Case Report-Management of Pansinusitis with Periorbital Cellulitis Complicating External Sinus Lifting Procedure

View PDF

Case Report-Management of Pansinusitis with Periorbital Cellulitis Complicating External Sinus Lifting Procedure

Nasser Al-Alami*

Member of International Association of Maxillofacial Surgeons; ICMFS; Pan Arab Association of Oral and Maxillofacial Surgeons, Saudi Arabia

*Corresponding author: Nasser Al-Alami, Member of International Association of Maxillofacial Surgeons; ICMFS; Pan Arab Association of Oral and Maxillofacial Surgeons, Saudi Arabia.

Citation: Al-Alami N. (2022) Case Report-Management of Pansinusitis with Periorbital Cellulitis Complicating External Sinus Lifting Procedure. J Oral Med and Dent Res. 3(2):1-06.

Received: December 13, 2022 | Published: December 26, 2022

Copyright^© 2022 genesis pub by Al-Alami N. CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non-Commercial-No Derivatives 4.0 International License., This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.

DOI: https://doi.org/10.52793/JOMDR.2022.3(2)-28

Abstract

Perforation of the maxillary sinus membrane is a common complication during sinus lifting procedures (10-40%). Maxillary sinusitis might result and displacement of the graft material may be a contributing factor. Antibiotic Regimes with removal of the implants perforating the sinus have been used for management of sinusitis with immediate or late replacement of the dental implants. Patient with recurrent severe maxillary, ethmoid and frontal sinusitis attended our center complaining from periorbital cellulitis. She visited multiple ENT clinics for several months with limited improvement on antibiotics and nasal decongestants but the infection was severe and recurrent. CT scan revealed titanium membrane displacement into the maxillary sinus. Drainage was done intraorally and removal of the titanium membrane. She had history of External sinus lifting procedure right side 9 years ago for placement of 3 implants to replace upper posterior teeth. Patient insisted not to remove the implants being stable and essential for her chewing.

She accepted any treatment not involving removal of dental implants without warranty on the result. After curettage of infected bone graft and granulation tissue, sinus membrane was elevated and PRF used to fill the space above the implant apices. The infection resolved completely within 10 days. Follow up of the patient for more than 60 months did not show any recurrence. CT Scan taken after one year shows formation of bony partition between the implants and the maxillary sinus.

Introduction

Perforation of Schneiderian membrane. The most common intraoperative complication of lateral open sinus lifting is perforation of Schneiderian membrane. It has been reported in average 20-25% of sinus augmentation cases.

Risk factors:

1. The thickness of the Schneiderian membrane.

2. Presence of bony septa in the sinus.

3. Height of the alveolar bone

4. Surgeon skills and experience

Occurrence of perforation might compromise the viability of the augmented bone and lead to postoperative complication. Sinusitis might be a consequence as a result of bone graft or dental implant infection after contamination of the maxillary sinus by bacteria from the oral cavity or Sinusitis has been reported in 4.2 to 8.4% of cases after sinus lifting (6).

Contributing factors:

1. Blockage of the ostium due to overfilling of the sinus or mucositis.

2. Interruption of mucosal activity due to large perforation of the membrane.

3. Decreased air flow into the sinus.

4. Protruding dental implants into the sinus.

Clinical manifestations:

1. Purulent drainage around the implants.

2. Facial pain and pressure.

3. Nasal Congestion.

4. Foul smell.

5. Ocular pruritis.

It was found that sinusitis is rare after small perforations of the Schneiderian membrane for healthy patients. Study done on 175 augmented sinuses reported one infection in intact sinuses (115) 0.8% and 3 infections in perforated sinuses (60) 5%. All four infections resolved after culture sensitivity and placement of the patient on an appropriate antibiotic for 10 days. (Avelox-moxifloxacin hydrochloride), 400 mg daily for 10 days plus Flonase (fluticasone propionate), two sprays in each nostril daily for 21 days (1). Intraoperative Complications may lead to postoperative complications, they did not influence implant survival (6). Management of sinusitis is complex and might necessitate removal of the graft material and dental implants after control of infection by systemic antibiotic course. Medical management involves systemic antibiotic course, use of nasal douching with saline solution, irrigation of the sinus with antiseptic solution and use of corticosteroids and antihistamine medications. Medical management alone is not predictable on outcome and sinus surgery is indicated if the pathology persists after nonsurgical treatment. Sinus surgery might be performed by endoscopy through the nasal or oral cavity (Functional Endoscopic Sinus Surgery-FESS) or via conventional Cadwellluc osteotomy. It involves irrigation of the sinus and occasionally removal of contaminated bone graft and dental implants.

Chiapasco M proposed treatment protocols based on a combined endoscopic (FESS) and intra-oral surgical approach under general anesthesia. For one out of 20 patients, it was necessary to perform a second combined surgical treatment to treat the persisting sinusitis. Surgery involved co-operation between ENT and Maxillofacial Surgeons (5).

Case Report

62 years old patient with recurrent severe maxillary, ethmoid and frontal sinusitis attended our center complaining from periorbital cellulitis. She attended multiple ENT clinics for several months with limited improvement on antibiotics and nasal decongestants but the infection was severe and recurrent. CT scan revealed titanium membrane displacement into the maxillary sinus. She had history of External sinus lifting procedure right side 9 years ago for placement of 3 implants to replace upper posterior teeth. Patient insisted not to remove the implants being stable and essential for her chewing in Figure 1 and Figure 2.

Figure 1: External sinus lifting procedure right side.

Figure 2: Periorbital cellulitis.

Drainage was done intraorally and removal of the titanium membrane but infection recurred when patient stopped antibiotics. Treatment plan was discussed with the patient and she refused the traditional treatment to remove the 3 dental implants penetrating the maxillary sinus right side. On the other hand, this case was considered life threatening as periorbital cellulitis can lead to cavernous sinus thrombosis, meningitis, brain abscess and death. An alternative solution was approved by the patient to perform curettage of the infected bone graft and Granulation tissue in the maxillary sinus right side, elevation of the perforated Schneiderian membrane and use of PRF membrane to isolate the dental implant apices from the perforated Schneiderian membrane and maxillary sinus to promote healing. This approach is unique and no high expectations were given to the patient about the success although improvement was anticipated. After 7 days of oral antibiotic Avalox (Moxifloxacin 400mg OD) patient was ready for the procedure. The maxillary sinus was irrigated using diluted antiseptic solution with curettage of infected bone graft and granulation tissue. PRF membranes used to fill the space between the dental implants and the Schneiderian membrane. No collagen membrane used to avoid any unwanted reaction. The plan was to eliminate source of infection and to provide a sort of isolation between the dental implants and the maxillary sinus right side in Figure 3-5.