Recently, an article in the
Journal of Otolaryngology, Head and Neck Surgery, extrapolated data from a
County hospital in Minnesota and calculated a national cost of inpatient
hospital care for odontogenic deep neck space infections to be $200 million
annually (1). Absent from this article
was any mention of the cost or incidence of odontogenic rhinosinusitis. The reported incidence in the literature of dental
pathology as a cause of rhinosinusitis is 10-12% (2). The primary source data for this incidence is
from the 1950s and there is no documentation in the referenced articles of the
data used to calculate this incidence.
Therefore, the true incidence odontogenic rhinosinusitis is unknown and,
based on my experience, most likely underappreciated.
 |
| By BruceBlaus (Own work) via Wikimedia Commons |
Prior to reviewing odontogenic rhinosinusitis, we need to
discuss common definitions.
Rhinosinusitis is inflammation of the paranasal sinus and/or nasal
cavities. This inflammation may be
caused by allergic, infectious or immunogenic etiologies. Acute rhinosinusitis lasts up to 4 weeks,
subacute rhinosinusitis lasts up to 12 weeks, and chronic rhinosinusitis lasts
greater than 12 weeks. Acute
rhinosinusitis is a clinical diagnosis based on the history and physical
exam. Symptoms of sinusitis have been
divided among major and minor factors (3).
The diagnosis requires either two major factors or one major factor and
2 minor factors. Major factors include
facial pain, facial congestion, nasal obstruction (blockage), purulent (discolored)
nasal drainage (anterior or posterior), lack of or absence of smell, or
fever. Minor symptoms include headache,
fatigue, halitosis (bad breath), and dental pain, cough or ear pressure or
pain.
Major Symptoms
|
Minor Symptoms
|
Facial Pain
|
Headache
|
Facial Congestion
|
Fatigue
|
Nasal Obstruction
|
Halitosis
|
Purlent Drainage
|
Dental Pain
|
Loss of Smell
|
Cough
|
Fever
|
Ear Pressure/Pain
|
Odontogenic rhinosinusitis is defined as sinusitis induced
by a dental lesion. The common
etiologies include periapical and periodontal disease, odontogenic lesions and
iatrogenic and traumatic causes. Iatrogenic
causes include complications of tooth extractions, implants, sinus
augmentation, osteotomies and other orthodontic surgery, and a foreign body
reaction to either the root canal sealant or filling material used in root
canal therapy. A significant amount of
literature is dedicated to complications associated with dental implants and
sinus lifts. The reported incidence of rhinosinusitis
resulting from sinus augmentation is 0-27% (4).
However, when strict criteria are used to define rhinosinusitis, the
incidence is 4.5%. Approximately 1/3 of
these patients will progress from acute to chronic rhinosinusitis. Chronic rhinosinusitis requiring surgical
intervention from sinus augmentation is reported to be 1.3% of patients(4). Sinus inflammation consisting of mucous
membrane thickening on preaugmentation CT imaging is a statistically significant
risk factor for post procedure acute or chronic rhinosinusitis (5). These are
patients who would benefit from a preaugmentation ENT evaluation.
Treatment of sinusitis consists of saline irrigations,
topical and systemic decongestants, antibiotics, topical and systemic steroids
and allergy treatment. Antibiotics are used
to treat acute rhinosinusitis and acute exacerbations of chronic
rhinosinusitis. The specific antibiotic
used is based on common microbiology patterns or the result of endoscopically-guided
cultures. Recommended first-line
antibiotics include Augmentin, high-dose amoxicillin, and extended spectrum
cephalosporins. Surgery for acute or
chronic rhinosinusitis is usually a last resort after maximal medical therapy
has failed.
Odontogenic rhinosinusitis presents a unique challenge to
the otolaryngologist. The diagnosis is
frequently delayed. A dental source for
the sinus infection is frequently not considered until after both medical and
surgical therapy has failed to resolve the patient's symptoms and radiographic
disease. A primary cause for the delay
in diagnosis is the failure of the radiologist and ENT physician to adequately
assess dental pathology on CT imaging.
In a 2010 retrospective case series involving 21 patients with known odontogenic
rhinosinusitis, the initial radiology report failed to mention radiographic
findings of dental pathology in 14 or 67% percent of the patients (6). There are symptoms which suggest an
odontogenic source for the infection in patient presenting with
rhinosinusitis. First, the large
majority of patients will present with unilateral symptoms. This means that the patient will complain of
nasal discharge, cheek pain, dental pain or nasal obstruction primarily on one
side. Another unique symptom to
odontogenic rhinosinusitis is a foul smell noted by the patient. In 76 patients with known odontogenic rhinosinusitis,
33 or 43% reported a foul smell (6,7,8).
In addition to early diagnosis, a successful outcome of
odontogenic rhinosinusitis requires appropriate antibiotic therapy based on the
common microbiology findings of a mixed polymicrobial infection. Like other odontogenic-induced infections,
first-line antibiotic coverage for ORS is clindamycin. Additionally, successful treatment depends on
eliminating the source of the infection.
This requires early involvement of the dental health professional. In general, dental procedures take precedence
over the ENT procedures. Situations
where ENT surgery would precede dental surgery include the following:
1. A complications of rhinosinusitis
requiring emergent surgery.
2. Sinus surgery in
an infected maxillary sinus performed prior to closure of an oral antral
fistula to increase the chance of success.
3. Sinus surgery for pre-existing
sinus disease prior to sinus augmentation (9).
The most important aspect of successful treatment consists
of good coordination of care and communication between the dentist and ENT
physician.
Case 1
 |
| A 51 year old female presents with one year of left facial & tooth pain, left nasal obstruction, postnasal drainage and headaches. Past dental history is significant for RCT of teeth 10 & 11, apicoectomy of tooth #10, and dental implants #12 & 13. The implants failed and she developed an oral antral fistula after removal of the implants and debridement of necrotic bone. Coronal CT image demonstrating severe left maxillary and ethmoid sinus disease. This one sided sinus disease was of odontogenic origin. |
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| A coronal CT 2 months after ethmoid and maxillary sinus surgery showing complete resolution of sinus disease. |
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| Several months later, she underwent a successful sinus lift with implantation and a coronal CT image demonstrating ossification of the sinus augmentation. |
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Case 2
 |
|
A 70 year old male with postnasal drainage presents
with a right nasal cavity mass demonstrated on nasal endoscopy. |
 |
|
A yellow discharge is associated with the object. A coronal CT image demonstrates extrusion of
a dental implant 9.5mm into the right nasal cavity. |
 |
Additional implants extruding into the maxillary sinuses without
radiographic disease.
|
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Case 3
 |
|
A 69 year old female presents with 12 months of brown-yellow
nasal drainage, mild right facial pressure, right nasal congestion and a foul
taste and smell. She presented to her
general dentist 3 months prior to her ENT consultation with a right gingival
buccal lesion that resolved with clindamycin. A coronal CT image of the
paranasal sinuses demonstrates maxillary and ethmoid sinusitis ipsilateral to
right maxillary periapical tooth disease with buccal plate and maxillary
sinus floor boney erosion. |
 |
|
A sagittal image through the right maxillary
sinus shows periapical disease of teeth #2 and 3. This is another odontogenic sinusitis requiring dental treatment as the initial treatment for her sinus problem. |
Posted by: Tim Haegen MD of the
Arizona Sinus Center
References
1. Morbidity and cost of odontogenic infections. Eisler L, Wearda K, Romatoski K, Odland
RM. Otolaryngol Head Neck Surg. 2013
Jul;149(1):84-8.
2. Clinical aspects of odontogenic maxillary sinusitis: a case
series. Longhini AB. Ferguson BJ. International Forum of Allergy & Rhinology.
1(5):409-15, 2011 Sep-Oct.
3. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol
Head Neck Surg 1997;117:S1-7.
4. ENT assessment in the integrated management of candidate for
(maxillary) sinus lift. Pignataro L, Mantovani M, Torretta S, et al. ActaOto rhino laryngolItal 28:110–119, 2008.
5. Late signs and symptoms of maxillary sinusitis after sinus
augmentation. Manor Y, Mardinger O, Bietlitum I, et al.OralSurg Oral Med Oral
Pathol Oral RadiolEndod 110:e1–e4, 2010.
6. Clinical aspects of odontogenic maxillary sinusitis: a case
series. Longhini AB. Ferguson BJ. International Forum of Allergy &
Rhinology. 1(5):409-15, 2011 Sep-Oct.
7. Microbiology of acute and chronic maxillary
sinusitis associated with an odontogenic origin. Brook I. Laryngoscope.
115(5):823--‐5, 2005 May.
8. Late signs and symptoms of maxillary Sinusitis
after Sinus augmentation. Manor Y, Mardinger O, Bietlitum I, et al. Oral Surg
Oral Med Oral Pathol Oral RadiolEndod 110:e1-e4, 2010.
9. The characteristics and new treatment paradigm of dental implant-related chronic rhinosinusitis. Chen YW, Huang CC, Chang PH, Chen CW, Wu CC, Fu CH, Lee TJ. Am J Rhinol Allergy. 2013 May;27(3):237-44.
