DOI: 10.21276/aimdr.2016.2.5.

DE1

Case Report ISSN (O):2395-2822; ISSN (P):2395-2814

Section: Dentistry
Surgical Management of Extra-Oral Mandibular
Cutaneously Pus Draining Sinus Tract in a 13-years Old
Girl - A Case Report.
Baksh-Inder singh Lyall1, Jasneet Kaur2, Isha Aggarwal3, Divye Malhotra4, Monika Negi5
1
Senior Lecturer, Dept. of Pedodontics and Preventive dentistry, Luxmi Bai Institute of Dental sciences and Hospital, Patiala, Punjab , India.
2
MDS, Department of Pedodontics, Himachal Dental college, Sundernagar, H.P, India.
3
Senior lecturer, Dept. of Orthodontics, Gian Sagar Dental college, Banur, Punjab.
4
Professor, Dept. of Oral Surgery, Himachal Dental college, Sundernagar, H.P, India.
5
PG student, Department of Oral Pathology, Himachal institute of Dental Sciences, Poanta Sahib, H.P, India.

Received: July 2016

Accepted: July 2016

Copyright: © the author(s), publisher. Annals of International Medical and Dental Research (AIMDR) is an
Official Publication of “Society for Health Care & Research Development”. It is an open-access article distributed
under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Odontogenic cutaneous sinus tract is a rare but well-documented condition. A common manifestation of pulp necrosis is
draining sinus tract or fistula, which could be intra-oral or extra-oral. The microbiologically induced inflammation spreads
along the path of least resistance by penetrating the alveolar bone. Ultimately, to form a path of drainage, the inflammatory
process can reach the surrounding tissues. These conditions are often misdiagnosed as other non-pulp pathologies. So
misdiagnosed as a local skin lesion and maltreated by systemic antibiotics, we came across a 13-year-old girl patient who
presented with a cutaneous lesion of dental etiology in the sub-mental region with frequent purulent discharge which was
not responding to systemic antibiotics. The management of this condition using endodontic therapy of the involved tooth
followed by surgical excision of sinus tract so as to minimize the residual scar formation are presented here.

Keywords: Extra-oral sinus tract, odontogenic infections, skin diseases.

INTRODUCTION time because of the drainage through the sinus tract,

a chronic abscess can remain asymptomatic for
The term sinus tract "refers to a tract leading from an extended periods of time. If there is a closure of the
enclosed area of inflammation to an epithelial sinus tract, then the chronic abscess may become
surface" (An Annotated Glossary of Terms in symptomatic.[4] Misdiagnosis adds to the chronicity
Endodontics). It also states that the term dental of the lesion and has profound effects on facial
fistula "should be discouraged, and the more proper esthetics due to unnecessary treatments resulting in
term sinus tract should be used." In 1961, Bender cutaneous scarring and dimpling. For this reason, the
and Seltzer reported that they found sinus tracts to be differential diagnosis of this entity is of utmost
lined with granulation tissue not epithelium.[1] A importance.
chronic inflammation of pulpal origin is one of the There is little reported literature on the prevalence of
reasons for an extra oral sinus of odontogenic extra-oral cutaneous sinus lesions in the paediatric
origin.[2] Microorganisms and their by-products, dental patient as the presentation is often delayed
which are present in the periradicular area, might resulting in misdiagnosis and consequential
perforate the cortical plate with the infection mismanagement.[5]
draining onto the mucosal or cutaneous surface Therefore, this article presents a case of pediatric
following the path of least resistance, after exiting patient having an extra-oral cutaneous sinus tract in
from the necrotic pulp canal system.[3] the sub-mental region, management initiated
conservatively by nonsurgical endodontic treatment
Name & Address of Corresponding Author of the offending teeth followed by the surgical
Dr. Baksh-Inder singh Lyall excision of the sinus tract so as to minimize the
Senior Lecturer, Dept. of Pedodontics and Preventive residual scar formation and dimpling as esthetics
dentistry, was of great concern to the patient herself and her
Luxmi Bai Institute of Dental sciences and Hospital, Patiala,
Punjab , India. parents.
E mail: [email protected]
CASE REPORT
After formation of a sinus tract, the inflammation at
the apex of the root may persist for a long period of A 13 year old girl patient reported to the Department

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 Lyall et al; Extra-Oral Mandibular Cutaneously Pus Draining Sinus Tract

Section: Dentistry
of Pedodontics and preventive dentistry with chief apical third of the roots. Apical periodontitis due to
complaint of pus drainage around the sub-mental pulpal necrosis was set as definite diagnosis.
region associated with sharp pain since last 2 weeks.
The patient gave a history of recurrence and
remission of the fever for one month, for which she
was treated by a general physician. The medical
history was noncontributory.
The patient recalled that the sinus tract started 6
months ago, as a small swelling in the sub-mental
region, associated with mild discomfort in the area.
Soon after, it developed to a small skin lesion with
spontaneous drainage. Following, she asked medical
advice from a physician that started treating the
lesion as of skin infection by means of systematic
antibiotic administration. Since there was a
recurrence of the lesion and fever over and over
Figure 2: Intra-oral view exhibiting grossly decayed
again, she was referred to our dental institute for our
mandibular first molars (36,46).
opinion.
Root canal treatment with rubber dam isolation of
the involved tooth was performed. Surgical excision
of sinus tract was planned as to prevent dimpling and
to minimize residual scar formation. Under local
anesthesia, primary incision was made around the
lesion [Figure 3]. The area was dissected to
surgically remove the cord-like tract of approx. 1.6-
1.8 cm in size [Figure 4&5]. The skin was
undermined to relax the affected area and restore the
normal facial contour. Sub-cuticular sutures was
placed [Figure 6]. After 3 months of follow up, the
cutaneous lesion had healed completely with neat
linear scar formation, which is esthetically
Fig 1 (A) satisfactorily for patient herself and her parents
[Figure 7].

Fig 1(B)
Figure 1: (A & B)- Extra-oral cutaneous lesion on the Figure 3: Primary incision around the lesion.
right side of the cheek with purulent discharge.

Detailed extra oral examination revealed a cutaneous

lesion (5-6cm) on the right side of the cheek and
purulent discharge was elicited from it on palpation
[Figure 1a & 1b]. Intra oral examination revealed
patient had grossly carious mandibular first
molars.[Figure 2] The involved tooth with the lesion
i.e. 46 was not tender on percussion and it did not
respond to heat and electric pulp testing. On
radiographic examination, it was found that there
was an evidence of dental caries, which involved the
pulp in the disto-occlusal aspect of the crown and
Figure 4: Surgical removal of the sinus tract.
diffuse periapical radiolucency associated with the

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 Lyall et al; Extra-Oral Mandibular Cutaneously Pus Draining Sinus Tract

Section: Dentistry
suppurative lymphadenitis.[9] However, these lesions
continue to be a diagnostic dilemma. The evaluation
of a cutaneous sinus tract must begin with a
thorough patient history and awareness that any
cutaneous lesion of the face and neck could be of
dental origin. Winstock[10] described cutaneous
lesions with dental infections. Kaban[11] elaborated
the path of spread of chronic dental infections.
Approximately 80% of the reported cases are
associated with mandibular teeth and 20% with
maxillary teeth.[12] Most commonly involved areas
are the chin and sub-mental region.[13]
Figure 5: Cord like sinus tract of size (1.6-1.8 cm).
Root-canal therapy is the treatment of choice if the
tooth is restorable. Extraction is indicated for non-
restorable teeth.[9] In the case of a chronic
odontogenic sinus tract, extraction of the causal
tooth may not be sufficient for complete healing to
occur. In those cases, the cord-like tract must be
eliminated. It can be either cut from its insertion
(attachment) to the underlying alveolar bone or
removed by complete excision. Biopsy alone should
be avoided as it may lead to exacerbation of
infection or scarring. Antibiotic therapy is indicated
when there are signs of systemic involvement (e.g.,
fever or lymphadenopathy).[14]
In this case, report the cord was removed from its
Figure 6: Sub-cuticular suture were placed. origin to the point of skin attachment, which allowed
relaxation of the facial skin, elimination of the skin
dimpling in the affected area, and restoration of
normal facial contours.

CONCLUSION
Elimination of the source of infection by endodontic
treatment or tooth removal generally results in
resolution of the sinus tract. But in the case of an
older sinus tract, wound contraction and scar tissue
formation may require surgical management to
Figure 7: Complete healing of the lesion after 3 months
excise the cord-like tract. This report describes a
of follow up. case involving a cutaneous sinus tract of dental
origin that required surgical removal of the sinus
tract from the periapical zone of the causal teeth. The
DISCUSSION aim of this paper is to present a dental and medical
literature review of cutaneous sinus tract with a
Cutaneous sinus tracts of dental origin have been dental origin and to present the surgical technique
well documented in both the medical literature 1–9 used to eliminate the cord-like tract and dimpling of
and the dental literature.[6-7] However, these lesions the skin for esthetic concerns.
can present a diagnostic challenge 2 because these
tracts often have a clinical appearance similar to REFERENCES
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How to cite this article: Lyall BIS, Kaur J, Aggarwal I,

Malhotra D, Negi M. Surgical Management of Extra-Oral
Mandibular Cutaneously Pus Draining Sinus Tract in a 13-
years Old Girl- A Case Report. Ann. Int. Med. Den. Res.
2016; 2(5):DE01-DE04.

Source of Support: Nil, Conflict of Interest: None declared

Annals of International Medical and Dental Research, Vol (2), Issue (5) Page 4