Cutaneous draining sinus tract of odontogenic origin: unusual presentation of a challenging diagnosis.

Abstract: A 44-year-old woman presented with a chronically draining lesion on her cheek just lateral to the nasofacial sulcus. The lesion was refractory to treatment with oral antibiotics. Physical examination revealed poor dentition, and a panoramic radiograph demonstrated periapical abscesses in the maxillary right lateral incisor and canine. A diagnosis of cutaneous fistula of odontogenic origin was made, and the patient was treated with tooth extraction. The cutaneous fistula subsequently resolved. Intraoral examinations and radiographs are critical for making the diagnosis of cutaneous draining sinus tract of odontogenic origin. Many patients undergo unnecessary surgical therapies before having the correct diagnosis made, but root canal therapy or surgical extraction is the treatment of choice. A dental origin must be considered for any chronically draining sinus of the face or neck.

Key Words: cutaneous sinus tract of odontogenic origin, dental sinus, dentocutaneous fistula, facial sinus

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Making the diagnosis of a draining sinus tract in the setting of a chronic dental infection can be challenging for several reasons. The cutaneous lesions do not always arise in close proximity to the underlying infection, and only about half of all patients ever recall having had a toothache. (1) The sinus tracts appear most commonly on the chin or jaw line, but they can also appear elsewhere on the face or neck. (2,3) Lesions have even been reported to occur as far away from the oral cavity as the chest, thigh, or sacrum. (3-6) Many patients seek evaluation from several physicians before an accurate diagnosis is made. Furthermore, because the cutaneous lesions can mimic other disorders, such as basal cell carcinoma or furuncle, several inappropriate surgeries and courses of antibiotics are commonly used before definitive therapy is instituted. (3,7,8) It has been estimated that half of all patients undergo multiple surgeries and trials of antibiotics before definitive diagnosis. (9) Such diagnostic and therapeutic misadventures highlight the importance of communication between medical subspecialists and general dentistry practitioners in the evaluation of patients with head and neck lesions. (10)

Case Report

A 44-year-old woman sought evaluation of a chronically draining, dimpled, crusted small nodule on her right cheek just lateral to the nasofacial sulcus (Fig. 1). Gentle pressure on the surrounding tissue elicited thick purulent drainage from the central punctum. The nodule had been present for several months and was initially diagnosed as a furuncle. However, because the drainage was refractory to antibiotic treatment, pus from the lesion was cultured, an intraoral examination was performed (Fig. 2), and a panoramic radiograph was obtained (Fig. 3). The culture yielded growth of Streptococcus viridans. Intraoral examination revealed extremely poor dentition. The radiograph demonstrated a severely carious maxillary right lateral incisor and canine with periapical radiolucencies. The diagnosis of periapical abscess with dentocutaneous sinus tract was made. The patient was treated successfully with elective tooth extraction. After resolution of the infection, a small umbilication in the skin remained.

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Discussion

Pathogenesis

Carious exposure with bacterial invasion of the tooth pulp leading to a periapical abscess is the most common cause of dentocutaneous sinus tracts. The inflammation destroys the cancellous alveolar bone and proceeds along the periosteum until perforation occurs. (1,4) An intraoral or extraoral sinus can develop, depending on the path of the inflammation, which is dictated by surrounding muscular attachments and fascial planes. (9) For example, if the bone perforation on the mandible occurs above the muscular attachment, then an intraoral sinus will result. If the perforation occurs below the level of muscular attachment, then a cutaneous sinus will result. (11,12)

[FIGURE 3 OMITTED]

The majority of sinuses that arise are intraoral. (13,14) Approximately 80% of cutaneous sinuses that occur arise from mandibular teeth and thus appear on the chin or submental region. (15) One large review in 1986 noted that only 12 of 137 cases of odontogenic cutaneous sinus tracts in the literature arose from maxillary incisors and canines, as did the present case. (12) Very few cases reported since that time have documented maxillary origin. (2,16,17)

Rarely, a dental cyst or unerupted tooth can be the source of the infection. A retained root fragment can be the cause in edentulous patients. (18,19)

Diagnosis

Dentocutaneous sinus tracts appear as soft, slightly depressed nodules, often fixed to underlying structures, with a central opening from which fluid can be expressed. Palpation of the surrounding tissue may produce pus, which supports the diagnosis. (4,9) The majority arise on the chin, mandible, or submandibular area. (12) On the basis of clinical appearance, the differential diagnosis includes pyogenic granuloma, actinomycosis, thyroglossal duct cyst, branchial cleft cyst, furuncle, squamous cell carcinoma, and epidermal cyst. (1)

Intraoral and dental examinations are critical for making the diagnosis. In particular, the examiner should look for dental caries or restorations and periodontal disease. (9,20) The examiner should keep in mind that the involved tooth can even appear normal. (21) One bizarre dentocutaneous fistula was even filled with hair. (22)

Early radiographs can prevent unnecessary surgeries when the teeth appear clinically normal. (23) A panoramic or periapical radiograph will show a radiolucency at the apex of the infected tooth. A gutta-percha cone can be used to trace the sinus tract to its origin, which is usually a nonvital tooth. (9) It has been suggested that some dental computerized tomography software may be superior to panoramic or intraoral radiographs. (24)

Biopsy, if performed, will show nonspecific findings such as pseudoepitheliomatous hyperplasia and chronic inflammation. (4) At times, the cutaneous lesions have been interpreted to represent epidermal inclusion cysts. (25) Some studies have indicated that the sinus tracts can be focally lined with stratified squamous epithelium. (16,19) When present, the sinus tract lining is derived from mucosal epithelium. (26) Intraoral granulation tissue is vascular and will show plasma cells, Russell bodies, and lymphohistiocytic infiltrate on histopathologic examination. (27)

Most infections are polymicrobial, and culture often yields growth of anaerobes or facultative anaerobes such as streptococcal species. (3,13,28,29) Obligate anaerobes account for 60% of total species isolates and are particularly associated with painful endodontic infections. (30)

Treatment

Root canal therapy or surgical extraction is the treatment of choice. (28,31) Antibiotics may be used as an adjunct to surgical therapy in the setting of diabetes, immunosuppression, or systemic signs of infection such as fever. Antibiotic therapy alone will not be effective in these cases because of the absence of adequate circulation in a necrotic pulp system and abscess. If antibiotics are to be used, penicillin V potassium is the first choice. Clindamycin or amoxicillin-clavulanate may be used if the infection is unresponsive. (28) After surgery, the cutaneous lesion usually resolves in 1 to 2 weeks. (9) The patient may be left with a residual umbilication of the skin that can be surgically revised if it is cosmetically unappealing. (32)

Conclusion

Dental origins should be considered for any chronically draining sinus of the face or neck. A high index of suspicion and radiologic evidence of a periapical infection are necessary to make the diagnosis and may spare the patient numerous unnecessary therapies. Surgery such as root canal therapy or extraction remains the first line of treatment.

This case was presented in a poster format at the 97th Annual Scientific Assembly of the Southern Medical Association in Atlanta, GA, November 2003.

Accepted April 7, 2004.

References

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RELATED ARTICLE: Key Points

* Intraoral examinations and radiographs are critical for making the diagnosis of cutaneous draining sinus tract of odontogenic origin.

* Root canal therapy or surgical extraction is the treatment of choice.

* Dental origin must be considered for any chronically draining sinus of the face or neck.

Daniel J. Sheehan, MD, Brad J. Potter, DDS, MS, and Loretta S. Davis, MD

From the Section of Dermatology, Department of Medicine, and the School of Dentistry, Medical College of Georgia, Augusta, GA.

Reprint requests to Loretta S. Davis, MD, Section of Dermatology, Medical College of Georgia, 1004 Chafee Ave, Augusta, GA 30904. Email: [e-mail]