A FACIAL S I N U S OF U N U S U A L ETIOLOGY

W. DONALD MACLENNAN, L.R.C.P. & S., F.D.S.R.C.S.Ed. and *W. SIMPSON, B.D.S. , F.D.S.R.C.S.Ed.

Maxillo-facial and Plastic Unit, Bangour, Scotland

I N T R O D U C T I O N

THE possibility of a discharging sinus of the face proving to be of dental origin is mentioned in many of the basic surgical textbooks. Bailey and Love (I962) describe a definite clinical entity, namely median mental sinus arising from infection at the apices of the lower incisor teeth, on or below the chin but always in the midline. They also suggest that facial swellings of dental origin should not be treated by hot fomentations applied to the face as they predispose to external pointing. Stones (r965) suggests that dental infection may give rise to a facial sinus o n occasion, due to the fact that pus once it has penetrated bone, will track through the soft tissues following the line of least resistance.

T h e s e sinuses although relatively uncommon have been reported regularly in recent years particularly in the American literature. In this country Winstock (I959) reviewed four cases of facial sinuses all occurring in patients under the age of 25 years. Three cases originated from different teeth in the maxilla and one case arose from a mandibular tooth. Hamilton (I959) in a paper reporting nine cases of facial sinuses in patients from 15 to 75 years of age, all originating from the mandible, feels that although most cases appear to originate from the mandible, it is possible that the maxillary teeth may also give rise to facial sinuses. From these two papers and others it is obvious that facial sinuses can originate from both the mandible and maxilla and that any tooth may be responsible. Although most cases would appear to be in the younger age group, they can in fact occur at any age.

CASE REPORT

The patient, a girl aged I5 was referred to the Plastic Surgery Clinic by her doctor because of a discharging sinus of the right cheek present for two months. When the patient was admitted to this unit for investigation and any necessary operative treatment, it was seen that the sinus was almost I cm. in diameter, was discharging profusely and that there appeared to be some infra-orbital ecchymosis from the sinus to the inner canthus of the right eye (Fig. i). Further examination revealed a healthy young woman with no relevant medical history, although she did recall a fall on the right side of her face six months previously and she felt that this was the cause of her discharging sinus. She appeared to have a well-cared-for mouth apart from a carious 5/with some related swelling in the upper buccal sulcus opposite this tooth. Radiographs revealed a large radiolucent area of the right maxilla related to the5/ , with a radiopacity of the right maxillary sinus (Fig. 2). Bacteriological examination showed the causal organism to be Streptococcus haemolyticus sensitive to penicillin, streptomycin, chloromycetin, terramycin, erythromycin and novobiocin. It was surmised from the clinical and radiographical examinations that the non-vital 5/ had given rise to a dental cyst which had subsequently become infected causing the facial sinus. Under general anaesthesia the large cystic lesion (Fig. 3) was enucleated and the 5/ extracted. It was seen that

* Now Senior Registrar, Wythenshawe Hospital, Manchester. Io6

FIG. 2

FIG. I---Pre-operative photograph of patient showing facial sinus of right cheek. FIG. 2--Pre-operative malar projection to show radiopacity of right maxillary sinus.

FIG. 4-

FIG. 3~axillary cyst lining exposed through buccal incision. FIG. 4--Post-operative malar projection to show apparently normal right maxillary sinus,

zo8 BRITISH JOURNAL OF ORAL SURGERY

the cyst had obliterated the right maxillary sinus almost completely, and it was therefore decided to remove the wall between the cyst and the maxillary antrum and so producing one large cavity. After preparing an intra-nasal antrostomy the sinus was excised, the tract curetted and the intra-oral and extra-oral wounds closed in layers. The patient progressed very satisfactorily. She appeared to have no trouble from the right maxillary sinus and Figure 4 shows what would appear to be a perfectly healthy antrum one year after operation.

DISCUSSION

Although Cooksey and Middleton (I959) report a case of maxillary sinusitis causing a facial sinus, there would appear to be no previously reported case of an infected dental cyst involving the maxillary sinus giving rise to a sinus on the face and the above has been recorded for this reason. This case once again underlines the fact that it is extremely important to eliminate a dental cause for facial sinuses. It would appear that most of them are initially diagnosed as infected sebaceous cysts although this case was originally thought to be due to an infected maxillary sinus following a fracture of the lateral wall of t he antrum. Once the correct diagnosis has been made the treatment of such cases is relatively simple and a good result is usually obtained. In the treatment it will be noted that the cystic cavity, after enucleation of the lining, and the antrum were formed into one large cavity which we feel after regeneration of the remaining antral lining will constitute a new maxillary sinus. This of course is opposed to the normally accepted method of treating cystic lesions involving the antrum, by decompression of the cyst. It has been the practice in this unit with cysts involving the antrum to a large extent, to use the method described here with good results and it is interesting to note that in a paper by Bramley (I963) reviewing 80 cases of treated oro-antral fistulae that in one case after a radical curettage of a maxillary sinus, he re-entered the antrum some time later and removed a piece of antral lining for examination. The histological report indicated a normal healthy lining and this would appear to substantiate to a certain extent our clinical observations and hypotheses regarding the regeneration of the antral lining.

SUMMARY

A dental cyst presenting as a facial sinus is recorded, the literature regarding facial sinuses reviewed and the treatment of this particular case is discussed.

REFERENCES

BAILEY, H. & LOVE, R. J. (z962). A Short Practice of Surgery, I2th ed., p. 476. London: H. K. Lewis.

BRAMLEY, P. (I963). Paper presented at meeting of British Oral Surgery Association (Personal Communication).

COOKSEY, D. E. and MIDDLETON, R. A. (I959). ,7. oral Surg. x7, 14. HAMILTON, A. (I959). Brit. ft. Surg. x99, 433- STONES, H. (I965). Oral and Dental Diseases, 5th ed., p. 4o2. Edinburgh: Livingstone. WINSTOCK, D. (r959). Proc. roy. Soc. Med. 5z, 749.