Recurrent pain and swelling associated with impacted maxillary third molar

Abstract

A 57-year-old woman reporting intermittent severe pain and swelling for 5 years in the left maxillary jaw was evaluated at the oral and maxillofacial surgery clinic at the University of Detroit Mercy School of Dentistry. The pain intensity had increased markedly in the past 2 to 3months. She had difficulty swallowing and opening her mouth, and a bad odor associated with a bloody mucous discharge. Her medical and surgical history included chronic neck pain, arthritis, degenerative disk disease, choroid cyst, headaches associated with Arnold-Chiari malformation, sinus surgery due to recurrent sinusitis, and an eye surgery for strabismus. Her dental history included periodic pain and soreness associated with impacted tooth no. 16. Her health history included a 40 pack-year smoking history, and at the time of her examination she was smoking 1 pack per day. She denied alcohol or illicit drug use. Extraoral examination identified a nonerythematous, firm swelling on the left side of her face without evidence of lymphadenopathy. On the basis of the long-standing pain and swelling, the difficulty in opening, and the history of surgery in the left maxillary sinus, the decision was made to examine the patient with cone-beam computed tomography (CT). This technique permits a view of the anatomy in 3 planes of space. It also provides a larger field of view than panoramic radiographs, which was especially beneficial due to the unknown position of the left third molar. The cone-beam CT scan revealed diffuse opacification of the left maxillary sinus with destruction of the alveolar process and resorption of the walls of the maxillary sinus. The pathologic alterations extended beyond the field of view, and considering the likely involvement of extra-antral soft tissues it was decided that CT was necessary for complete radiographic visualization of the condition. A bone window axial view of the CT scan revealed the lesion in the left maxillary sinus associated with destruction of the anterior, posterior-lateral, and medial walls of the left maxillary sinus, with extension into the pterygopalatine fossa as well as the buccal and masticator spaces (Figure 1). Soft-tissue sections depicted infiltration of the lesion into the medial and lateral pterygoid muscles, and extension into the nasal fossa (Figure 2) and greater palatine foramen (Figure 3). Destruction of the palate and left maxillary alveolar ridge was also observed (Figure 4). Microscopic examination after an incisional biopsy revealed a proliferation of squamous epithelium. Cells exhibiting increased nuclear-cytoplasmic ratios, pleomorphism, individual cell keratinization, and increased mitotic activity were noted (Figure 5).