1

Introduction

Chronic maxillary sinusitis frequently developed as infectious complication of odontogenic pathologic processes, such as periapical abscess, periodontal disease, extraction of posterior teeth with projecting roots, maxillary cystic lesions or foreign bodies (endodontic materials, dental implants) .

The inflammatory process of dental origin can spread through the maxillary alveolar process to the Schneiderian sinus membrane, with the developing of an oroantral communication that, if not correctly treated can produce maxillary sinusitis and become chronic. Treatment of complicated oroantral fistula requires removal of infected soft and hard tissues associated with the management of sinus pathology . Although several intraoral flap designs have been proposed for the mucosal coverage , stable closure of the oroantral communication can be hardly achieved in the presence of residual sinus disease, often requiring prolonged antibiotic therapy and multiple surgical revisions.

Functional endoscopic sinus surgery (FESS) has proven effective and safer in the treatment of chronic sinusitis than the conventional intraoral surgical approach (Caldwell–Luc procedure) . FESS allows, through a minimally invasive approach to the sinus cavity, the preservation of the sinusal mucosa and the restoration of a physiological drainage .

Although recurrent inflammatory sinus disease associated with chronic oro-antral communication still remains one of the current indications for the traditional extensive sinusal revision , the authors reported their personal experience with a minimally invasive combined surgical treatment for chronic sinusitis of dental origin.

2

Patients and methods

Subjects affected by odontogenic sinus infection recently admitted to the Unit of Maxillofacial surgery, Padova University Hospital, Italy, were treated by means of combined nasal endoscopic and intraoral approach under local anaesthesia.

Inclusion criteria were the following: patients with chronic maxillary sinusitis (defined as symptoms persisting beyond 12 weeks ) due to odontogenic causes associated with oroantral communication.

Patients with clinical and radiological diagnosis of rhinogenic sinusitis or with comorbid conditions that contraindicated the local anaesthesia were excluded from the study population.

At the first examination, patient’s medical, clinical, and dental history was collected. Data about previous tooth extraction in the upper jaw and associated major and minor symptoms of sinus infection, such as pain located in the anterior aspect of the maxilla, headache, nasal obstruction, nasal and intraoral purulent or mucoid discharge, and olfactory disturbance were collected . Individual symptoms severity score (SSS) was also evaluated by means of a 7-point analogue scale with a score of 0–7 (0 = absence of symptoms; 3 = mild and tolerable symptoms; 5 = severe symptoms that interfere with normal activities; 7 = very severe symptoms) .

The oral cavity was inspected for signs of dental or periodontal disease, and for the presence of oroantral fistula. All subjects enrolled underwent a nasal endoscopy with flexible fiberoptic endoscope, a digital panoramic radiograph and a computed tomography for diagnosis confirmation . In particular, major endoscopic physical findings, such as mucosal erythema, swelling and mucoid/purulent discharge from the middle meatus were assessed .

Preoperative coronal and axial sinus CT scans were evaluated for the presence of mucosal thickening, opacification or swelling of the maxillary mucosa, and obstruction of the osteomeatal complex . Moreover, information obtained by the CT scan was correlated with the endoscopic findings for the preoperative planning.

2

Patients and methods

Subjects affected by odontogenic sinus infection recently admitted to the Unit of Maxillofacial surgery, Padova University Hospital, Italy, were treated by means of combined nasal endoscopic and intraoral approach under local anaesthesia.

Inclusion criteria were the following: patients with chronic maxillary sinusitis (defined as symptoms persisting beyond 12 weeks ) due to odontogenic causes associated with oroantral communication.

Patients with clinical and radiological diagnosis of rhinogenic sinusitis or with comorbid conditions that contraindicated the local anaesthesia were excluded from the study population.

At the first examination, patient’s medical, clinical, and dental history was collected. Data about previous tooth extraction in the upper jaw and associated major and minor symptoms of sinus infection, such as pain located in the anterior aspect of the maxilla, headache, nasal obstruction, nasal and intraoral purulent or mucoid discharge, and olfactory disturbance were collected . Individual symptoms severity score (SSS) was also evaluated by means of a 7-point analogue scale with a score of 0–7 (0 = absence of symptoms; 3 = mild and tolerable symptoms; 5 = severe symptoms that interfere with normal activities; 7 = very severe symptoms) .

The oral cavity was inspected for signs of dental or periodontal disease, and for the presence of oroantral fistula. All subjects enrolled underwent a nasal endoscopy with flexible fiberoptic endoscope, a digital panoramic radiograph and a computed tomography for diagnosis confirmation . In particular, major endoscopic physical findings, such as mucosal erythema, swelling and mucoid/purulent discharge from the middle meatus were assessed .

Preoperative coronal and axial sinus CT scans were evaluated for the presence of mucosal thickening, opacification or swelling of the maxillary mucosa, and obstruction of the osteomeatal complex . Moreover, information obtained by the CT scan was correlated with the endoscopic findings for the preoperative planning.