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Corresponding author at: Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan.
Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, JapanDepartment of Otolaryngology-Head and Neck Surgery, Sato Clinic & Hospital, Oita, Japan
The successful management of odontogenic maxillary sinusitis (OMS) involves a combination of medical treatment with dental surgery and/or endoscopic sinus surgery (ESS). However, there is no consensus for the optimal timing of ESS. Although several studies have emphasized dental surgery as the primary treatment modality for OMS, there is recent evidence to suggest that ESS alone may be an effective treatment approach.
The purpose of this study is to retrospectively investigate the pathophysiology of the current intractable OMS and the role ESS, especially ESS preceding dental treatment, plays in its pathophysiology.
Methods
Ninety-seven adults (60 males and 37 females, 48 ± 12 years) who underwent ESS for intractable OMS were retrospectively examined.
Results
In a great deal of the cases (85 cases, 87.6%), causative teeth of OMS were periapical lesions after root canal treatment (endodontics). The root canal procedures were not sufficient; hence, the root-canal-treated teeth had periapical lesions causing OMS.
In postoperative nasal endoscopy and cone-beam CT scans for all patients, the natural ostiums and the membranous portions of the maxillary sinuses were enlarged and the ostiomeatal complexes remained widely open. The ventilation and drainage of all patients’ maxillary sinuses seemed to be successfully restored.
Temporary acute sinusitis recurrence after primary ESS for OMS was observed in 10 cases (11.8%) when the patients caught a cold. However, since the natural ostium and the membranous portion of the maxillary sinuses and the ostiomeatal complexes remained widely open, antibiotic administration alone without dental treatment cured the temporary acute sinusitis.
Regarding the causative teeth (endodontic treated teeth), in 83 out of 85 cases (97.6%), causative teeth were able to be preserved with only antibiotic treatment and without dental retreatment. In two cases, extraction of the teeth was necessary because the teeth became mobile. Regarding the causative teeth after dental restoration, in 2 out of 2 cases (100%), causative teeth were able to be preserved with antibiotic treatment alone.
Conclusion
ESS is highly indicated for OMS requiring surgery. The treatment results of intractable OMS are exceptionally good once the ventilation and drainage of the maxillary sinus is successfully restored after surgery. Consequently, ESS can be considered the first-line therapy for intractable OMS caused by root canal treatment (endodontics) and dental restoration, followed by close dental follow-up and dental treatment when necessary.
Maxillary dental infections can cause sinusitis and this pathophysiologic condition is called odontogenic maxillary sinusitis (OMS). Untreated dental diseases with endodontic or periodontic lesions of the maxilla accompanied with unilateral opacification of the maxillary sinus was previously a common type of OMS [
. However, current pathophysiology of OMS and its treatment have changed.
Regarding the etiology of OMS, because of an increase of personal hygiene awareness in Japan, it has become rare that untreated dental diseases (i.e. dental caries) cause OMS [
]. On the other hand, there is no consensus for the management of causative teeth of OMS. Furthermore, optimal timing of ESS and whether intractable OMS patients undergo primary dental treatment, ESS or both is still controversial. Although previous studies have emphasized dental procedure as the primary treatment modality for OMS, there is recent evidence to suggest that ESS alone may be an effective treatment approach [
The purpose of this study is to retrospectively investigate the pathophysiology of the current intractable OMS and the role ESS, especially ESS preceding dental treatment, plays in its pathophysiology.
2. Materials and methods
This study has been carried out in accordance with “The Code of Ethics of the World Medical Association (Declaration of Helsinki)” for experiments involving humans.
Ninety-seven adults (60 males and 37 females) ranging in age from 24 to 71 years (48 ± 12 years, mean ± SD) who underwent ESS for intractable OMS were retrospectively examined. Antibiotic administration without dental treatment was performed for OMS and the endodontic or periodontic lesions of the causative teeth for two to three months prior to ESS.
2.1 Diagnosis of OMS
Regarding the diagnosis of OMS, evaluation of all patients with unilateral persistent chronic rhinosinusitis included inspection of the maxillary teeth with a cone-beam computed tomography (CT) scan for endodontic and periodontic lesions including evidence of periapical lucencies. Furthermore, the relationships between the periapical lesions of the causative teeth and the maxillary sinus were observed using cone-beam CT scan to obtain accurate diagnosis.
In all patients, sinus symptoms outweighed dental symptoms with patients having minimal to absent dental complaints. Sinonasal symptoms of OMS were unilateral and consistent with cardinal symptoms of acute and chronic sinusitis such as purulent anterior rhinorrhea, postnasal drip, facial pressure and nasal congestion.
2.2 Complications of OMS
Seventeen out of 97 OMS patients (17.5%) had nasal polyps. Fourteen patients (14.4%) had sinus mycosis. Sixty-seven patients (69.1%) had nasal allergies. Two patients (2.1%) had asthma.
2.3 Endoscopic sinus surgery and postoperative treatment
The ESS was performed as a first-line therapy for these cases of intractable symptomatic OMS. Not only the enlargement of the natural ostium and membranous portion of the maxillary sinus but also the ostiomeatal complex were opened widely by ESS. In addition, other sinuses were opened widely when necessary. Periapical lesions and apex of the teeth were left intact under nasal endoscope. In the case in which a radicular cyst caused the intractable OMS, extraction of the tooth and removal of the cyst were performed during ESS.
Antibiotic administration without dental treatment was performed for the endodontic or periodontic lesions of the causative teeth of OMS. Low-dose macrolide antibiotics were administered orally to all patients for three months postoperatively.
2.4 Assessment of outcomes of endoscopic sinus surgery
Surgical outcomes of OMS were assessed by the absence of inflammation on nasal endoscopy or the absence of opacification by cone-beam CT scans.
3. Results
3.1 Etiology of the causative teeth for OMS
Eighty-five patients (87.6%) had already had prior root canal treatment (endodontics) (Fig. 1). This prior dental treatment caused the intractable OMS. The root canal procedures were not sufficient; hence, the root-canal-treated teeth had periapical lesions causing OMS (Fig. 1). In five patients (5.1%), since the causative teeth had already been extracted, the etiology of the causative teeth was unknown. In three patients (3.1%), intractable OMS occurred after the extraction of wisdom teeth. Two patients (2.1%) had periapical lesions following dental restoration. In one patient (1.0%), a tooth with marginal periodontitis caused the intractable OMS. In one patient (1.0%), a tooth with radicular cyst caused the intractable OMS.
The right second molar has undergone endodontics. The cone-beam CT scan shows periapical lesion following insufficient root canal treatment, which results in maxillary sinusitis on the same side.
Among the causative teeth, 46 out of 116 teeth (39.7%) were first molars, 42 teeth (36.2%) were second molars, 18 teeth (15.5%) were second premolars, 4 teeth (3.5%) were third molars, 4 teeth (3.5%) were first premolars, 1 tooth (0.86%) was a canine and 1 tooth (0.86%) was a lateral incisor.
3.2 Endoscopic sinus surgery outcomes
In postoperative nasal endoscopy and cone-beam CT scans for all patients, the natural ostiums and the membranous portions of the maxillary sinuses were enlarged and the ostiomeatal complexes remained widely open (Fig. 2). The ventilation and drainage of all patients’ maxillary sinuses seemed to be successfully restored during the follow-up period (1–8 years).
Fig. 2Postoperative endoscopic view of the left maxillary sinus (A: a 0-degree rigid endoscopic view, B: a 70-degree rigid endoscopic view)
In postoperative nasal endoscopy, the left ostiomeatal complex (OMC) remains widely open (A) and the left natural ostium and the membranous portion of the left maxillary sinus are enlarged and widely opened (B) (*). The ventilation and drainage of the left maxillary sinus are successfully restored after endoscopic sinus surgery.
Temporary acute sinusitis recurrence after primary ESS for OMS was observed in 10 cases (11.8%) when the patients caught a cold (Fig. 3). However, since the natural ostium and the membranous portion of the maxillary sinuses and the ostiomeatal complexes remained widely open, antibiotic administration alone without dental treatment cured the temporary acute sinusitis.
Fig. 3Left temporary acute maxillary sinusitis recurrence after primary endoscopic sinus surgery (A: flexible endoscopic view via an enlarged left natural ostium and membranous portion of the left maxillary sinus, B: Cone-beam CT scan, multiplanar reconstruction, coronal section)
Left temporary acute maxillary sinusitis recurrence after primary endoscopic sinus surgery is observed when the patient catches a cold. The mucosa just above the periapical lesion of the causative tooth becomes edematous. However, since the natural ostium and the membranous portion of the left maxillary sinus and the left ostiomeatal complex remain widely open (*), antibiotic administration alone without dental treatment cured temporary acute sinusitis.
Regarding the endodontic-treated causative teeth (root-canal-treated teeth with periapical lesions), in 83 out of 85 cases (97.6%), causative teeth were able to be preserved with antibiotic treatment alone. Dental retreatment of the OMS causative teeth was not necessary. In two cases, extraction of the OMS causative tooth was necessary because the teeth became mobile at 2 years and 10 months and 7 years after primary ESS.
Regarding the causative teeth after dental restoration, in 2 out of 2 cases (100%), causative teeth were able to be preserved with antibiotic treatment alone.
Regarding the causative teeth of radicular cyst, extraction of the tooth and removal of the cyst were performed at the same time during ESS.
4. Discussion
4.1 Current etiology of OMS
Cone-beam CT scanning is extremely accurate and useful in the diagnosis of OMS in addition to physical examination [
]. Dental evaluations by plain dental radiography frequently fail to detect maxillary dental infection that could cause OMS. The relationship between causative teeth (endodontic and periodontic lesions including evidence of periapical lucencies) and the maxillary sinus can be accurately observed and OMS can be accurately diagnosed using the cone-beam CT scans.
Various odontogenic pathologies can cause OMS, including pulpitis, periapical lesions, periodontitis, oroantral fistulas or foreign bodies in the sinus related to dental treatment [
When the root canals of teeth are incompletely filled with a filling material during endodontics, insufficient root canal treatment causes pulpitis and pulp necrosis in the root canal at the root apex [
The present study showed, in 85 out of 97 patients (88.6%), prior root canal treatment (endodontics) was the cause of intractable OMS. The root canal procedures were not sufficient; hence, the root-canal-treated teeth had periapical lesions causing OMS.
4.2 Pathophysiology of OMS
When odontogenic inflammation such as periapical lesion is constantly presented at the floor of the maxillary sinus, the maxillary sinus is exposed to the potential danger of inflammation [
. Bauer reported that inflammation and infection from tooth roots could spread through the maxillary alveolar bone and sinus mucosa, thereby causing sinus inflammation and infection [
. Regarding the retardation factors on the treatment of sinusitis, mucociliary function, bacteria and virus infections, occlusion of ostiomeatal complex and a combination of these three factors cause an inflammatory vicious cycle in the closed maxillary sinus and result in intractable OMS [
4.3 Histopathology of the maxillary sinus mucosa of OMS
Regarding the histopathology of the maxillary sinus mucosa with usual chronic inflammatory maxillary sinusitis, the number of ciliated epithelial cells decreases, goblet cells become hypertrophic and secretions are viscous. Consequently, mucociliary functions of the epithelium of the maxillary sinus mucosae are inhibited.
On the other hand, the histopathology of the maxillary sinus mucosa with OMS is characteristic. Our previous histopathological investigation of intractable OMS revealed that the maxillary sinus mucosa appeared gyrus-like in appearance and that the number of ciliated epithelial cells did not decrease, goblet cells were not hypertrophic and the secretions were not viscous but purulent [
]. Zhang et al. reported similar histopathological findings that the maxillary sinus mucosa of OMS presented as papillary folds in the surface of the epithelium and papillary-like folded mucosa was covered with intact pseudostratified columnar ciliated epithelium [
Consequently, from the histopathological point of view, the ciliated columnar epithelium of intractable OMS is not severely damaged and not irreversibly injured. As a result, mucociliary function of the epithelium almost certainly recovers once the ventilation and drainage of the maxillary sinus is successfully restored. Regarding the aforementioned three retardation factors on the treatment of OMS, the treatment strategy centers around how to manage the two remaining factors: infections and occlusion of the ostiomeatal complex.
4.4 Management of causative teeth for OMS
Regarding the treatment of OMS, ESS is highly indicated for intractable OMS requiring surgery [
]. The results of the present study showed that the treatment results of intractable OMS are exceptionally good once the ventilation and drainage of the maxillary sinus is successfully restored after surgery [
]. It has been reported that successful treatment of OMS first requires management of the odontogenic source and several studies have emphasized dental surgery as the primary treatment modality for OMS. For instance, the American Academy of Endodontics published a 2018 position statement on maxillary sinusitis of endodontic origin, suggesting that dental treatment should be performed first, followed by ESS only if needed [
]. As a result, extraction of the causative tooth of the OMS is usually performed. When the causative tooth is extracted, the inflammation chain between dental lesions and maxillary sinusitis will improve. However, other inflammation chains, such as retardation factors of sinusitis still exist. The worst situation for the patient is that OMS is not cured even though the causative tooth has been extracted.
Since a large number of inflammatory cells infiltrate into the maxillary sinus mucosa [
], intractable OMS which has fallen into a vicious cycle of inflammation in the closed maxillary sinus is difficult to cure using only conservative therapy such as antibiotic administration and dental treatment [
]. Raman et al. reported that the increased inflammation observed in odontogenic chronic rhinosinusitis relative to chronic rhinosinusitis without nasal polyps may help explain why odontogenic chronic rhinosinusitis tends to be refractory to medical and dental therapy [
There is no consensus for the optimal timing of ESS for OMS. Although several studies have emphasized dental surgery as the primary treatment modality for OMS, there is recent evidence to suggest that ESS alone may be an effective treatment approach [
Our previous histopathological study revealed, despite increased severe inflammation, the ciliated columnar epithelium of intractable OMS is not severely damaged and not irreversibly injured [
]. Consequently, mucociliary function of the epithelium will almost certainly recover once the ventilation and drainage of the maxillary sinus is successfully restored after improving the occlusion of the ostiomeatal complex [
]. When the ventilation and drainage of the maxillary sinus is successfully restored after ESS, periapical lesions and odontogenic infection will lead to silent chronic lesions using only antibiotic therapy alone and most causative teeth can be preserved [
]. That is the reason why ESS preceding dental treatment or extraction of the causative tooth is highly indicated for surgery-requiring intractable OMS.
The results of this study revealed, if the ventilation and drainage of the maxillary sinus is successfully restored after ESS, most of the causative teeth (endodontic treated teeth, i.e., root-canal-treated teeth with periapical lesions) with minimal to absent symptoms can be preserved with only antibiotic treatment alone [
The treatment results of intractable OMS are exceptionally good once the ventilation and drainage of the maxillary sinus is successfully restored after ESS. The preservation rate of the causative teeth (endodontic treated teeth with periapical lesions) was 97.6%. The causative teeth were able to be preserved with antibiotic treatment alone without dental retreatment.
Consequently, ESS can be considered the first-line therapy for intractable OMS caused by root canal treatment (endodontics), followed by close dental follow-up and dental treatment when necessary.
Ethical statement
The authors assert that all procedures contributing to this case report comply with the ethical standards of the relevant national and institutional guideline on human experimentation (Ethical Committee of Kurume University) and with the Helsinki Declaration of 1975, as revised in 2008.
Financial disclosure
None.
Declaration of Competing Interest
None.
References
Sato K.
Pathology of recent odontogenic maxillary sinusitis and the usefulness of endoscopic sinus surgery.
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