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Case Report

Migratory and misleading abscess of

orofacial region
Kubsad Veerabhadrappa ArunKumar, Dhruvakumar Deepa1
Department of Oral
and Maxillofacial
Surgery, 1Department
of Periodontology,
Subharti Dental College
and Hospital, Meerut,
Uttar Pradesh, India

Abstract:
Acute pericoronitis usually presents with severe localized pain, swelling and sometimes trismus. However,
chronic pericoronitis and periodontal abscess produce a dull pain, moderate swelling and are occasionally seen
migrating into distant sites producing fistulae intraorally and/or extraorally. This may quite often cause diagnostic
dilemmas necessitating thorough medical and dental history, careful clinical examination and sometimes special
investigations to confirm the etiology and or origin of infection. Here, we present three such cases and their
management.
Key words:
Migratory abscess, orofacial abscess, pericoronitis, spread of infection

INTRODUCTION

D
Access this article online
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DOI:
10.4103/0972-124X.152408
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Address for
correspondence:
Dr.Dhruvakumar Deepa,
B10, Ambedkar Bhawan,
Subhartipuram, Meerut,
Uttar Pradesh, India.
Email:deepa_arun@
rediffmail.com
Submission: 28052014
Accepted: 02022015
470

ental infections involving the teeth or

associated tissues are caused by oral
pathogens that are predominantly anaerobic
and usually of more than one species. Origins of
infections are most commonly progressive dental
caries or extensive periodontal diseases. Other
causes could be related to pathogens introduced
deeper in the oral tissues by trauma caused by
dental procedures such as the contamination
of dental surgical sites(e.g.,tooth extraction)
and needle tracks during local anesthesia
administration.
Cutaneous sinus tract of the face due to
odontogenic infections are uncommon. Most of
the reported cases have been caused by chronic
periapical abscess of the mandibular teeth.[1,2]
The remoteness of the cutaneous sinus tract from
its sites of origin within the oral cavity often
leads to misdiagnosis and needless cutaneous
surgery. Patients are assuming the cutaneous
sinus to be unrelated to the dental infection,
often seek treatment from a dermatologist or
from their physician. After a misdiagnosis of
the lesion, topical and surgical therapies are
frequently attempted on the cutaneous aspect of
the lesion, and no dental treatment is provided.
Sometimes, there is an initial cessation of pus
from the sinus, along with apparent healing,
but there is always a recurrence as the primary
etiology is unnoticed. Treatment must be
focused on the elimination of the source of
infection; once the infection is eliminated there
is a prompt resolution of the sinus tract. If the
source of the infection is a retained root or
nonrestorable tooth or if the involved tooth is
periodontally hopeless, extraction of the tooth is

the only possible treatment. Areport indicated

that 75%of cutaneous sinus tracts are treated by
tooth extraction.[2] Many pathologic conditions
in and around the oral cavity, including the
common periapical dental abscess, the less
common recurrent squamous cell carcinoma, a
rare developmental anomaly, can manifest on the
face and neck as cutaneous sinus tracts.[13] Here
we report three cases of cutaneous sinus tract of
dental origin that underwent complete resolution
following treatment in three cases.

CASE REPORTS
Case 1
A male patient aged 26years presented to the
department of Periodontology with a nodular
swelling of the cheek of 8months duration.
Furthermore, complained of occasional purulent
discharge since 8months. Patient had no
significant medical history. History further
revealed the occurrence of swelling in cheek,
well localized, reduced after burst. Patient had
experienced pain in upper posterior tooth before
swelling. Thorough history also revealed that he
had visited a dermatologist for the same and was
advised with medication, after which the lesion
did not heal. Patient then visited dentist who
referred him to the institution for the management
of the same. When the patient was examined, he
had tender nodular swelling on cheek Routine
blood investigations were performed prior to
the initiation of the treatment. Diabetic and
infective status(HIV and HbsAg tests) were
checked to rule the immunocompromised
status. Treatment included tracing the sinus
tract intraorally and excision along with the
extraction of the involved molar tooth. Healing
was uneventful[Figure1ah].

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ArunKumar and Deepa: Migratory abscess

Figure 1: (a) Preoperative photograph of the extra-oral chronic fistula (b) Preoperative photograph of the intraoral proximal caries (c) Intra-operative photograph of fistula
tract (d) Fistula tract excision (e) Intra-oral closure (f) Postoperative healing socket (g) Postoperative extra-oral closure (h) Postoperative healed sinus after 3 weeks

Figure 2: (a) Preoperative extra oral draining fistula (b) Preoperative intra oral lesion (c) Preoperative intra oral periapical radiograph (d) Preoperative antero-posterior view
radiograph revealing the course of the sinus tract (e) Postoperative intra-oral photograph after 2 weeks

Figure 3: (a) Preoperative extra-oral photograph showing the scar of the previous stab incision attempted by the surgeon (b) Intra-oral photograph showing the infection
around the right mandibular third molar region (a and d) Computer tomograph revealing the course of the sinus tract (e-g) Intra-operative showing excision of fistula and
Limbergs flap, postoperative photographs
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ArunKumar and Deepa: Migratory abscess

Case 2
A male patient aged 22years presented with a draining sinus
on the cheek. Clinically, a draining lesion on the left cheek
2cm above the inferior border of the mandible was noticed.
Patient also complained of pain in right cheek, followed
by light red discharge since 1month. Dental examination
revealed carious lesion on the maxillary molar teeth and
radiograph showed abscess extending beyond the pulp and
involving the periapical area. Guttapercha cone was inserted
into the sinus tract and gently pushed inside until there was
no resistance. Anteroposteror view radiograph showed
the tip of the guttapercha cone to be close to the lesion. No
specific complaints related to teeth or soft tissue intraorally.
Porcelain crown on incompletely obturated root canals was
evident on the radiograph. Management included antibiotic
therapy with abscess drainage, scaling and root planning.
The extraoral active discharge gradually stopped. Patient is
referred for root canal treatment no.16 followed by prosthetic
rehabilitation[Figure2ae].
Case 3
A 30yearold male patient complained of recurrent swelling
and discharge from right cheek. On two occasions, patient had
experienced bad breath and reduced mouth opening. Once,
a stab incision and drainage was attempted extra orally by a
dermatologist. Clinical features included linear depressions
evident in right cheek, discharge positive on palpation.
Intra oral examination revealed nothing significant except
an impacted third molar with mild pericoronitis. Computed
tomography revealed the entire course of the sinus tract from
its site of origin to its exit on extraoral region. Management
included antibiotic therapy; extra oral fistula was traced till
mandibular third molar. Surgical extraction of third molar
was done, and fistula excised. Extraoral surgical wound was
treated with Limbergs flap. Healing was uneventful. Patient
is under followup[Figure3ag].

Oral cutaneous fistula leads to esthetic problems due to the

continued leakage of saliva from the oral cavity to the face.
Causes for orocutaneous fistulae include due to malignancy,
inflammation, trauma being the most common causes.[5] Other
causes may be due to failed implants leading to possible
extraoral sinus tract discharge, failed endodontic therapy.[6,7]
Interestingly even calculus formation was reported as a cause
of a persistent sinus tract after root canal therapy in two cases.
In one case reported(Ricucci et al.), sinus tract developed
that did not heal after conventional root canal therapy and
apical surgery.[8] Extraction of that tooth revealed calculus
like material on the root surface. Other case had showed
radiographic signs of healing after apicectomy. Histology of the
apical biopsy specimen demonstrated a calculus like material
on the surface of the root apex. The presence of calculus on the
root surfaces of these teeth may have contributed to endodontic
treatment failure.[8]
Neoplastic fistulae result from the penetration of a neoplasm
from the oral cavity to the overlying skin(most common cause,
squamous cell carcinoma.). Actinomycosis, although rare
is one of the most common infections that result in a fistula
from the oral cavity to the skin. Fistulae may arise from the
developmental cysts of the neck region, such as thyroglossal
duct, dermoid, sebaceous, preauricular and branchial arch
cysts. Nasopalatine duct cysts occasionally secrete fluid to the
anterior palate and the site of the duct. Lymph nodes infected
with mycobacterium tuberculosis cause scrofula, a condition
in which infection spreads from the node to the skin through
a sinus tract. This infection most commonly occurs in the neck.
Catscratch disease is another consideration in the differential
diagnosis of sinus tracts from lymph nodes.[9]
In all the three cases reported here, tooth and associated tissues
were identified as the etiology for the spread of the infections
to oral and extraoral tissues.

DISCUSSION

CONCLUSION

Infections originating in a tooth or its supporting structures

or in the jaws or soft tissues can spread to distant sites of head
and neck and chest region. The path of an infection could be
understood from the thorough knowledge of the anatomy of
the head and neck. In the facial region, the loose, fatcontaining
tissue of the lips and cheeks is continuous. However, it is
partially partitioned by the muscles of facial expression, which
arise from the bones of the face and which, as variably wide
plates, traverse the subcutaneous tissue, to end in the skin. In
infections that are not caused by extremely virulent bacteria,
the muscles with their thin perimysia play a role in directing
the spread of the infection. In this respect, dental abscesses that
erode and perforate the outer compact lamella of the upper or
lower jaw sometimes do not progress toward the oral vestibule,
but find their way through the subcutaneous tissue to the skin.[4]

The presence of a cutaneous sinus on the face must alert the

physician, surgeon or the dermatologist to make a dental
examination. This case series illustrates that pericoronitis
and other infections of the oral cavity can present with a
welllocalized abscess away from the causative site. An
understanding of the anatomy of the region is very important
to establish a correct diagnosis and deliver prompt treatment.

The muscles and fasciae constitute a relative barrier to the

spread of infection; the sinus tract may or may not become
cutaneous depending on its location relative to the mandibular
and maxillary attachments of the facial muscles. If the apex of
the involved tooth is superior to the muscle attachment on the
maxilla or inferior to the muscle attachment on the mandible, the
infection may spread extraorally to form a cutaneous sinus.[4]
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How to cite this article: ArunKumar KV, Deepa D. Migratory and

misleading abscess of oro-facial region. J Indian Soc Periodontol
2015;19:470-3.
Source of Support: Nil, Conflict of Interest: None declared.

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