The curious case of "Whoozy Voice"

When you are in practice for more than 10 years, you get settled in a routine. The procedures which used to make your heart beat faster when you were raw, new and inexperienced become not very exciting now.

Earlier a failed root canal or a failed dental implant used to give me sleepless nights. But when you keep doing these procedures day in and day out, you start taking these failures into stride and "AAL IZ WELL" becomes the mantra with which you live by.

Failures and complications are part of the battle that you are fighting in those four walls of your clinic and each failure will teach you an invaluable lesson that no textbook or teacher can teach you.

Personally I love these lines by Janelle Monáe :

“There’s no mountain you can’t climb, It just takes a little time. ’cause you got what it takes, just learn from your mistakes, Try and try again and one day you’ll step up and then”

You will also realize with time that whenever you will start becoming over confident of your clinical skills, you will come across that one case which will jolt you back to reality and bring you down from the 7 th sky that you were floating in.

Today I share one such case, so grab that coffee, tea or beer mug and read on, you will definitely learn something useful from this one.

A 73 year old female recently visited my clinic with complain on pain in left upper back region of the jaw.

On examining her clinically I could see a carious 27 (maxillary left 2nd molar ).I shot an x ray to find this radiological picture.

A carious 27 with caries extending in the distal root with periapical infection. I did not think it was a tooth that I would want to save and hence I advised the patient that this tooth should be removed. It was 22nd October, the last working day before Diwali, she was in pain and wanted relief, so she immediately agreed.

Please have look at the OPG, nothing out of the ordinary there too.

Sometimes patients anxiously ask you "Docsaab, sahi se nikal to jaega na?" and when you are MDS in Oral and Maxillofacial surgery, from a Govt. dental college, you have that inherent ingrained arrogance in you when it come to extractions like these and you usually just ignore the question but your face is beaming with confidence similar to

SKY's (Surya Kumar Yadav) face during that match in IPL.

So I went ahead, sectioned the tooth in three parts and removed all the roots with ease. The patient was surprised when I told her "Aunty it's done"

"Done already? Beta I hope poora nikal gaya, kuch reh to nahi gaya andar?"

"Yes aunty, don't worry, you can take the roots with you if you want"

and I asked the assistant to pack the roots and give it to aunty.

She was very happy and I was very happy too as now I can have good 4 days of Diwali break.

You must be wondering "when will I learn something new from this case"

When you think it is the end, it will always be the beginning of a new twist in the story. So here is how it goes.

The patient called me as soon as Diwali holidays were over.

"Sir I have slight pain in the extraction area" I could sense that she was anxious and worried. She was a controlled diabetic and was also 73 years old.

Both these emotions can come naturally to such patients.

It was the 5th day so my immediate attention was towards dry socket, which usually occurs between 3rd to 5th day after extraction.

"Aunty it is probably some minor issue and I see no reason for you to be worried, please come over at 6 pm today, I'll have a look at it and if needed I'll give you a small medicated dressing that will help you with the pain."

"Happy Diwali sir, this is for you" She said and kept a big box of sweets and chocolates for my kids.

"Thank you so much ! Come aunty let's have a look at what's troubling you."

"I don't know but when she speaks her voice seems whoozy. ", said her son as he settled in the visitors chair.

"Whoozy? as in?"

"As if air is coming out as she speaks, is that relevant?"

"Probably some sinusitis because of seasonal change" I said without even thinking twice on what he had just said. I was in for a surprise, and not a very pleasant one.

As I examined the extraction socket I could see it was completely filled with food debris and the buccal gingiva slightly swollen.

"Aunty did you not brush and rinsed your mouth with warm saline water?"

"No beta I was afraid I might do something wrong"

This is a very common thing with post surgical patients where they usually avoid brushing and cleaning the area where the procedure had been performed.

Usually they are scared that they might do some damage which would lead to pain and infection.

This happens in spite telling them repeatedly to maintain hygiene. But that's how it is.

I cleaned the socket with saline and asked her to gargle.

Till the time she took the water from the glass and spat in the spittoon I was thinking of dry socket and dry socket only.

"Are ye paani to naak se aa raha hai" She said wiping her left nostril with the tissue we had given her.

"Nose se?" and I stopped there for a minute.

Everything went silent in my brain and then came the realization-It is Oro antral communication you fool !!

It was right there in front of my eyes- slight pain in the cheek area, change of voice, whoozy noise as she spoke and finally the tell tale sign- water flowing out of the nostril.

Oro antral communication in an extraction done by me?

How is that even possible? I am always so fucking careful about this.

That pre op OPG for a simple extraction was also taken to check for the antrum and the proximity of the tooth roots with it.

As I said earlier, every once in a while will come a case which was routine until it came back with a complication which will jolt you out of your lethargic daily routine and how you handle it will prove to the patient if you were the right doctor for her or not.

I immediately shot an RVG.

The RVG showed nothing when read in isolation. So I ordered an OPG (and I thanked my stars that I had an inhouse OPG machine)

One look at the OPG confirmed my suspicion. You can see that the antrum lining was breached.

But how and why? The extraction was atraumatic and swift and I had not curetted the socket at all.

My analysis is that since there was a periapical pathology on the roots, it had already breached the lining and when the tooth was removed the communication between the oral cavity and the antrum was then established.

So the next question is - How is it that the patient had no water coming out of the nostril in the days following the extraction?

Well, the best guess is when the patient did not clean the area of the food debris, it kept on accumulating in the socket and completely obliterated it so the fluids did not find the way to go into the sinus, but as soon as I cleaned the socket with saline and the patient gargled and spat in the spittoon the communication became clear and the fluids started to flow through the maxillary antrum and found there was out of the nostril.

I informed the patient clearly about the complication that had occurred and the need to close the communication immediately. She understood my reasoning and asked me to do whatever was needed to help her out of this.

I took a buccal flap and closed the communication. It took me some 40 minutes to do it.

Here is the final result.

Explained the do's and don'ts to her and prescribed her antibiotics and nasal spray for the sinus inflammation.

I think it will heal nicely in the next 7-10 days.

Another battle fought, another life long learning which came out of it. Never take things for granted and keep on sharpening your skills so that you can handle complications like this without any hitch or hassle.

Did I charge the patient for the second surgical procedure. Hell yeah !

In the end it was a good break from the routine dental practice and the adrenaline rush was worth it !

It's almost midnight and the story needs to come to an end.

See you all soon with another interesting story, until then its good bye from me.

Do let me know what are your thoughts on this case.