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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 141-144

An unusual case of maxillary osteomyelitis in a young female


Department of Oral Medicine and Radiology, Vidya Shikshan Prasarak Mandal's Dental College, Nagpur, Maharashtra, India

Date of Submission26-Jul-2016
Date of Acceptance18-Oct-2017
Date of Web Publication9-Nov-2017

Correspondence Address:
Apurva S Mohite
33 B, Cosmos Town, Trimurti Nagar, Nagpur - 440 022, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_87_16

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   Abstract 

Osteomyelitis of facial bones is an uncommon condition. Maxillary osteomyelitis is rare compared to mandibular osteomyelitis because the extensive blood supply and strut-like bone of the maxilla make it less vulnerable to chronic infections. We report an unusual case of maxillary osteomyelitis involving the right half of the maxilla in a 27-year-old, systemically healthy female. She reported with pain in the upper right region of the jaw since 1 year. Her past dental history revealed that she underwent dental extraction 1 year back in the same region due to pain and mobility of teeth. Intraoral examination revealed exposed necrotic bone in the right maxillary region with mobility of teeth and pus discharge. Radiographic investigations confirmed the diagnosis of osteomyelitis of the right maxilla. The patient was advised hemimaxillectomy, following which the patient was given a surgical and later a permanent obturator to close the surgical defect.

Keywords: Hemimaxillectomy, maxillary osteomyelitis, necrotic bone, obturator


How to cite this article:
Mohite AS, Motwani MB, Assudani PV. An unusual case of maxillary osteomyelitis in a young female. J Indian Acad Oral Med Radiol 2017;29:141-4

How to cite this URL:
Mohite AS, Motwani MB, Assudani PV. An unusual case of maxillary osteomyelitis in a young female. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Dec 5];29:141-4. Available from: https://www.jiaomr.in/text.asp?2017/29/2/141/217919


   Introduction Top


The word “osteomyelitis” originates from the ancient Greek words osteon (bone) and muelinos (marrow) and means infection of the medullary portion of the bone.[1] It was first described by the French surgeon Edouard Chassaignac in 1852.[2] In the maxillofacial region, it rarely involves the maxilla because of the significant collateral blood flow in the midface, thin cortical plate and scarcity of medullary tissue in the maxillary bone. However, when the condition occurs, it may cause serious complications such as infection of the cranial cavity and brain. Thus, it is essential that maxillary osteomyelitis be diagnosed and treated aggressively to avoid subsequent dreaded consequences.[3] We present an unusual case of maxillary osteomyelitis in a young, otherwise healthy female, along with its diagnosis and management.


   Case Report Top


A 27-year-old female patient reported to the Department of Oral medicine and Radiology, with the complaint of pain in the upper right front region of the jaw since 1 year. Her past medical history was not significant. Her past dental history revealed that she had visited a dental consultant 1 year back due to pain and sudden appearance of a swelling in the upper right region of the jaw. History also revealed that mobile teeth in that region were extracted by the dental consultant. She did not carry any previous radiographs or documents that would specify the reason for extraction of the teeth. She gave a history of pus discharge from the extraction site 2 days after the extraction, after which the swelling gradually decreased in size but did not subside completely. She was then referred to an Ear, Nose and Throat speciality consultant followed by a general surgeon who prescribed her medication which were also not completely helpful. She then reported to our outpatient department with the complaint of pain in the same region. The pain was gradual in onset, dull aching and intermittent in nature. It aggravated on mastication and slightly decreased on taking medication (analgesic – diclofenac sodium 50 mg) prescribed by the previous consultants. She gave a history of unilateral mastication from the left side due to pain and pus discharge from the right maxillary region. General examination of the patient revealed that all the parameters were normal with no signs of pallor or icterus. Vital signs were within the normal limits. The build of the patient was medium, and her appetite was not affected. Extraoral clinical examination showed facial asymmetry due to a diffuse swelling over the right side of the face which extended anteroposteriorly from the right ala of the nose to 1 cm anteriorly to the pretragus area and superoinferiorly from the right infraorbital rim to the right corner of mouth. The overlying skin was intact and there was no change in the color of the skin. No paresthesia was noted over the swelling. Local temperature was slightly raised over the swelling. The swelling was soft in consistency and nontender on palpation. Regional lymphadenopathy was absent.

Intraoral examination showed that the lateral incisor, canine and premolars were missing from the first quadrant. There was exposed necrotic bone in the right maxillary region in the area of missing teeth, involving the entire alveolus. In addition, there was mobility of teeth in the first quadrant (Grade II mobility in 16, 17, 18 and Grade III mobility in 11), and the entire bony segment was mobile. Pus discharge was present from the vestibule on palpation. No intraoral sinus was present. The pus was muddy yellow in color, and the volume increased on applying pressure. Unhealed extraction sockets were seen in the same region and the whole segment was covered with slough and calculus. Narrowing of palatal vault was also seen [Figure 1].
Figure 1: Showing exposed necrotic maxillary alveolar bone and unhealed extraction sockets

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A provisional diagnosis of chronic suppurative osteomyelitis involving the right maxilla was made. Squamous cell carcinoma with secondary infection of the right maxilla was included in the differential diagnosis. Radiographic investigations included maxillary anterior topographic occlusal view, orthopantomograph (OPG), and computed tomography (CT) scan. Complete blood count and human immunodeficiency virus (HIV) testing were also done. The lesion was very extensive, and hence, it was quite certain that it would require surgical management and mere antibiotic therapy would not help. Therefore, culture and sensitivity of the pus was not done. Fungal infections were ruled out because the patient was systemically healthy and it is relatively rare. The blood counts of the patient were normal, and hence, other blood dyscrasias were ruled out (Hemoglobin: 11 gm%, bleeding time: 2 min, clotting time: 5.5 min, total leukocyte count: 10800 cells/dl). Patient's serum was negative for HIV antibodies. Occlusal view and OPG [Figure 2] and [Figure 3] showed unhealed extraction sockets with a large defect involving the alveolar bone. Moderate horizontal bone loss was seen in the maxillary central incisors and a periapical abscess in the maxillary right central incisor was apparent on the occlusal radiograph. CT scan in its axial section [Figure 4] revealed significant mucosal thickening bilaterally in the maxillary sinuses and right ethmoidal sinus showed opacification. Significant extensive permeative lytic lesion involving the right zygoma, wall of maxillary sinus on the right side, full length of hard palate, and alveolar process of maxilla on the right side and floor of right orbit was seen. All the features were suggestive of osteomyelitis involving right maxilla. Squamous cell carcinoma of the right maxilla was included in the radiological differential diagnosis, however, the ragged ill-defined borders characteristic of malignancy were not present, instead unhealed sockets were seen. Therefore, a clinicoradiographic diagnosis of chronic suppurative osteomyelitis involving right maxilla was made, and the patient was advised hemimaxillectomy. Sequestrectomy was not possible as the entire right maxilla was affected and necrotic. Weber Fergusson's incision was given on right side periosteum over the anterior wall of right maxilla. Whole of the inferior part of right maxilla was necrosed and came out in small bony chunks, the largest measuring 1 × 1 cm. Sinus was normal, lined by edematous mucosa. The defect was closed with a surgical obturator [Figure 5]. Postoperatively, the patient was given intravenous antibiotics and analgesics for 5 days (augmentin 1.2 g IV BD, metrogyl 100 ml IV TDS, dynapar IM BD, rantac IV BD, dexa 8 mg TDS), and she was advised betadine gargles for 30 days. Postoperative histopathological report confirmed suppurative osteomyelitis. Patient was then given a permanent obturator to close the defect [Figure 6], which showed good healing on the first follow-up visit 15 days postoperatively [Figure 7] and [Figure 8].
Figure 2: Maxillary occlusal view showing unhealed extraction sockets and interdental bone loss between the central incisors

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Figure 3: OPG showing missing maxillary teeth on right side and large defect in the alveolar bone

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Figure 4: CT scan showing extensive osteolytic lesion on the right side of maxilla

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Figure 5: Showing post surgical defect

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Figure 6: Showing the post surgical defect closed with an obturator

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Figure 7: Post operative OPG (15 days after surgery)

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Figure 8: Extraoral clinical picture of the patient

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   Discussion Top


With the present era of advanced antibiotics, osteomyelitis presents as a subchronic condition and is more commonly associated with debilitated, immunosuppressed, or medically compromised patients. Maxillary osteomyelitis is rare compared to mandibular osteomyelitis because of the extensive blood supply and strut-like bone of the maxilla, which makes it less prone to chronic infection.[4] The present case report describes the occurrence of chronic suppurative osteomyelitis of the maxilla in a 27-year-old systemically healthy female. The exact etiological factor responsible for the occurrence of osteomyelitis in this case could not be traced, however, the fact that the patient underwent dental extractions at the same site was contemplated as one of the possible causes of infection.

The occurrence, type, severity, management and prognosis of chronic osteomyelitis of the jaws depends on many factors, including the composition and virulence of the microbiota, immunologic response of the host, extension and severity of the infection, as well as the source of the infection. The differential diagnosis for this case included peripheral squamous cell carcinoma because the lesion involved the alveolar mucosa. However, as the patient did not have any tobacco or areca nut chewing habit and exposure of the bone was seen with suppuration rather than destruction, possibility of osteomyelitis was more. Furthermore, osteosarcoma (osteolytic type), Ewing's sarcoma, lymphosarcoma, metastatic tumor chondrosarcoma, and fungal infections (cryptococosis, histoplasmosis) can be considered; however, the age of the patient, location and absence of systemic illness, and the radiological findings in this case confirmed the diagnosis of chronic suppurative osteomyelitis.

Infection of the maxilla can cause serious complications for the patient such as infection of the cranial cavity and brain.[5] Thus, it is essential that any maxillary osteomyelitis be treated aggressively by the surgeon to avoid subsequent dreaded consequences. Chronic osteomyelitis in adults is generally treated with antibiotics and surgical debridement. Empiric antibiotic therapy is not usually recommended. Depending on the type of chronic osteomyelitis, patients may be treated with parenteral antibiotics such as amoxicillin and clavulanic acid combination (Augmentin 1.2 g IV BD) for 2–6 weeks. However, without adequate debridement, chronic osteomyelitis does not respond to most antibiotic regimens, irrespective of the duration of the therapy.[3]

Surgical intervention forms one of the mainstay treatments for the definitive management of osteomyelitis of the jaws. It is aimed at providing drainage to the area of infection, removal of sequestrum and other foreign bodies, and getting new blood supply to the area. It ranges from simple sequestrectomy to segmental resection and reconstruction in recalcitrant cases.[6] In the present case, the patient underwent hemimaxillectomy followed by intense intra venous antibiotic therapy (Augmentin 1.2 g IV BD), which aided in uneventful and early healing of the surgical wound. In addition, the use of surgical and permanent obturator has had a marked effect on rehabilitation of the patient, both aesthetically and functionally.


   Conclusion Top


With the advent of important medical and surgical advances, osteomyelitis has become a long lost disease. However, when extensive form occurs, especially in a young healthy female, prompt and aggressive treatment along with maintenance of aesthetics becomes vital. In this case, the patient responded very well to the treatment and was satisfied with the postoperative results. Even then it should be kept in mind that at times disease presentation can be fulminant and can relapse, the rate being as high as 20%. Therefore, periodic, long-term monitoring of the patient is important.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Baltensperger MM, Eyrich GK. Textbook on Osteomyelitis of the Jaws. New York: Springer publications. p. 5-50.  Back to cited text no. 1
    
2.
Flemming H. Osteomyelitis of the skull. California and Western Medicine. 1925;XXIII: 985-8.  Back to cited text no. 2
    
3.
Yadav S, Malik S, Mittal HC, Puri P. Chronic suppurative osteomyelitis of posterior maxilla: A rare presentation. J Oral Maxillofac Pathol 2014;18:481.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Shamanna K, Rao R, Banu A. Osteomyelitis of maxilla: A rare case. J Pub Health Med Res 2014;2:50-2.  Back to cited text no. 4
    
5.
Gaetti-Jardim E Jr, Ciesielski FIN, Possagno R, de Castro AL, Marqueti AC, Gaetti-Jardim EC. Chronic osteomyelitis of the maxilla and mandible: Microbiological and clinical aspects. Int J Odontostomat 2010;4:197-202.  Back to cited text no. 5
    
6.
Peravali RK, Jayade B, Joshi A, Shirganvi M, Rao CB, Gopalkrishnan K. Osteomyelitis of maxilla in poorly controlled diabetics in a rural Indian population. J Maxillofac Oral Surg 2012;11:57-66.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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