Extraoral Sinus Tract Misdiagnosed as an Endodontic Lesion

JOURNAL OF ENDODONTICS Copyright © 2003 by The American Association of Endodontists

Printed in U.S.A. VOL. 29, NO. 12, DECEMBER 2003

Extraoral Sinus Tract Misdiagnosed as an Endodontic Lesion Nestor Cohenca, DDS, Sunil Karni, BDS, and Ilan Rotstein, DDS

significant findings. His dental history revealed a left coronoidectomy surgery performed a year previously due to difficulties in opening his mouth (27 mm). His chief complaint was the presence of an extraoral sinus tract on his lower left cheek that appeared 4 months previously (Fig. 1). His dental records disclosed that 6 months previously he was treated with 600 mg/d clindamycin (Dalacin C; Upjohn, Puurs, Belgium) for a swelling that appeared on the left side of his face. He was then referred to an oral surgeon for evaluation. Three weeks later, the oral surgeon diagnosed the condition as a non-odontogenic abscess, and the patient was referred to a plastic surgeon who drained the abscess and suggested that the lesion could be dental-related and prescribed amoxycillin and clavulanic acid (Augmentin; SmithKline Beecham, Brentford, England) 1500 mg/d for a week. Two months later, the swelling reappeared with episodes of spontaneous drainage. The patient was then examined by a different oral surgeon, who suggested the possible origin of the lesion was the mandibular left first molar. He recommended an exploratory surgery and possible extraction of the tooth involved. The exploratory surgery was performed and proved to be inconclusive. Drainage of the exudates was then performed, and the patient was treated again with 600 mg/d clindamycin (Dalacin C; Upjohn, Puurs, Belgium) for a week. During the following weeks, the patient remained asymptomatic but a permanent extraoral sinus tract had developed on his lower left cheek. Three months later, yet another oral surgeon examined the patient and performed a second exploratory surgery. During surgery, a tract was found connecting the opening of the sinus with the

The extraoral sinus tract may occur as a result of an inflammatory process associated with a necrotic pulp. However, several non-odontogenic disorders may also produce an extraoral sinus tract. Thus, the differential diagnosis of this clinical finding is of paramount importance in providing appropriate clinical care because misdiagnosis of this condition may result in healing failure or unnecessary treatment. This case report of a 19-yrold male patient describes an extraoral cutaneous sinus tract misdiagnosed as an endodontic lesion. Consequently, the patient underwent unnecessary exploratory procedures and antibiotic therapy. Identification of the inflammatory source of the lesion and removal of the affected tissue led to tissue healing.

The sinus tract is defined as a channel leading from an enclosed area of inflammation to an epithelial surface (1). The opening of the sinus tract can be located either intraorally or extraorally. Intraorally, the opening is usually visible on the attached buccal gingiva or in the vestibule. Extraorally, the sinus tract may open anywhere on the face and neck. However, it is most commonly found on the cheek, chin, and angle of the mandibule, and occasionally also on the floor of the nose (2–5). An extraoral sinus tract of dental origin may be confused with a wide variety of diseases including local skin infections, ingrown hair or occluded sweat gland duct, osteomyelitis, neoplasms, tuberculosis, actinomycosis, and congenital midline sinus of the upper lip (6 –13). Possible dental causes include trauma, retained roots, residual chronic infection of the jaws, and pulp disease (14 –15). If the etiology is pulpal, it usually responds well to endodontic therapy. Presented is a case report of an extraoral sinus tract of odontogenic origin, misdiagnosed as an endodontic lesion. Healing occurred only after surgery and removal of the affected tissue. CASE REPORT

FIG 1. Persisting extraoral cutaneous sinus tract in a 19-year-old male patient. Repetitive drainage and antibiotic therapy did not resolve the condition.

A 19-year-old male patient was referred for endodontic retreatment of the mandibular left first molar. Medical history revealed no 841

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FIG 2. Radiograph of the mandibular left molar region. A slight enlargement of the periodontal ligament space of the distal root of the first molar is noted. There is no evidence of a periradicular bony lesion and the adjacent teeth appear intact.

apical area of the distal root of the mandibular left first molar. Radiographic examination revealed a slight enlargement of the periodontal ligament space of the distal root of the first molar (Fig. 2). At this stage, the patient was referred for endodontic retreatment of the first mandibular molar. Clinical examination disclosed a sinus tract that could be tracked with a gutta-percha cone to the cervical area of the mandibular second molar (Figs. 3A and 3B). Upon examination of the mandibular left second molar, an occlusal carious lesion was detected. Pulp sensitivity tests were negative, and the tooth was slightly sensitive to percussion. A cavity test was performed, and the patient reported pain upon drilling. A coronal composite restoration was then placed, and the patient was referred for further radiographic analysis. A series of tomography radiographs taken with a tracer indicated that the sinus tract was related to the buccal area between the second and the third mandibular molars (Fig. 4). A second intraoral exploratory surgery was then performed revealing the presence of granulation tissue distally to the mandibular third molar. The inflamed area was connected to the sinus tract. The mandibular third molar was then extracted, and the area curetted for biopsy (Fig. 5). Histologic analysis revealed a chronic inflammatory process composed of connective and granulation tissue in the presence of bacteria. One week after surgery, the extraoral sinus tract stopped draining and its cutaneous opening closed. Two years later, the patient returned for follow-up examination. The mandibular left first and second molars were asymptomatic, and the patient was comfortable. Radiographically, there was no evidence of pathosis (Fig. 6). Evidence of a small scar associated with the original opening of the sinus tract was noted. DISCUSSION Chronic extraoral cutaneous sinus tracts represent a diagnostic challenge to the clinician, as they may be of either odontogenic or non-odontogenic origin (2–15). In the case presented here, differential diagnosis included: (a) a foreign body introduced to the area of the intraoral incision during the coronoidectomy; (b) chronic

FIG 3. Gutta-percha cone is used to track the origin of the sinus tract. (A) Clinical view. (B) Radiographic view shows gutta-percha cone pointing to the cervical region of the mandibular second molar.

FIG 4. Tomography radiograph shows sinus tract associated with the buccal tissues between the mandibular second and third molars.

periapical periodontitis associated with the distal root of the mandibular left first molar; (c) pericoronitis related to the mandibular left third molar; (d) pulp necrosis of the mandibular left second molar.

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FIG 5. Radiograph following extraction of the mandibular left third molar.

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cian must take into consideration the various false positive and false negatives of these tests (17–18). Extraoral cutaneous sinus tracts are usually lined with granulomatous tissue. The lumen may contain a purulent exudate composed mainly of polymorphonuclear leukocytes as well as chronic inflammatory cells lining the periphery (16). In more advanced stages, an epithelial lining may also be present (16). If correctly diagnosed and treated, the sinus tract is expected to disappear within 7 to 14 days. It has been observed that systemic antibiotic therapy will result in a temporary reduction of the drainage and apparent healing (19). The sinus tract, however, will recur once antibiotic treatment is completed unless the source of infection has been identified and eliminated (19). Unlike intraoral sinus tracts, extraoral tracts will heal with granulation tissue thus leaving a cutaneous scar (20). Therefore, the patient needs to be advised of a possible surgical revision of the scar. Usually, the surgical revision is uneventful and enhances cosmetic results. Nestor Cohenca, DDS, is Clinical Lecturer, Department of Endodontics, Hebrew University- Hadassah School of Dental Medicine, Jerusalem, Israel, and Assistant Professor, Division of Surgical, Therapeutic and Bioengineering Sciences, University of Southern California School of Dentistry, Los Angeles, California, USA. Sunil Karni, BDS, is Clinical Instructor, Department of Endodontics, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. Nestor Ilan Rotstein, DDS, is Associate Professor and Chair, Division of Surgical, Therapeutic and Bioengineering Sciences, University of Southern California School of Dentistry, Los Angeles, California, USA. Address reprint requests to Dr. Nestor Cohenca, USC School of Dentistry, Los Angeles, CA 90089, USA. E-mail: [email protected].

References

FIG 6. Two-year follow-up. Radiographically, the mandibular molars appear normal and there is no evidence of pathosis.

Pulp necrosis should always be ruled out before performing more invasive procedures. Periradicular pathoses may result in formation of a fistulous sinus tract. In such cases, the inflammatory exudate travels through tissues and structures of minor resistance to exist anywhere on the oral mucosa or the skin. Muscular attachments determine whether the sinus tract will open intraorally or extraorally (4). Early diagnosis of the origin of the sinus tract will prevent unnecessary treatments and enhance healing. It has been reported that the longer the sinus tract persists, the more likely it is to have an epithelial lining (16). In the case presented here, several clinicians misdiagnosed the origin of the sinus tract, and the patient underwent unnecessary surgical procedures and antibiotic therapy twice. In this regard, the clinician must bear in mind that the location of the sinus tract opening does not necessarily indicate the origin of the inflammatory exudate. Therefore, tracking of the sinus with a gutta-percha point, or a similar radiopaque tracer, should be carried out routinely. In addition, accurate pulp sensitivity tests must be performed to determine whether the sinus tract exudate is of pulpal origin. When correctly performed and adequately interpreted these tests will aid in avoiding misdiagnosis at an early stage. However, while interpreting the results, the clini-

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