xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

the maxillary alveolar ridge resulting in the maxillary tooth roots to be in close proximity or even penetrate through the floor of the maxillary sinus. This anatomic proximity of the tooth root apices to the maxillary sinus likely underlies the development of ORS in patients with maxillary den tal pathology, such as tooth extraction and other dento alveolar lesions including dentigerous cysts, dental caries, and radicular cysts. 388 Patients with ORS can present with dental symptoms such as dental pain and hypersensitivity or sinonasal symptoms including facial pain and pressure, congestion, nasal obstruction, purulent rhinorrhea, loss of smell, and post nasal drip. A common misperception, 29% of patients do not present with tenderness/pain to palpation over the affected sinus. 389 Nasal endoscopy most commonly demonstrates purulence in the middle meatus. 390 Imag ing can be helpful in further delineating symptomology. ORS is particularly likely when there is severe maxillary sinus opacification (50-75%). 390,391 It is not uncommon to have ORS extend beyond the maxillary sinus (up to 88% involvement of the anterior ethmoid and 36% of the frontal sinus), 390 although bilateral disease is less likely (16-19%). 392 Additional findings on CT imaging indicative of ORS most commonly include periapical lucencies, 390 as well as thinning of the maxillary sinus floor and presence of foreign bodies. 392 However, Turfe et al. demonstrated that these CT findings are missed in up to 66% of radiol ogy reports. 390 Furthermore, if only plain films are relied upon, ORS findings can be missed 55% to 86% of the time (Table VII-8). Historically, the overall prevalence of ORS has been quoted to be 10% to 15%. 393 However, this percentage may be much higher. In a recent series examining 134 patients with unilateral sinus disease, Turfe et al. demonstrated that 45% of unilateral sinus disease was odontogenic in origin; the remainder was either non-odontogenic inflammatory (35%), or neoplastic (19%). 390 The most common cause of ORS is iatrogenic. 391,394 Bomeli et al. evaluated the fre quency of acute maxillary RS and found oro-antral fistu las to be the only independent predictor of RS. 336 Other etiologies assessed included periodontal disease, project ing tooth roots, and apical abscess were not independent predictors, but there were interaction effects. However, the presence of periodontal disease along with either a pro jecting tooth root or an abscess was predictive of ORS using regression analysis. It has been hypothesized that endosseous implant placement that projects into the max illary sinus may also be a nidus for infection resulting in acute maxillary sinusitis, 395,396 while some authors refute this concept. 397 In addition, a recent 20-year retrospec tive study suggests that implants with less than 3 mm sinus penetration are not associated with clinical or radi ological signs of RS. 398 A recent review on ORS demon

strated that about 80% of teeth with periapical osteitis have mucosal thickening of the maxillary sinus, com menting on the association between the 2 entities. 399 The authors postulate that bacteria from the diseased den tal roots spread through of the bone to the maxillary sinus. 399 The microbiology of ORS is unique in that anaerobic microorganisms are more commonly prevalent. 400 Data reliably demonstrate that the polymicrobial nature of ORS (ie, Peptostreptococcus, Prevotella, Staphylococcus, Strep tococcus, and Actinomyces spp.) overlaps in microbiolog ical findings with intraoral/periapical flora 400 and that a lack of these typical bacteria is highly predictive of a non odontogenic source. 401 The current literature demonstrates an absence of a well-designed and published investigation into the role of odontogenic infections in ARS. Currently, our understand ing of odontogenic ARS is based on low level evidence.

Odontogenic Infections as a Contributing Factor for ARS Aggregate Grade of Evidence: C (Level 2: 1 study; level 4: 7 studies; Table VII-8).

VII.D Management of ARS VII.D.1 ARS Management: Antibiotics While antibiotics have traditionally been prescribed for ARS, routine use has recently been questioned given the high spontaneous resolution rate and unknown cost benefit ratio. 137,403 Six systematic reviews of RCTs show small benefit of antibiotics compared to placebo for ARS with cure rates at 7-15 days in 91% and 86%, respectively. 318,403–407 Number needed to treat ranged from 10 to 19, greater when diagnosed on clinical grounds alone. A higher proportion with CT evidence of fluid lev els and complete sinus opacification demonstrated faster cure. Burgstaller et al. 404 analyzed RCTs of patients with ≥ 7 days of symptoms managed with either antibiotic or placebo. Treated patients had increased rates of improve ment at days 3 and 7, but there was no significant difference after day 10. In addition, a recent Cochrane review from Lemiengre et al. 318 did not find that antibiotics reduced either time to pain relief or general feeling of illness, but instead increased the rate of adverse events, with the num ber needed to treat before harm being 8.1 (Table VII-9).