ORIGINAL ARTICLE
Odontogenic sinusitis: a case series studying diagnosis and management Kevin L. Wang, MD1 , Brent G. Nichols, MD2 , David M. Poetker, MD, MA3 and Todd A. Loehrl, MD3
Background: Odontogenic sinusitis is a well-recognized, but understudied form of sinusitis. Odontogenic sinusitis requires unique diagnostic criteria and a treatment regimen that differs from non-odontogenic sinusitis. The purpose of this article is to present a case series of patients with odontogenic sinusitis in order to clarify key disease characteristics and management techniques.
tal surgery alone, 2 (10%) resolved with ESS aer failing dental surgery, 2 (10%) resolved with medical management alone, and 1 (5%) resolved with medical management after failing dental surgery. Forty-six (84%) patients had unilateral odontogenic sinusitis. The Lund-Mackay score for all patients was (mean ± standard deviation [SD]) 4.0 ± 3.2.
Methods: Retrospective case series of 55 patients with odontogenic sinusitis. Each patient underwent chart and imaging review to analyze demographic factors, diagnostic criteria, clinical course, and management.
Conclusion: Odontogenic sinusitis is oen misdiagnosed. Radiology reports commonly do not mention dental pathology. Management of odontogenic sinusitis needs to be tailored to each individual patient and involves varying combinations of medical management, dental surgery, and C 2015 ARS-AAOA, LLC. ESS.
Results: Fiy-five patients were identified retrospectively. Forty-four were diagnosed at initial visit. Twenty-eight (64%) of these patients were diagnosed by computed tomography (CT) scan showing dental pathology, 11 (25%) by known temporal relationship to a dental procedure, and 5 (11%) by presentation with oral-antral fistula. Only 65% of radiology reports for all patients mentioned dental pathology. Overall, 21 (38%) patients had disease resolution. Of these, 7 (33%) resolved with endoscopic sinus surgery (ESS) alone, 7 (33%) resolved with concurrent ESS and dental surgery, 2 (10%) resolved with den-
C
hronic sinusitis affects 29.7 million Americans, resulting in $5.8 billion in health care costs and 73 million days of restricted activity per year.1, 2 Odontogenic sinusitis has historically been identified as a causal factor in 10% to 12% of sinusitis cases, but other studies have suggested that this number may be as high as 41%.3, 4 Odontogenic sinusitis is sinusitis of dental origin. Dental pathology includes infections arising from maxillary
1 Medical
College of Wisconsin, Milwaukee, WI; 2 Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI; 3 Division of Rhinology and Sinus Surgery, Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI Correspondence to: David M. Poetker, MD, Department of Otolaryngology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226; e-mail: [email protected] Potential conflict of interest: None provided. Received: 7 June 2014; Revised: 29 December 2014; Accepted: 9 January 2015 DOI: 10.1002/alr.21504 View this article online at wileyonlinelibrary.com.
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Key Words: odontogenic sinusitis; sinusitis; rhinosinusitis; endoscopic sinus surgery; dental; imaging; diagnosis; management How to Cite this Article: Wang KL, Nichols BG, Poetker DM, Loehrl TA. Odontogenic sinusitis: a case series studying diagnosis and management. Int Forum Allergy Rhinol. 2015;5:597–601.
teeth, maxillary dental trauma, and dental procedures.3 Although it is a recognized subtype of sinusitis, odontogenic sinusitis has proven difficult to clinically differentiate from other forms of sinusitis due to its nonspecific presentation.5 Poor recognition and inadequate treatment may lead to prolonged disease and further complications.6 Despite its prevalence, dental pathology is often missed on imaging, and standard protocols regarding diagnosis and management are lacking in the literature.7 It has been our clinical experience that odontogenic sinusitis is an important and relatively common form of sinusitis that requires accurate diagnosis and a treatment regimen that differs from non-odontogenic sinusitis. By examining the course of disease for each patient, including diagnosis, imaging, treatment and follow-up, we hope to clarify key disease characteristics that will lead to improved physician awareness and management.
Wang et al.
Patients and methods We retrospectively reviewed the medical charts of all patients diagnosed with sinusitis seen in the Department of Otolaryngology at the Medical College of Wisconsin, from November 2007 to July 2013. Diagnosis of sinusitis was based on clinical practice guidelines as published by the American Academy of Otolaryngology–Head and Neck Surgery Foundation.8 Patients with either a diagnosis of odontogenic sinusitis or a history suggesting odontogenic sinusitis were selected for review. Patients with confirmed odontogenic sinusitis by chart review and imaging review were then analyzed for demographic factors, presentation and course of disease, diagnostic criteria, imaging, management, and length of follow-up. Imaging review was performed to determine laterality of disease and dental pathology. Odontogenic sinusitis was only considered bilateral if there was evidence of bilateral dental pathology resulting in bilateral maxillary sinusitis with optional further extension into other sinuses. Lund-Mackay score was then calculated for each patient to determine disease severity.
Results A total of 3031 patients were diagnosed with sinusitis between November 2007 and July 2013. Of these 3031 patients, 133 patients were selected for further review based on their history and imaging reports, which were suggestive of odontogenic sinusitis. Fifty-five patients from this group had objective evidence of dental pathology on computed tomography (CT), independently confirmed by the senior authors (DMP, TAL). These patients were added to the study. Of note, only 36 (65%) of the radiology reports commented on the dental findings. In addition, all patients had evidence of sinus inflammation on nasal endoscopy or CT imaging. Of these 55 patients, 33 (60%) were female and 22 (40%) were male. The average age of these patients was 55 years. Forty-four of the 55 patients were diagnosed with odontogenic sinusitis at the time of the initial visit. This includes 28 patients (64%) who were diagnosed after a CT scan showed dental pathology leading to sinusitis, 11 patients (25%) who were diagnosed after a temporal relationship was established between symptoms and a dental procedure, and 5 patients (11%) who were diagnosed after presentation with oral-antral fistula (OAF) (Table 1, Fig. 1). The remaining 11 of 55 patients were diagnosed retrospectively during this study with the aid of CT imaging. Upon retrospective review of CT imaging, 46 (84%) patients had unilateral odontogenic sinusitis. Nine (16%) patients had bilateral odontogenic sinusitis. Lund-Mackay score for all patients was (mean ± standard deviation [SD]) 4.0 ± 3.2. Forty-five percent of all dental pathology consisted of periapical disease including cysts and abscesses. Twenty-eight percent consisted of OAFs. Fourteen percent consisted of foreign bodies including implants and graft
TABLE 1. How patients were diagnosed in the clinic How diagnoseda
Patients n (%)
Dental pathology visualized on CT imaging
28 (64)
Known prior dental procedure
11 (25)
Oral-antral fistula
5 (11)
a All diagnoses confirmed with CT imaging. CT = computed tomography.
material. The remaining 13 percent had congenital abnormalities including tooth roots within the maxillary sinus. Prior to being established with our department, 40 (73%) patients underwent, and subsequently failed, medical management alone. After establishing care with our department, 21 patients had resolved disease, 10 patients had persistent disease, and 24 patients were lost to follow-up (Table 2). Of the 21 patients that had resolved, 7 (33%) resolved with endoscopic sinus surgery (ESS) alone, 7 (33%) resolved with concurrent ESS and dental surgery, 2 (10%) resolved with dental surgery alone, 2 (10%) resolved with medical management alone, 2 (10%) resolved with ESS after failing dental surgery, and 1 (5%) resolved with medical management after failing dental surgery (Table 2, Fig. 2). Disease was considered resolved when a lack of inflammation or mucosal disease was noted on nasal endoscopy or sinus CT. The follow-up duration for patients who resolved was 4.9 ± 6.2 months (Table 2). Dental procedures performed (with or without concurrent ESS) that led to disease remission include tooth extractions and OAF closures. Of note, 2 patients only had a root canal performed and initially had persistent disease that subsequently became resolved after ESS.
Discussion Odontogenic sinusitis is a well-recognized subtype of sinusitis and may make up to 41% of all cases.4 However, diagnosis may be easily missed and guidelines on sinusitis often do not mention odontogenic sinusitis and rarely outline a diagnostic or management approach.7 Our case series is the largest study to date that provides a retrospective analysis of the presentation and outcomes of patients with odontogenic sinusitis. We studied the clinical courses of 55 patients, including diagnosis, imaging, sequence of management, and follow-up. Twenty percent of these patients were only diagnosed after retrospective review. Actual missed diagnoses in clinical practice may be higher. This highlights the difficulty in differentiating odontogenic sinusitis from other types of sinusitis. There are no symptoms that are clearly unique to odontogenic sinusitis. Although foul odor may arise due to an odontogenic source, Lee and Lee5 and Longhini and Ferguson7 have
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Odontogenic sinusitis: a case series
FIGURE 1. Method of diagnosis of odontogenic sinusitis in our study. All patients had their diagnosis confirmed by CT imaging. CT = computed tomography.
TABLE 2. Sequence and result of management Sequence of management
Resolved n (%)
Persistent n (%)
Length of follow-up of resolved cases in months (mean ± SD)
ESS
7 (33)
4 (40)
3.4 ± 1.7
Concurrent dental surgery and ESS
7 (33)
0 (0)
4.1 ± 4.8
Dental surgery
2 (10)
3 (30)
21.0 ± 4.2
ESS following failure of dental surgery
2 (10)
2 (20)
2.5 ± 0.7
Medical management only
2 (10)
1 (10)
1.1 ± 0.5
Medical management following failure of dental surgery
1 (5)
0 (0)
1.0 ± n/a
ESS = endoscopic sinus surgery; SD = standard deviation.
FIGURE 2. Treatment pathways of patients with odontogenic sinusitis. ESS = endoscopic sinus surgery.
shown this to occur in only 26% and 48% of their patients, respectively. In addition, despite the fact that odontogenic sinusitis must have a dental source, multiple studies have shown that dental pain is not a specific symptom, with Longhini and Ferguson7 and Pokorny and Tataryn9 reporting dental pain symptoms in only 29% and 39% of their patients, respectively. It is theorized that the absence of dental pain is due to a lack of pressure at the site of dental infection
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International Forum of Allergy & Rhinology, Vol. 5, No. 7, July 2015
as the adjacent maxillary sinus allows drainage and relief of pressure.3 Fortunately, dental pathology including periapical disease and OAFs, can be visualized with CT imaging. This makes CT imaging an important diagnostic tool; however, actual mention of dental pathology may not always be noted on radiology reports. In our study, 35% of patients did not have dental pathology mentioned on the official
Wang et al.
radiology report. Thus, otolaryngologists should familiarize themselves with identifying dental pathology on CT imaging. This is especially important as routine dental radiographs are not able to consistently visualize the aforementioned dental pathology. It has been reported that dental radiographs may miss between 55% and 86% of dental pathology that are involved in odontogenic sinusitis.4, 7 However, new imaging techniques may improve upon this. Cone beam CT (CBCT), an alternative to dental radiographs, can more accurately visualize dental pathology. A recent study showed that when compared to CBCT, dental radiographs miss 60% of apical periodontitis as well as 97% of apical infections that extend into the maxillary sinus.10 As improved “frontline” imaging such as CBCT becomes more popular, diagnosis of odontogenic sinusitis may occur earlier in the disease process and missed diagnoses may become less frequent. Gathering a comprehensive dental history is also an invaluable tool in clarifying a diagnosis of odontogenic sinusitis, especially in iatrogenic cases. This is especially important as Lechien et al.’s11 large retrospective review studying the etiology of odontogenic sinusitis reveals 66% of disease has an iatrogenic cause. Although 64% of our patients were diagnosed in clinic after dental findings on CT imaging, a separate 25% of patients had a known dental procedure prior to symptoms. This temporal relationship suggested a diagnosis of odontogenic sinusitis and these patients had their disease confirmed by CT imaging. After retrospective review of the CT imaging of our patients, the majority of dental disease consisted of periapical disease and OAFs. For all our patients, CT imaging showed involvement of the maxillary sinuses. The majority of our patients had unilateral odontogenic sinus disease (84%), which includes extramaxillary extension to further unilateral sinuses. The remainder (16%) of our patients had bilateral disease. For our patients to qualify for bilateral odontogenic sinusitis, bilateral dental pathology and maxillary sinus involvement was required. Saibene et al.’s12 case series studying extramaxillary extension in odontogenic sinusitis had similar results with 81% having unilateral disease and 19% having bilateral disease. However only 32% of their bilateral sinus disease patients had confirmed bilateral dental disease, compared to 100% seen in our study. Prior studies have not attempted to objectively determine disease severity of odontogenic sinusitis patients. Lund-Mackay scoring attempts to radiographically grade sinusitis and the LundMackay score for our patients was 4.0 ± 3.2. Management options for odontogenic sinusitis are similar to that of non-odontogenic sinusitis, with the addition of dental surgery complementing medical management and ESS. Specific management protocols for odontogenic sinusitis have not yet been established. Multiple studies have shown excellent results with ESS and dental surgery, although the ideal sequence of management is not clear. Longhini and Ferguson7 performed a case series of 21 patients with odontogenic sinusitis. Nineteen of these patients resolved with only dental surgery. Six patients in their study
who only underwent ESS failed to resolve their disease until dental surgery was performed. Lee and Lee5 performed a similar case series involving 27 patients. Nineteen patients in their study underwent ESS with subsequent dental surgery and all resolved their disease. Both study authors recommend that dental surgery be a core component of management, although the proposed sequence differs between studies. It is also suggested that dental surgery alone may be successful in treating odontogenic sinusitis. The patients in our study have had a much more variable response to treatment. Unlike the previously mentioned studies, our study contains patients who have failed dental surgery, including 3 who failed dental surgery alone and 2 who failed both dental surgery and subsequent ESS.5, 7, 12 Of our patients with successfully resolved disease, 33% underwent sinus surgery alone and an additional 33% resolved after concurrent sinus surgery and dental surgery. These results differ from previous studies that have emphasized dental surgery as the primary treatment for odontogenic sinusitis. Although we agree that it is important to target the dental source of infection, it appears that ESS alone without dental surgery may be effective in treating odontogenic sinusitis. This may be explained by the fact that both dental disease and sinusitis have varying grades of severity. Patients that resolved without dental surgery may have had a lower grade of sinusitis. In these cases, it is possible that ESS alone was able to create enough exposure to allow postoperative antibiotics and supportive care to resolve or sufficiently suppress the disease. It should be noted that 10% resolved with medical management alone; these cases likely represent very mild disease. In addition, the heterogeneous response to treatment reveals a few important points: (1) not all patients respond equally to treatment; (2) despite this variable response, it is important to involve an oral surgeon in management decisions; and (3) a combination of underdiagnosis and unique treatment regimen likely leads odontogenic sinusitis to make up a significant portion of recalcitrant cases of sinusitis. Our proposed regimen when considering a diagnosis of odontogenic sinusitis is to first perform a thorough dental history and oral physical exam. Patients with dental symptoms, a temporal relationship between sinusitis symptoms and dental procedures, or patients with teeth in poor repair should clue the otolaryngologist of a possible odontogenic source. Second is to ensure that the CT scan visualizes the maxillary teeth and that the otolaryngologist is prepared to identify dental pathology. CT imaging that reveals maxillary sinusitis should always be further inspected for a dental source. Third is to involve an oral surgeon if there is suspicion of odontogenic sinusitis and to evaluate whether the patient would be a candidate for dental surgery. This is especially important when encountering OAFs because we work closely with our oral surgery colleagues to diagnose and correct this pathology. Medical management should always be attempted first with subsequent reevaluation. We suggest dental surgery as first-line surgical treatment
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Odontogenic sinusitis: a case series
for odontogenic sinusitis. Although a significant portion of our patients did resolve with ESS alone, we believe that it is logical and important to first target the source of infection. If the patient fails to resolve or improve sufficiently after dental surgery, we then suggest performing ESS as the next step treatment. It is important to keep in mind that creating treatment algorithms are difficult especially without the ability to control for treatment selection. Our proposed regimen is based on not only our data but also clinical experience. Our study population has several important limitations. Recruitment of patients was limited to patients referred to tertiary academic center. This population tends to have more patients with refractory disease. In addition, a large number of patients were lost to follow-up. These patients may have had very different disease course than those who completed their follow-up. Both nasal endoscopy and CT imaging was used to follow disease progression. Nasal endoscopy is not as sensitive for identifying disease and this may have led to a false increase in resolved cases. Finally,
due to the nature of retrospective review, we were unable to consistently gather data regarding specific symptoms and exact details regarding antibiotic regimens, and type of sinus and dental surgeries performed.
Conclusion Odontogenic sinusitis should be considered when evaluating patients with sinusitis. It is easily overlooked, and dental pathology may not be noted on radiology reports. Due to its unique management regimen, inadequately treated odontogenic sinusitis may make up a significant portion of recalcitrant cases that do not respond to conventional treatment. It is important that otolaryngologists familiarize themselves with identifying dental pathology on CT imaging and be ready to confer with our oral surgery colleagues in the event that a patient may benefit from a multifaceted approach to treatment. Best management practices are not clear cut and likely needs to be tailored to each individual patient.
References 1.
2.
3. 4.
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Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat 10. 2012;(252):1–207. Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol Suppl. 2004;193:3–5. Brook I. Sinusitis of odontogenic origin. Otolaryngol Head Neck Surg. 2006;135:349–355. Melen I, Lindahl L, Andreasson L, Rundcrantz H. Chronic maxillary sinusitis. Definition, diagnosis and relation to dental infections and nasal polyposis. Acta Otolaryngol. 1986;101:320–327.
5.
6.
7.
8.
Lee KC, Lee SJ. Clinical features and treatments of odontogenic sinusitis. Yonsei Med J. 2010;51:932– 937. Patel NA, Ferguson BJ. Odontogenic sinusitis: an ancient but under-appreciated cause of maxillary sinusitis. Curr Opin Otolaryngol Head Neck Surg. 2012;20:24–28. Longhini AB, Ferguson BJ. Clinical aspects of odontogenic maxillary sinusitis: a case series. Int Forum Allergy Rhinol. 2011;1:409–415. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(3 Suppl):S1–S31.
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9.
Pokorny A, Tataryn R. Clinical and radiologic findings in a case series of maxillary sinusitis of dental origin. Int Forum Allergy Rhinol. 2013;3:973–979. 10. Shahbazian M, Vandewoude C, Wyatt J, Jacobs R. Comparative assessment of periapical radiography and CBCT imaging for radiodiagnostics in the posterior maxilla. Odontology. 2015;103:97–104. 11. Lechien JR, Filleul O, Costa de Araujo P, Hsieh JW, Chantrain G, Saussez S. Chronic maxillary rhinosinusitis of dental origin: a systematic review of 674 patient cases. Int J Otolaryngol. 2014;2014:465173. 12. Saibene AM, Pipolo GC, Lozza P, et al. Redefining boundaries in odontogenic sinusitis: a retrospective evaluation of extramaxillary involvement in 315 patients. Int Forum Allergy Rhinol. 2014;4:1020–1023.
Odontogenic sinusitis: a case series studying diagnosis and management Kevin L. Wang, MD1 , Brent G. Nichols, MD2 , David M. Poetker, MD, MA3 and Todd A. Loehrl, MD3
Background: Odontogenic sinusitis is a well-recognized, but understudied form of sinusitis. Odontogenic sinusitis requires unique diagnostic criteria and a treatment regimen that differs from non-odontogenic sinusitis. The purpose of this article is to present a case series of patients with odontogenic sinusitis in order to clarify key disease characteristics and management techniques.
tal surgery alone, 2 (10%) resolved with ESS aer failing dental surgery, 2 (10%) resolved with medical management alone, and 1 (5%) resolved with medical management after failing dental surgery. Forty-six (84%) patients had unilateral odontogenic sinusitis. The Lund-Mackay score for all patients was (mean ± standard deviation [SD]) 4.0 ± 3.2.
Methods: Retrospective case series of 55 patients with odontogenic sinusitis. Each patient underwent chart and imaging review to analyze demographic factors, diagnostic criteria, clinical course, and management.
Conclusion: Odontogenic sinusitis is oen misdiagnosed. Radiology reports commonly do not mention dental pathology. Management of odontogenic sinusitis needs to be tailored to each individual patient and involves varying combinations of medical management, dental surgery, and C 2015 ARS-AAOA, LLC. ESS.
Results: Fiy-five patients were identified retrospectively. Forty-four were diagnosed at initial visit. Twenty-eight (64%) of these patients were diagnosed by computed tomography (CT) scan showing dental pathology, 11 (25%) by known temporal relationship to a dental procedure, and 5 (11%) by presentation with oral-antral fistula. Only 65% of radiology reports for all patients mentioned dental pathology. Overall, 21 (38%) patients had disease resolution. Of these, 7 (33%) resolved with endoscopic sinus surgery (ESS) alone, 7 (33%) resolved with concurrent ESS and dental surgery, 2 (10%) resolved with den-
C
hronic sinusitis affects 29.7 million Americans, resulting in $5.8 billion in health care costs and 73 million days of restricted activity per year.1, 2 Odontogenic sinusitis has historically been identified as a causal factor in 10% to 12% of sinusitis cases, but other studies have suggested that this number may be as high as 41%.3, 4 Odontogenic sinusitis is sinusitis of dental origin. Dental pathology includes infections arising from maxillary
1 Medical
College of Wisconsin, Milwaukee, WI; 2 Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI; 3 Division of Rhinology and Sinus Surgery, Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI Correspondence to: David M. Poetker, MD, Department of Otolaryngology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226; e-mail: [email protected] Potential conflict of interest: None provided. Received: 7 June 2014; Revised: 29 December 2014; Accepted: 9 January 2015 DOI: 10.1002/alr.21504 View this article online at wileyonlinelibrary.com.
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International Forum of Allergy & Rhinology, Vol. 5, No. 7, July 2015
Key Words: odontogenic sinusitis; sinusitis; rhinosinusitis; endoscopic sinus surgery; dental; imaging; diagnosis; management How to Cite this Article: Wang KL, Nichols BG, Poetker DM, Loehrl TA. Odontogenic sinusitis: a case series studying diagnosis and management. Int Forum Allergy Rhinol. 2015;5:597–601.
teeth, maxillary dental trauma, and dental procedures.3 Although it is a recognized subtype of sinusitis, odontogenic sinusitis has proven difficult to clinically differentiate from other forms of sinusitis due to its nonspecific presentation.5 Poor recognition and inadequate treatment may lead to prolonged disease and further complications.6 Despite its prevalence, dental pathology is often missed on imaging, and standard protocols regarding diagnosis and management are lacking in the literature.7 It has been our clinical experience that odontogenic sinusitis is an important and relatively common form of sinusitis that requires accurate diagnosis and a treatment regimen that differs from non-odontogenic sinusitis. By examining the course of disease for each patient, including diagnosis, imaging, treatment and follow-up, we hope to clarify key disease characteristics that will lead to improved physician awareness and management.
Wang et al.
Patients and methods We retrospectively reviewed the medical charts of all patients diagnosed with sinusitis seen in the Department of Otolaryngology at the Medical College of Wisconsin, from November 2007 to July 2013. Diagnosis of sinusitis was based on clinical practice guidelines as published by the American Academy of Otolaryngology–Head and Neck Surgery Foundation.8 Patients with either a diagnosis of odontogenic sinusitis or a history suggesting odontogenic sinusitis were selected for review. Patients with confirmed odontogenic sinusitis by chart review and imaging review were then analyzed for demographic factors, presentation and course of disease, diagnostic criteria, imaging, management, and length of follow-up. Imaging review was performed to determine laterality of disease and dental pathology. Odontogenic sinusitis was only considered bilateral if there was evidence of bilateral dental pathology resulting in bilateral maxillary sinusitis with optional further extension into other sinuses. Lund-Mackay score was then calculated for each patient to determine disease severity.
Results A total of 3031 patients were diagnosed with sinusitis between November 2007 and July 2013. Of these 3031 patients, 133 patients were selected for further review based on their history and imaging reports, which were suggestive of odontogenic sinusitis. Fifty-five patients from this group had objective evidence of dental pathology on computed tomography (CT), independently confirmed by the senior authors (DMP, TAL). These patients were added to the study. Of note, only 36 (65%) of the radiology reports commented on the dental findings. In addition, all patients had evidence of sinus inflammation on nasal endoscopy or CT imaging. Of these 55 patients, 33 (60%) were female and 22 (40%) were male. The average age of these patients was 55 years. Forty-four of the 55 patients were diagnosed with odontogenic sinusitis at the time of the initial visit. This includes 28 patients (64%) who were diagnosed after a CT scan showed dental pathology leading to sinusitis, 11 patients (25%) who were diagnosed after a temporal relationship was established between symptoms and a dental procedure, and 5 patients (11%) who were diagnosed after presentation with oral-antral fistula (OAF) (Table 1, Fig. 1). The remaining 11 of 55 patients were diagnosed retrospectively during this study with the aid of CT imaging. Upon retrospective review of CT imaging, 46 (84%) patients had unilateral odontogenic sinusitis. Nine (16%) patients had bilateral odontogenic sinusitis. Lund-Mackay score for all patients was (mean ± standard deviation [SD]) 4.0 ± 3.2. Forty-five percent of all dental pathology consisted of periapical disease including cysts and abscesses. Twenty-eight percent consisted of OAFs. Fourteen percent consisted of foreign bodies including implants and graft
TABLE 1. How patients were diagnosed in the clinic How diagnoseda
Patients n (%)
Dental pathology visualized on CT imaging
28 (64)
Known prior dental procedure
11 (25)
Oral-antral fistula
5 (11)
a All diagnoses confirmed with CT imaging. CT = computed tomography.
material. The remaining 13 percent had congenital abnormalities including tooth roots within the maxillary sinus. Prior to being established with our department, 40 (73%) patients underwent, and subsequently failed, medical management alone. After establishing care with our department, 21 patients had resolved disease, 10 patients had persistent disease, and 24 patients were lost to follow-up (Table 2). Of the 21 patients that had resolved, 7 (33%) resolved with endoscopic sinus surgery (ESS) alone, 7 (33%) resolved with concurrent ESS and dental surgery, 2 (10%) resolved with dental surgery alone, 2 (10%) resolved with medical management alone, 2 (10%) resolved with ESS after failing dental surgery, and 1 (5%) resolved with medical management after failing dental surgery (Table 2, Fig. 2). Disease was considered resolved when a lack of inflammation or mucosal disease was noted on nasal endoscopy or sinus CT. The follow-up duration for patients who resolved was 4.9 ± 6.2 months (Table 2). Dental procedures performed (with or without concurrent ESS) that led to disease remission include tooth extractions and OAF closures. Of note, 2 patients only had a root canal performed and initially had persistent disease that subsequently became resolved after ESS.
Discussion Odontogenic sinusitis is a well-recognized subtype of sinusitis and may make up to 41% of all cases.4 However, diagnosis may be easily missed and guidelines on sinusitis often do not mention odontogenic sinusitis and rarely outline a diagnostic or management approach.7 Our case series is the largest study to date that provides a retrospective analysis of the presentation and outcomes of patients with odontogenic sinusitis. We studied the clinical courses of 55 patients, including diagnosis, imaging, sequence of management, and follow-up. Twenty percent of these patients were only diagnosed after retrospective review. Actual missed diagnoses in clinical practice may be higher. This highlights the difficulty in differentiating odontogenic sinusitis from other types of sinusitis. There are no symptoms that are clearly unique to odontogenic sinusitis. Although foul odor may arise due to an odontogenic source, Lee and Lee5 and Longhini and Ferguson7 have
International Forum of Allergy & Rhinology, Vol. 5, No. 7, July 2015
598
Odontogenic sinusitis: a case series
FIGURE 1. Method of diagnosis of odontogenic sinusitis in our study. All patients had their diagnosis confirmed by CT imaging. CT = computed tomography.
TABLE 2. Sequence and result of management Sequence of management
Resolved n (%)
Persistent n (%)
Length of follow-up of resolved cases in months (mean ± SD)
ESS
7 (33)
4 (40)
3.4 ± 1.7
Concurrent dental surgery and ESS
7 (33)
0 (0)
4.1 ± 4.8
Dental surgery
2 (10)
3 (30)
21.0 ± 4.2
ESS following failure of dental surgery
2 (10)
2 (20)
2.5 ± 0.7
Medical management only
2 (10)
1 (10)
1.1 ± 0.5
Medical management following failure of dental surgery
1 (5)
0 (0)
1.0 ± n/a
ESS = endoscopic sinus surgery; SD = standard deviation.
FIGURE 2. Treatment pathways of patients with odontogenic sinusitis. ESS = endoscopic sinus surgery.
shown this to occur in only 26% and 48% of their patients, respectively. In addition, despite the fact that odontogenic sinusitis must have a dental source, multiple studies have shown that dental pain is not a specific symptom, with Longhini and Ferguson7 and Pokorny and Tataryn9 reporting dental pain symptoms in only 29% and 39% of their patients, respectively. It is theorized that the absence of dental pain is due to a lack of pressure at the site of dental infection
599
International Forum of Allergy & Rhinology, Vol. 5, No. 7, July 2015
as the adjacent maxillary sinus allows drainage and relief of pressure.3 Fortunately, dental pathology including periapical disease and OAFs, can be visualized with CT imaging. This makes CT imaging an important diagnostic tool; however, actual mention of dental pathology may not always be noted on radiology reports. In our study, 35% of patients did not have dental pathology mentioned on the official
Wang et al.
radiology report. Thus, otolaryngologists should familiarize themselves with identifying dental pathology on CT imaging. This is especially important as routine dental radiographs are not able to consistently visualize the aforementioned dental pathology. It has been reported that dental radiographs may miss between 55% and 86% of dental pathology that are involved in odontogenic sinusitis.4, 7 However, new imaging techniques may improve upon this. Cone beam CT (CBCT), an alternative to dental radiographs, can more accurately visualize dental pathology. A recent study showed that when compared to CBCT, dental radiographs miss 60% of apical periodontitis as well as 97% of apical infections that extend into the maxillary sinus.10 As improved “frontline” imaging such as CBCT becomes more popular, diagnosis of odontogenic sinusitis may occur earlier in the disease process and missed diagnoses may become less frequent. Gathering a comprehensive dental history is also an invaluable tool in clarifying a diagnosis of odontogenic sinusitis, especially in iatrogenic cases. This is especially important as Lechien et al.’s11 large retrospective review studying the etiology of odontogenic sinusitis reveals 66% of disease has an iatrogenic cause. Although 64% of our patients were diagnosed in clinic after dental findings on CT imaging, a separate 25% of patients had a known dental procedure prior to symptoms. This temporal relationship suggested a diagnosis of odontogenic sinusitis and these patients had their disease confirmed by CT imaging. After retrospective review of the CT imaging of our patients, the majority of dental disease consisted of periapical disease and OAFs. For all our patients, CT imaging showed involvement of the maxillary sinuses. The majority of our patients had unilateral odontogenic sinus disease (84%), which includes extramaxillary extension to further unilateral sinuses. The remainder (16%) of our patients had bilateral disease. For our patients to qualify for bilateral odontogenic sinusitis, bilateral dental pathology and maxillary sinus involvement was required. Saibene et al.’s12 case series studying extramaxillary extension in odontogenic sinusitis had similar results with 81% having unilateral disease and 19% having bilateral disease. However only 32% of their bilateral sinus disease patients had confirmed bilateral dental disease, compared to 100% seen in our study. Prior studies have not attempted to objectively determine disease severity of odontogenic sinusitis patients. Lund-Mackay scoring attempts to radiographically grade sinusitis and the LundMackay score for our patients was 4.0 ± 3.2. Management options for odontogenic sinusitis are similar to that of non-odontogenic sinusitis, with the addition of dental surgery complementing medical management and ESS. Specific management protocols for odontogenic sinusitis have not yet been established. Multiple studies have shown excellent results with ESS and dental surgery, although the ideal sequence of management is not clear. Longhini and Ferguson7 performed a case series of 21 patients with odontogenic sinusitis. Nineteen of these patients resolved with only dental surgery. Six patients in their study
who only underwent ESS failed to resolve their disease until dental surgery was performed. Lee and Lee5 performed a similar case series involving 27 patients. Nineteen patients in their study underwent ESS with subsequent dental surgery and all resolved their disease. Both study authors recommend that dental surgery be a core component of management, although the proposed sequence differs between studies. It is also suggested that dental surgery alone may be successful in treating odontogenic sinusitis. The patients in our study have had a much more variable response to treatment. Unlike the previously mentioned studies, our study contains patients who have failed dental surgery, including 3 who failed dental surgery alone and 2 who failed both dental surgery and subsequent ESS.5, 7, 12 Of our patients with successfully resolved disease, 33% underwent sinus surgery alone and an additional 33% resolved after concurrent sinus surgery and dental surgery. These results differ from previous studies that have emphasized dental surgery as the primary treatment for odontogenic sinusitis. Although we agree that it is important to target the dental source of infection, it appears that ESS alone without dental surgery may be effective in treating odontogenic sinusitis. This may be explained by the fact that both dental disease and sinusitis have varying grades of severity. Patients that resolved without dental surgery may have had a lower grade of sinusitis. In these cases, it is possible that ESS alone was able to create enough exposure to allow postoperative antibiotics and supportive care to resolve or sufficiently suppress the disease. It should be noted that 10% resolved with medical management alone; these cases likely represent very mild disease. In addition, the heterogeneous response to treatment reveals a few important points: (1) not all patients respond equally to treatment; (2) despite this variable response, it is important to involve an oral surgeon in management decisions; and (3) a combination of underdiagnosis and unique treatment regimen likely leads odontogenic sinusitis to make up a significant portion of recalcitrant cases of sinusitis. Our proposed regimen when considering a diagnosis of odontogenic sinusitis is to first perform a thorough dental history and oral physical exam. Patients with dental symptoms, a temporal relationship between sinusitis symptoms and dental procedures, or patients with teeth in poor repair should clue the otolaryngologist of a possible odontogenic source. Second is to ensure that the CT scan visualizes the maxillary teeth and that the otolaryngologist is prepared to identify dental pathology. CT imaging that reveals maxillary sinusitis should always be further inspected for a dental source. Third is to involve an oral surgeon if there is suspicion of odontogenic sinusitis and to evaluate whether the patient would be a candidate for dental surgery. This is especially important when encountering OAFs because we work closely with our oral surgery colleagues to diagnose and correct this pathology. Medical management should always be attempted first with subsequent reevaluation. We suggest dental surgery as first-line surgical treatment
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for odontogenic sinusitis. Although a significant portion of our patients did resolve with ESS alone, we believe that it is logical and important to first target the source of infection. If the patient fails to resolve or improve sufficiently after dental surgery, we then suggest performing ESS as the next step treatment. It is important to keep in mind that creating treatment algorithms are difficult especially without the ability to control for treatment selection. Our proposed regimen is based on not only our data but also clinical experience. Our study population has several important limitations. Recruitment of patients was limited to patients referred to tertiary academic center. This population tends to have more patients with refractory disease. In addition, a large number of patients were lost to follow-up. These patients may have had very different disease course than those who completed their follow-up. Both nasal endoscopy and CT imaging was used to follow disease progression. Nasal endoscopy is not as sensitive for identifying disease and this may have led to a false increase in resolved cases. Finally,
due to the nature of retrospective review, we were unable to consistently gather data regarding specific symptoms and exact details regarding antibiotic regimens, and type of sinus and dental surgeries performed.
Conclusion Odontogenic sinusitis should be considered when evaluating patients with sinusitis. It is easily overlooked, and dental pathology may not be noted on radiology reports. Due to its unique management regimen, inadequately treated odontogenic sinusitis may make up a significant portion of recalcitrant cases that do not respond to conventional treatment. It is important that otolaryngologists familiarize themselves with identifying dental pathology on CT imaging and be ready to confer with our oral surgery colleagues in the event that a patient may benefit from a multifaceted approach to treatment. Best management practices are not clear cut and likely needs to be tailored to each individual patient.
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