Odontogenic Fungal Maxillary Sinusitis: A Case Report of a Displaced Dental Foreign Body

Abstract

Odontogenic etiology accounts for 10–12% of cases of maxillary sinusitis. Although uncommon, direct spread of dental infections into the maxillary sinus is possible due to the close relationship of the maxillary posterior teeth to the maxillary sinus. An odontogenic infection is a polymicrobial aerobic–anaerobic infection, with anaerobes out numbering the aerobes. Diagnosis requires a thorough dental and clinical evaluation, including radiographs. Management of sinus disease of odontogenic origin often requires medical treatment with appropriate antibiotics, surgical drainage when indicated, and treatment to remove the offending dental etiology. A 35-year-old, non-smoking woman visited our clinic, with a history of 6 months of facial pain, purulent nose discharge, and a foul taste in her mouth. The patient was otherwise healthy. Nasal endoscopy showed purulent discharge coming from the left middle meatus with a congested nasal mucosa and with a past history of dental treatments. CT PNS showed fractured free floating and an impacted foreign body through the premolar tooth and a right maxillary polyp with evidence of similar dental procedure done bilaterally. Functional endoscopic sinus surgery with extraction of the affected tooth and closure of oroantral fistula was done. The association between an odontogenic condition and maxillary sinusitis requires a thorough dental examination of patients with sinusitis. Concomitant management of the dental origin and the associated sinusitis will ensure complete resolution of the infection and may prevent recurrences and complications. A combination of a medical and surgical approach is generally required for the treatment of odontogenic sinusitis. An endoscopic shaver-assisted approach to is a reliable, minimally invasive method associated with less morbidity and lower incidence of complications.

Introduction

Among the four pairs of paranasal sinuses, the maxillary sinuses are the biggest ones and those most frequently damaged. The anatomical and clinical significance of the maxillary sinus was first described by Nathaniel Highmore (Highmore 1613–1685) in 1651 with a report on the drainage of an infected sinus through the extraction socket of a canine tooth. Since that report, dental treatment of maxillary teeth has played an important part in the pathophysiological affection of maxillary sinus or antrum of Highmore [1].

Odontogenic sinusitis accounts for approximately 10–12% of maxillary sinusitis cases with the incidence being higher in women and that younger individuals (3rd and 4th decade) appearing to be more susceptible [2, 3]. The maxillary sinus is virtually sterile but susceptible to microbial infection via the nasal ostium or oral cavity [4]. Sinusitis related to odontogenic causes occurs when the schneiderian membrane is violated by conditions such as infections of the maxillary posterior teeth, pathologic lesions of the jaws and teeth, maxillary (dental) trauma, or by iatrogenic causes such as dental and implant surgery complications and maxillofacial surgery procedures.

Odontogenic maxillary sinusitis, whether chronic or acute, resulting from endodontic and periodontal infections represents the most classic and somewhat common scenario. Nevertheless, odontogenic sinusitis may also result from extractions, dislocation of foreign bodies into the maxillary sinus (teeth or tooth fragments), or iatrogenic penetration of dental materials in the maxillary sinus (as a result of endodontic treatments). Moreover, the inflammatory process of the maxillary sinus, initially present in the vast majority of cases, may extend to other paranasal sinuses as well [5].

Presenting symptoms range from mucopurulent, often unilateral, discharge; cheek and/or facial pain; perception of foul smell and/or taste; postnasal dripping and gingival swelling [6, 7]. An odontogenic source should be considered in individuals with symptoms of maxillary sinusitis and a history of dental or jaw pain; dental infection; oral, periodontal, or endodontic surgery; and in those people resistant to conventional sinusitis therapy.

Clinical relevance of this variety of sinus disease differs in pathophysiology, microbiology, and management as compared to sinusitis of fungal or bacterial origin due to community acquired disease. Odontogenic sinusitis may show bacterial or fungal aetiology. Both aerobes and anaerobes have been associated with odontogenic sinusitis [8]. Infectious processes are often polymicrobial and drug resistant, requiring surgery for complete resolution.

The identification and treatment of the underlying dental condition are mandatory for the proper management [9, 10]. A maxillofacial conventional computed tomography (CT) scan usually allows the surgeon to evaluate the sinusal involvement, whereas orthopantomograms, dentascan CT scans, and, more recently,cone-beam CT scans are currently used for dental assessment [11, 12].

Modern surgical treatment relies both on dental surgery addressing the underlying dental condition and functional endoscopic sinus surgery, which allows for restoration of the normal sinusal drainage [3]. When present, an odontogenic foreign body should be surgically removed. Surgical management of oroantral communication is indicated to reduce the likelihood of causing chronic sinus disease. The management of odontogenic sinusitis includes a 3- to 4-week course of antimicrobials effective against the oral flora pathogens [13].

Case Report

A 35-year-old, non-smoking woman visited our clinic, with a history of 6 months of facial pain, purulent nose discharge, and a foul taste in her mouth that did not respond to long-term antibiotic treatment. The patient was otherwise healthy. Nasal endoscopy showed purulent discharge coming from the left middle meatus with a congested nasal mucosa. The patient denied any other prior nasal problem, infectious or functional; however the patient confessed to having dental problems, for which she had undergone various dental treatments, including endodontic and periodontal treatments, which held little to no success in treating her dental condition.

An opinion from the orofaciomaxillary surgeon was sought, which concluded that the gutta-percha stick used for endodontic restoration of root canals of teeth had been accidentally pushed into the maxillary sinus by a previous dentist through left first molar tooth. The gutta percha stick was seen as a radiopaque material in left maxillary sinus floor with sinus obliteration confirmed with intra oral periapical radiograph and orthopantomography (OPG).

In collaboration, radiographic examinations [orthopantomography] and paranasal sinuses computed tomography (CT)] were performed.

CT PNS was reported as having a possibility of fractured dental implant causing oroantral fistula and sinusitis of left maxillary sinus (Figs. 1, 2). The same also indicated presence of right maxillary sinusitis, either reactionary  or owing to similar procedures done on the right molar teeth.

1. Free floating within the left maxillary sinus.

2. Entering into the sinus attached to the tooth (Fig. 3).

Fig. 1.

CT-PNS showing two foreign bodies one within the left maxillary sinus and another entering through its floor

Fig. 2.

OPG

Fig. 3.

Intra oral periapical radiograph showing the gutta percha

A combined approach in collaboration with the dental surgeon was done.under antibiotic cover, patient was taken up for functional endoscopic sinus surgery with extraction of the causative tooth and repair of the oroantral fistula.

Intraoperative Details

• Step 1 Thorough decongestion of the nasal cavity.

• Step 2 Left uncinectomy done after medialisation of the middle turbinate. Frank mucopus with fungal debris evacuated from the left maxillary sinus (Fig. 4).

• Step 3 Complete uncinectomy with middle meatal antrostomy done.Foreign body (gutta-percha) seen lying free on the sinus floor.

• Step 4 Removal of the foreign body and sinus exploration done. Wide middle meatal antrostomy achieved (Fig. 5, 6).

• Step 5 Intraoral examination done.Affected tooth removed with the second foreign body attached to the tooth.Point of foreign body entry through the tooth noted (Fig. 7).

• Step 6 Buccal mucoperiosteal flap elevated to close the oroantal fistula (Rehrmann Flap) (Fig. 8).

• Step 7 Right sided uncinectomy done with middle meatal antrostomy. Polyp in the left maxillary sinus cleared with establishment of an adequate middle meatal antrostomy.

• Step 8 Bilateral merocel packing done and left in situ for 48 h.

Fig. 4.

Fungal debris (F) evacuated from the left maxillary sinus. U uncinate, MT middle turbinate

Fig. 5.

Free floating gutta-percha (GP) lying on the sinus floor

Fig. 6.

Gutta percha after removal

Fig. 7.

Extracted tooth with the point of entry of the gutta percha

Fig. 8.

Buccal mucoperiosteal advancememnt flap raised and closed over the oroantral fistula

Patient was stable post operatively and was discharged after 2 days of observation in a stable condition.

Post operative 1 month follow up done. Bilateral well healed middle meatal cavities and the oroantral fistula noted.

Histopathological report of the fungal debri showed aspergillus.

Discussion

Maxillary sinus growth starts at approximately 3 months of intrauterine life, and by the 5th month, growth extends into the adjacent maxilla. The final growth of the maxillary sinus corresponds with the eruption of permanent teeth between 12 and 14 years of age [14]. The roots of the second molars are in closest proximity to the sinus floor, followed in frequency by the roots of the second molar, first molar, second premolar, and first premolar [14]. The relative positions of the roots to the sinus are reported in several studies [14–18]. It was reported that the frequency of close proximity (0.5 mm or less) of roots of posterior maxillary teeth to the sinus floor: second molars 45.5%, first molars 30.4%, second premolars 19.7% and first premolars 0% [16]. Thus,the close anatomical relationship of the maxillary sinus and the roots of maxillary molars, premolars and in some instances canines, can lead to several endodontic complications. A study carried out in 411 Romanian patients by Albu and Baciut based on a dental examination and on a computed tomography (CT) analysis, reported a maxillary sinusitis prevalence of 25.00% [19].

Classically, Odontogenic maxillary sinusitis is considered in patients with upper tooth pain, dental infection, dental surgery, unilateral maxillary sinusitis, foul drainage or smell, and resistance to conventional sinusitis therapy [20–23]. Recognition of OMS is important because failure to address the dental pathology can result in failure of medical and surgical therapies and persistence of symptoms [24, 25]. An odontogenic infection is a polymicrobial aerobic–anaerobic infection, with anaerobes outnumbering the aerobes.

As a part of dental procedure, the sinus may be invaded by either sealer or by solid materials such as gutta percha or silver cones. Mechanical irritation results from overfilling the root canal, thereby impinging foreign materials on the vital tissues. The material produces an inflammatory reaction with an area of rarefaction in the periapical tissues. Such inflammation is likely to persist until the foreign object is removed.

Removal of foreign bodies through an endonasal endoscopic approach is the treatment of choice. Endoscopically assisted Caldwell- luc procedure for removal of a dental foreign body has also been described in literature.

Conclusion

The association between an odontogenic condition and maxillary sinusitis requires a thorough dental examination of patients with sinusitis. Concomitant management of the dental origin and the associated sinusitis will ensure complete resolution of the infection and may prevent recurrences and complications. A combination of a medical and surgical approach is generally required for the treatment of odontogenic sinusitis. An endoscopic shaver-assisted approach to is a reliable, minimally invasive method associated with less morbidity and lower incidence of complications.

Compliance with Ethical Standards

Conflict of interest

The authors declares that they have no conflict of interest.

Informed Consent

Informed consent was obtained from all individual participants included in the study.