Odontogenic Sinusitis Treatment

[Dr. Ashley Agan]
Starting out, let's just set the stage with terminology overview, when you're speaking of odontogenic sinusitis, comparing it to other forms of chronic rhinosinusitis or acute sinusitis, and how do you think about that?

[Dr. John Craig]
Yes, it's so critical, but until recently, we didn't have just a simple definition. What we've tried to be consistent with in recent studies, both consensus statements, there's a treatment consensus and a diagnostic consensus out there. Here's the definition. Bacterial maxillary sinusitis, with or without extension to other paranasal sinuses, secondary either to adjacent infectious dental pathology or following complications from dental procedures. It's a mouthful, but it covers all the different etiologies that cause dental-related sinusitis. We're trying to be all-inclusive and make sure we're not forgetting about all the different types.

Now, I believe you said how to compare it or contrast it to rhinosinusitis. It is distinct. It is not chronic rhinosinusitis. I think this is a problem in older literature. It almost talks about it like it's a subtype of rhinosinusitis. This is completely different. It's a secondary sinusitis caused by, like we said, dental pathology or dental complications from procedures. We really just have to keep distinguishing it. What are some clinical differences? For one, this is a condition that's almost always unilateral. Very simple distinguishing point. Most rhinosinusitis is bilateral.

90% to 95% of ODS is going to be unilateral. We mentioned that it's distinct from the standpoint of it being from oral or dental bacteria. Another distinct point is that there's no deficiency in mucociliary function. It's been shown in multiple histopathologic studies. The mucociliary function is presumably intact as opposed to some forms of rhinosinusitis where it might be distorted. We know that there's different microbiology behind this. We mentioned dental and oral bacteria. That's been shown in multiple studies, including one from us, just that oral anaerobes and oral alpha hemolytic strep species, for instance, like strep intermedius, strep constellatus, are definitely more common in ODS.

[Dr. Ashley Agan]
When you're doing sinus surgery, are you just doing a maxillary antrostomy, or are you treating every sinus that's diseased on the scan?

[Dr. Gopi Shah]
Also, can you just do balloons, or how big does antrostomy have to be?

[Dr. John Craig]
Balloons, we agreed on in our management national consensus to not be appropriate for most cases of odontogenic sinusitis, largely because there's usually significant edema in the middle meatus, might even be tough to cannulate the maxillary sometimes, very friable edema. Then you need a wide enough opening to clear out-- The whole point of surgery is to clear out all the pus. It's almost like draining an abscess. You really want to clear that out. With a balloon dilation, I know I've heard some people say, "Well, you could flush the sinus after," but I don't know. I've seen the inside of a lot of maxillary sinuses with this condition, and there's so much polypoid edema in there, I don't know that you could reliably flush out all that pus. I don't know, for me, and I know other colleagues studying this, we want a wide maxillary antrostomy, clear out the pus. Now, the next question you ask is an intriguing one. How much sinus surgery do you then need to do? A group, they looked at this, so, Ahmad Safadi, he and his group looked at 45 patients prospectively. They had maxillary, ethmoid, and frontal disease, and they did only a maxillary antrostomy and showed 100% resolution of the disease, presuming the dental source is treated.

It's only one study so far, and we're going to look at this too, but it is intriguing that maybe you don't need to open all disease sinuses like we do with other forms of rhinosinusitis. I would say that that's in the non, or uncomplicated ODS situation, where you don't have spread outside into the eye, brain, other areas. If you have complicated ODS, I think it makes sense, if you're going in, you should drain all the purulent sinusitis potential source of that infectious complication, but if you're wondering what I do, I've evolved, I say, or migrated over time, I used to address all disease sinuses, but I admit, I had a frontal stenosis after one of those cases. I had to do a Draf Ⅲ for that patient to resolve that, and then I saw Dr. Safadi's paper, and it got me thinking maybe we don't have to open all sinuses.

We don't have the perfect answer yet, but I do think it's reasonable based on what's been published, and then just what I've seen, that if you're not comfortable opening a frontal sinus, you shouldn't go up into an ODS frontal sinus especially. It's very inflamed, probably higher risk for stenosis. We don't have that answer yet, but I think maxillary only is an intriguing option.

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[Dr. Ashley Agan]
Do you do any post-operative antibiotics, or any other special medications or treatment?

[Dr. John Craig]
Yes, I'm still doing antibiotics after these cases. I think I usually do 10 days of post-op antibiotics. It comes down to it's a raging, purulent sinusitis, can I be confident I got every last bit out of the infection? Maybe not, and so that's what I've been doing. Not to say that that's evidence-driven, but there's nothing on post-operative antibiotic use for ODS. There's some studies showing no benefit in rhinosinusitis, but I think this is different and just needs to be studied better.

[Dr. Ashley Agan]
Do you ever wait for a culture from the OR before you call something in and get sensitivities, or do you say, "Listen, this is going to be oral flora and Augmentin is going to be fine?"

[Dr. John Craig]
I love when I can give Augmentin. That's my favorite. Yes, I usually start empirically. If it's somehow resistant to that, then I'll call the patient and switch the antibiotic.