Cutaneous facial sinus tract of dental origin

410 Pediatric Dermatology Vol. 27 No. 4 July ⁄ August 2010

CUTANEOUS FACIAL SINUS TRACT OF DENTAL ORIGIN

Abstract: Cutaneous sinus tract on the head and neck area in a child may originate from dental disease. A high degree of clinical suspicion and complementary tests are often needed, as the diagnosis is usually not straight forward. Anatomical correlation is also useful in tracing the affected tooth or teeth. We present the case of a boy with a facial sinus tract that originated from periapical abscesses of maxillary molars.

Cutaneous sinus tracts on the face originated from dental disease have been described in medical and dental literature (1,2). As highlighted in these reports, the diagnosis of this entity may be difficult, often achieved after usual diagnostic and therapeutic work up procedures have failed. CASE PRESENTATION An 8-year-old healthy boy consulted for an asymptomatic draining lesion on his left cheek. A month before he referred a blunt trauma on this area and since then, a slowly growing nodule appeared along with intermittent purulent discharge from it. He denied having a history of dental disease or ache. Clinical examination showed on his left cheek a 1 cm friable, crusted-surface draining nodule, with retraction of the surrounding skin (Fig. 1). He was otherwise healthy. An infected hematoma was initially diagnosed and oral antibiotic (flucloxaciline 50 mg ⁄ kg ⁄ day) was

Figure 1. Erythematous nodule with purulent discharge in the left cheek area.

Figure 2. Periapical radiograph showing dental abscess. (red arrow).

indicated for 1 week, with no clinical improvement. Dental evaluation was then performed, showing caries in the first and second left molar of the maxilla (Fig. 2). A periapical radiograph later revealed radiolucent areas at the root of these teeth, which confirmed the diagnosis of dental periapical abscesses with secondary cutaneous sinus tract formation. Dental extraction of the affected teeth was performed with good clinical outcomes of both dental and cutaneous lesions. DISCUSSION Chronic dental infections can lead to sinus tracts on the facial and neck area. However, distant location of the sinus tract regarding its site of origin and the scant symptomatology may explain why this condition is frequently overlooked (3). Periapical abscesses caused by carious tooth are the principal cause of odontogenic sinus tract formation and result from inflammatory degeneration of the pulp and periodontal membrane of the affected tooth. The infection may then spread through soft tissues of the face, following the path of least resistance. The point of drainage usually depends on the location of the apex of the affected tooth in relation to muscular attachments in the mandible and maxilla (4). If the infection path moves superior to the attachment of the buccinator muscle (as in our patient), cutaneous spread with fistula formation is possible. Odontogenic sinus tracts appear as a papule or nodule with purulent discharge usually in the chin or jaw (5). Fixation of the tract to adjacent tissue results in dimpling of the surrounding skin. Panoramic or periapical radiographs are useful in confirming a clinical suspicion. Pulp vitality tests and tracing the sinus tract to its origin with a gutta-percha

Brief Reports

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(radiopaque tapered rubber cylinder) may be used to confirm dental etiology (5,6). Root canal therapy or dental extraction, are the treatments of choice, with resolution of the sinus tract and cutaneous lesion within weeks. Anatomical and clinical correlation allows this case to serve as a reminder that dental origin should be considered as a cause in a chronically draining sinus of the face and neck area. A high degree of clinical suspicion and complementary studies are needed to complete this task.

pigmented papulo-nodules located on the face, neck, chest wall, and the higher back. These lesions have arose on a pre-existent large congenital histologically confirmed nevus spilus extending along the face, neck, the left shoulder and the left chest wall. Histological examination of three excised nodules led to the diagnosis of Spitz nevus. Our patient may have a high risk for melanoma since he has many criteria predisposing to this risk. Some of these criteria are related to NS but we should also take into account the chemotherapy induction and the high number of Spitz nevi.

REFERENCES

BACKGROUND

1. Johnson BR, Remeikis NA, Van Cura JE. Diagnosis and treatment of cutaneous facial sinus tracts of dental origin. J Am Dent Assoc 1999;130:832–836. 2. Cantatore JL, Klein PA, Lieblich LM. Cutaneous dental sinus tract, a common misdiagnosis: a case report and review of the literature. Cutis 2002;70:264–267. 3. Sheehan DJ, Potter BJ, Davis LS. Cutaneous draining sinus tract of odontogenic origin: unusual presentation of a challenging diagnosis. South Med J 2005;98:250–252. 4. Kaban LB. Draining skin lesions of dental origin: the path of spread of chronic odontogenic infection. Plast Reconstr Surg 1980;66:711–717. 5. Spear KL, Sheridan PJ, Perry HO. Sinus tracts to the chin and jaw of dental origin. J Am Acad Dermatol 1983;8:486– 492. 6. Tavee W, Blair M, Graham B. An unusual presentation of a cutaneous odontogenic sinus. Arch Dermatol 2003;139: 1659–1660.

Nevus spilus corresponds clinically to a tan to brown macular nevus speckled with smaller, darker macules. Spitz nevus arising on a nevus spilus (NS) is a rare, but well-known condition. Furthermore, the induction in children of multiple naevi by chemotherapy has been documented in the literature. We report a chemotherapyinduced agminated Spitz nevus arising on a congenital NS in a child. CASE REPORT A 3-year-old boy was treated at the age of 2 months for a vesico-prostatic rhabdomyosarcoma. He had a surgical

F. MARDONES, M.D.*,à J. OROZ, M.D.*,  C. MUN˜OZ, M.D.* C. ALFARO, D.D.S.  R. SOTO, D.D.S.à *Dermatology Department, Hospital Clı´ nico Universidad de Chile, Santiago, Chile,  Dermatology Department, Hospital Roberto del Rı´ o, Santiago, Chile, àHuman Morphology Department, Universidad de los Andes, Santiago, Chile Address correspondence to Felipe Mardones, M.D., Departamento de Dermatologı´ a, Hospital Clı´ nico Universidad de Chile, Santos Dumont 999, Santiago, Chile, or email: fmardonesv@ yahoo.com.

AGMINATED SPITZ NEVI ARISING ON A NEVUS SPILUS AFTER CHEMOTHERAPY

Abstract: Agminated Spitz nevus arising on a background of nevus spilus (NS) is a rare condition. We report here a further case in a child that is original because it is induced by chemotherapy. A 3-year-old boy presented 3 months after the onset of a chemotherapy for a vesico-prostatic rhabdomyosarcoma, multiple

Figure 1. Multiple pigmented or red-colored papulo-nodules arising on a large nevus spilus.