Marwan.doc

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 123

Management of facial fistulas and sinuses

Marwan G. Saied, B.D.S., F.I.C.M.S. (1)
Ahmed A. Al-Kinani, M.B.Ch.B., F.I.C.M.S. (2)

ABSTRACT
Background: A major difference between the treatment of the skin lesions and the odontogenic and non-
odontogenic sinuses. We aimed to analyze a substantial number of consecutive causes in order to clinical suspicion
in the differential diagnoses may be correctly weighted.
Materials and methods: The material of this research consisted of 40 patients. A complete history is collected from the
patients with the duration and the site of the sinus present, the patient was examined for factors of the fistulas and
sinuses and its associations, and patient having any concomitant lesions, a medical consultation done for opinion
and management. Clinical examination with facial fistulas and sinuses was mandatory to avoid any mistakes that
may occur. A treatment plan was contemplated regarding a conservative line will be followed or a surgical
intervention was indicated results.
Results: The common etiological causes: congenital and acquired causes. Fifteen patients have eighteen facial
sinuses and fistulas (40.9%) developed because of non-odontogenic infections, fifteen patients had fifteen facial
sinuses (34%) because of odontogenic infections, four congenital sinuses (9%) developed at three patients, two
patients with two facial sinuses (4.5%) due to tumor growth, three patients with three facial fistulas (6.8%) due to
traumatic causes and one patient with one facial sinus (2.2%) because of Actinomycosis and unknown cause for
each.
Conclusions: The maxillofacial surgeon should be aware of causes of whether developmental anomalies, deep
seated infections, epithelization of the tract, insufficient or inadequate drainage, deep lining foreign bodies and
certain types of infections.
Key words: Facial fistulas and sinuses, management, odontogenic and non-odontogenic causes. (J Bagh Coll
Dentistry 2015; 27(2):123-129).

INTRODUCTION
Facial fistulas and sinuses comprise an

important group of lesions which may present to
specialists in numerous branches of medicine. The
true fistula, an abnormal communication between
the lumen of one viscous and the lumen of another
body surface, is rare. The more common clinical
presentation is the sinus, a blind tract lined with
granulations leading from an epithelial surface
into the surrounding tissues.

The special consideration for facial fistulas
and sinuses are because of their resemblance of its
appearances to basal cell carcinoma, sebaceous
cyst, and other skin lesions as a furuncle can be
misdiagnosed as a sinus tract to the skin of the
face (1) (Table1).

Infective facial fistulas and sinuses
Dental cause

The opening of the sinus may be found at far
distance from the dental focus of infection, a sinus
from a tooth infection opened on the chest and
another on the upper third of the thigh (3).

Dental infections simulating skin lesions (4) .
Cutaneous sinuses tract of dental origin in
children (5), a dental etiology as part of differential
diagnosis should be kept in mind with oro-facial
skin lesion (6).

(1) Maxillofacial Surgeon, Department of Maxillofacial surgery,

Al-Wasity Hospital, Ministry of Health
(2) Plastic Surgeon, Department of Plastic surgery, Al-Wasity

Hospital, Ministry of Health

Table1: Etiology of facial fistulas and sinuses (2)

Actinomycosis
Actinomycosis is a chronic spreading

suppurative and granulomatous lesion caused
primarily by Actinomyces israelii. Draining
sinuses are formed through which the
characteristic “Sulphur granules” are discharged.
A persistent periapical disease with recurrent
sinus tracts, histological diagnosis confirmed
actinomycosis, the lesion was treated with
antibiotics and periapical surgery (7).

Osteomyelitis

A case of sinus discharge at infra orbital
region after repair of orbital floor defect by a
silastic sheet and another case of two sinuses

1 Embryological Preauricular sinus. Labial region.

2 Infective

Dental causes.
Specific infections e.g. T.B.,
actinomycosis.
Osteomyelitis.
Dental implant.
BRONJ

3 Trauma
Transected salivary ducts.
Infected fractures.
Bullet injury.

4 Carcinoma
Result of carcinomatous
growth.
Effect of radiation.

5 Miscellaneous Malnutrition (cancrum oris).

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 124

discharging at submental region due to infected
mandibular fracture (8) .

An additional cause for oral cutaneous fistulas
is bisphosphonate-related osteonecrosis of jaws
(BRONJ) (9) , so any oral/ dental causes increasing
BRONJ include abscesses, periodontal disease.
The risk of development of BRONJ with oral
bisphosphonate is very small but increase when
therapy exceeds 3 years (10) .

Dental implant
Dental implants can develop infections, leading to
intraoral and possibly extraoral sinus tract
drainage (11) .

Carcinomatous Cause of Facial Fistulae

An orocutaneous fistula can occur after any
operation on the oral cavity to remove a tumour
and the most important causative factors are
previous radiotherapy and inadequate control of
nutritional status, diabetes and anaemia in the
preoperative period, poor operative technique.
Often the fistula will be the result of surgical
intervention for the neoplastic disease (12) .

A case of an orocutaneous fistula reported
with pathological fracture of the mandible in
patient with osteoradionecrosis which followed
orthovoltage radiation (13). Also a case reported
of an oropharyngocutaneous fistula in an
irradiated patient (14).

MATERIALS AND METHODS

The material of this study consisted of 40
patients with (44) facial fistulas and sinuses (26
males and 14 females and the average was
20years) suffering of a fistula or sinus in the facial
region, between September 2009 and November
2013, at the Al-Wasity hospital for reconstructive
surgery at Al-Resafa institute of ministry of
health, Baghdad- Iraq. They were either referred
from other hospitals or outpatient clinic of the
same hospital. The common an etiological cause
were divided into two groups: Congenital and
acquired causes and the acquired causes divided
into odontogenic infection, non-odontogenic
infection, traumatic, tumor growth, actinomycosis
and unknown causes (Table 2). Our definition of
the face as the front part of the head which
includes lips, cheeks, nose, eyes, forehead and one
finger below lower border of the mandible. We
excluded the fistulas and sinuses which occur in
the neck or inside the mouth. On admission a
complete history was collected from the patients

concerning name, age, gender, residency, the
duration and the site of the sinus present. Clinical
examinations of the patients is mandatory which
include inspection, palpation and probing the
sinus as well as radiographic examination which
include conventional radiographical views like
periapical, occlusal, panoramic views of the
mandible and lower portions of maxilla and
supplementary methods like sinography with
stainless steel wire 0.5 mm in diameter or
sinogram with injection of radiopaque dye
(ipomer) through sinus tract.

We examined cutaneous tissue of the face to
look for any skin lesion or dental lesion or
malignant tumor. Also parotid region and
submandibular with submental regions have
examined to look for any salivary gland fistulas or
dental lesion. Teeth are checked and recorded
(deciduous and permanent), recorded whether
sound healthy or carious teeth, also looking for
any swelling intraorally. Also intraoral palpation
of a cord-like structure connecting the skin lesion
with the underlying alveolar ridge is helpful in
establishing the diagnosis and according to the
diagnosis, a treatment plan was contemplated,
regarding a conservative line will be followed or a
surgical intervention was indicated.

RESULTS
Fourteen patients have seventeen facial sinuses at
submandibular region, four patients with four
facial sinuses at submental region, eleven patients
with eleven facial sinuses at cheek region, three
patients with three facial sinuses at preauricular
region and canthal regions for each, one patient
with two labial sinuses, one patient with facial
sinus at temporal region, parotid region, chin
region, zygomatic region for each, (Table 3). Four
patients having facial fistula (either orocutaneous
or salivary fistula), thirty-four patients having
facial sinus, two patients having facial fistula and
sinus, and two patients have bilateral facial
sinuses (Table 4).
Table 2: Causes of facial Fistulas and sinuses

Causes %
Non-odontogenic infection 40.9%
Odontogenic infection 34%
Congenital 9%
Traumatic 6.8%
Tumor 4.5%
Actinomycosis 2.2%
Un known 2.2%

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 125

Table 3: Sites of facial fistulas and sinuses

Table 4: Number and percentage of patients with fistulas and sinuses

The facial sinuses were more in males
prevalent than in females (65% versus 35%)
(Figure 1), and the (16-30) year's cohort made up
the largest group (32.5%) (Figure 2).

Surgical interruption was adopted in 31
patients with 35 facial sinuses or fistulas (Figure
3). Six of the patients with facial sinus associated
with a mandibular fracture infection.

Sites Patients Number of fistulas and sinuses Percentage

Submandibular region 14 17 38.6%
Cheek region 11 11 25%

Submental region 4 4 9%
Preauricular region 3 3 6.8%

Canthal regions 3 3 6.8%
Temporal region 1 1 2.2%

Labial region 1 2 4.4%
Zygomatic region 1 1 2.2%

Chin region 1 1 2.2%
Parotid region 1 1 2.2%

Type Number of patients Percentage
Facial fistula only 4 10%
Facial sinus only 34 85%

Facial fistula and sinus 2 5%
Facial sinus "bilaterally" 2 5%

0-15 16-30 31-45 46-60 60 Onward

Figure 2: Age distribution

Figure 3: Mode of treatment

Males 60%

FEMALES 40%

Figure 1: Sex distribution

S urg ic al tre atme n t co nse rva tio n trea tme nt re fus e trea tme nt

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 126

DISCUSSION
A chronic facial lesion is occasionally the skin

manifestation of a fistula of dental abscess origin.
It will persist until the abscess nidus is obliterated.
The distance of the lesion from the oral cavity and
the patient freedom from tooth discomfort do not
exclude the dental cause.

This study showed that (32.5%) of the affected
patients were in the age group (16-30) years old
while (22.5%) were in the age group( 31-45) years
of age, (20%) were in the age group of (0-15)
years of age, (15%) were in the age group (46-60)
years of age and (10%) were in the age group 60
onward. Seventy-five percent of patients were
under 45 years, this goes with Malik and Bailey
series (2), perhaps because of shorter life
expectancy. The predominant males to females
ratio was supported by Mortenson et al. (15) and
Malik and Bailey series (2) were more than 60%
of patients were males and about 40% were
females.

In this study Non-odontogenic infections was
the most common cause and this include for
example patients with facial sinuses due to
infected bone graft. Also in this series TMJ
arthritis cause a facial sinus in one of our patients
who was uncontrolled diabetic patient and other
patient presented with orocutaneous fistula at
submandibular region after excision of sequamous
cell carcinoma of the tongue with pectoralis major
flap for reconstructive due to infection with
staphylococcus aureus and pseudomonas
microorganisms .While in previous studies the
distributions of cases based towards odontogenic
origin and this is perhaps because many of
patients may go to other departments or remain
totally symptomless or the sinuses usually
develop in connection with the developmental
anomalies or because of presence of a deep seated
infection or the presence of certain types of
infection of the tract wall. Odontogenic infections

is a second of frequency in this study while in
Malik and Bailey series (2) in two years period
treated 100 consecutive cases of facial sinuses
with a mean of 50 patients per year was the
commonest cause of facial sinuses . One patient
was diagnosed by general surgeon as a skin lesion
so he treated three times by local excision of the
sinus for one year duration while the diagnosis
was infected keratocyst in the ramus of the
mandible, other patient presented with a
submandibular sinus for six months duration as
skin lesion and the diagnosis was infected carious
lower mandibular first molar tooth. A dental
examination and radiographs recommended to
rule out infection of dental origin (16) . One patient
presented with a facial sinus discharging pus at
lateral canthal region of left eye due to
osteomyelitis of the left maxilla. We reported four
sinuses discharging in four patients due to
infected maxillary teeth while Chernosky (1940)
said maxillary sinuses discharging are rare and the
gravity is accepted as the reason for the facility
with which lower jaw abscess proceed to
fistulization . So we think a cutaneous facial sinus
tract of dental origin are often initially
misdiagnosed and inappropriately treated. Correct
diagnosis and treatment will result in predictable
and rapid healing of these lesions. The third cause
of facial sinuses was congenital cause, which
result in four facial sinuses in three patients (9%)
and these includes preauricular sinuses in two
patients. The fourth cause of facial sinuses and
fistulas was a traumatic cause. The fifth cause of
facial sinuses was a tumor growth which result in
two facial sinuses in two patients (4.5%) while
this finding recorded in Malik and Bailey series
a third cause. The sixth cause of facial sinuses
was actinomycosis infection which results in one
facial sinus (2.2%) and this goes with Malik and
Bailey series who they considered this finding
one of uncommon causes (Figure 4).

Figure 4: Patient with multiple sinuses due to actinomycosis infection.

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 127

The basic technique for management of facial
fistula or sinus depends on the correct diagnosis
which includes the awareness of the possibility of
an odontogenic sinus by knowing that striking
granulomatous lesion which may occurs about the
gum, the face, and the neck and which may
presents one end of a persistent sinus tract. The
other end of this sinus usually originates in the
apical abscess of a tooth but may take its origin in
any osteomyelitis process of the jaw or foreign
body infections. Out of the forty four facial
fistulas and sinuses, four sinuses and three facial
fistulas were treated conservatively, the treatment
involve the detection of the cause which lead to

the sinus or fistula formation either infected tooth
with periapical pathosis or salivary gland injury
have been treated conservatively through dressing
extraorally with iodoform packing intraorally.
Surgical treatment was considered in thirty two
facial sinuses and three facial fistulas. Fourteen
sinuses due to odontogenic infection treated by
extraction of the tooth and endodontic therapy of
the tooth with curettage of the sinus tract with
antibiotic or removal odontogenic cyst, four
sinuses due to foreign body infection treated by
removal of the bony sequestrum or the stainless
steel wire (Figure 5).

A B

C
Figure 5: A: patient with sinus discharge due to infected stainless steel wire for fixation of bone

graft of right mandibular body reconstruction;
B: radiograph shows infected stainless wire fixation;

C: patient after the removal of the infected stainless steel wire and healed sinus discharge

Two sinuses due to infected mandibular
fracture in some patients because of the presence
of a tooth in the mandibular fracture lead to
infected fracture and sinus formation treated by
extraction of the tooth with curation of the socket
of tooth, three sinuses and one orocutaneous
fistula due to bone graft infection (autogenous
outer table of iliac crest bone), four sinuses and
one cutaneous fistula due to osteomyelitis of the

jaws, one sinus due to arthritis of TMJ who was a
known case of IDDM result in a temporal abscess
with a cutaneous sinus discharge we treated him
by controlling the blood sugar level with drainage
of temporal abscess, one patient with
orocutaneous fistula postoperatively to excision of
carcinoma of tongue treated by a free flap (Radial
Chinese flap) (Figure 6) , two patients with four
congenital sinuses an elliptical incisions were

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 128

made and sinus tract were dissected out together
with direct closures while for the facial sinuses for
actinomycosis infection treated by debridement
with a heavy antibiotics.

The use of a negative pressure vacuum
associated closure technique for orocutaneous
fistulas was reported (17).

A B

Figure 6: Patient with orocutaneous fistula, A: Closure of orocutaneous fistula by forarm radial
free flap (Chinese flap), B: intraorally, C: extraorally.

All patients except the patient treated for
excision of a malignant tumor were operated upon
under local anesthesia or conservatively. Two

patients refuse the treatment and one only one
facial sinus unhealed. The majority of the patients
kept on regular follow up for 2-3 weeks (Table 5).

J Bagh College Dentistry Vol. 27(2), June 2015 Management of

Oral and Maxillofacial Surgery and Periodontics 129

Table 5: Treatment of 44 cases of facial sinuses

REFERENCES

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6. Diagnosis and treatment of odontogenic cutaneous
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7. Jeansonne BG. Periapical actinomycosis: a
review. Quintessence Int 2005; 36(2):149-53.

8. Rowe NL, Williams J. Maxillofacial injuries. 1985
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13(1): E52-7.

10. Eklund MK. Bisphosphonate-related osteonecrosis
of the jaws (BRONJ). Southwest Oral Surgery and
Implant Blog; 2010.

11. Tözüm TF, Sençimen M, Ortakoglu K, Ozdemir A,
Aydin OC, Keles M. Diagnosis and treatment of a
large periapical implant lesion associated with
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Med Oral Pathol Oral Radiol Endod 2006; 101(6):
e132-8.

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lesions. 3ed ed. 1985. p. 193-203.

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infections. 3rd ed. W.B. Saunders Co.; 1994.

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patient. Int J Oral Maxillofac Surg 1999; 28: 364-5.

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granulomas and cysts. An investigation of 1600
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:الخالصة
نحن تھدف إلى تحلیل عدد كبیر من األسباب متتالیة من أجل االشتباه السریري في . شأ وغیر سنیة المنشأھناك فرق كبیر بین معالجة اآلفات الجلدیة والنواسیر سنیة المن: المقدمة

.التشخیص التفریقي یمكن المرجحة بشكل صحیح
لنواسیر الحاضر، تم فحص المریض لعوامل من یتم تحصیل التاریخ الكامل من المرضى الذین یعانون من مدة وموقع ا. مریضا 40المواد من ھذا البحث وتألفت من : المواد و الطرائق

كان الفحص السریري للناسور والتجاویف الوجھیة إلزامیة لتجنب أي أخطاء قد . الناسور والمتعلقات لھا، وجود أي اآلفات المصاحبة، واالستشارة الطبیة القیام بھ إلبداء الرأي واإلدارة
.العالج تحفظیًا أو التداخل جراحیًا تم التفكیر في وضع خطة العالج فیما سیكون. تحدث
بسبب العدوى غیر ,) ٪40.9(حیث خمسة عشر مریضًا یحتوون على ثمانیة عشر من النواسیر و التجاویف الوجھیة . األسباب الخلقیة والمكتسبة: إن االسباب العامة تتضمن: النتائج

وضعت في ثالثة مرضى، ) ٪9(بسبب التھابات سنیة المنشأ، وأربع نواسیر الوجھیة الخلقیة ) ٪34(سنیة المنشأ، وكان خمسة عشر مریضا یحتوون على خمسة عشر النواسیر الوجھیة
نتیجة ألسباب الصدمة ومریض ) ٪6.8(ورم، ثالثة مرضى مع ثالثة التجاویف الوجھیة وذلك بسبب نمو ال) ٪4.5(واثنین من المرضى الذین یعانون من اثنین من النواسیر الوجھیة

.بسبب داء الشعیات والسبب غیر معروف لكل واحد) ٪2.2(واحد مع ناسور وجھي واحد
میقة الجذور، أو االندمال بتشكل النسیج الظھاري من الجھاز، أو یجب أن یكون جراح الوجھ والفكین على علم باالسباب سواء ان تكون تشوھات تنمویة، أوااللتھابات الع: االستنتاجات

.الصرف غیر كافیة، و االجسام األجنبیة العمیقة وأنواع معینة من االلتھابات

Treatment No. of Cases %
Endodontic treatment of lower anterior teeth. 1 2.25%
Treatment of osteomyelitis of jaws. 5 11.4%
Treatment of salivary gland injury fistulas. 3 7%
Extraction and antibiotic treatment of maxillary teeth. 8 18.3%
Extraction, antibiotic and excision of sinus tract treatment of mandibular teeth. 4 9.1%
Surgical extraction and curettage of infected non-erupted mandibular tooth. 1 2.25%
Tumor treatment of mandibular ameloblastoma. 2 4.5%
Enculation of mandibular keratocyst cyst and antibiotic 1 2.25%
Removal of foreign body from the mandible, check and TMJ. 4 9.1%
Treatment of mandibular fractures infection. 2 4.5%
Treatment of mandibular bone graft infection. 4 9.1%
Treatment of TMJ arthritis in the temporal region. 1 2.25%
Treatment of orocutaneous fistula in submandibular region. 1 2.25%
Treatment of congenital sinuses in the lower lip and preauricular regions. 4 9.1%
Treatment of actinomycosis of submandibular region. 1 2.25%
Refuse treatment. 2 4.5%
Total 44 100%