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Oral Surgery/sinus drainage

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QUESTION: Dear DR. Ryan,
 The last time i corresponded with you was June 6th i believe concerning sinus drainage following extraction of my top 6 teeth in May 2011,Im sure a copy of our most recent conversation is in the sites archives,but just to summarize.I had 6 teeth extracted in May 2011,by Oct./Nov,I began to see sinus drainage in my mouth,I had bucccal flap surgery in Feb,2012 over the site of the last molar,top right.The oral surgeon wasnt sure,but i guess he thought that was the most likely place it was coming from.That was unsuccessful,the drainage persisted,I was referred to an ENT,who did a cat scan and could not find the source,he referred me to WVU Oral Surgery Dept.That is the point where our last correspondence ended,when I was yet to go to WVU,which you agreed would be a good idea.I saw the Oral Surgeon at WVU who had xrays done and examined me and could not find the source,He did not offer to refer me to the ENT Dept.,but wished me good luck and said he hoped it stopped soon.Shortly after that i saw another Oral surgeon who had xrays done,examined me and could not find the source.FYI,as all this is progressing,the drainage is increasing steadily.Next,i saw an ENT at WVU,a cat scan was done and nothing could be found as a source.He then ordered a Cone Beam Scan,which did not reveal the source of the drainage.I asked in what millimeter sections the scan was done ,but the ENT did not know.He wished me all the best as we parted,and i asked him is there anywhere in the country that i could go to to get help to find the drainage source,he answered he did not know where he could refer me to.That was 2 weeks ago app.Im sorry to take up so much of your time,but now please let me tell you what i experience myself,The drainage is much more profuse now than before,i seems to come through the soft tissue above my gumline,on either side of the center of my mouth on both sides.If i can give you a laymans description,its as if the soft tissue above my gumline,in the areas where my canines were extracted,was as a cement wall with an enormous amount of liquid behind it,and the moisture is weeping through the wall,there is not one obvious hole or leak,but its as though it is saturated and weeping through.I can only wear my dentures in the AM for a few hours and then the drainage is overflowing them and i have to remove them and i usually have a paper towell in my mouth to absorb the fluid.Lying down is the only way to slow it down,but is becoming less effective as the drainage is increasing.When i go to bed for the night and have been asleep for lets say 2 hours,when i awake,my mouth is sometimes completely dry,but as i stand the drainage begins in exactly the area as i described.My life has been put on hold for all practical purposes,I spend most of my day lying down on the couch,with a folded paper towell in the front of my mouth over my gums extending over the soft tissue above the gumline to absorb the fluid.When i feel with my tongue all around the inside of my mouth i feel no drainage anywhere,only in the area as ive described.I am completely discouraged at my situation and at a loss where to turn,Ive been to everyone in my area,and the answer is always the same.It has been almost two years since i had my teeth extracted,it will be 2 yrs in May,and im worse off now than before.In my mind,i reason it out as follows,I believe there was a tear created in my miniscus when my canine teeth were pulled,i believe that at first the drainage was held back somewhat,and that over time it has weakened the tissue above my gumline and is weeping through that tissue.There is no obvious sign of a fistula or any of the usual symptoms of one,but the drainage is definately coming from the area i described.One night i awoke to relieve myself,and as im standing,my mouth began to drip fluid onto the floor,i looked in the mirror quickly and it was coming from the site ive described,it was as water dripping from a faucet.As the day progresses and im awake longer,the drainage becomes thicker,and when i rinse my mouth to remove it,after a short time of rinsing,it just keeps coming and my nose will begin to run,usually on the left,and my left ear  will become like plugged as though i had water in it.I believe that at a certain poitn,my rinsing is actually drawing the mucus out and affecting my sinuses and ear.I dont know,neither do i understand why nothing is showing up on all the imaging ive had done,but i do know my own body and what im experiencing,I do know the area where the drainage is excreting from.I asked the oral surgeon and the ENt both could they do exploratory surgery to find the source,to which they replied that was not an option.I would like to ask your opinion or reccomendations of where i can turn or what i can do to find a resolution to this problem.It seems that ive exausted all my options in this area of the country,every doctor that ive seen has been educated at WVU it seems,i believe that i need to go outside this area to someone who may have at some time seen a situation such as mine.At the present time,i cannot think of any options to find a cure for this drainage problem and i cant continue on the course im on.Ive lost 18 pounds since having my teeth removed in May 2011,my days are spent for the most part lying down and i can feel my health declining,not to mention that im cannot be the father or husband that my family needs.I thank you Sir for your past advise,and will wait hopefully to hear from you at your convienence,thankyou again.
        Sincerely,
         James

ANSWER: James, I am so sorry to hear what you have been going through. Is there any possibility you could take a picture of the fluid or the area that is the problem? Is there any pain on the gums when you touch the area? I am very interested in your problem and would like to get to he bottom of it.

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Ryan,
 
 Thankyou sir for replying to my most recent question,Im sorry to be late in replying to you,ive been waiting for an email that an answer is available but have not recieved one as yet.I discovered you had answered by going back to the  website and then saw you had answered.I very much appreciate your answer and your empathy for my situation.To answer your  reply,a picture of my gums would only appear to be saliva,it would not give a true representation of the consistency of  the fluid,which is as though it were model airplane glue for lack of a better description.I have had more than one ENT and Oral surgeon tell me that it is only excess saliva despite my trying to explain to them the consistency of the fluid/drainage.I have asked if it could be CSF and was told that it could not be.When ive been lying down for an hour or two,or if i wake in the night,the paper towel in my mouth will be wet,but only in the area above my gumline.when i feel around all the surfaces in my mouth,everything else is dry,except where the paper towel is covering the soft tissue.I have no pain in my gums nor any sensitive areas.The last ENT that i saw at WVU prescribed to me a patch to be worn behind my ear.It is called scopolamine 1.5 mg.He felt it may help in drying up excess fluids,and in fact when i first tried it,it did deccrease the amount of fluid temporarily,but after a few days it only served to thicken the discharge making it even harder to remove. I also enquired if an MRI could be taken,if it might be more revealing than a cat scan,i was told it would not.This is probably irrelevant,but one sensation ive experienced since having my teeth removed is a tingling numbness in both ears,for lack of an educated description,it can be likened to the sensation one might get when after theyre outside in very cold tempatures,and then come into a warm house,and your ears kind of burn,tingle,itch.Im sure you must have experienced this sensation at some point in your lifeThis sensation probably has nothing to do with the drainage in my mouth,but im trying to give you all the details that i can in an effort to help you as a professional to put all the pieces together.Im having a hard time being able to get my head wrapped around the whole situation,even understanding the anatomy involved.I know that there is a communication happening in my body,somewhere,somehow,that for some reason is not showing up on xrays,cat scans,conebeam scans or actual physical examinations.If it were only some small amount of discharge,i suppose i could or would have to,learn to live with it.However,that is not the case,this is a large amount of discharge,continuosly,it is deablitating.I asked for my medical records from the Oral Surgeon that extracted my teeth,and he also did the buccal flap surgery,he gave me only a photocopy of my original xrays before the surgery was done,i asked for the original xrays,but was told that what i was given, was the way they did things now.Im only a carpenter,and a disabled one at that,but my instincts tell me that the roots from my canine teeth extended well into my maximus sinuses,i believe a communication was developed that cant come through the extraction site because it healed well,so like water or electricity,the drainage has taken the path of least resistance.I reason it out that the tear in my sinuses is at the lower part of my sinuses,ergo,when i lay down,the pressure is less at the area of the tear in my sinuses.I may be wrong,but thats the only scenario that makes sense to me.Why it dosent show up on any type of imaging is beyond my understanding.In addition,the top vertabrea in my spine has become very painful at times,it is painful even to light pressure,at times the pain is very sharp.I do have stenosis of the spinal column,and systemic arthiritis,and degenerative disc disease,so im sure all of this is irrelevant,im only trying to give you all the facts that i can think of.I asked the ENT,could some sort of contrast be injected into my sinuses,and observe where it exits from the area above my gumline,i was told that was not an option either.Sir,I cant think of any more information to give you at this time,I sincerely thank you for your assistance and advise.I thank you for taking the time to answer my questions,in closing....can you tell me if in all your experience youve ever come across a situation like mine,and if so,what was the diagnosis and treatment involved, to remedy the problem?Im sorry to take more of your time,but something just occured to me,one of the ENTs or Oral surgeons ive seen,made the comment to me that my sinuses are lower than what is considered normal i guess.Im not sure what the implications of that statement are,but i thought i should mention it to you.I will close here,please accept my most sincere appreciation for your help in my case as well as your assistance to others youve helped.We live in a very whats in it for me society,your gift of your time and experience to others is commendable to say the least.

         Best Regards,
         James

Answer
I have only sen one other case of similarity to yours. Except the patient was edentulous. CT findings and radiographs did not show anything. I reluctantly was talked into an exploratory surgery which to my surprise, i found a small piece of fragmented teeth that did not show up on a radiograph. This does not seem to be your situation.  

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James M. Ryan. DDS, MS; Board Certified Oral and Maxillofacial Surgeon

Expertise

Dr. Ryan's expertise is in the field of Oral and Maxillofacial Surgery. Specifically, Dr. Ryan is an expert in Orthognathic Surgery. He holds uniques experience as the former Assistant Program Director of the Oral and Maxillofacial Surgery Residency Training Program at Washington Hospital Center where he trained residents to perform these complicated surgical procedures. Additionally, Dr. Ryan also has a tremendous amount of experience in reconstruction of the maxillofacial skeleton related to trauma and tooth loss. Dr. Ryan is an expert in 3 dimensional treatment planning for Orthognathic Surgery, Dental Implant Surgery and Wisdom Teeth removal. To learn more about Dr. Ryan, his full profile can be seen at www.eosdds.com

Experience

Diplomate of the American Board of Oral and Maxillofacial Surgery with current hospital affiliations at: Washington Hospital Center Holy Cross Germantown Hospital National Institute of Health/NIDCR

Organizations
American Dental Association. American Association of Oral and Maxillofacial Surgeons. District of Columbia Society of Oral and Maxillofacial Surgeons. District of Columbia Dental Society. American Board of Oral and Maxillofacial Surgeons. Health Volunteers Overseas.

Publications
Journal of Oral and Maxillofacial Surgery Journal of The American Dental Association

Education/Credentials
S.U.N.Y @ Stony Brook- B.S. in Biochemistry, Stony Brook, NY. Northeastern University- M.S. in Perfusion Technology, Boston, MA. D.D.S.- New York University College of Dentistry, New York, NY. Certificate and Chief Resident- Washington Hospital Center, Washington, DC. Clinical Fellow- The Johns Hopkins Hospital, Baltimore, MD.

Awards and Honors
Dr. Ryan has received numerous awards including: 2006 American Association of Oral and Maxillofacial Surgeons Dental Student Award, Washington Hospital Center 2008 Nurses' Choice Physician Collaboration Award, 2009 Resident Research Summit Scholarship Award, and the 2011 Outstanding Surgical Attending in the Department of Oral & Maxillofacial Surgery at Washington Hospital Center. He has also authored/coauthored and published several journal articles and held several teaching positions,including assistant professor, while at NYUCD.

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