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LETTER TO EDITOR
Year : 2020  |  Volume : 9  |  Issue : 8  |  Page : 4483-4484  

Unusual presentation of an extraoral and multiple intraoral sinus tracts in a 6-year-old pediatric patient


Department of Dentistry, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India

Date of Submission02-May-2020
Date of Decision11-Jun-2020
Date of Acceptance26-Jun-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Tulika Wakhloo
Department of Dentistry, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_754_20

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How to cite this article:
Wakhloo T, Reddy GS, Chug A. Unusual presentation of an extraoral and multiple intraoral sinus tracts in a 6-year-old pediatric patient. J Family Med Prim Care 2020;9:4483-4

How to cite this URL:
Wakhloo T, Reddy GS, Chug A. Unusual presentation of an extraoral and multiple intraoral sinus tracts in a 6-year-old pediatric patient. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 23];9:4483-4. Available from: http://www.jfmpc.com/text.asp?2020/9/8/4483/293079



Dear Editor,

We would like to present this brief report highlighting the unusual and simultaneous presentation of an extraoral and multiple intraoral pus draining sinus tracts of dental origin in a pediatric patient. A 6-year-old female was referred to the department of dentistry with chief complaint of pus discharge from the left side of the face for the past 2 months. The patient in her previous physician visits was advised extensive investigations, prescribed multiple antibiotics and medicated dressings and underwent incision and drainage of the cutaneous lesion under GA, with no improvements in symptoms. The patient gradually developed a swelling in the same region with intermittent low-grade fever since 1 month.

Extraorally, the patient had facial asymmetry with a diffuse swelling over the left mandibular angle and submandibular region. The swelling was tender on palpation, associated with an extraoral sinus on left cheek with granulation tissue, spontaneous pus discharge, and crusting of the surrounding skin [Figure 1]a. Intra oral examination revealed mandibular deviation with a decreased mouth opening of 15 mm. Multiple intra oral pus draining sinuses were present on the gingiva associated with a discolored left primary molar [Figure 1]b. Panoramic radiograph revealed dental caries of left primary molar associated with resorption of left inferior border of mandible [Figure 2]. Considering the clinical presentation, age of the patient, chronicity of the lesion and limited mouth opening, extraction of the involved teeth with excision of the extra oral sinus tract was planned under GA.
Figure 1: 1a: Extra oral sinus with spontaneous pus discharge. 1b: Multiple draining intra oral sinus tracts associated with discolored left primary molar

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Figure 2: Panorex showing carious left primary molar associated with resorption of left inferior border of mandible

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Intraoral drainage is more common than extra oral drainage with the mandibular teeth being a more common source than the maxillary teeth.[1],[2] Extra oral sinus tracts can be non-odontogenic and odontogenic in origin and often present a diagnostic challenge. Only 50% of the patients with facial cutaneous sinus tracts have tooth-related symptoms because of which, patients are often attended to by health care professionals other than dentists.[2] The distance of the extraoral sinus from the primary odontogenic etiology further confuses the clinical picture. The differential diagnosis includes osteomyelitis, furuncle, congenital fistula, salivary gland fistula, deep mycotic infection, granulomatous disorder, pustule, myositis, foreign body lesion, infected cyst, suppurative lymphadenitis, and neoplasm.[1],[2],[3]

The unusual clinical presentation seen with respect to the primary molars in the present case is attributed to the delay in diagnosis due to asymptomatic teeth and multiple antibiotic therapies which blocked the drainage partially through incomplete healing.[1] It has been reported that permanent tooth buds in the line of infection may be expelled as foreign bodies through the extra oral sinus tract in which case the parent may complain of loss of a tooth through the extra oral sinus tract.[4] Inappropriate management like biopsy, curettage, antibiotic therapy, surgical excision of the cutaneous lesion, and radiotherapy may provide temporary relief but are inevitably followed by recurrence and compromised aesthetics due to skin scarring.[2] Primary health care physicians encountering such cases should therefore take a history of trauma to teeth, toothache before development of sinus and examine the oral cavity for presence of heavily discolored or treated teeth; as they are the patients first point of contact in the peripheral areas. This article emphasizes on considering an odontogenic source of infection and timely referral to a dental surgeon in such clinical presentations to avoid misdiagnosis. This will ensure prompt dental treatment aimed towards eliminating the source of infection and good prognosis while avoiding development of acute sequelae and subsequent hospital admission. Patient consent was obtained for publication in scientific journals.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bashar AK, Akter K, Chaudhary GK, Rahman A. Primary molar with chronic periapical abscess showing atypical presentation of simultaneous extraoral and intraoral sinus tract with multiple stomata. BMJ Case Rep 2019;12:e229039.  Back to cited text no. 1
    
2.
Sammut S, Malden N, Lopes V. Facial cutaneous sinuses of dental origin–A diagnostic challenge. Br Dent J 2013;215:555-8.  Back to cited text no. 2
    
3.
Brown RS, Jones R, Feimster T, Sam FE. Cutaneous sinus tracts (or emerging sinus tracts) of odontogenic origin: A report of 3 cases. Clin Cosmet Investig Dent 2010;2:63-7.  Back to cited text no. 3
    
4.
Kalaskar RR, Damle SG. Loss of permanent mandibular lateral incisor and canine tooth buds through extraoral sinus: Report of a case. J Indian Soc Pedod Prev Dent 2006;24:50-2.  Back to cited text no. 4
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