Management of Antral Disease

Question 1

What is the pathology of acute sinusitis and what is it often misdiagnosed as?

Answer 1

• Common condition that often presents with pain suggesting a dental cause
• Almost all acute Sinusitis is due to viral infection in the nasal passages and sinuses
• Inflammation inhibits mucociliary clearance, and oedema restricts sinus drainage by narrowing the ostium, raising the internal pressure

Question 2

What are the clinical features of acute sinusitis?

Answer 2

• Onset almost always follows a respiratory viral illness
• Infection of the lining mucosa is by the same virus that caused the original infection and usually resolves with the main infection in 7-10 days
• Symptoms lasting longer probably indicate bacterial infection
• There is sudden onset of pain from the sinus, often poorly localised with tenderness of the overlying skin
• Teeth with roos in or close to antrum are painful on pressure
• there is also nasal congestion, Weakened sense of smell, and sometimes referred pain to the ear
• Fluid will often discharge into the nose on tilting the head of lying down and movement of the head worsens pain. Involvement of ethmoid or sphenoid sinuses ois often perceived by pts as headaches

Question 3

How is acute Sinusitis diagnosed?

Answer 3

• Usually history and examination
• Radiography of sinuses provides little additional information in acute sinusitis
• If rx are required - CT to detect polyps after repeated attacks and not for diagnosis

Question 4

What is the management of acute sinusitis?

Answer 4

• Self-limiting
• No active treatment may be required, but nasal decongestants aid drainage, speed recovery and provide symptomatic relief
• Many pts manage well with non-prescription steam inhalations
• More severe cases benefit from ephedrine or oxymetazoline nose drops, but these should not be continued for more than 7 days
• Even when bacterial is present, antibiotic tx is not indicated
• Even though most cases resolve, sinusitis can become recurrent or chronic

Question 5

What are the clinical features of chronic sinusitis?

Answer 5

• Those of the acute disease but milder and without generalised symptoms of upper respiratory tract viral infection
• Rarely causes symptoms of pain except during acute exacerbations
• When pain is poorly localised, rx examination of the sinuses may reveal mucosal thickening, mucosal polyps or a fluid level. Ideally CT, but the antrum well visualised on DPT
• Bacterial rather than viral
• Chronic sinusitis in some pts produces nasal polyps, oedematous thickenings and pedunculated polyps (polyp with stalk) of the mucosa. These can fill the lumen, block drainage and cause persistence of sinusitis

Question 6

What is the management of chronic sinusitis?

Answer 6

• When no dental disease is present, the bacteria are initially those found in acute sinusitis, but the flora gradually shifts to an anaerobic population after 3 months
• Patients with chronic sinusitis without a dental cause must be referred to a specialist. Polyps, allergic and fungal causes must be excluded by endoscopy
• AB tx alone usually fails and a combined approach with improving drainage, saline irrigation, reducing inflammation with topical steroids and tackling infection is required

Question 7

What is the aetiology and clinical features of odontogenic sinusitis? What is the treatment?

Answer 7

• Potential dental causes are relatively frequent in chronic sinusitis but may not necessarily be the primary cause
• Odontogenic sinusitis is usually unilateral
• Commonest dental causes: (Carry out vitality testing, clinical exam and rads to find cause)
  PA periodontitis from non-vital molar
  Extraction
  RCT
  Severe periodontal disease
  Excessive sinus lift graft material placed for implants
• When dental infection is a factor, additional anaerobic oral bacteria are found. AB tx is only effective in conjunction with removal of cause
• Appropriate regimens are amoxicillin with clavulanic acid or a penicillin with metronidazole or are guided by culture and sensitivity

Question 8

What is the aetiology of fungal sinusitis? What is the diagnosis and treatment?

Answer 8

• Results from inhalation and germination of air-borne fungal spores that are not cleared by mucociliary transport, usually due to existing sinus infection
• The causative fungi originate in soil and their spores are widespread in the environment
• The commonest type is a ‘fungus ball’ or mycetoma, or tangled mass of fungal hyphae bound together with mucus and inflammatory exudate. The ball may grow to fill the sinus
• Radiographic diagnosis: presence of spotty mineralisation in the fungus ball
• Treated by the surgical removal of the fungus followed by irrigation and sometimes topical or systemic anti fungal tx

Question 9

Aetiology and clinical features of allergic fungal sinusitis? What can the radiographic signs mimic and what is the tx?

Answer 9

• Some pts mount a florid type 1 hypersensitivity reaction to fungus in the sinuses
• Serum IgE usually raised
• Inflammatory reaction produces thick putty-like masses of dense mucin containing numerous eosinophils and a few fungal hyphae
• Mucosal polyps are usually present
• Produce worrying signs radiographically (chronic inflammation may cause resorption of the sinus wall, mimicking a malignant neoplasm)
• Requires surgical removal of thick ‘allergic mucin’, sometimes with anti fungal drugs too

Question 10

Who is at risk of invasive fungal sinusitis? What is the treatment?

Answer 10

• In the immunocompromised, the fungi may invade the sinus wall, cause rapid extensive destruction and often a fatal outcome
• Require aggressive surgical and anti fungal tx

Question 11

What can antral musical thickenings (AMT) indicate?

Answer 11

• Can occur in asymptomatic people

- Not always signify sinusitis

Question 12

What are the radiographic features of maxillary pseudocysts (MSC), how are they formed and what is the treatment?

Answer 12

• Common finding on DPT
• Dome shaped radiopacity floor of antrum
• Not lined by epithelium (not a real cyst)
• Formed by the accumulation of serum beneath the periosteum, lifting it off the bone and the sinus floor to form ‘cystic shape’
• Asymptomatic, harmless and require no tx

Question 13

Where do mucus retention cysts arise from and what is the treatment?

Answer 13

• Common coincidental finding floor of antrum
• Arise from inflammation of the sinus lining e.g. secretory duct becomes obstructed
• No tx required

Question 14

What are mucoceles and what is the tx?

Answer 14

• True cyst, lined by epithelium and contained mutinous secretions accumulated within a blocked or obstructed sinus cavity
• Rarely present maxillary sinus, more common in frontal sinus
• Difficult to distinguish from malignant lesion
• Endoscopic removal

Question 15

How many cases of inflammatory maxillary sinus disease are of dental origin? What are the aetiological factors?

Answer 15

• 10-12%
• Pathology: pulpal necrosis, periodical disease, advanced periodontal disease, radicular/dentigerous cysts
• Iatrofgenic: OAC, implants, extruded root filling materials, sodium hypochlorite solution

Question 16

What are signs and symptoms of zygomaticomaxillary fracture? What are the types of fracture that can occur?

Answer 16

Zygomatic complex fracture of:

• Zygomatic arch
• Inferior orbital rim
• Zygomaticomaxillary buttress
• Lateral orbital rim or orbital floor

Signs

• Infraorbital haematoma
• Conjunctival haemorrhage
• Step defect
• Trismus

Symptoms

• Double vision
• Malocclusion
• Numb cheek

Question 17

What can damage to the floor of the antrum during dental extractions cause?

Answer 17

• If antrum is opened, a displaced root or bacteria from the mouth can introduce infection
• There is also damage to the ciliated lining and loss of normal mucociliary transport
• If sinusitis becomes established and the fistula has not been closed, the walls of the passage may become epithelialised, polyps develop in the sinus mucosa and the opening becomes a permanent fistula

Question 18

What are signs that a tooth or root has been displaced into the antrum?

Answer 18

• Tooth suddenly disappears during extraction
• Blowing nose may force air into the mouth or cause frothing from the socket
• Pt may notice air entering the mouth during swallowing, or fluid from the mouth escapes into the nose
• Bleeding from the nose on the affected side, occasionally
• Later, a salty taste or unpleasant discharge
• Facial pain if acute sinusitis develops
• Rarely, astral lining or polyps may prolapse into mouth

Question 19

What is the management of a displaced tooth in the antrum?

Answer 19

1. Explain to pt how the accident has happened and give necessary reassurance
2. Do not try to retrieve lost root immediately by digging through the socket opening and damaging the linking and astral floor further
3. If a root or tooth has been displaced into the antrum, should be removed by elective surgery
   - Position of the root should be confirmed (may be within alveolar process or between the mucosal lining and bony floor)
   - If fragment not visible by PA or occlusal - CBCT provides best localisation (plain films taken with head in two different positions will reveal whether the tooth is mobile)
   - After acute sinusitis has been treated, these surgical approach depends on position of tooth and whether there is a wide oroantral opening. The classical method is to reflect a mucopeiosteal flap in the labiobuccal sulcus, open the antrum in the canine fossa (caldwell-luc approach) and find root with direct vision or endoscopy which can then be removed on a sucker nozzle
   - If the top causes minimal antral reaction or lies between bone floor and mucosal lining, removal may not be essential but there is risk of infection later

Question 20

What is the usual test for oroantral communication?

Answer 20

• Ask pt to blow gently against pinched nostrils. Air (detectable with cotton wool), blood, pus or mucus will then be expelled from opening into the mouth
• Unprepared communications undergo epithelialisation to form a fistula, which is
  thereby prevented from healing spontaneously (usually a large fistula give adequate drainage but a pinhole fistula is often associated with recurrent acute sinusitis
• If pt is not seen until later, typically chronic antral infection, persistent discharge and proliferation of granulation tissue or sinus polyps

Question 21

What are the principles of managing displaced root/tooth in the antrum

Answer 21

The communication (non-epithelialisd)

• If small or only suspected, treat conservatively by socket pack and suturing
• Or, reflect a mucoperiosteal flap and suture it to give air-tight seal over opening
• Definite or large communication should be closed immediately surgically

Post op

• Give penicillin for 5 days and 10 day course of decongestant and inhalations
• Warn pt against blowing nose

Established fisula (epithelialised communication) with infections

• Control chronic sinusitis by removal of polyps, usually via Caldwell-Luc approach, or through opening if large enough
• Excise entire epithelialised fistula
• Close opening by reflecting mucoperiosteal flap

Question 22

What are the signs and symptoms of Carcinoma of the antrum

Answer 22

• Oral and dental symptoms result from involvement of its floor. This may cause pain in the teeth or under a denture, as the disease advances, teeth may become loose and swelling becomes obvious
• Any dental radiograph from person over 40 showing opaque maxillary antrum or erosion of the antral wall without obvious dental or nasal disease indicates a need for further investigation