Osteomyelitis is an inflammatory condition of the bone characterized by an infection that begins in the medullary cavity, rapidly involves the Haversian systems, and extends to the periosteum. It is considered one of the most challenging infectious diseases to manage due to its potential for progressive bony destruction and the formation of sequestra.[1] While osteomyelitis frequently affects the mandible, involvement of the maxilla is rare, attributed to the rich vascularity and porous nature of the maxillary bone, which aids in rapid infection dissipation.[2] Maxillary osteomyelitis is most commonly observed in individuals aged 50 to 60 years and is often a complication of odontogenic infections, particularly in immunocompromised patients. [3] It can be classified based on its etiology into three primary categories: traumatic, rhinogenic, and odontogenic.[4] The main contributory factors include systemic conditions such as diabetes mellitus, immunocompromised states (e.g., HIV, chemotherapy), and chronic sinus infections.[5] The clinical presentation of maxillary osteomyelitis can vary widely, ranging from mild facial pain and swelling to severe cases involving bone sequestration, fistula formation, and significant bony destruction. Early recognition and appropriate management are crucial to prevent complications such as cranial cavity infections or facial deformities.[2] Management typically involves a combination of surgical debridement and targeted antibiotic therapy, with treatment approaches tailored based on the patient’s clinical condition and underlying systemic diseases.[1] This case series aims to assess the contributory factors associated with maxillary osteomyelitis and evaluate its variable clinical features. By examining a series of cases, this study seeks to provide valuable insights into the clinical presentation, management approaches, and outcomes of patients diagnosed with this rare but challenging condition.

This retrospective case series was conducted at MGM Hospital, Kamothe, focusing on four patients diagnosed with maxillary osteomyelitis. The study aimed to evaluate the clinical presentation, contributory factors, and treatment outcomes of maxillary osteomyelitis. Patients included in the study were diagnosed based on clinical, radiological, and histopathological findings. Data were collected retrospectively from hospital records, including demographic information, clinical presentation, imaging studies, culture reports, and histological analyses. Diagnostic methods included orthopantomogram (OPG), computed tomography (CT), magnetic resonance imaging (MRI), and microbiological studies to identify causative organisms and assess antibiotic sensitivity. All patients received empirical broad-spectrum antibiotics initially, which were later adjusted based on culture sensitivity reports. Surgical interventions such as debridement, sequestrectomy, abscess drainage, and the use of a maxillary feeding plate were employed based on the severity of the condition. Follow-up evaluations included monitoring clinical improvement, radiological evidence of bone healing, and assessment of complications. The study aimed to analyze patterns in presentation, the effectiveness of treatment modalities, and clinical outcomes to enhance understanding and management of maxillary osteomyelitis. Case Presentations Case 1: A 64-year-old male presented with right facial heaviness, nasal discharge, right retro-orbital pain, and altered sensorium for one week. He had a history of Type 2 Diabetes Mellitus for 10 years and was recently diagnosed with hyponatremia. On examination, blackish discoloration with slough and bony destruction of the hard palate was noted. All routine laboratory investigations were performed, and a Contrast-Enhanced CT (CECT) of the brain with paranasal sinuses (PNS) revealed invasive fungal right maxillary sinusitis with intraorbital extension. The imaging also showed erosion of the maxillary walls and the tympanic part of the facial nerve, indicating extensive disease progression. The patient was started on intravenous (IV) antibiotics and antifungal therapy with Liposomal Amphotericin B due to the suspicion of invasive mucormycosis. Surgical intervention included right medial maxillectomy and aggressive debridement of necrotic tissue to control the spread of infection. Histopathological examination confirmed the diagnosis of chronic osteomyelitis with superimposed mucormycosis, highlighting the dual infectious process contributing to the severe clinical presentation. The patient’s management also involved stabilizing his systemic condition, particularly optimizing blood glucose levels and correcting electrolyte imbalances. The follow-up included monitoring the site for healing, assessing for residual infection, and preventing complications such as an oroantral fistula. The use of Liposomal Amphotericin B was critical due to its efficacy in treating invasive fungal infections like mucormycosis, especially in immunocompromised patients. Case 2: A 55-year-old female presented with right facial pain and swelling persisting for three months, with noticeable swelling over the right upper alveolus for the past month. The patient had no known comorbidities. On examination, there was significant swelling present over the right canine extending to the first molar, along with right maxillary tenderness and evidence of bony erosion. Routine investigations, including a High-Resolution CT (HRCT) of the paranasal sinuses (PNS), indicated erosion of the inferior wall of the right maxillary sinus. The patient was managed with intravenous antibiotics and oral antifungal therapy. Surgical intervention involved a right limited infrastructure maxillectomy with primary closure under general anesthesia. Histopathological examination (HPE) revealed granulation tissue on the right side of the inferior maxilla, including the hard and soft palate, confirming the diagnosis of maxillary osteomyelitis. The postoperative period was uneventful, and the patient was closely monitored for signs of infection resolution and wound healing. The case highlights the importance of combining medical and surgical management to achieve favorable outcomes in osteomyelitis of the maxilla. Case 3: A 67-year-old male presented with right-sided facial pain for six months and right nasal obstruction for the past two months. He had a known history of Type 2 Diabetes Mellitus (T2DM) and Hypertension (HTN) for four years, for which he was on regular medication. Clinical examination revealed the presence of an oroantral fistula and marked tenderness over the right maxillary region. Routine investigations, including a High-Resolution CT (HRCT) of the paranasal sinuses (PNS), demonstrated bony erosions on all walls of the right maxillary sinus, involving the superior alveolar arch, right zygoma, lamina papyracea, and the greater wing of the sphenoid, suggesting an invasive process. HRCT of the thorax also indicated the presence of left lung aspergilloma. Further evaluation with MRI of the PNS and orbit revealed an ill-defined soft tissue lesion with moderate inhomogeneous enhancement, involving the right maxillary sinus and causing significant bony destruction. The patient was initiated on intravenous (IV) antibiotics and antifungal therapy. Surgical management included right endoscopic debridement using a modified Denker's approach under general anesthesia, followed by a right total maxillectomy. Histopathological examination (HPE) confirmed the diagnosis of chronic osteomyelitis with aspergilloma. The postoperative course was uneventful, with regular follow-up to monitor for infection resolution, healing of the oroantral fistula, and overall clinical improvement. The case underscores the importance of a multidisciplinary approach in managing invasive fungal infections in immunocompromised patients. Case 4: A 64-year-old female presented with right facial pain and swelling for three months. On examination, there was significant tenderness over the right maxillary region, and granulation tissue was noted in the right upper premolar fossa, which was sent for histopathological examination (HPE). Imaging studies included a CT scan of the face, which revealed erosion and destruction of the anterior, medial, and lateral walls of the right maxillary sinus, with findings suggestive of a fungal infection or malignancy. An MRI of the paranasal sinuses (PNS) and orbit showed a large lobulated soft tissue mass involving the right maxillary sinus, causing bony erosion. HPE confirmed the diagnosis of chronic osteomyelitis with moderately differentiated squamous cell carcinoma (SCC). The case highlights the importance of considering malignancy in the differential diagnosis of maxillary osteomyelitis, especially when imaging shows aggressive bony destruction. Management involved a multidisciplinary approach, including oncological evaluation and planning for appropriate surgical and medical interventions. The patient was monitored closely for treatment response and potential complications associated with the dual pathology of osteomyelitis and malignancy.

The case series on maxillary osteomyelitis demonstrates both similarities and differences among the four cases in clinical presentation, radiological findings, and treatment outcomes. Common symptoms included facial pain, swelling, and maxillary tenderness, although one patient presented with altered sensorium and another with an oroantral fistula, indicating advanced disease. Two patients had Type 2 Diabetes Mellitus, highlighting diabetes as a significant risk factor, while the other two had no known comorbidities, suggesting that maxillary osteomyelitis can also occur in healthy individuals. Radiological findings consistently showed maxillary bone erosion, but the extent varied, with one case involving intraorbital extension and another showing systemic spread to the lungs. Treatment involved empirical antibiotics, antifungal therapy, and surgical interventions such as maxillectomy and debridement. Histopathology confirmed chronic osteomyelitis in all cases, with additional findings of mucormycosis, aspergilloma, and squamous cell carcinoma (SCC) in specific patients (Table 2). All patients showed improvement with treatment, with the multidisciplinary approach proving particularly important in the case with SCC. The study underscores the need for early diagnosis, tailored treatment, and comprehensive management strategies to improve outcomes in this rare but challenging condition. Table 1. Clinical Presentation, Management, and Histopathological Findings in Patients with Maxillary Osteomyelitis Case Age/ Gender Presenting Complaints Comorbidities Management HPE Findings Case 1 64/M Facial heaviness, nasal discharge, retro-orbital pain, altered sensorium T2DM, Hyponatremia IV antibiotics, Amphotericin B, Medial maxillectomy Chronic osteomyelitis with mucormycosis Case 2 55/F Facial pain with swelling, alveolar swelling None IV antibiotics/antifungals, Limited infrastructure maxillectomy Osteomyelitis maxilla Case 3 67/M Facial pain, nasal obstruction T2DM, HTN IV antibiotics/antifungals, Endoscopic debridement, Total maxillectomy Chronic osteomyelitis with aspergilloma Case 4 64/F Facial pain with swelling None Multidisciplinary approach, Surgical/medical management Chronic osteomyelitis with SCC

Maxillary osteomyelitis is a rare but serious condition that often arises from odontogenic infections, trauma, or systemic diseases such as diabetes mellitus. The cases presented in this series align with existing literature, highlighting diabetes as a significant predisposing factor for maxillary osteomyelitis [6]. Two of the four patients in this series had Type 2 Diabetes Mellitus, emphasizing the importance of glycemic control in preventing infections. Previous studies have also demonstrated that diabetes mellitus is associated with increased severity and complexity of osteomyelitis due to impaired immune responses and delayed wound healing [7]. The clinical manifestations in this series included facial pain, swelling, and, in advanced cases, complications such as fistula formation and extensive bony destruction. Imaging consistently showed maxillary bone erosion, supporting the critical role of radiological assessments in determining the extent of disease and guiding surgical management [8]. The treatment approach combined empirical antibiotics, antifungal therapy, and surgical interventions, which is consistent with the recommended management strategies for maxillary osteomyelitis [9]. Notably, the use of a multidisciplinary approach, particularly in cases involving invasive fungal infections or coexisting malignancies, contributed to favorable outcomes. These findings underscore the necessity for early recognition and comprehensive management strategies in treating maxillary osteomyelitis. Timely intervention, especially in patients with systemic conditions like diabetes, is crucial to preventing severe complications and ensuring optimal recovery. This case series adds to the growing body of evidence advocating for a tailored approach to management based on individual clinical presentations and underlying risk factors.

This case series highlights the complexity of maxillary osteomyelitis, emphasizing the need for early diagnosis, tailored medical and surgical management, and a multidisciplinary approach, especially in immunocompromised patients. Effective treatment strategies can significantly improve clinical outcomes and prevent severe complications.

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