33 yr old male with c/o pus oozing out from his upp. left third molar region

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CHIEF COMPLAIN: c/o pus oozing out from his upper. left third molar region

PATIENT HISTORY: A 33yr old man visited our hospital on 10/02/22 with c/o pus oozing out from his upper. left third molar region. He is an auto driver by profession. When he was 1.5 yrs old he hit his left eye with a sharp object while playing with a sharp cutter and severely damaged his eye. His parents took him to a clinician but he needed Sx which was not done due to financial problems. After that, while staying in Bangalore he visited many hospitals but again Sx was recommended which he didn't want. Now he has completely lost vision in his left eye for the past 6 - 7 years. He left his studies in 2004 - 05 came to Bangalore to find a job, worked as a construction worker making steel frames for buildings. Went back home after 3 months. Again returned to Bangalore for the same work. This time stayed for 1 - 1.5 years. During his stay i.e 2008 - 09 started alcohol consumption(20 ml/day) due to peer pressure. Returned home after staying in Bangalore for 1 - 1.5 yrs. After that takes alc. once/month 20 ml or only during some occasions. Returned to Bangalore in 2010. This time started having tobacco(due to peer pressure) 4 - 5 times/ day around 2 gms still continuing. From 2009 to 13 got money along with peer pressure, so used to have cigarettes( 3 - 4 cigarettes/day ). After 2013 had only 1 cigarette/ 4 months. In 2013 went back home, started farming potatoes, spices, rice. From 2016 to date drives auto in Mathabhanga( W.B ). From the year 2008 to 2016 c/o periodic cough was mostly dry which was seasonal i.e one episode in Summer, one in Winter, and used to last for 10 - 15 days which would go away after having cough syrup. From 2016 - 19 started having alc. again 50ml 2 days/wk due to peer pressure. In 2015 had a fight with a cousin over a lottery business, was hit in the left jaw where pain persisted for 2 - 3 days. After that pain resolved on its own. Around Dec 2021 pt c/o pain, swelling, and little cream-colored pus from the upp. left side molar tooth(NOTE: On the upper jaw his wisdom tooth is missing from both sides i.e never arise) for which he visited a Dentist, took some tablets, and the pain and swelling resolved. 5 days later again pain and swelling started from the same region, visited Dr., started taking medications, but on the 4th day of course lot of pus came out after which his pain and swelling reduced significantly. He used to block his nostrils and create pressure inside to drain pus ? from the maxillary sinus. Once while doing that noticed a little bloodstain on his nostrils. On 01/01/22 went to a dentist who cleaned his teeth after which the pus amount decreased a bit. On 04/01/22 Physician gave him medications and ordered OPG and CBCT. The patient could not do the tests at that time visited another Physician on 16/01/22 who gave him Clavam 625 mg( 1 tab BD for 5 days ), Tab. Metrogyl 200 mg ( 1 tab for 5 days ), Tab. Voveran D ( 1 tab BD for 5 days ). On 17/01/22 pain increased very much. on 18/01/22 pain decreased. After OPG, CBCT reports on 22/01/22 Physician gave him Tab. Taxim O ( 1 tab BD for 5 days ) which he didn't take. On 05/02/22 for the first time, reddish pus came out. Seeing that he took Taxim O on 7th and 8th. When he came here pain has reduced a lot, but pus is there. 

 

                                                    

CBCT report.

OPG report

RADIOGRAPHIC PROVISIONAL DIAGNOSIS:

• Radiographic features can be suggestive of left maxillary sinusitis with ?osteomyelitic changes in the left floor and the medial and lateral borders of the maxillary sinus.
• D/D: Suspected aggressive lesion?
• Oro antral communication distal to #28 region
• Pulpal calcification in the teeth of the Lf posterior maxilla and posterior mandibular region. 

                                                      

                                   Pus aspirated from the pt. suspected of maxillary osteomyelitis

                                                                                      Nasal endoscopy video      
CHEST X-RAY

ECG

CT PNS of our 33 old man admitted currently with us with pus discharge from left 2nd upper molar

tooth showing connection with temporal lobe

CECT NECK REPORT

• Nasopharynx, oropharynx and hypopharynx normal
• Suproglottic, glottic and subglottic larynx normal
• Thyroid normal
• Carotid arteries and UV normal
• Parotid glands normal
• Submandibular glands normal
• Skull bone normal
• Visualized bone normal

       IMPRESSION: 

• Expansile unilocular lytic lesion involving the maxillary arch on the left side bulging in the lumen of the left maxillary sinus               

                                         F/S/O Locally aggressive odontogenic/non-odontogenic lesion of the jaw

                                                      ....................Suggested HPE correlation ...................

• The lesion is causing significant narrowing of the maxillary sinus and reaching up to the orbital floor superiorly.
• Other extensions as above 
• Cervical lymphadenopathy as above

CECT NECK

• Expansile unilocular lytic lesion involving the maxillary arch on the left side bulging in the lumen of the left maxillary sinus 

                               - The lesion is causing significant narrowing of the maxillary sinus and reaching up to the orbital floor superiorly.

                               - Lesion is showing fluid component and enhancing solid component

                               - Significant cortical thinning is noted with multiple areas of cortical break involving the                                       posterior and anterior - superior aspect

                               - The enhancing solid component of the lesion is extending posteriorly into the pterygopalatine and infratemporal fossa

                               - Mild edema of retroantral soft tissue, pterygoid, and buccinators muscles

• The left maxillary sinus is narrowed by the above lesion and shows retained secretion/ mucosal thickening
• Rest of the paranasal sinus normal
• Enlarged left eyeball with a focal posterior protrusion - Staphyloma. Rest of the orbit normal  

       Lymph node 

                                                                                     Right side                                   Left side

                                             Level 1A                                 -                                                -

                                             Level 1B                                 -                     10mm, ovoid, fatty hilum present

                                             Level  II                                  -                      5 - 10mm, ovoid, fatty hilum present

                                             Level III                                  -                     5 - 10mm, ovoid, fatty hilum present

                                             Level IV                                  -                                                -

Enterococcus species grown. Sensitive to all the drugs.

Gram stain in favor of anaerobic infection

Most likely fusobacterium species

10/02/22

• Pt came with c/o pus discharge from left upper molar for 1.5 month
• Crossconsulted with periodontologist
• Provisional diagnosis: Chronic suppurative osteomyelitis
• D/D: Oro antral communication

11/02/22

• Referred to Dept. of oral and maxillofacial surgery
• Investigation done: OPG( reveals periapical radiolucency Lvl 26+27)
• Provisional Diagnosis: Osteomyelitis of the left maxilla
• Advice: CT facial bones with 30 reconstruction
• Rx: Tab. Augmentin 625mg BD

                 Tab. Metrogyl 400mg TID

                 Tab. Voveram 75mg BD

                 PAN 40mg IV/BD

                 Warm saline rinsing of the mouth

12/02/22

• Nasal endoscopy done
• Crossconsulted with ENT surgeon. 
• RBS, LFT suggested
• Provisional Diagnosis: Lt oroantral fistula with chronic maxillary sinusitis
• RBS - 154mg/dl, S. creatinine - 0.8, Na+ - 132, K+ - 3.8, Cl- - 98, Blood urea - 12mg/dl
• LFT : TB - 0.97, DB - 0.20, AST - 29, ALT - 159, TP - 6.8, Alb - 4.2, A/G - 1.62
• Serology -ve
• Rx: Inj. Cefotaxime 1gm IV/BD 

                 Inj. Metrogyl 100ml

                 Inj. PAN 40mg IV/BD

                 2% Betadine gurgles dilute with water 2-3 times/ day

                  Tab. Acetelofenac + PCM

13/02/22

• Hemogram : Hb - 15.4g/dl, TLC - 7,500 cells/cumm, PLT - 2.5 lakhs/cumm
• CUE : Alb-nil, Pus cells- 3 to 4, Epi. cells - 2 to 4
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration
• Rx: Inj. Cefotaxime 1gm IV/BD 
                 Inj. Metrogyl 100ml
                 Inj. PAN 40mg IV/BD
                 2% Betadine gurgles dilute with water 2-3 times/ day
                  Tab. Acetelofenac + PCM

14/02/22

• CECT Neck done
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration
• Rx: Inj. Cefotaxime 1gm IV/BD 
                 Inj. Metrogyl 100ml
                 Inj. PAN 40mg IV/BD
                 2% Betadine gurgles dilute with water 2-3 times/ day
                  Tab. Acetelofenac + PCM

15/02/22

• Pus sent for culture + sensitivity test
• GRBS 102mg/dl
• Rx:  Inj. Metrogyl 100ml
        Inj. PAN 40mg IV/BD
        Inj. Augmentin 1-2g,m IV/BD for 5days
        Inj. Voveran 75mg IM BD for 5 days
        Chlorhexidine mouth wash TID

16/02/22

• Biopsy sample sent
• HbA1C - 6.8
• GRBS - 72mg/dl (8 am), 74mg/dl (2 pm), 140mg/dl (8 pm)
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration with Denovo DM
• BP - 110/70 mmHg, PR - 62 BPM
• Rx: Inj. Augmentin 1.2gm IV/BD for 5 days

                 Inj. Metrogyl 500mg IV TID

                 Inj. voveran 75mg IM/BD

                 Inj. PAN 40mg IV/BD

                 Tab. Acetelofenac + PCM

                 Chlorhexidine mouth wash TID

17/02/22

• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration with Denovo DM
• BP - 100/80 mmHg, PR - 70 BPM
• GRBS - 136mg/dl (8 am), 110mg/dl (2 pm), 126mg/dl (8 pm)
• Rx: Inj. Augmentin 1.2gm IV/BD for 5 days
                 Inj. Metrogyl 500mg IV TID
                 Inj. voveran 75mg IM/BD
                 Inj. PAN 40mg IV/BD
                 Tab. Acetelofenac + PCM
                 Chlorhexidine mouth wash TID
GRBS 6th hourly

18/02/22

• Pt c/o blood oozing from the site of incision, while talking/ chewing food, no h/o pain fever, vomiting
• Pt was taken to OMFS opd
  
  
  
• Pt feels slightly less pus coming out during nighttime than it was before his admission
• BP - 110/80 mmHg, RR - 20cpm, GRBS - 116mg/dl 
• Haemogram: Hb - 15.6g/dl, TLC - 7,500, Platelet - 2.45 lks, RBC - 6.29 millions/cumm 
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration with Denovo DM
• Rx: Inj. Augmentin 1.2gm IV/BD 
                 Inj. Metrogyl 500mg IV TID
                 Inj. voveran 75mg IM/BD
                 Inj. PAN 40mg IV/OD
                 Chlorhexidine mouth wash TID

19/02/22

• relatively little pus oozed out since today morning
• no more oozing of blood from the site of the biopsy incision today. Last happened yesterday morning
• No fresh complaint
• BP - 100/80mmHg, PR - 76bpm, RR - 20cpm, GRBS - 120mg/dl
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration with Denovo DM type II
• Rx: Inj. Augmentin 1.2gm IV/BD 
                 Inj. Gentamycin 40mg in 100ml NS over 30mins TID
                 Inj. voveran 75mg IM/BD
                 Inj. PAN 40mg IV/OD
                 Chlorhexidine mouth wash TID

                                                                    Pus collected

20/02/22

• relatively little pus oozed out since today morning
• no more oozing of blood from the site of the biopsy incision today. 
• No fresh complaint
• BP - 110/80mmHg, PR - 76bpm, RR - 18cpm, GRBS - 110mg/dl
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration with Denovo DM type II
• Rx: Inj. Augmentin 1.2gm IV/BD 
                 Inj. Gentamycin 40mg in 100ml NS over 30mins TID
                 Inj. voveran 75mg IM/BD
                 Inj. PAN 40mg IV/OD
                 Chlorhexidine mouth wash TID

21/02/22

• relatively little pus oozed out since today morning
• No fresh complaint
• BP - 110/80mmHg, PR - 72bpm, RR - 18cpm, GRBS - 103mg/dl(8 am), 250mg/dl(2 pm), 84mg/dl (8 pm)
• Provisional diagnosis: Lt oroantral fistula with chronic maxillary sinusitis, Lt spheroid degeneration with Denovo DM type II
• Rx: Inj. Augmentin 1.2gm IV/BD 
                 Inj. Gentamycin 40mg in 100ml NS over 30mins TID
                 Inj. voveran 75mg IM/BD
                 Inj. PAN 40mg IV/OD
                 Chlorhexidine mouth wash TID

22/02/22

• relatively little pus oozed out since today morning
• No fresh complaint
• BP - 110/80mmHg, PR - 80bpm, RR - 18cpm, GRBS - 104mg/dl
• Biopsy report:

Provisional Diagnosis: Osteomyelitis

Histopathological findings: 

 

H and E stained section show the presence of parakeratinised stratified sq. epithelium of variable thickness along with underlying connective tissue stroma. The epithelium does not show any dysplastic features. The underlying connective tissue stroma is composed of dense collagen fiber bundles and chronic inflammatory cell infiltrate chiefly composed of lymphocytes. Hemorrhagic areas are also seen in the given specimen.

The above histopathological features suggestive of  inflammatory lesion

Diagnosis: Inflammatory lesion

• Rx: Inj. Augmentin 1.2gm IV/BD 
                 Inj. Gentamycin 40mg in 100ml NS over 30mins TID
                 Inj. voveran 75mg IM/BD
                 Inj. PAN 40mg IV/OD
                 Chlorhexidine mouth wash TID

Preoperative diagnosis: Infected odontogenic cyst of the left side of the maxilla. Glandular odontogenic cyst,?Reparative giant cell granuloma

Surgery executed: Enucleation and curettage

Postoperative diagnosis: ?Glandular odontogenic cyst, ?Reparative giant cell granuloma, ?Infected radicular cyst.

Specimen sent to: General pathology, oral pathology for histopathological examination

Operative findings: Cystic lining was found on the left side of the maxilla.

Operative procedure: The patient was wheeled to OT at around 9:30 am. Oral intubation was done uneventfully. Standard draping and facial preparation with betadine. Marking for the vestibular incision was done in the left maxillary vestibule from 27 to 21. 2% lignocaine with 1:80000 adrenaline infiltrated along the incision marking. Incision given. Full-thickness mucoperiosteal flap raised Anterior antrostomy done connecting to the posterior perforation measuring approx 1 *  2 cm. Cystic lining appreciated. Enucleation and curettage of the cyst done i.r.t anterior. medial, posterosuperior, and inferior aspects of the maxilla. Irrigation was done thoroughly using betadine, saline, and hydrogen peroxide. Cavity packed with medicated dressing(bactigras). Closure dine by suturing buccal fat pad to the gingival mucosa using  3 0 vicryl. Closure of the vestibular mucosa done using 3 0 vicryl. Extubation was done uneventfully.

Post operative instructions: 

I) NBM until further orders

ii) Monitor vitals 4th hourly: GRBS[2 hr after the meal(after NBM break)]

iii) Head raised to 30 degrees, cold fomentation over the operated site

iv) Inj. Augmentin 1.2mg IV BD  @ 7pm, 7am

v) Inj. Gentamycin 40mg in 100ml NS TID @ 7pm, 3am, 11am

vi)Inj. Voveran 75mg IV BD  @ 7pm, 7am

vii)Inj. Dexona 8mg IV BD  @ 7pm, 7am

viii)Inj. PAN 40mg IV BD  @ 7pm, 7am

ix) Inj. Zofer 4mg IV @ S - 0 - S

x) Chlorhexidine mouthwash TID from 1/03/22