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An infected cyst, associated with a supernumerary fourth molar in the ascending ramus of the mandible, presented with parotid swelling, trismus and pain. It was managed as a parotid infection but recurred and a draining pre-auricular sinus developed, which was thought to be a parotid fistula. This was managed by cautery, followed by excision of the fistula, both of which were unsuccessful. Following this, further investigations revealed that the cause of the facial sinus was in fact a cyst associated with a mandibular fourth molar in the posterior ascending ramus. The tooth was extracted, via a pre-auricular extra-oral approach, under general anaesthetic.
Clinical Relevance: This case shows how a dental panoramic radiograph can be extremely helpful at ruling out certain pathology. It also demonstrates how the symptoms of an infection arising from a tooth in the ramus may be misdiagnosed as salivary gland pathology.
Article
A parotid fistula is a communication between the skin and parotid duct or gland through which saliva is discharged.1 The most common cause is trauma, followed by malignancy, operative complication and infection.2
Supernumerary teeth are additional teeth in the normal series, which may occur in any region of the dental arch, although they are more frequent in the maxilla than the mandible.3 The prevalence ranges from 1.5% to 3.5% in the permanent dentition.4
Odontogenic cysts affect the tooth-bearing region of the jaws, with dentigerous cysts being the second most common type of odontogenic cyst. Dentigerous cysts are formed from the dilatation of the dental follicle surrounding the crown of the tooth. They are attached to the neck of the tooth and often prevent the eruption of the tooth and may even displace it for a considerable distance.5 The degree of displacement may be dramatic, with reports of the mandibular third molar in the ramus, condylar or coronoid regions or to the inferior cortex of the mandible.6 Dentigerous cysts around supernumerary teeth account for about 5% of all dentigerous cysts.7
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