Case Report | Open Access
Maxime Mermod, Martin Broome, Remy Hoarau, Daniel Zweifel, "Facial Pain Associated with CPAP Use: Intra-Sinusal Third Molar", Case Reports in Otolaryngology, vol. 2014, Article ID 837252, 4 pages, 2014. https://doi.org/10.1155/2014/837252
Facial Pain Associated with CPAP Use: Intra-Sinusal Third Molar
Objective. This paper describes a patient with left hemifacial pain elicited by the use of a CPAP mask. Case Report. A 74-year-old man was referred with a history of pain in the left maxillary sinus related to the use of his CPAP interface, thereby prohibiting the use of the latter. Computed tomography revealed an intra-sinusal ectopic third molar in the left maxillary sinus floor corresponding to the painful area. After removal of the ectopic tooth under local anesthesia by a Caldwell-Luc approach, the patient was relieved of his symptoms. Conclusion. Although an ectopic tooth in the maxillary sinus is rare, this case points out the importance of actively looking for a regional problem if patients cannot tolerate the CPAP interface since this can lead to issues of incompliance and medical complications due to the untreated obstructive sleep apnoea syndrome.
Obstructive sleep apnoea (OSA) is a common medical condition with significant medical consequences. The prevalence of this disease in the United States is currently estimated to be between 5 and 10% . It has been shown that continuous positive airway pressure (CPAP) improves both objective and subjective measures of OSA [2–4]. We describe a case of an otherwise healthy patient presenting with unilateral chronic episodic pain in the region of the left maxillary sinus from an atypical dentoalveolar origin elicited by the use of his CPAP mask, thereby prohibiting its use. To our knowledge, this is the first case of ectopic maxillary third molar presenting as episodic facial pain only related to the air diffusing from the CPAP interface.
2. Case Report
A 74-year-old man was referred to the maxillofacial department of our hospital with a long history of chronic episodic facial pain and discomfort arising from the left maxillary sinus. The pain appeared to be related only to the cold air emanating from his full-face mask CPAP interface he used for the treatment of his moderate OSA. His medical history was otherwise unremarkable; in particular there was no history of facial trauma or regional infection and swelling.
Examination revealed mild maxillary sinus pain elicited by percussion in the retromolar area of the left upper quadrant, distal to the only visible molar, which was reactive to cold and not painful to percussion. Nasal endoscopy revealed no purulent discharge.
An orthopantomogram (OPG) was requested as an overview of the state of the patients’ dentition (Figure 1). It revealed radioopacity in the left upper retromolar area superimposed onto the maxillary sinus. A computed tomography (CT) scan was arranged (Figure 2) which showed a hyperdense structure in the floor of the left maxillary sinus which was consistent with an ectopic third molar. It was inverted and presented a complete crown with incomplete root formation. The crown showed either no or very little mucosal covering on its cranial aspect (Figure 2).
After informed consent from the patient had been obtained, we planned an elective procedure under local anesthetic. A mucoperiosteal flap was raised in the region of the permanent first, second, and third molar and extended to the left maxillary tuberosity (Figure 3(a)), a small window to access the sinus was created (Figure 3(b)), and the ectopic tooth was extracted through that window (Figure 3(c)). The surgical wound was closed with 3.0 Vicryl.
Postoperatively, the patient made an uneventful recovery and there was no recurrence of his symptoms in a 3-month follow-up period.
The aetiology of facial pain related to CPAP use can be classified as pressure related or airflow related causes.
Dental or periodontal pain for instance is mainly explained by direct pressure of the device on the gums. This is the case in 15 to 20% of patients treated with CPAP . Abrasion and pain on the ridge of the nose is an issue in 13 to 37% of CPAP users .
On the other hand, nasopharyngeal symptoms, like nasal obstruction, rhinorrhoea, sneezing, blocked ears, or excessive mucus, are present in 15 to 65% of the cases. These are more frequent in patients with preexisting problems  and appear to be airflow related. The incidence of sinusitis is approximately 8% . More insight in the pathophysiology of those symptoms is needed .
The approach to facial pain in CPAP users should not be limited to typical causes of CPAP device related problems. It should encompass classical causes of facial pain such as dentoalveolar pathology, sinusitis, temporomandibular joint disorders, and neuropathic pain . Thus a workup should include a detailed otolaryngological and dental examination.
To date, only 35 cases of ectopic teeth erupting in the maxillary sinus have been reported in the English literature . When erupting into the maxillary sinus, these teeth can present with localised symptoms of sinonasal infection such as nasal discharge, nasal obstruction, facial pain, or fever. Nonetheless, in most instances the condition will remain undiagnosed until it is discovered spuriously due to X-rays performed for unrelated reasons. In our case, the patient demonstrated a cranially displaced and anteriorly rotated tooth with the crown in direct contact with the sinus. Wehypothesize that since the tooth was so exposed, the patient developed dentin hypersensitivity  leading to pain and discomfort when the ectopic tooth was subjected to thermal factors such as the cold air of the CPAP.
The eruption of a tooth in nondentate areas is rare, although various cases of teeth erupting in the nasal septum , mandibular condyle , coronoid process , and palate  have been reported.
Ectopic tooth formation may happen due to an abnormal interaction between oral epithelium and the underlying mesenchyma during odontogenesis, from pathological processes (cleft palate, infection, bone hyperdensity, and genetic factors) or from trauma .
Diagnosis and treatment planning are best made by CT scanner . Surgical access to the maxillary sinus is best achieved by a Caldwell-Luc approach to prevent the complication of oroantral communication .
Complete removal of diseased tissue is thought to be mandatory as certain diseases such as cysts or malignancies may coexist with ectopic molars . In asymptomatic cases the patient should be followed periodically with radiographs .
The use of CPAP is associated with a reduction in daytime sleepiness and the improvement of quality of life . It is also well documented that successful CPAP therapy results in reduced cardiovascular mortality. Despite the well documented efficacy of the CPAP therapy, adherence to the treatment remains a great challenge . Hence, we should explore every possibility to improve treatment adherence and in cases of associated pain take care to exclude even rare causes.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
- P. V. Tishler, E. K. Larkin, M. D. Schluchter, and S. Redline, “Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing,” The Journal of the American Medical Association, vol. 289, no. 17, pp. 2230–2237, 2003.
- D. Margel, T. Shochat, O. Getzler, P. M. Livne, and G. Pillar, “Continuous positive airway pressure reduces nocturia in patients with obstructive sleep apnea,” Urology, vol. 67, no. 5, pp. 974–977, 2006.
- M. P. Fitzgerald, M. Mulligan, and S. Parthasarathy, “Nocturic frequency is related to severity of obstructive sleep apnea, improves with continuous positive airways treatment,” American Journal of Obstetrics & Gynecology, vol. 194, no. 5, pp. 1399–1403, 2006.
- J. L. Kiely, M. Murphy, and W. T. McNicholas, “Subjective efficacy of nasal CPAP therapy in obstructive sleep apnoea syndrome: a prospective controlled study,” European Respiratory Journal, vol. 13, no. 5, pp. 1086–1090, 1999.
- J. L. Pepin, P. Leger, D. Veale, B. Langevin, D. Robert, and P. Levy, “Side effects of nasal continuous positive airway pressure in sleep apnea syndrome: study of 193 patients in two French sleep centers,” Chest, vol. 107, no. 2, pp. 375–381, 1995.
- P. E. Brander, M. Soirinsuo, and P. Lohela, “Nasopharyngeal symptoms in patients with obstructive sleep apnea syndrome. Effect of nasal CPAP treatment,” Respiration, vol. 66, no. 2, pp. 128–135, 1999.
- A. Kalan, G. S. Kenyon, T. A. R. Seemungal, and J. A. Wedzicha, “Adverse effects of nasal continuous positive airway pressure therapy in sleep apnoea syndrome,” The Journal of Laryngology & Otology, vol. 113, no. 10, pp. 888–892, 1999.
- A. M. Hegarty and J. M. Zakrzewska, “Differential diagnosis for orofacial pain, including sinusitis, TMD, trigeminal neuralgia,” Dental Update, vol. 38, no. 6, pp. 396–405, 2011.
- J. F. Lamb, O. F. Husein, and A. C. Spiess, “Ectopic molar in the maxillary sinus precipitating a mucocele: a case report and literature review,” Ear, Nose & Throat Journal, vol. 88, no. 8, pp. E6–E11, 2009.
- A. Davari, E. Ataei, and H. Assarzadeh, “Dentin hypersensitivity: etiology, diagnosis and treatment; a literature review,” Journal of Dentistry, vol. 14, no. 3, pp. 136–145, 2013.
- T. A. van Essen and J. B. van Rijswijk, “‘Intranasal toothache”: case report,” The Journal of Laryngology & Otology, vol. 127, no. 3, pp. 321–322, 2013.
- H. Yusuf and A. A. Quayle, “Intracondylar tooth,” International Journal of Oral & Maxillofacial Surgery, vol. 18, no. 6, p. 323, 1989.
- M. T. Fernandez and M. A. T. Meraz, “Infected cyst in the coronoid process,” Oral Surgery, Oral Medicine, Oral Pathology, vol. 73, no. 6, p. 768, 1992.
- J. P. Pracy, H. O. Williams, and P. Q. Montgomery, “Nasal teeth,” The Journal of Laryngology & Otology, vol. 106, no. 4, pp. 366–367, 1992.
- S. Ramanojam, R. Halli, M. Hebbale, and S. Bhardwaj, “Ectopic tooth in maxillary sinus: case series,” Annals of Maxillofacial Surgery, vol. 3, no. 1, pp. 89–92, 2013.
- L. Bodner, “Teeth in the maxillary sinus—imaging and management,” The Journal of Laryngology & Otology, vol. 111, no. 9, pp. 820–824, 1997.
- Y. H. Goh, “Ectopic eruption of maxillary molar tooth—an unusual cause of recurrent sinusitis,” Singapore Medical Journal, vol. 42, no. 2, pp. 80–81, 2001.
- R. A. Smith, N. C. Gordon, and S. F. de Luchi, “Intranasal teeth. Report of two cases and review of the literature,” Oral Surgery, Oral Medicine, Oral Pathology, vol. 47, no. 2, pp. 120–122, 1979.
- H. M. Engleman and M. R. Wild, “Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS),” Sleep Medicine Reviews, vol. 7, no. 1, pp. 81–99, 2003.
- T. E. Weaver, G. Maislin, D. F. Dinges et al., “Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning,” Sleep, vol. 30, no. 6, pp. 711–719, 2007.
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