Journal of Cytology
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Year : 2014  |  Volume : 31  |  Issue : 1  |  Page : 47-49
Cytological approach for diagnosis of non-healing oroantral fistula associated with candidiasis

1 Department of Oral Pathology and Microbiology, Rural Dental College and Hospital, PIMS University, Loni, Maharashtra, India
2 Department of Oral Pathology and Microbiology, Bapuji Dental College and Hospital, Davangere, Karnataka, India

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Date of Web Publication15-Apr-2014


Oroantral fistula (OAF) and oral candidiasis are common to come across as separate individual lesions. However when candida organisms infect maxillary sinus through OAF then diagnosis should not be limited to clinical diagnosis only. In such situation role of cytological examination can prove to be fruitful. A female with chronic long standing OAF, not responding to conventional treatment approach is reported. On incisional biopsy, the case was diagnosed as chronic maxillary sinusitis with OAF. However patient did not respond to any treatment approach and later presented with a more progressive lesion involving maxillary sinus. A cytosmear stained with periodic acid Schiff stain, revealed the presence of numerous candidal hyphae. Finally, case was diagnosed as OAF with a superadded candidal infection. Patient responded well to antifungal treatment followed by reclosure of OAF. We should not neglect a simple cytological examination which may prevent wrong diagnosis and wrong treatment.

Keywords: Maxillary sinusitis; oral candidiasis; oral cytology; oroantral fistula

How to cite this article:
Jadhav KB, Ahmed Mujib B R, Gupta N. Cytological approach for diagnosis of non-healing oroantral fistula associated with candidiasis. J Cytol 2014;31:47-9

How to cite this URL:
Jadhav KB, Ahmed Mujib B R, Gupta N. Cytological approach for diagnosis of non-healing oroantral fistula associated with candidiasis. J Cytol [serial online] 2014 [cited 2022 Dec 6];31:47-9. Available from:

   Introduction Top

Oroantral fistula (OAF) is an abnormal communication between the oral cavity and the maxillary sinus. It is a complication which can occur during extraction of maxillary posterior teeth. [1] The controversy revolves around maxillary premolar, first molar and second molar. [2] The chances of occurrence of oroantral communication increases, if there is an underlying peripical infection or a preexisting sinus disease. [1] Nearly 71% cases of OAF are associated with sinus pathology. The chronic long standing nature of OAF may be due to fungal infection like mucormycosis. [3]

The sinus pathology is a predisposing factor for chronic non-healing nature of OAF. Many times this aspect is overlooked and simply the diagnosis of non-specific maxillary sinusitis is given, which leads to improper treatment. So identification of specific pathogen causing sinus disease is essential.

   Case Report Top

The case we present here is a 34-year-old female patient [Figure 1]a who was complaining about non-healing opening in the upper left front region and exposure of root of one tooth. The lesion started as a small swelling in the left maxillary anterior vestibular area in the region of canine eminence. The swelling ruptured and exuded the discharge. After few days, patient noticed the area where the swelling ruptured was not healing and instead, it was showing small aperture. The aperture went on increasing to the present size of 0.5 cm × 0.5 cm. Patient revealed the history of trauma in maxillary left front teeth region during field work 2 years back.
Figure 1: (a) A 34-year-old female patient presenting with mild to moderate swelling in left maxillary sinus area (arrow). (b) Intraoral examination revealed the oroantral communication (arrow) in maxillary left anterior labial vestibule at mucogingival junction in the area of canine. (c) The dorsal surface of tongue was coated with white leathery coat with central rhomboidal shaped erythematous area (arrow). (d) The cytosmear revealed PAS positive numerous long thin fi laments of candidal organism (arrow). Budding yeast cells were seen scattered along the with pseudohyphae (PAS, ×200)

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Extraoral examination revealed a mild swelling in the left maxillary sinus area [Figure 1]a. On intraoral examination [Figure 1]b oroantral communication was noticed in maxillary left anterior labial vestibule at mucogingival junction in the area of canine. The opening was around 0.5 cm × 0.5 cm in size exposing the apical third portion of root of canine. The dorsal surface of the tongue was coated with white leathery coat with central rhomboidal shape erythematous area [Figure 1]c. No caries was detected in all maxillary left anterior teeth. On pulp vitality test maxillary left lateral incisor and canine was found to be non-vital.

The clinical diagnosis of OAF secondary to chronic periapical abscess in relation to maxillary left canine was established. The conventional approach was undertaken to close the fistula and access opening was created in maxillary left canine. Patient was followed up for observation of healing at closure of OAF and also to continue with root canal treatment of maxillary left canine. After 4 weeks of primary closure of OAF, still there were no signs of healing and instead the OAF was re-established as it was before commencing the treatment. Patient also complained of dull gnawing pain in the maxillary sinus area and more heaviness in the same region.

Looking at non-healing chronic nature of OAF, the incisional biopsy from the margin of OAF was planned to seek histological changes in the region of OAF. On histopathology, the diagnosis of chronic maxillary sinusitis was given. Based on histopathological diagnosis, reclosure of OAF was planned. For chronic maxillary sinusitis antibiotics and nasal wash was prescribed. The patient was followed-up regularly to assess for healing at OAF and check for the status of chronic maxillary sinusitis. Patient reported with non-healing of OAF and even chronic maxillary sinusitis did not respond to treatment. This time to avoid surgical trauma, a cytological smear was prepared by swabbing the unhealed OAF.

Cytosmear stained with periodic acid Schiff stain, revealed a pale homogenous stroma, with abundant acute inflammatory cells. Numerous long thin filaments of candidal organism having budding yeast cells were seen scattered along with pseudohyphae [Figure 1]d. Based on the cytological features, the diagnosis of OAF with superadded candidiasis was given. Patient finally received antifungal medication of nystatin suspensions followed by reclosure of oroantral communication. After about 5-6 weeks patient was completely all right and clinical healing was complete. There were no sign of candida organism on repeated cytological examination at the site of closure.

   Discussion Top

Many microorganisms are present normally as commensals in the oral cavity and maxillary sinus. [4],[5],[6] OAF is commonly associated with maxillary sinusitis of bacterial origin. [1] Present case is an example for clinicians where they can learn that, sinus disease secondary to OAF is not only of bacterial origin but it could be also of fungal origin.

Since there is no history of extraction of tooth, OAF would have arisen due to periapical pathology secondary to trauma. The candida organisms from oral cavity might have colonized the OAF leading to sinus pathology. Candida organisms can be easily detected at tissue level as candida hyphae at superficial epithelial surface, but sometime these superficial hyphae are washed away from tissue during processing in various chemicals. This might be the reason why candida organisms were not detected and diagnosed in biopsied tissue. This was resulted to non-specific diagnosis of maxillary sinusitis.

Mere presence of this fungus in oral cavity is not sufficient to produce the disease. There must be actual penetration of fungus in to the tissue, although such invasion is superficial and occurs only when there is breach in the continuity of epithelium. [7] In present case, OAF must have become reason for the colonization of candida organisms over the maxillary sinus lining. The other predisposing factors for candidiasis can be prolonged intake of antibiotics, corticosteroids; anemia, etc. [7],[8] Since initially patient was diagnosed with non-specific maxillary sinusitis. So inadvertent use of antibiotics could also be responsible for occurrence of superadded infection of candidiasis with OAF. According to Katzenstein, sinus mycoses can be classified as

  1. Non-invasive chronic mycoses (fungus ball),
  2. Allergic mycosis,
  3. Chronic indolent invasive mycosis, and
  4. Fulminating invasive mycoses.

Types 3 and 4 are found in the immunosuppressed where as in immunocompetent, types 1 and 2 are common, with a granulomatous inflammatory response and necrosis. [9],[10]

Candida organism can grow as opportunistic pathogen especially in presence of human immunodeficiency virus (HIV) infection. [7] Cases with spontaneous development of OAF in HIV associated periodontal disease have been reported. [11] Since there was no HIV associated periodontal disease in patient, the remote possibility of HIV as cause for candida growth and occurrence of OAF could be ruled out. Furthermore, the mucosa of the dorsum surface of the tongue (filiform papillae) may represent a site of residual colonization and reservoir of organisms. [12] Since patient's dorsal surface of tongue was showing white coat with central erythematous area [Figure 1]c. This would have been possible source for colonization of candida organisms in maxillary sinus through OAF.

Cases with association of fungal organisms like aspergillosis and mucormycosis have been reported. The mycetes most often involved was Aspergillus fumigatus (76.9%). [13] Even after extensive literature search, no report was found for sinus formation with candida.

   Conclusion Top

This case is good learning lesson for clinicians and histopathologists for stepwise approach in diagnosing OAF associated with sinus disease. It is understood that sinus pathology should be primarily treated for the successful closure of OAF. For the proper treatment of sinus disease identification of causative agent (pathogen) is essential in order to avoid treatment based on non-specific diagnosis. Sometimes simple cytological examination also might help to identify particular pathogen causing sinus disease. Therefore, sinus disease secondary to oroantral communication should be primarily screened for pathogen through simple cytological approach.

   Acknowledgments Top

The authors would like to thank to Dr. Keertikumar Rai, Professor and Head, Department of Oral and Maxillofacial Surgery, and Dr. Ashok, Professor and Head, Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere, Karnataka, India for their support and help.

   References Top

1.Logan RM, Coates EA. Non-surgical management of an oro-antral fistula in a patient with HIV infection. Aust Dent J 2003;48:255-8.  Back to cited text no. 1
2.Güven O. A clinical study on oroantral fistulae. J Craniomaxillofac Surg 1998;26:267-71.  Back to cited text no. 2
3.Mane RS, Patil BC, Mohite AA. Rhinocerebral mucormycosis presenting as oroantral fistula. Clin Rhinol An Int J 2012;5:135-7.  Back to cited text no. 3
4.Avila M, Ojcius DM, Yilmaz O. The oral microbiota: Living with a permanent guest. DNA Cell Biol 2009;28:405-11.  Back to cited text no. 4
5.Rouabhia M. Interactions between host and oral commensal microorganisms are key events in health and disease status. Can J Infect Dis 2002;13:47-51.  Back to cited text no. 5
6.Mariante AR, Araújo E, Dall′Igna C, Cantarelli V, Palombini BC, Moreira JS. Microbiology of middle meatus in healthy individuals. Int Arch Otorhinolaryngol 2008;12:506-12.  Back to cited text no. 6
7.Sivapathsundharam B, Gururaj N. Mycotic infection of the oral cavity. In: Rajendran R, Sivapathsundharam B, editors. Shaffers Textbook of Oral Pathology. 5 th ed. New Delhi: Elsevier Publisher; 2006. p. 504-10.  Back to cited text no. 7
8.McIntyre GT. Oral candidosis. Dent Update 2001;28:132-9.  Back to cited text no. 8
9.Vennewald I, Henker M, Klemm E, Seebacher C. Fungal colonization of the paranasal sinuses. Mycoses 1999;42 Suppl 2:33-6.  Back to cited text no. 9
10.Ferreiro JA, Carlson BA, Cody DT 3 rd . Paranasal sinus fungus balls. Head Neck 1997;19:481-6.  Back to cited text no. 10
11.Felix DH, Wray D, Smith GL, Jones GA. Oro-antral fistula: An unusual complication of HIV-associated periodontal disease. Br Dent J 1991;171:61-2.  Back to cited text no. 11
12.Epstein JB, Silverman S Jr, Fleischmann J. Oral fungal infection. In: Silverman S Jr, Eversole LR, Truelove EL, editors. Essentials of Oral Medicine. Canada: B C Decker Inc. Publisher; 2002. p. 170-1.  Back to cited text no. 12
13.Castelnuovo P, Gera R, Di Giulio G, Canevari FR, Benazzo M, Emanuelli E, et al. Paranasal sinus mycoses. Acta Otorhinolaryngol Ital 2000;20:6-15.  Back to cited text no. 13

Correspondence Address:
Kiran B Jadhav
Department of Oral Pathology and Microbiology, Rural Dental College and Hospital, PIMS University, Loni - 413 736, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9371.130704

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