Novel approach to the maxillary sinusitis after sinus graft

A 47-year-old patient was referred to our department with the chief complaint of foul odor, tenderness on the right sinus, and headache. Sinus elevation using the crestal socket osteotome, bone graft, and implant insertion had been initiated at a local clinic 10 days previously. Further clinical examinations showed gingival redness and swelling of the right buccal gingiva, pus discharge from the right nose, and lymphadenopathy of the right. A Waters’ view plain-film radiograph showed haziness of the right maxilla confirming sinusitis of the right maxilla (Fig. 1).

Explantation of the infected implant and sinus irrigation was initiated. Sinus irrigation was conducted by lateral antrostomy through the canine fossa. The canine fossa is the thinnest area of the anterior wall and is easily accessed. Through the window, pus was aspirated using a syringe, and cultured. The remaining infected bone graft materials were removed by inserting a suction and irrigation tip into the window and lightly irrigating with saline solution (Fig. 2a, b). A tube drain was inserted and then sutured to the gingiva. A flexible silastic suction tip was inserted into the right nostril towards the ostio-meatal complex. Further copious irrigation of the sinus was initiated through the silastic drain in the oral cavity (Fig. 3a, b).

Four consecutive irrigation sessions 4 days apart were executed, and the drain was removed on the last day of irrigation. Amoxicillin (500 mg), pseudoephedrine hydrochloride (60 mg), carbocisteine (750 mg), and NSAIDs were given three times daily for a total of 21 days.

After removal of the infected bone graft materials and implant, the patient had immediately relieved symptoms of headache. After four irrigation sessions, discomfort on the right buccal area had diminished, and pus accumulation was not observed. The microbiological culture of the maxillary sinus on the first day of treatment revealed the presence of α-hemolytic Streptoccus viridans. A follow-up computed tomography (CT) at 3.5 months displayed radiolucency in the infected right maxillary sinus, and was conclusive of recovery (Fig. 4).

Odontogenic and non-odontogenic sinusitis differ in cause, pathophysiology, and microbiology. Therefore, specifically identifying the cause is the first step for a successful outcome. Elimination of the source of infection is the essential step to relieve symptoms and prevent recurrence of sinusitis. Odontogenic sinusitis can be treated medically and/or surgically. Medical treatment regimens are based on antibiotics, determined through bacterial culture, and decongestants. Administrating antibiotics is a crucial step in managing odontogenic sinusitis. One study found α-hemolytic Streptoccus viridans, microaerophilic streptococci, and Stapylococcus aureus to be the most common aerobic bacteria, and anaerobic gram-negative bacilli, Peptostreptococcus spp, and Fusobacterium spp to be the most common anaerobic bacteria [3]. These findings are interesting since most common non-odontogenic origin microbes are Streptococcus pneumonia, Haemophilus influenza, and Moraxella catarrhalis [5]. Therefore, antibiotic selection should be carefully contemplated following a pus culture such as in our case. Quick and accurate measures must be taken sine oral antibiotics are only effective against oral flora and sinus pathogens for only 21 to 28 days [6].

Surgical regimens may vary depending on the etiology of rhinosinusitis. Lechien et al [4] did a review that studied the proportion owing to odontogenic chronic maxillary sinusitis. Iatrogenic, marginal periodontitis, apical periodontitis, apical granuloma, odontogenic cyst, odontoma, ectopic tooth, peri-implantitis were all reviewed. Iatrogenic etiology accounted for most of the cases being 65.7%.

The classic Caldwell luc approach was commonly used, despite its morbidity and 9–15% recurrence rate, for chronic odontogenic sinusitis [7]. Therefore less invasive endoscopic sinus surgery (ESS) techniques have been promoted because it is safer, quicker, has less impact on the sinus mucus clearance, advocates less bleeding, and allows for a shorter hospital stay [4]. But, it has limitation of exposure to the anterior maxillary anterior wall and lacrimal recess, and access to the anterior wall [8]. Some recent literature have proposed puncturing the canine fossa in combination of ESS [7], while some recommend using a dilated balloon [9]. But, most of the recent methods require the practitioner to have access to an endoscope or they are not adequate for odontogenic cases.