left for replacing over the defect. The patient was given routine injectable antibiotics (covering both aerobic and anaerobic) and anti-inflammatory and analgesics. Hydration of the patient was maintained via intravenous fluid therapy and with the help of Ryle’s tube.

Figure 5.

Bicoronal flap reflected showing perforations in frontal bone.

Figure 6.

After sequestrectomy of frontal sinus (anterior table).

Outcome and follow-up

Patient’s postoperative healing was uneventful, and suture removal was done on the 7th postoperative day. He was discharged on 10th postoperative day after shifting to oral antibiotics for 2 more weeks with maxillary obturator in place (figure 7). The patient is on regular follow-up and is completely disease free after 4-year follow-up.

Figure 7.

Patient with obturator.

Discussion

Spread of infection from maxilla to frontal sinus makes this case a rare one. This case describes clinically and radiographically atypical OML of maxilla, nasal, orbital and frontal bone. The patient does not have any problem except difficulty in eating because the widespread necrosis and formation of large sequestrum develops slowly, although the onset of OML is often acute. A very few cases reported of OML of dental origin affecting the facial and cranial bones. Calayatud-Perez et al⁸ reported OML of parietal bone from the dental origin. Postoperative OML of zygomatic bone after fixation of fractured zygoma with transosseous wire was reported in 1992.⁹ Rai et al¹⁰ in 2017 described an interesting case of OML of nasal bone resulting in complete exposure of the nasal sequestrum due to the negligence of the patients towards seeking timely management.

The routinely used management modality for such cases is the removal of the necrotic bone along with the sequestrum followed by thorough curettage. The same treatment protocol was followed in the present case; however, it required a lot of necrotic bone removal owing to extensive involvement of facial bones, which is not a common scenario. Removal of extensive amount of bone led to formation of an oronasal communication; hence, an obturator was given to the patient.

Seventy percent of the Indian population lives in villages. It raised the question on local doctors at the village level who without knowing the aetiology prescribe the antibiotics to the patient and makes the condition worse. Many poor and ill-literate patients depend on such local doctors for their treatment. The present case also indicates the recruitment of expert dental/oral surgeon to the village level for the benefit of poor, as in the present case presence of chronic infection in the maxillary teeth and sinus may have been the aetiology.

Learning points.

• Osteomyelitis of zygomatic and frontal bone is very rare.

• Infection from maxillary teeth can reach up to the frontal sinus if neglected.

• Proper clinical and radiographic diagnosis is very important.

• Early surgical intervention, with proper antibiotics and fluid therapy, is required for good result.

• A long-term follow-up of the patient is very important.