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Treatment of severe sinus infection after sinus lift procedure  a case report
Treatment of severe sinus infection after sinus lift procedure  a case report
Treatment of severe sinus infection after sinus lift procedure  a case report
Treatment of severe sinus infection after sinus lift procedure  a case report
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Treatment of severe sinus infection after sinus lift procedure a case report

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  • 1. 430 SINUS INFECTION AFTER SINUS LIFT PROCEDURE • ALMAGHRABI ET AL Treatment of Severe Sinus Infection After Sinus Lift Procedure: A Case Report Bandar Abdulrahman Almaghrabi, BDS, MS,* Michael N. Hatton, DDS, MS,† Sebastiano Andreana, DDS, MS,‡ and Mark A. C. Hoeplinger, MD§ T he maxillary sinus is an airfilled cavity located on both sides of the maxilla. It is pyramidal in shape and is the largest of the sinus cavities. Sinuses communicate to the nasal cavity via small bone channels called ostea.1,2 The biological role of the sinuses is debated,2– 4 but a number of possible functions have been proposed: • Decreasing the relative weight of the front of the skull, especially the bones of the face • Increasing resonance of the voice • Providing a buffer against blows to the face • Insulating sensitive structures such as dental roots and eyes from rapid temperature fluctuations in the nasal cavity • Humidifying and heating of inhaled air because of slow air turnover in this region3,5,6 This cavity is frequently reinforced with internal vertical septae that can create further intrasinus cavities. The size *Research Instructor, Postgraduate Periodontal Resident, Department of Periodontics and Endodontics, SUNY at Buffalo, Buffalo, NY. †Clinical Associate Professor, Department of Oral Diagnostic Sciences; Clinical Assistant Professor, Department of Oral and Maxillofacial Surgery SUNY at Buffalo, Buffalo, NY. ‡Associate Professor, Director of Implant Dentistry, Department of Restorative Dentistry, SUNY at Buffalo, Buffalo, NY. §Private Practice, Clinical Instructor, Department of Otolaryngology, University of Buffalo School of Medicine; Medical staff of Mercy Hospital of Buffalo, Women and Children’s Hospital and Millard Filmore Gates Circle Hospital at Buffalo, NY. Reprint requests and correspondence to: Bandar Abdulrahman Almaghrabi, BDS, MS, SUNY at Buffalo, 250 Squire Hall, Buffalo, NY 14214, Phone: 716-907-8444, Fax: 716-829-6840, E-mail: baa8@buffalo.edu ISSN 1056-6163/11/02006-430 Implant Dentistry Volume 20 • Number 6 Copyright © 2011 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0b013e318236525c Maxillary sinus floor augmentation may have a variety of postoperative complications including infection, sequestration of bone, and maxillary sinusitis. Complications can also occur due to a preexisting sinus condition called ostium stenosis. This case report presents a complication after sinus lift and grafting procedure due to an unrecognized ostium stenosis. Case Report: A 50-year-old male patient had sinus augmentation on his right side. However, postoperatively, his symptoms were protracted. A CT scan showed thickening of the Sch- neiderian membrane and scattered graft material. Management included endoscopic nasal examination and ostium enlargement, antibiotic coverage, and full enucleation of the graft and diseased tissue. Conclusion: Patency of the sinus ostium should be carefully evaluated before sinus lift/grafting procedure using CT technology. Radiology and otolaryngology consultations may be necessary to rule out ostium stenosis before surgery. (Implant Dent 2011; 20:430 – 433) Key Words: ostium, stenosis, otolaryngologist, sinus lift complications of the sinus can vary on individual basis. Adults have a mean width of 35 mm at the base and a mean height of 25 mm.7 After tooth extraction, bone remodeling of the alveolus occurs, which often leads to an inadequate alveolar height and width for dental implant placement. A frequently performed clinical technique, the “sinus lift,” was published by Tatum.8 He described a modified CaldwellLuc approach from the lateral aspect of the maxillary sinus and elevation of the Schneiderian membrane. This, in turn, provided a closed space for hard tissue grafting procedures. Tatum’s technique, however, has potential complications. A common intraoperative complication is perforation of the Schneiderian membrane during dissection.9 –11 Postoperative sinus floor augmentation may consist of complications that may include, infection, sequestration of bone, and maxillary sinusitis.12 Loss of the grafting material may also occur. Previous investigations have reported that complications can occur in up to 20% of patients after sinus floor augmentation.6,8 The literature suggests that complications tend to be associated with preexisting sinus disease or documented susceptibility to sinus disease.13–15 Ostium stenosis is a narrowing of the ostium size due to chronic sinus disease or congenital factors. It is a defect not previously described as being responsible for complications following sinus lift operations, and about 24% of patients who present for sinus lift procedures may have this finding.16 This case report presents an unforeseen complication after sinus lift and graft procedure. CASE REPORT A 50-year-old white male patient came to the University at Buffalo School of Dental Medicine (Buffalo, NY) to seek dental replacement of previously extracted teeth in the areas of teeth 3 and 14. The patient’s medical
  • 2. IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 Fig. 1. Preoperative pictures during initial examination. Fig. 2. Presurgical CT scan showing some remnants of the grafting material with thickened Schneiderian membrane and ostium stenosis. Fig. 3. Instrumentation: fiberoptic probe and inflatable device. history included an allergy to penicillin. At this time, the patient was taking multivitamins, Diazepam (SigmaAldrich, St. Louis, MO), Asmanex (Merck & Co., Whitehouse Station, NJ), Symbicort (AstraZeneca Pharmaceuticals, Wilmington, DE), and Albuterol (Mylan Pharmaceuticals Inc., Morgantown, WV). The latter three medications were used to control reactive airway disease, whereas Diazepam was prescribed to control anxiety and insomnia. A panoramic x-ray of the patient showed alveolar atrophy and sinus pneumatization in the areas of teeth 3 and 14 (Fig. 1). Treatment options were discussed with the patient, and a mutual decision was made to undergo sinus lift/ mineralized tissue graft procedures, before implant placement. We decided to provide care starting on the patient’s right side. The left side was planned to be done at a future appointment. Risks, benefits, and alternatives of the proposed procedure were discussed with the patient. All questions were answered. The patient signed a standard surgical consent form. Local anesthesia was administered using one carpule of 2% lidocaine, with epinephrine (1:50,000). A full-thickness flap was reflected over the lateral aspect of the right maxillary wall. An osseous window was created in a standard fashion using both rotary and piezoelectric surgery techniques. During the procedure, the Schneiderian membrane was torn (Ͻ5 mm), and it was closed using a collagen membrane (Colla Tape; Zimmer, Carlsbad, CA) with dimension of 1 ϫ 2.5 ϫ 7.5 mm.17 The intact side of the membrane was fully reflected to achieve an ideal space for grafting. Before graft placement (irradiated cancellous particulate allograft bone; Rocky Mountain Tissue Bank, Aurora, CO), the membrane perforation was checked for complete coverage. Four grams of bone graft material (irradiated cancellous particulate allograft bone; Rocky Mountain Tissue Bank) was placed into the sinus lift cavity. A collagen membrane (Conform, Ace Surgical Supply, Brockton, MA) was placed over the lateral aspect of the bone window. The flap was replaced, and 4.0 nonresorbable suture material (Cytoplast PTFE; Osteogenics Biomedical, Lubbock, TX) was used to stabilize the flap. This patient was prescribed 150 mg clindamycin four times per day for 10 days and 0.75 mg dexamethasone four times per day for 6 days. The patient started these medications one day before surgery. The first postsurgical week was uneventful. However, 2 weeks after the 431 surgery, the patient reported pain and discomfort, with drainage from his nasal cavity on the operative side. A periapical radiograph was taken which showed that grafting material was intact. Yellow mucus discharge from the right nostril was cultured in standard transport media. A mixture of aerobic and anaerobic bacteria was noted. The patient was prescribed clindamycin 300 mg along with metronidazole 250 mg to reduce the possibility of having anaerobic bacterial infection. The patient showed no improvement, and he was then prescribed tetracycline 500 mg, for 10 days. On the second day of taking tetracycline (21 days after the surgery), the patient reported swelling in the right maxillary sinus area. There was also pain on palpation, malaise, and fever. Surgical intervention was done via incision and drainage under local anesthesia. Four days later, the patient reported that the swelling subsided, with a decrease in nasal discharge. The patient was monitored on a frequent basis. A CT scan was obtained which revealed that the bone graft was scattered in the anterior and floor regions of the right sinus area with most of the pieces adhering to the soft tissue lining. Of special note was that thickened soft tissue which completely blocked the right maxillary sinus ostium. The treatment plan was discussed. He agreed to have the graft material removed from the right maxillary sinus. After several weeks, the intraoral soft tissue stoma had closed. Under local anesthesia, a full-thickness flap was reflected over the right maxillary sinus wall, and access was made through the previous lateral window. Findings included showed frank pus accumulation and unattached bone grafting material. The area was curetted and irrigated with saline. Suturing was done using a 3.0 PTFE with interrupted technique. After soft tissue healing of the site, the patient noted discomfort and tenderness over the right maxillary sinus. A yellow nasal discharge persisted from the right nostril. We referred the patient for consultation with an otolaryngologist. CT scans were obtained, which revealed remnants of
  • 3. 432 SINUS INFECTION AFTER SINUS LIFT PROCEDURE • ALMAGHRABI ET AL DISCUSSION Fig. 4. Nasal endoscopy: ethmoid thickening with ostium stenosis. Fig. 5. Sinus ostium after enlargement using inflatable device and shaving the ethmoid thickening. Fig. 6. Polyps removed along with bone grafting material after maxillary sinus membrane enucleation. Fig. 7. Postsurgical radiographic image. the grafting material and stenosis of the right maxillary ostium (Fig. 2). The otolaryngologist performed an endoscopic examination under general anesthesia (Fig. 3). Findings were consistent with stenosis of the right maxillary sinus ostium (Fig. 4). Balloon catheterization and widening of the ostium were completed (Fig. 5). Cultures were taken during the surgery, and the sinus was examined using a fiberoptic probe. These cultures had shown presence of Prevotella species and were identified as Prevotella melaninogenica. The base of the Schneiderian membrane on the other hand appeared intact. No other abnormalities were noted. The patient did improve after the procedure and was less symptomatic. Two months later, the patient developed copious clear mucus discharge from the right nasal cavity and also noted tenderness of the right maxillary sinus. In addition, he reported intermittent blockage of the right nasal airway and difficulty with air flow through the right nasal passage. Based on the persistent symptoms and consultation with his otolaryngologist, surgical exploration by an oral and maxillofacial surgeon was offered to the patient. The consulting otolaryngologist was not experienced in removing dental material from a grafted sinus and asked that a dental surgeon perform the procedure. Standard surgical consent was obtained. Under local anesthesia, the oral and maxillofacial surgeon elevated a fullthickness mucoperiosteal flap over the right lateral aspect of the maxilla. The previous lateral window was used to gain access into the base of the sinus. The window was enlarged, and a thorough curettage of the graft material was done. Multiple sinus polyps and grafts material attached to the thickened Schneiderian membrane were removed (Fig. 6). The sinus was thoroughly irrigated, and the osseous window was covered with a collagen membrane. The flap was brought again to its original position and closed with interrupted sutures. The patient showed remarkable improvement (Fig. 7) and was symptom free on a 1-year follow-up. Alveolar atrophy and maxillary sinus pneumatization after tooth extraction can create a significant challenge for dental implant placement in the posterior maxilla. To increase the bone height of the posterior alveolar areas of the maxilla, “sinus lift” procedures have become commonly used in dental implant surgery.6 This communication describes a persistent postoperative maxillary sinusitis, which can be traced to stenosis ostium of the maxillary sinus. Anatomical variation of the osteomeatal complex (which can include narrowing of the ostium) can have deleterious effects on sinus drainage.13,18 –20 Narrowing of the sinus ostium can arise from congenital, inflammatory, or neoplastic sources. Stenosis ostium has a prevalence of 24%16,21 and can be associated with acute and chronic sinusitis where the permeability of the ostium is altered.21–24 Mucosal edema can obliterate the ostium, along with nasal polyp formation.25,26 A patient’s medical history is an important factor before undertaking a sinus lift procedure, especially in regard to nasal symptoms. This patient did have a history of reactive airway disease. He also had a history of nasal problems, which were not active at the time of the original procedure. In fact, he had seen the same treating otolaryngologist in the past to stabilize the sinus symptoms before proceeding with the sinus lift procedure. Chronic sinusitis is more prevalent among patients with reactive airway disease.16 Although this patient had an intraoperative tear of the Schneiderian membrane during the graft procedure, we believe that the persistent sinusitis was indeed related to stenosis ostium. The patient had adequate pre- and postoperative antibiotic coverage for the procedure. The incidence of membrane perforation varies widely in the literature.27,28 It is not uncommon and is usually dealt with as described above.3,27,29 Schneiderian membrane perforation can be associated with postoperative complications, such as acute or chronic sinus infection, wound dehiscence, loss of the graft material, and a
  • 4. IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 disruption of normal sinus physiologic function.3,30 –33 Becker et al,27 however, found that sinus perforation per se did not necessarily result in implant loss, displacement of graft material, or infectious complications. The authors believe that this patient’s protracted course was indeed due to ostium stenosis. CONCLUSION Ostium stenosis cannot be visualized on intraoral dental radiographs or panoramic films. On the basis of this case, we now strongly recommend the use of a CT scan before proceeding with sinus lift procedures. Patency of the ostium should be carefully evaluated, along with any preexisting sinus disease or other aberrant anatomical factors of the sinus. All of these issues must be taken into account before commencing a sinus lift/grafting procedure. If the dental clinician is unfamiliar with reading a CT of the paranasal sinuses, we recommend a radiologist review the scan. An otolaryngologist should be consulted preoperatively if there are issues with the CT or the patient has a history of sinus ailments. On the basis of this case, we now strongly believe that a patent ostium should be verbally included in any consultant’s report. DISCLOSURE The authors claim to have no financial interest in any company or any of the products mentioned in this article. REFERENCES 1. Phillips JE, Ji L, Rivelli MA. Threedimensional analysis of rodent paranasal sinus cavities from X-ray computed tomography (CT) scans. Can J Vet Res. 2009;73:205-211. 2. Norris AM, Laing EJ. Diseases of the nose and sinuses. Vet Clin North Am Small Anim Pract. 1985;15:865-890. 3. van den Bergh JP, ten Bruggenkate CM, Disch FJ. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res. 2000;11:256-265. 4. Ritter FN. The Paranasal Sinuses: Anatomy and Surgical Technique. Saint Louis, MO: Mosby; 1973:ix, 153. 5. Blanton PL, Biggs NL. Eighteen hundred years of controversy: The paranasal sinuses. Am J Anat. 1969;124:135-147. 6. Wagenmann M, Naclerio RM. Ana- tomic and physiologic considerations in sinusitis. J Allergy Clin Immunol. 1992;90: 419-423. 7. Small SA, Zinner ID, Panno FV, et al. Augmenting the maxillary sinus for implants: Report of 27 patients. Int J Oral Maxillofac Implants. 1993;8:523-528. 8. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986:30:207-229. 9. Smiler DG, Johnson PW, Lozada JL, et al. Sinus lift grafts and endosseous implants. Treatment of the atrophic posterior maxilla. Dent Clin North Am. 1992;36: 151-186; discussion 187-188. 10. Schwartz-Arad D, Herzberg R, Dolev E. The prevalence of surgical complications of the sinus graft procedure and their impact on implant survival. J Periodontol. 2004;75:511-516. 11. Proussaefs P, Lozada J, Kim J, et al. Repair of the perforated sinus membrane with a resorbable collagen membrane: A human study. Int J Oral Maxillofac Implants. 2004;19:413-420. 12. Timmenga NM, Raghoebar GM, van Weissenbruch R, et al. Maxillary sinusitis after augmentation of the maxillary sinus floor: A report of 2 cases. J Oral Maxillofac Surg. 2001;59:200-204. 13. Timmenga NM, Raghoebar GM, Boering G, et al. Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg. 1997;55: 936-939; discussion 940. 14. Raghoebar GM, Batenburg RH, Timmenga NM, et al. Morbidity and complications of bone grafting of the floor of the maxillary sinus for the placement of endosseous implants. Mund Kiefer Gesichtschir. 1999;3:S65–S69. 15. Timmenga NM, Raghoebar GM, Liem RS, et al. Effects of maxillary sinus floor elevation surgery on maxillary sinus physiology. Eur J Oral Sci. 2003;111:189-197. 16. Beaumont C, Zafiropoulos GG, Rohmann K, et al. Prevalence of maxillary sinus disease and abnormalities in patients scheduled for sinus lift procedures. J Periodontol. 2005;76:461-467. 17. Testori T, Wallace SS, Del Fabbro M, et al. Repair of large sinus membrane perforations using stabilized collagen barrier membranes: Surgical techniques with histologic and radiographic evidence of success. Int J Periodontics Restorative Dent. 2008;28:9-17. 18. Bertrand BM, Robillard TA. Comparative study of standard radiology, sinuscopy and sinusomanometry in the maxillary sinus of the adult (about 465 maxillary sinuses). Rhinology. 1985;23: 237-246. 19. Aust R, Drettner B. The functional size of the human maxillary ostium in vivo. Acta Otolaryngol. 1974;78:432-435. 20. Aust R, Stierna P, Drettner B. Basic 433 experimental studies of ostial patency and local metabolic environment of the maxillary sinus. Acta Otolaryngol Suppl. 1994; 515:7-10; discussion 11. 21. Gilbert JG. Antroscopy in maxillary sinus disease associated with nasal polyposis. J Laryngol Otol. 1989;103:861-863. 22. Stierna P, Soderlund K, Hultman E. Chronic maxillary sinusitis. Energy metabolism in sinus mucosa and secretion. Acta Otolaryngol. 1991;111:135-143. 23. Aust R, Drettner B. Oxygen tension in the human maxillary sinus under normal and pathological conditions. Acta Otolaryngol. 1974;78:264-269. 24. Carenfelt C, Lundberg C. Purulent and non-purulent maxillary sinus secretions with respect to pO2, pCO2 and pH. Acta Otolaryngol. 1977;84:138-144. 25. Drettner B. The permeability of the maxillary ostium. Acta Otolaryngol. 1965; 60:304-314. 26. Melen I, Friberg B, Andreasson L, ´ ´ et al. Ostial and nasal patency in chronic maxillary sinusitis. A long-term posttreatment study. Acta Otolaryngol. 1986; 102:500-508. 27. Becker ST, Terheyden H, Steinriede A, et al. Prospective observation of 41 perforations of the Schneiderian membrane during sinus floor elevation. Clin Oral Implants Res. 2008;19:1285-1289. 28. Jensen J, Sindet-Pedersen S, Oliver AJ. Varying treatment strategies for reconstruction of maxillary atrophy with implants: Results in 98 patients. J Oral Maxillofac Surg. 1994;52:210-216; discussion 216-218. 29. van den Bergh JP, ten Bruggenkate CM, Krekeler G, et al. Maxillary sinusfloor elevation and grafting with human demineralized freeze dried bone. Clin Oral Implants Res. 2000;11:487-493. 30. Chanavaz M. Maxillary sinus: Anatomy, physiology, surgery, and bone grafting related to implantology—Eleven years of surgical experience (1979–1990). J Oral Implantol. 1990;16:199-209. 31. van den Bergh JP, ten Bruggenkate CM, Groeneveld HH, et al. Recombinant human bone morphogenetic protein-7 in maxillary sinus floor elevation surgery in 3 patients compared to autogenous bone grafts. A clinical pilot study. J Clin Periodontol. 2000;27:627-636. 32. Aimetti M, Romagnoli R, Ricci G, et al. Maxillary sinus elevation: The effect of macrolacerations and microlacerations of the sinus membrane as determined by endoscopy. Int J Periodontics Restorative Dent. 2001;21:581-589. 33. Cho SC, Wallace SS, Froum SJ, et al. Influence of anatomy on Schneiderian membrane perforations during sinus elevation surgery: Three-dimensional analysis. Pract Proced Aesthet Dent. 2001;13:160163.

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