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Oral Cutaneous Fistulas Follow-up

  • Author: James Cade, DDS; Chief Editor: William D James, MD  more...
 
Updated: Sep 03, 2015
 

Further Outpatient Care

With any cutaneous fistula or sinus tract, careful follow-up is mandatory. The potential for infection with swelling and pain is always present. Fistulas provide natural pockets in which infection can start.

The patient may require supportive care. Fistulas are unsightly and cause patient distress. Severe persistent infections, especially actinomycosis and osteomyelitis, can be distressing and frustrating for the patient.

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Further Inpatient Care

The possibility of a neoplastic cause may require biopsy and further treatment. If the biopsy specimen is positive for malignancy, a complete medical workup including MRI, positron emission tomography, and/or CT scanning is needed.

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Deterrence/Prevention

The early detection of dental problems and preventative dentistry are the best deterrents of oral cutaneous fistula formation. Because poor oral hygiene and trauma cause most dental infections, good hygiene and the prevention of trauma may prevent oral cutaneous fistula formation.

With oral antral fistulas, if a cleft or fistula from the oral cavity to the sinus is too large for surgical closure, prosthetic devices such as dentures and obturators can be used to prevent nasal speech and the aspiration of liquids and food.

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Complications

Cavernous sinus thrombosis

Cavernous sinus thrombosis is a serious sequela of infection, but one that is rarely life threatening. This condition can originate from an infection of the anterior maxillary teeth, which is usually confined to the anterior maxillary vestibule; however, if it hematogenously spreads above the levator anguli oris muscle, it can involve the floor of the nose; the facial, angular, or ophthalmic veins; and the cavernous sinus. If the hematogenous spread does not extend beyond the facial vein, periorbital swelling and fistula formation can occur. Infection spread because of continuity through the tissue can produce the same result.

Cavernous sinus thrombosis can also develop from an infection of the maxillary third molars that hematogenously spreads through the pterygoid plexus of veins to the angular vein, ophthalmic vein, and cavernous sinus. This process may be more subtle than that of a maxillary cuspid infection that spreads through the periorbital region because the spread of infection is not as rapid.

Periocular facial swelling is a sign of infection and thrombosis of the cutaneous sinus, which is a life-threatening condition.

Infection of the periorbital region can extend through hematogenous spread via the ophthalmic vein to the cavernous sinus. Spreading via the facial or external route is rapid because of the large open system of veins that directly leads to the cavernous sinus. Once infection reaches this sinus, the abducens nerve, which causes abduction of the eye and is closest to the sinus, is often affected. Other structures in the wall of the cavernous sinus include the internal carotid artery, trochlear nerve, oculomotor nerve, maxillary vein, and ophthalmic vein. Paralysis of the external ocular muscles, vision impairment, headache, nausea, and fever can occur. The cavernous sinus is located at the base of the brain, from where infection can spread to the meninges and brain. Brain abscesses and meningitis were invariably fatal until the advent of antibiotics, and they remain serious complications.

Ludwig angina

Ludwig angina occurs when septic cellulitis is present in the bilateral submental, submandibular, and sublingual spaces, with elevation of the tongue. The most common sources of this infection are infections in the dental apices or an impaction of the mandibular second and third molars. Ludwig angina is a life-threatening cellulitis that can close the airway. Patients with Ludwig angina often require a tracheotomy (see the image below). In addition, infection can spread to the masticator space and, in rare instances, to the lateral pterygoid space.

Cutaneous fistula due to a dental infection that c Cutaneous fistula due to a dental infection that causes Ludwig angina. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.

Trismus with cavernous sinus thrombosis and Ludwig angina

Trismus is present with cavernous sinus thrombosis and Ludwig angina, and immediate intervention by means of incision and drainage and antibiotic therapy is imperative to prevent its spread to the mediastinum. From the lateral pterygoid space, infection can spread to the posterior pharyngeal space and mediastinum. Once the infection spreads to the mediastinum, treatment is difficult, and death may occur. If the infection spreads to the carotid space, erosion of the carotid artery may occur and create a great potential for hemorrhage.

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Prognosis

With mucoceles, removal of the fluid-filled sac and surrounding minor salivary glands results in an excellent prognosis for cure.

Most dental infections are treated with incision and drainage and antibiotics, which result in an excellent prognosis. Usually, no morbidity and mortality occur. Cellulitis can lead to Ludwig angina and cavernous sinus thrombosis.

The mortality rate of cavernous sinus thrombosis was 75% but now has decreased to 30% with newer antibiotics and steroid therapy. See Cavernous Sinus Thrombosis for more information.

The mortality rate for Ludwig angina was 50% before the use of newer antibiotics. Now, the mortality rate is less than 10%. Deaths are due to complications such as aspiration pneumonia, spread to the mediastinum, sepsis, pleural cavity infection, and respiratory obstruction.

Trismus is present with cavernous sinus thrombosis and Ludwig angina, and immediate intervention is imperative to prevent its spread to the mediastinum. Once the infection spreads, treatment is difficult, and death is more likely.

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Patient Education

For excellent patient education resources, visit eMedicineHealth's Oral Health Center. Additionally, see eMedicineHealth's patient education articles Dental Abscess and Toothache.

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Contributor Information and Disclosures
Author

James Cade, DDS Clinical Dentist, Honeycutt Family Dentistry

James Cade, DDS is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association, American Academy of Oral and Maxillofacial Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Maureen B Poh-Fitzpatrick, MD Professor Emerita of Dermatology and Special Lecturer, Columbia University College of Physicians and Surgeons

Maureen B Poh-Fitzpatrick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, New York Dermatological Society

Disclosure: Nothing to disclose.

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Cutaneous fistula due to a dental infection that causes Ludwig angina. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.
Gunshot wound causing an oral cutaneous fistula. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.
Squamous cell carcinoma causing an oral cutaneous fistula. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.
Squamous cell carcinoma of the sinus that penetrates the maxillary ridge.
 
 
 
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