Sinusitis of dental origin
I- INTRODUCTION:
By definition, sinusitis corresponds to an inflammation of the mucosa of one or more sinuses. This inflammation is largely dominated by infectious causes, due to the contiguity of the teeth.
In practice, the diagnostic approach distinguishes acute sinusitis, which is mainly infectious, from chronic sinusitis, the etiologies of which are more varied and the course of which may be marked by one or more episodes of acute sinusitis.
The rise of implantology makes it more necessary to have a good understanding of the potential pathological relationships between teeth and maxillary sinuses, to prevent them and, if necessary, to know the treatments to apply.
2- ANATOMICAL, EMBROYOLOGICAL, HISTOPHYSIOLOGICAL REMINDERS:
First described by Nathaniel Highmore in 1651, the maxillary sinuses are two more or less symmetrical paired cavities dug into the thickness of the maxilla.
They are annexed to the nasal fossae with which they communicate by an ostium at the level of the middle meatus.
1-Embryology
The initial outline of the maxillary sinus results in an invaginated cleft in the lateral wall of the nasal cavity around the 12th week of intrauterine life. This invagination will increase in volume with facial growth to invade the body of the maxilla. The growth of this cavity occurs in the anteroposterior direction.
at birth: it is a rudimentary cavity in the form of a slit flattened from top to bottom “volume of a bean”
at 6 years old: it takes the shape of the adult pyramid but continues to grow.
at 15 years: growth stops except at the posterior-inferior end, which only takes its definitive shape after the eruption of the upper wisdom tooth.
2- Anatomy
The maxillary sinus or “Highmore’s antrum” is very often described in the form of a quadrangular pyramid with an external apex and an internal base.
The maxillary sinus has 5 walls to describe:
previous
- internal
- inferior (alveolar)
- superior (orbital)
- posterior
- And a side Summit.
Lower wall:
- Centered on the dental apices of the 2nd PM and 1st molar
- Depending on the size of the sinus, this wall may be related to the apices of the other two molars, the first premolar, or even the canine.
- The dental roots remain separated from the sinus mucosa by a more or less thick, sometimes spontaneously dehiscent, fringe of spongy bone.
- the floor of the maxillary sinus is usually lower than the floor of the nasal passages.
Upper wall :
- ” Orbital “: very fragile, it constitutes the major part of the triangular orbital floor, it is located in an oblique plane outside and below. It represents the roof of the sinus, even in its thickness.
- Crossed by the groove and the suborbital canal
Anterior wall : “ Jugale ”
- Due to the relationships it affects with the cheek. The low thickness of this wall, which is 01 mm on average, makes trepanation easy and quick in the classic “ Caldwell-Luc ” intervention.
- Intercalated between pillars of high resistance: canine, maxillomalar, orbital rim, alveolar rim.
Posterior wall:
- It responds to the maxillary tuberosity which separates the sinus from the infratemporal fossa
- It is a thick wall perforated on the outside by the upper and post dental canal which contains the nerves of the same name.
Inner wall : “ Base”
- It is a partition separating the sinus from the nasal cavities, of rectangular shape classically divided into 02 superimposed parts.
The edges:
- There are 4 of them: upper, anterior, posterior, lower which is the most important given its close relationship with the antral teeth.
The summit:
- Corresponds to the zygomatic process of the maxilla
The extension of the sinus :
- Especially in the large sinuses, they can be classified into: orbital, malar, zygomatic, upper and lower palatine, alveolar extension.
Sinusitis of dental origin
3-Histo-physiology :
- The sinus is lined by a membrane called “Schneider’s membrane” made of a thin respiratory-type mucosa with vibratile cilia resting on a glandular chorion.
- The epithelium is prismatic ciliated pseudo-stratified separated from the chorion by a basal membrane, it is made up of collagen and elastic fibers, ground substance and cells, fibroblasts, gland (tubulo-acinar) vessels, nerves and lymphatics.
- Secretory : results from glandular secretion and transepithelial exchanges.
- Ciliary function : Mucociliary movement alone allows continuous drainage of a sinus through the ostium.
- Purification and defense function against infections : the 02 previous functions ensure the drainage of the sinus and participate in its purification by eliminating foreign particles with an antibacterial action by the lysozymes and immunoglobulins contained in the mucus and thanks to the polymorphonuclear cells and macrophages of the chorion by the mechanism of inflammation.
3-Etiologies
– All dental infections can spread to the sinus:
- Periodontitis and desmodontitis
- Periodontal disease
- Pulpit a retro
- Abscess from a dead tooth (purulent collection🡪 fistulization in the sinus).
- Cysts
– Foreign bodies in the sinuses:
- Projection of a tooth or its apex during an extraction and left in place.
- Rarely excess of sealing paste
- Impacted teeth.
- Osteitis.
- There are many germs involved.
- The flora is polymorphic.
- Anaerobes are numerous and can be associated with oral germs.
- There is continuity and identity of dental and sinus infection. The infection spreads from close to close.
4- Pathophysiology of dental inflammatory and infectious foci:
The mechanisms of occurrence of maxillary sinusitis of dental origin were presented by Terracol 1993 who distinguishes several stages:
- After dental caries has reached the pulp, the infection spreads to the apex of the dental root, causing septic desmodontitis.
- This can evolve:
- either towards apical periodontitis or a radiculodental cyst which will become chronic,
- either towards osteitis of the floor with formation of a submucosal collection
- This collection can open into the sinus cavity:
- either abruptly cause sinus empyema,
- either progressively leading to acute suppurative maxillary sinusitis
5- Clinical examination
- 1 – Interrogation: precise:
- Dental history: abscess, treatment…
- Sinus signs: pain, nose blowing, posterior discharge, foul odor.
- 2 – Examination itself:
* Exobuccal: looking for painful points: suborbital, submalar, in the canine fossa
* Endobuccal: palpation of the canine fossa, vestibule, maxillary tuberosity is performed
* Rhinoscopy: allows examination of the nasal cavities and especially the middle turbinate where purulent discharge can be found. Rhinoscopy can be anterior (with a speculum) or posterior.
- Posterior rhinoscopy : it is more difficult; allows examination of the cavum.
- X-ray examinations:
- The main incidences in sinus pathology are
– Nose-chin-plaque (NMP) or Blondeau incidence (lower face)
- Nose-forehead-plate (NFP) or face-on
- Orthopantomogram
- Computed tomography
- Cone Beam
- Magnetic resonance imaging (MRI).
- Sinus puncture: It is for exploratory purposes. Performed at the level of the inferior meatus (below the inferior turbinate)
- Sinus endoscopy or sinusoscopy:
- Allows direct visualization of the sinus by optical fibers through an orifice made at the level of the inferior meatus (inferior meatotomy).
Sinusitis of dental origin Sinusitis of dental origin
6- Clinical forms
1- Empyema of the sinus or pyosinus:
- It is the breaking of a purulent collection into the healthy sinus.
a- Clinical examination :
- Sudden onset after acute apical desmodontitis of an antral tooth.
- Pain radiating to the orbit.
- Fever of 38°.
- Abrupt cessation of pain by blowing a unilateral fetid purulent fluid, without treatment, progression to chronic sinusitis.
b-Radiological examination : a homogeneous unilateral opacity of the maxillary sinus.
2- Acute maxillary sinusitis:
- It is more often of nasal origin than of dental origin.
1. Sinus examination:
a – Clinical examination:
Functional signs :
Are unilateral: Intense, radiating pain, increased in the declive position or during exercise. Discharge of muccopus from the corresponding nostril.
Moderate or absent fever, no nasal obstruction.
The inspection :
may be normal or show ipsilateral jugal edema.
Palpation :
pain on pressure of the corresponding canine fossa
b. Rhinoscopic examination:
Anterior rhinoscopy : using a speculum and Clar’s mirror confirms congestion of the turbinates and the presence of pus in the middle meatus, the mucosa remains normal.
Posterior rhinoscopy : This is more difficult and inconsistently shows pus in the cavum or on the tail of a middle turbinate.
c. Radiological examination: NMP incidence shows sinus opacity.
Sinusitis of dental origin
2. Stomatological examination:
The interrogation reveals:
In the preceding days, dental pain suggestive of acute pulpitis, pulsating, radiating to the entire maxilla, exacerbated during the night.
*vitality tests: normal at the beginning then disappear during the progression towards pulp necrosis
*Acute desmodontitis: dead tooth, spontaneous, continuous pulsatile pain increased by contact with the opposing tooth
*Negative reaction to pulp vitality tests
3. Evolution:
- In the absence of treatment or if it is unsuitable, the progression may be towards:
*Anterior ethmoido fronto maxillary pansinusitis with purulent and fetid rhinorrhea.
On examination, the middle meatus is very edematous mixed with frank pus.
*transition to chronicity.
3-Chronic maxillary sinusitis:
Defined by the persistence of permanent or intermittent rhinosinusal symptoms for more than 12 weeks (Papon 2009)
They are the most frequent and the most difficult to discover, they can be chronic from the outset or follow an acute period.
1. Sinus examination:
a-Clinical examination:
Functional signs :
- Inconstant pain, rarely intense, unilateral.
- Unilateral, purulent, fetid rhinorrhea (especially when tilting the head forward or towards the healthy side) sometimes associated with an irritating cough, difficulty swallowing.
- Subjective cacosmia.
- Nasal obstruction is sometimes noted (improved by blowing nasal secretions).
General signs: non-existent
b. Rhinoscopic examination:
Anterior rhinoscopy:
presence of pus or mucopurulent fluid in the nasal cavity.
Posterior rhinoscopy :
Presence of pus on the tail of the middle turbinate or the cavum.
- The X-ray shows a veiled sinus. Thickening of the sinus mucosa is manifested radiologically by a “framed” image
2. Stomatological examination:
it is necessary to insist on the corresponding premolar-molar sector:
- Swelling of the vestibular base, fistula, CBS, carious pathology, restoration, mobility or decay at the level of an antral tooth
- Palpation of the vestibular fundus looks for an anomaly of the reliefs or pain
- Absence of vitality of the causal tooth
- Without treatment, chronic sinusitis can spread to the rest of the sinuses of the face (ethmoidal, frontal, etc.) and cause pansinusitis or to neighboring structures and cause loco-regional infectious accidents (osteitis, fistulas, etc.)
4- Clinical forms according to the germ:
1- Aspergillosis : This is the most common mycosis (+++ men).
*These infections appear to be of dental origin in more than half of the cases
*The causal agent is Aspergillus fumigatus and more rarely Aspergillus niger.
*Favoring factors in:
– Non-invasive fungal sinusitis: filling paste
– Invasive fungal sinusitis: immunosuppression (HIV), hemopathic, chemotherapeutic, transplant
- the fungal agent forms a concretion (fungal ball) placed on the mucosa which can remain strictly normal or on the contrary present a significant inflammatory reaction.
- Chronic form :
- Chronic pain in the suborbital region or on one side of the face.
- Chronic homolateral rhinorrhea, more or less fetid, sometimes blackish and bloody.
- Radio: diffuse or localized opacity in the form of isolated or multiple rounded images within which the presence of dental paste strongly suggests the diagnosis.
- Only bacteriological sampling (mycelial filaments) after direct examination has diagnostic value.
- Pseudo-tumorous forms:
- More or less rapid invasion of neighboring structures (orbit, nasal passages)
- Regional hemorrhage suggesting a malignant process with bone lysis of the sinus walls.
2- Actino-mycotic maxillary sinusitis:
- She is exceptional.
- Accompanied by genial swelling with multiple fistulization.
- Initial involvement may be a dental apex or deaf pus containing yellowish grains.
- Anaerobic culture confirms the diagnosis
5- Clinical forms according to age:
- Osteomyelitis in infants under 6 months has become very rare
- The infection develops in the bone tissue because the maxillary sinus is not yet individualized
- Sinusitis is not observed before the eruption of permanent teeth.
Sinusitis of dental origin
6. Clinical forms according to intensity
– Pain is mild or absent.
– Intermittent, light posterior rhinorrhea.
– Pharyngeal paresthesia, cough and morning sputum.
– Fetid breath without alteration of the general condition.
– Deceptive form: in the form of distant damage: ocular, cardiac, dermatological.
– Dental examination: dental pain, periodontitis, sign of chronic apical infection.
– Radiological examination: CT or NMP: localized opacity(ies) in the lower sinus floor “at sunset or sunrise”, sometimes multiple polylobed.
7- Bilateral maxillary sinusitis:
- They represent diagnostic traps because they preferentially guide the search for a field pathology.
8- Recurrent forms:
- They result from ignorance or non-sterilization of the dental focus or the presence of an ectopic tooth.
9-Traumas:
Acute maxillary sinusitis due to superinfection of an intrasinus hematoma can occur after intrasinus dental luxation. These are:
– Accidents of upper germectomy in children
– Extractions of impacted wisdom teeth
– Excess root canal treatment
-Post-implant sinusitis
10- Specific sinusitis :
- Tuberculous and syphilitic maxillary sinusitis: exceptional
To be eliminated by:
*IDR with tuberculin, ECB in case of pus (KOCH BACILLUS)
*TPHA, VDRL, ECB in case of pus (pale treponema)
7. Oronasal-sinus communication (OSCB)
- This accident is closely related to the thickness of the bone separating the apex or the dental root from the sinus floor. It is frequent when the thickness is reduced (thin).
CBNS follows a breach of the sinus mucosa following:
– a surgical cause (tooth extraction, cystic enucleation, etc.)
- It manifests itself by:
- A reflux of oral air at the alveolus;
- The discharge of blood from the corresponding nostril.
- The carefully pushed foam probe sinks through the break-in.
- At mealtimes: rejection of food through the nose.
- It is highlighted by the VALSALVA maneuver. : take a deep breath, close the mouth, pinch the nostrils; exhale through the nose: air bubbles come out of the alveolus.
- Treatment of CBNS:
- If the sinus is healthy and the perforation is minimal, healing occurs within a few days.
- If the sinus is healthy and the perforation is significant: immediate autoplasty (hermetic closure)
- If the sinus is infected, it will be necessary to treat the sinus first, before closing it surgically.
1- Treatment of the dental cause
2- Sinus treatment:
* Medical treatment:
- General antibiotic therapy: Amoxicillin-clavulanic acid or quinolone-metronidazole combination for at least 10 days
- Oral corticosteroid therapy (less than 10 days).
- Nasal decongestants + nasal washing several times a day with physiological saline.
* Surgical treatment:
- Sinus puncture-lavage has been abandoned in favor of endoscopic surgery via the endonasal route (middle meatotomy).
- The Caldwell-Luc procedure is currently used in addition to middle and inferior meatotomy techniques to approach the lower sinus floor or its anterior and internal surface. It is a “mini-Caldwell-Luc” allowing the passage of an endoscope or instruments.
- Caldwell Luc intervention (intraoral trephination + lower meatotomy)
- Complications
1 – Oculo-orbital complications:
- Periorbital cellulitis;
- Orbital cellulitis;
- Orbital subperiosteal abscess;
- Intraorbital abscess;
- Thrombophlebitis of the cavernous sinus.
2 – Endocranial complications:
- Intracranial abscess;
- Meningitis;
- Subdural empyema;
- Cerebral thrombophlebitis;
- Cranial nerve damage.
Sinusitis of dental origin
- CONCLUSION :
- Any hasty decision, especially surgical, is likely to end in failure and probably in worsening of the previous condition.
- For this, a complete general local assessment and a sinus scan are often necessary for better therapeutic management.
Sinusitis of dental origin
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.