eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa
Oral Cutaneous Fistulas: Follow-up
Updated: May 19, 2009
Follow-up
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.
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.
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.
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 Media File 1). 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 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.
Prognosis
With mucoceles, removal of the fluid-filled sac and surrounding minor salivary glands results in an excellent prognosis for cure.
Patient Education
For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Additionally, see eMedicine's patient education articles Dental Abscess and Toothache.
Miscellaneous
Medicolegal Pitfalls
Proper diagnosis of the cause and correct treatment can avoid legal pitfalls (see Treatment). Fistulas often take a long time to heal. Rule out neoplasia if a fistula does not respond to antibiotic therapy or surgical closure.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous Editor-in-Chief, William James, MD, to the development and writing of this article.
More on Oral Cutaneous Fistulas |
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| Differential Diagnoses & Workup: Oral Cutaneous Fistulas |
| Treatment & Medication: Oral Cutaneous Fistulas |
 Follow-up: Oral Cutaneous Fistulas |
| Multimedia: Oral Cutaneous Fistulas |
| References |
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Further Reading
Keywords
orofacial fistulas, sinus tract, intraoral fistulas, dentoalveolar abscesses, periapical infections, periapical granulomas, parulis, maxillary dental infections, trismus, mandibular space infections, osteomyelitis, lymphadenopathy, sialolith, dental implants, dens invaginatus, taurodontism, endodontics, maxillary sinusitis, Garre's osteomyelitis, dermoid cyst, Garre osteomyelitis
