A clinical predicament— diagnosis and differential diagnosis of

cutaneous facial sinus tracts of dental origin: a series of

case reports
Monika Gupta, MDS,a Debdutta Das, MDS,a Ravi Kapur, MDS,b and Nikhil Sibal,b
Haryana, India
M. M. COLLEGE OF DENTAL SCIENCES AND RESEARCH

A cutaneous draining sinus tract of dental origin is often a diagnostic challenge, because of its uncommon
occurrence and absence of dental symptoms. Proper diagnosis, treatment, and the elimination of the source of
infection are a must; otherwise, it can result in ineffective and inappropriate outcome of treatment. This article
presents 4 cases of facial lesions misdiagnosed as being of nonodontogenic origin. The correct diagnosis in each case
was cutaneous sinus tract secondary to pulpal necrosis, suppurative apical periodontitis, and osteomyelitis. In all
cases, facial sinus tracts of dental origin were excised and the source of infection eliminated. The purpose of this
paper is to provide diagnostic guidelines and examination protocols for differential diagnosis of cutaneous facial sinus
tracts of dental origin. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e132-e136)

A cutaneous sinus tract of dental origin is relatively osteomyelitis, congenital fistula, salivary gland fistula,
uncommon and may easily be misdiagnosed, owing to an infected cyst, and deep mycotic infection. Skin le-
its uncommon occurrence and absence of dental symp- sions, such as pustules, furuncles, foreign-body lesions,
toms.1 Such a lesion continues to be a diagnostic di- squamous cell carcinoma, and granulomatous disorders
lemma. A systematic review of several reported cases may be superficially similar in appearance to a draining
revealed that patients have had multiple surgical exci- sinus tract of dental origin, but they are not true sinus
sions, radiotherapy, multiple biopsies, and multiple anti- tracts.1
biotic regimens, all of which had failed, with recurrence of Definitive treatment of the draining sinus tract re-
the cutaneous sinus tract, because the primary dental eti- quires elimination of the source of infection, either by
ology was never correctly diagnosed or addressed to.2 root canal therapy in case of restorable tooth or by
However, all chronic draining sinus tracts of the face extraction in case of nonrestorable tooth, along with
and/or neck should signal the need for thorough dental complete excision of sinus tract lining.
evaluation. The purulent by-products of pulpal infec-
tion will seek the path of least resistance when exiting CASE REPORTS
from the root apex area and travelings through bone and Case 1
soft tissue. Once the cortical plate has been penetrated, A healthy 12-year-old girl had a pedunculated tumor-like
the sinus tract’s exit point is determined by the location growth under her chin, 1 cm in diameter for the past 2 years.
of muscle attachments and fascial sheaths. Dental eti- Previous treatment of the patient was with systemic antibiot-
ology can be confirmed by tracing the sinus tract to its ics and repeated excision 4 times, which were unsuccessful.
Intraoral examination revealed that the patient had a slight
origin with gutta-percha or similar radiopaque material,
distoincisal angle fracture of tooth 31. Electric pulp test and
both by orthopantomogram and intraoral periapical ra- heat test were nonresponsive in teeth 31, 32, and 41. The
diographic examination and by pulp vitality testing. other teeth responded within normal limits. Radiologic exam-
Differential diagnosis of a cutaneous draining sinus ination with gutta-percha cone introduced through the sinus
tract should include suppurative apical periodontitis, opening revealed a radiolucent area in relation to tooth 31
extending mesially to the distal surface of the root of tooth 41
and distally to the mesial surface of the root of tooth 32.
a
Oral and Maxillofacial Surgery, M.M. College of Dental Sciences Endodontic therapy in teet 31, 32, and 41 was started; the
and Research, Mullana, Ambala (Haryana), India. canals were enlarged and made infection free with sodium
b
Conservative Dentistry and Endodontics, M.M. College of Dental hypochlorite solution and hydrogen peroxide. Subsequently,
Sciences and Research, Mullana, Ambala (Haryana), India.
Received for publication Feb. 20, 2011; returned for revision Mar. 6,
an elliptic incision was placed around the extraoral discharg-
2011; accepted for publication May 1, 2011. ing sinus, and the whole sinus tract was excised, starting from
1079-2104/$ - see front matter the extraoral side to the origin, by combination of sharp and
© 2011 Mosby, Inc. All rights reserved. blunt dissection; currettage of the apical pathology was done.
doi:10.1016/j.tripleo.2011.05.037 After that, root canal fillings with gutta-percha cones, api-

e132
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Volume 112, Number 6 Gupta et al. e133

Fig. 1. A, Preoperative extraoral view showing gutta-percha inserted into the sinus tract on the chin. B, Intraoral view showing
slight fracture of distoincisal angle of left central incisor of the mandible. C, Orthopantomogram of gutta-percha traced to a
radiolucent area at the apex of the mandibular right central incisor, left central incisor, and left lateral incisor. D, Postoperative
healed sinus tract area on the chin. E, Postoperative orthopantomogram after 7 months.

coectomies, and retrograde fillings with glass ionomer cement sodium hypochlorite and hydrogen peroxide, and root canal
of involved teeth were performed (Fig. 1). filling was done with gutta-percha cones. Subsequently, a
spindle-shaped incision was placed around the extraoral dis-
Case 2 charging sinus; the whole sinus tract was excised starting
A 35-year-old woman sought treatment with a chief com- from the extraoral side to the origin by a combination of sharp
plaint of purulent and hemorrhagic discharge from the sub- and blunt dissection. Curettage of pathologic tissue from the
mandibular region for 6 months after extraction. The patient furcation area and periodontal therapy was instituted (Fig. 3).
gave a history of excision of sinus lining done twice, but the
purulent discharge continued. The patient was suffering from Case 4
uncontrolled type II diabetes for the past 10 years. Radiologic A 45-year-old woman wanted to get rid of nonhealing pus
examination revealed an irregular radiolucent area with the discharge from a growth on her left cheek of 10 months’
presence of a radiopaque mass inside the socket of tooth 46. duration. Drug history of repeated antibiotics administration
First, her uncontrolled diabetes was controlled in consultation was reported. Radiologic examination with gutta-percha cone
with an endocrinologist. Then an extraoral spindle-shaped introduced through the sinus opening revealed a periapical
incision was placed around the extraoral discharging sinus. radiolucent area in relation to tooth 25. Complete excision of
With the help of blunt and sharp dissection, the cord-like the sinus lining as in the other cases, along with extraction of
sinus tract was identified, starting from the extraoral side to tooth 25, was done (Fig. 4).
the origin, and the whole sinus tract was excised. After that,
soft bone was removed with bone rongeur, reached up to the
DISCUSSION
socket of tooth 46, which was confirmed by passing smooth
Extraoral manifestation of pulpoperiradicular patho-
stellate through from extraoral to intraoral region, and seques-
trectomy was performed from the socket of tooth 46. Histo- sis, is easily misdiagnosed by physicians and dentists.
pathologic report confirmed osteomyelitis (Fig. 2). A sinus tract prevents swelling or pain from pressure
build-up, because it provides drainage from the primary
Case 3 odontogenic site.3
A 14-year-old girl presented with an extraoral discharging
sinus with tumoral mass on the left cheek for 3 years. The Diagnostic guidelines
patient had carious exposure of tooth 36 with slight mobility. The following guidelines are advocated.
Electric pulp test and heat test was nonresponsive in tooth 36.
Radiologic examination with gutta-percha cone introduced 1. Evaluation of a cutaneous sinus tract must begin
through the sinus revealed irregular radiolucency in the fur- with a thorough history and awareness that any
cation area of tooth 36. Endodontic therapy in tooth 36 was cutaneous lesion of the face and neck could be of
started; the canals were enlarged and made infection free with dental origin. An acute or painful onset and the
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e134 Gupta et al. December 2011

Fig. 2. A, Extraoral view of the sinus tract in the right submandibular region. B, Orthopantomogram showing irregular radiolucent
area at apical area with presence of radiopaque mass inside the socket of right first molar of the mandible. C, Orthopantomogram
showing gutta-percha traced to a radiolucent area at the apex of the right first molar of the mandible. D, Postoperative
orthopantomogram. E, Healed sinus tract area in the right submandibular region.

Fig. 3. A, Intraoral periapical radiograph with files. B, Periapical radiograph after obturation with gutta-percha. C, Gutta-percha
inserted into sinus tract. D, Sinus lining removed and curettage of granulation tissue done from furcation area. E, Postoperative
periapical radiograph shows healing furcation area.

cutaneous tract and lesion are seldom accompanied lying alveolar bone in the area of the suspect tooth.
by symptoms from the oral cavity. During palpation, an attempt should be made to
2. Palpation of the tissues surrounding the sinus tract “milk” the sinus tract; production of a purulent
should reveal a cord-like tract attached to the under- discharge confirms the presence of a tract.
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Fig. 4. A, Preoperative extraoral view showing gutta-percha inserted into the sinus tract on the left cheek. B, Intraoral view
showing carious exposed left second premolar in the maxilla. C, Orthopantomogram of gutta-percha traced to radiolucent area at
the apex of left second premolar in the maxilla. D, Excised sinus tract along with extracted tooth.

3. If the sinus tract is patent, a lacrimal probe or a intraoral sinus tracts are likely to occur if the apices
gutta-percha cone can be used to trace its track from of teeth are superior to the maxillary muscle attach-
the cutaneous orifice to the point of origin, which is ments or inferior to mandibular muscle attachments.
usually a nonvital tooth, but in edentulous patients
could be a retained tooth fragment, an impacted
Examination protocols for differential diagnosis
tooth, or an odontogenic cyst. A radiograph is then
The clinical differential diagnosis includes pustule,
exposed with the probe in situ, pointing to the origin
of the primary pathosis. Oral examination may re- actinomycosis, osteomyelitis, orocutaneous fistula,
veal ⱖ1 severely decayed teeth or a healthy looking neoplasms, local skin infections (carbuncle and in-
tooth with an intact crown or slight fracture of fected epidermoid cyst), and pyogenic granuloma.
crown. Other causes are salivary gland fistula, thyroglossal
4. Pulp tests and periradicular diagnostic testing should duct cyst, branchial sinus, dacryocystitis, and suppura-
be performed on the suspected tooth and adjacent tive lymphadenitis.
teeth. More than 1 tooth may be pulpally involved Pustule is the most common of all purulent draining
and associated with the cutaneous odontogenic sinus lesions and is readily recognized by its superficial lo-
tract. cation and short course.
5. Microbiologic culturing and sensitivity test of the Actinomycosis exhibits multiple draining lesions and
sinus tract exudate should be done for microbial characteristic fine yellow granules in the purulent dis-
flora identification. Culture should also be carried charge. The tooth is often not involved radiographi-
out for suspected fungal or syphilitic infections. cally. If a sinus tract does not close after appropriate
6. Physiologic and anatomic factors that influence the removal of the primary cause, the most common alter-
spread and ultimate localization of dental infections native cause is actinomycosis.
need to be considered. The ultimate path of the sinus Osteomyelitis of jaw is usually secondary to some
(regardless of the source) depends on several fac- type of exogenic trauma, acquired infection after ex-
tors, most importantly the anatomy of tooth in- traction of diseased teeth, impacted teeth, or retained
volved, muscular attachments to the jaw, fascial roots. It rarely gives rise to a cutaneous sinus and is
planes of the neck, and involvement of permanent or mostly associated with history of some debilitating
deciduous teeth. Cutaneous sinus tracts rather than systemic disease or fracture.
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e136 Gupta et al. December 2011

Orocutaneous fistula is a common sequela of trauma In conclusion, the cutaneous dental sinus is an un-
to the head and neck region and leads to continual common but well documented condition. Its diagnosis
leakage of saliva to lower face or neck. is not always easy unless the treating clinician bears in
Neoplasm usually presents with fixation to underly- mind the possibility of its dental origin. A thorough
ing osseous structures.4 diagnosis requires cooperative referrals between physi-
Carbuncle involves a group of hair follicles and cians, dermatologist, surgeons, and dentists. Recogni-
weeping ooze; a red swollen lump under the skin has a tion of the true nature of the lesion facilitates prompt
white or yellow center. treatment, minimizes patient discomfort and esthetic
Infected epidermoid cyst or sebaceous cyst isa su- problems, and reduces the possibility of further com-
perficial, solitary, freely moveable secondarily infected plications.
mass.5
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Pyogenic granuloma is small reddish vascular lump
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Dacaryocystitis is redness, swelling, and pus ooze Reprint requests:
near the inner corner of eye. Dr. Monika Gupta, MDS (Oral and Maxillofacial Surgery)
Suppurative lymphadenitis usually occurs in teenag- Senior lecturer
ers or young adults and presents with a sore throat, M. M. College of Dental Sciences and Research
House 879, sector-8
fever, malaise, and prominent tender cervical lymph- Panchkula, Haryana, India
adenopathy. The pharynx is red with gray-yellow exu- Pin code 134109
dates. Neck stiffness is a symptom.5 [email protected]