Retrospective comparison of first-line treatments for odontogenic sinusitis based on duration of symptoms| ACTA Otorhinolaryngologica Italica

Abstract

Objectives. To investigate the clinical efficacy of dental treatment and endoscopic sinus surgery (ESS), each primary/combined treatment modality, in patients with odontogenic sinusitis (ODS), according to its phase, acute or chronic.
Materials and methods. We retrospectively reviewed clinical data on 172 patients diagnosed with ODS. They were divided into two groups: acute (≤ 3 months; 90 patients) and chronic (> 3 months; 82 patients) ODS. The success rate and time to resolution of each primary/combined treatment modality were compared between the two groups.
Results. In both ODS groups, the success rate was highest with combined ESS and dental therapy, followed by ESS alone and dental therapy alone. ESS outperformed dental therapy (96.6% vs 65.5% for acute ODS, p = 0.011; 80.6% vs 56.5% for chronic ODS, p = 0.046) and led to quicker resolution of symptoms for acute ODS than dental therapy (0.9 vs 1.7 months, p = 0.012). In the comparison between ESS alone and combined therapy, no significant difference was observed for acute ODS, whereas combined therapy demonstrated a superior success rate for chronic ODS (100% vs 80.6%, p = 0.046).
Conclusions. In our study, the clinical utility of dental treatment and/or ESS depended on the morbidity period of ODS. For chronic ODS, combined ESS and dental treatment seems to be an effective first-line treatment.

Introduction

Odontogenic sinusitis (ODS) is an inflammatory condition of the maxillary or extended paranasal sinuses that has a dental aetiology ¹. The causes and mechanisms of ODS are diverse. Major predisposing factors include periapical and periodontal lesions, such as cysts or abscesses, as well as iatrogenic causes, such as tooth extraction, oroantral fistula (OAF), other dental procedure-related infections, implant use, or foreign bodies ^2-5.

Dental infection can spread from a tooth that is close to the floor of the maxilla into the sinus chamber through the adjacent maxillary alveolar bone ⁶. ODS frequently occurs when the sinus mucosal lining (Schneiderian membrane) is injured during dental procedures ⁷. The ODS diagnosis is often overlooked because of its relatively varied clinical course, non-specific symptoms, and lack of information on radiological characteristics. Untreated ODS may progress to pansinusitis or cause severe complications that are intractable or difficult to treat ^3,8-11. In an international consensus statement on ODS ¹², diagnostic criteria were proposed based on the clinical and microbiologic features of ODS. A strong consensus was reached regarding a multidisciplinary approach involving both otolaryngologists and dental providers.

The number of ODS cases is on the rise, reportedly owing to the increase in dental procedures, which is associated with the aging population ¹³. However, there is no consensus on first-line treatment for ODS ¹⁴. Rhinologists and dental care providers differ in opinion in terms of the optimal sequence of dental care and endoscopic sinus surgery (ESS) ^15,16. In our institution, there have been several cases in which primary dental or ESS treatment alone failed, requiring secondary treatment.

ODS treatment can pose distinct challenges compared to rhinogenic sinusitis because the histopathological inflammatory changes in ODS are more severe ¹⁷, and the predominant bacterial cultures in ODS tend to be anaerobic and polymicrobial ^6,12,18-23. Notably, Brook et al. ^20,23,24 have revealed that the predominance of bacteria in the acute and chronic phases of ODS differs considerably. In acute ODS, aerobic bacteria predominate, whereas, in chronic ODS, anaerobes outnumber aerobic bacteria ^6,23,25. Therefore, we deemed it worthwhile to consider treating ODS according to its duration, as is common practice for rhinogenic sinusitis. Generally, acute sinusitis is defined as signs or symptoms of inflammation having lasted less than 4 weeks, and chronic sinusitis as those having lasted more than 12 weeks ^26,27.

To our knowledge, there have been no attempts to classify ODS according to its duration or to apply different treatment options in acute and chronic subgroups ^1,27. We supposed that irreversibly blocked sinus drainage or pathologic changes could be a possible mechanism in the development of recalcitrant ODS. We hypothesised that chronic ODS tends to be resistant to treatment and requires radical treatment or a combination of treatments. The purpose of the present study was to investigate the treatment outcomes of dental treatment or ESS as first-line therapy for patients with ODS and to compare the clinical utility of each treatment in the acute and chronic phases of ODS.

Materials and methods

We retrospectively reviewed the medical records of patients diagnosed with ODS, periodontitis, unilateral sinusitis, or peri-implantitis at the Departments of Otolaryngology or Dentistry at our tertiary Hospital from January 2001 to December 2020. Based on CT scan analysis and clinical history, 210 patients were confirmed to have ODS by two specialists in otolaryngology, dentistry, or radiology (Fig. 1). The primary radiological characteristics included unilateral maxillary sinus opacity with one or more of the following:

1. periapical lucency (soft tissue density around the dental root), including loss of the lamina dura;
2. maxillary alveolar bone defect;
3. maxillary sinus floor elevation;
4. dental material, implant graft, or tooth displaced into the maxillary sinus.

Exclusion criteria were previous sinus surgery or trauma, definite OAF, or fungal sinusitis. In our cohort, 7 patients with previous surgery or trauma, 24 with an OAF, and 7 with concomitant fungal sinusitis were excluded, as these factors may have caused recalcitrance to treatment, which may have affected the outcome. A total of 172 patients were analysed for demographics, symptoms, physical examination results, CT imaging characteristics, treatment modality, clinical course, and follow-up period. Based on the diagnostic criteria for sinusitis ²⁶, the patients were divided into two subgroups: acute and chronic ODS. Chronic ODS was diagnosed when symptoms or objective results suggestive of sinusitis persisted for more than 3 months, whereas acute ODS was defined as a morbidity duration of ≤ 3 months. Although the conventional classification of sinusitis ²¹ designates 4 to 12 weeks of morbidity as the subacute phase, we assigned this period to the acute phase in our study to investigate the overall tendency of treatment outcomes in a large cohort. ESS was performed to decrease inflammation and open the natural drainage pathways of the sinuses that were opacified on CT. For antibiotic therapy, either amoxicillin-clavulanic acid (1250 mg/day) or levofloxacin (500 mg/day) was prescribed.

Endoscopy was performed in all patients, and physical examination outcomes included endoscopic findings, such as the presence of nasal purulent discharge, mucosal inflammation, nasal polyps, dental inflammation or pus, cheek swelling, and cheek tenderness, which were evaluated by a rhinologist or dentist. The severity of sinusitis was assessed using the Lund-Mackay (LM) score on CT. After dental or sinus surgery, physical examinations and clinical progress evaluations were performed at follow-up outpatient visits every 1-3 weeks until complete recovery.

Treatment outcomes were assessed in terms of the success rate of each treatment modality and compared between the two ODS subgroups. Treatment success was defined as a complete resolution of referred symptoms, no signs of inflammation upon follow-up physical examination including nasal endoscopy, and clear results from radiologic examinations such as CT/X-ray imaging. In cases in which the clinical course revealed no improvement or symptom recurrence throughout the follow-up period, or lesions were aggravated within 1 month after primary treatment, the treatment was considered a failure and second-line treatment was attempted. The clinical utility of the treatment modality was evaluated based on the overall success rate, resolution time, and total follow-up period.

Statistical analysis was performed using IBM SPSS (version 20.0). Specifically, the chi-square test was utilised for the comparison of dichotomous data (treatment success, symptoms, clinical factors, examination findings), the Mann–Whitney U test for non-parametric continuous data (age, symptom duration, CT score), and the independent t-test for parametric continuous data (resolution time, total follow-up period). Using Kaplan-Meier curves, clinical outcomes were analysed between the different treatment modalities used in each group. Differences between the Kaplan-Meier curves were assessed using the log-rank test. A difference with a p value < 0.05 was considered statistically significant.

Results

A total of 172 patients with ODS were included in our study for analyses on medical history, clinical course, and follow-up imaging characteristics (Tab. I). The mean age was 54.1 years, and 110 (64%) patients were men. The average duration of symptoms was 3.4 weeks in the acute ODS group and 17.9 months in the chronic ODS group. The LM score for all patients was 4.73 ± 2.09.

The most common aetiological factors of ODS were dental implants and graft material (45%), followed by periodontitis/periapical disease, including cysts and abscesses, tooth extraction, and root canal treatment.

Presenting symptoms varied, with purulent rhinorrhoea (55%) being the most common, followed by post-nasal drip, nasal obstruction, facial pain, foul odour, headache, dental pain, cheek swelling, and hyposmia.

The distribution of objective findings was as follows: nasal purulent discharge (73% of patients), mucosal inflammation (34%), and nasal polyps (6%) upon nasal endoscopy, dental inflammation or pus (23%), and cheek swelling (5%). The CT findings included the following: periapical abscess (84% of patients), alveolar maxillary bone defect (31%), maxillary sinus floor elevation (27%), and an implant or tooth displaced into the sinus (34%). Dental therapy performed to treat ODS included extraction of the implant graft or causative tooth (87%), root canal treatment (12%), surgical curettage (7%), and Caldwell-Luc surgery (7%). The time to resolution of ODS for all patients who were cured was 1.3 ± 1.4 months. The total follow-up period was 3.4 ± 2.1 months. No recurrences or serious complications were observed during the follow-up period for any patient.

In this study, 90 (53%) patients with acute ODS and 82 (48%) with chronic ODS were included. There were no significant differences in sex, age, history of smoking, or underlying diseases, including hypertension, diabetes mellitus, allergic rhinitis, and asthma between the two groups.

Regarding treatment outcomes, the overall success rate was higher in patients with acute ODS than in those with chronic ODS (91.1% vs 85.4%). In the acute ODS group, 18 patients had 4-8 weeks of full antibiotic medication alone, among whom the disease was resolved in 13 (72%); however, 5 (28%) patients were lost to follow-up after failure of the first treatment. In the acute ODS group, 29 patients received dental therapy as primary treatment along with 1-3 weeks of medication, among whom the disease was resolved in 19 (66%). Among the 10 (34%) patients who had persistent disease despite dental treatment, 2 were lost to follow-up, and the disease was resolved in the remaining 8 after undergoing ESS as a secondary treatment. Another 29 patients with acute ODS underwent ESS with 1-3 weeks of medication, among whom the disease was resolved in 28 (97%); the remaining patient (3%) exhibited no improvement and was lost to follow-up. The remaining 14 patients with acute ODS were all cured with concurrent ESS and dental treatment. In the chronic ODS group, 16 patients were treated with medication alone, among whom the disease was resolved in 10 (63%); however, the treatment failed in 6 (38%) patients who were subsequently lost to follow-up. Among the 23 patients with chronic ODS who received dental therapy as primary treatment along with medication, the disease was resolved in 13 (57%), while the treatment failed in 10 (43%), 3 of whom were lost to follow-up, 6 of whom were cured with ESS as secondary treatment, and 1 of whom was not cured despite secondary ESS. Among the 31 patients with chronic ODS who underwent ESS as the primary treatment modality, 25 (81%) were cured and 6 (19%) had to undergo dental treatment after ESS; among those 6, 4 were cured while the other 2 were lost to follow-up. The remaining 12 patients with chronic ODS were cured with concurrent ESS and dental treatment (Fig. 2).

Regarding subjective symptoms, the most common in patients with acute ODS was purulent discharge (58%), while post-nasal drip (56.1%) was the most common in patients with chronic ODS. Notably, more patients with acute ODS (41%) reported facial pain than those with chronic ODS (16%) (p < 0.05). The distribution of physical findings was similar in the two groups, and the most common finding was purulent discharge upon nasal endoscopy. In addition, the distribution of the cause of ODS, CT results, and LM score were similar in the two groups.

Dental treatment was provided to 43 patients in the acute ODS group and 39 in the chronic ODS group. Of note, saucerization and simple dental curettage were performed in five patients (12%) in the acute ODS group and one patient (3%) in the chronic ODS group. On the other hand, Caldwell-Luc surgery, which requires general anaesthesia, was performed more frequently in the chronic ODS group (10%) than in the acute ODS group (5%).

For patients who underwent successful treatment, the duration to complete cure was 1.2 ± 1 months in the acute ODS group and 1.5 ± 1.8 months in the chronic ODS group. The mean total follow-up for the acute ODS group was 3 ± 1.8 months, and that for the chronic ODS group was 3.8 ± 2.4 months. There was no significant difference in the overall resolution and follow-up times between the two ODS groups.

In the present study, in both ODS groups, the success rate of treatment was highest with concurrent ESS and dental therapy, followed by ESS, dental therapy, and medication alone. In particular, in the comparison between ESS and dental therapy, the higher success rate (96.6% vs 65.5% in the acute ODS group, p = 0.011; 80.6% vs 56.5% in the chronic ODS group, p = 0.046; 88.3% vs 61.5% overall) and faster resolution time (0.9 vs 1.7 months in the acute ODS group, p = 0.012; 1.4 vs 2.2 months in the chronic ODS group, p = 0.45; 1.2 vs 1.9 months overall, p = 0.041) with ESS suggests that it is the better option among the two, considering that there was no significant difference in the total follow-up period (2.9 vs 2.8 months in the acute ODS group, p = 0.92; 3.9 vs 4.3 months in the chronic ODS group, p = 0.99; 3.3 vs 3.4 months overall, p = 0.93) (Fig. 3). Notably, in the comparison between ESS alone and ESS combined with dental therapy, there was no significant difference in the acute ODS group, while concurrent ESS with dental therapy yielded better results in the chronic ODS group than ESS alone, with a higher success rate and no significant difference of resolution time (100% vs 80.6%, p = 0.046 and 1.1 vs 1.4 months, p = 0.523 respectively) (Figs. 2, 4).

Discussion

In our study, we assessed the clinical utility of dental treatment and ESS in acute and chronic ODS, and treatment outcomes were dependent on morbidity periods and treatment modalities. The overall success rate was higher with acute ODS than with chronic ODS, and the overall success rate was highest with concurrent ESS and dental therapy, followed by ESS alone, dental therapy alone, and medication alone. Compared to dental treatment alone, ESS alone was associated with a higher success rate, shorter resolution time, and shorter follow-up period. Notably, in the chronic ODS group, the combination of ESS and dental treatment exhibited the best clinical utility as a first-line treatment, followed by ESS alone and dental treatment alone. In patients with acute ODS, on the other hand, we suggest ESS as the initial treatment, because there was no significant difference in success rate between patients who underwent ESS alone and those who underwent concurrent ESS and dental treatment, with the latter having a longer mean follow-up period (4.3 vs 2.9 months) and the disadvantage of multiple surgical sites involved.

There are no established guidelines and no standard treatment protocols for ODS. Previous reports vary in terms of treatment regimens and preferences ^12,15. Many previous researchers have recommended dental surgery as the primary treatment for ODS, based on the theory that removal of the source of infection should be prioritised. Longhini et al. ¹⁵ conducted a case series of 21 patients with ODS and reported successful treatment with dental surgery alone for 19. In a study by Wang et al. ²⁸, of the 21 patients cured, 7 (33%) had undergone ESS alone and 7 (33%) had undergone concurrent ESS and dental therapy. However, as the authors speculated that patients with ODS that resolved without dental surgery may have had a lower grade of sinusitis, they still recommended dental surgery as the first-line surgical treatment. The authors suggested performing ESS as subsequent treatment if the patient failed to improve sufficiently after dental surgery. In another study, conducted by Yoo et al. ²⁹, among 33 patients with ODS, two-thirds were cured with dental treatment and medical management without ESS. Patients who were smokers and had severe CT results tended to require ESS because of failure of dental treatment. However, their study design was limited to patients with ODS caused only by periapical abscess or dental caries, excluding other causes such as dental implants, trauma, surgery, or tooth extraction.

In contrast, several recent studies have revealed that ESS may be a more effective first-line treatment for ODS. Two meta-analyses ^30,31 demonstrated a high overall success rate for ESS in treating ODS, consistent with our results. Craig et al. ¹⁶ conducted a prospective study of 37 patients with ODS. In their study, primary ESS resulted in faster resolution of the 22-item sinonasal outcome test (SNOT-22) results, sinusitis symptoms, and endoscopic findings than did primary dental treatment. However, they did not evaluate the overall success rate for different treatment sequences, because of the limited sample size. Our study differs from previous studies in that we subdivided patients with ODS according to the duration of morbidity and aimed to analyse the clinical efficacy of either dental surgery or ESS as the primary treatment for ODS in each subgroup.

Furthermore, regarding the initial treatment in the acute phase of ODS, we observed differences in treatment outcomes for non-odontogenic acute sinusitis. Guidelines for acute rhinosinusitis ²⁶ generally advocate a policy of ‘watchful waiting’ combined with symptomatic therapy as an initial management strategy, and antibiotic therapy is recommended if symptoms worsen or persist for more than 7 to 10 days. In a large prospective study of patients with acute sinusitis by Blin et al. ³², initial treatment was successful in 96.2% of the patients in which antibiotics had been prescribed, and the disease spontaneously resolved in 88.7% of patients who were not prescribed antibiotics, which is contrary to our relatively low treatment success rate with antibiotic therapy alone for ODS. Several studies have emphasised the unique microbiological features of ODS. Belibasakis et al. ^21,22 reported that ODS tended to be polymicrobial owing to its dental origin, and anaerobes outnumber aerobes in many ODS cases. Zirk et al. ¹⁸ analysed the harvested bacteria from 121 patients with ODS who underwent surgery and discovered that Pseudomonas aeruginosa infection was significantly associated with misplaced foreign bodies (root filling, augmentative dental material), as well as anaerobic dominance, with 45 anaerobes versus 19 aerobes. However, there has been little research on the change in the profile of microbiological flora of ODS according to the phase; Brook et al. ^20,23-25 reported that the ratio of anaerobes and aerobes in ODS cases indeed depends on the phase of the ODS infection. We supposed that the period of morbidity is positively correlated to the formation of a bacterial biofilm or pathological changes, as well as blockage of natural drainage pathways, which could be a possible mechanism in the development of recalcitrant ODS.

In our clinical experience, the treatment outcome of ODS may be unpredictable and it is commonly intractable, requiring a multidisciplinary approach and an efficient treatment regimen that differs from that for non-odontogenic sinusitis. The ability to predict which patients with ODS would benefit from ESS, dental treatment, or both, may increase the clinical efficacy of ODS treatment, assisting clinicians in decision-making and consultation with the patient. Felisati et al. ³³ examined a multidisciplinary approach to address sinonasal complications arising from dental procedures. Those were subdivided into three groups: preimplantological, implantological, and classic dental treatments. Subsequently, they introduced a new classification system based on sinonasal conditions and dental pathogenesis. The majority of patients (254/257 or 98.8%) responded successfully to the proposed surgical treatment protocols. Fadda et al. ⁸ employed that classification system and protocol in the treatment of sinonasal complications resulting from dental disease and procedures. In their study of 31 patients, 16 (52%) were treated with ESS, 3 (10%) with an intraoral approach, and 12 (39%) using a combined approach. Their study underscored the importance of a combined approach when the maxillary alveolar process is affected by infectious diseases such as osteitis, osteomyelitis, peri-implant pathology, periapical lesions, maxillary sinus lift complications, or oroantral fistula/communication ^8-10. Their research also revealed that 51% of patients exhibited maxillary sinusitis associated with anterior ethmoid sinusitis and 13% with anterior ethmoid sinusitis and frontal sinusitis, highlighting the need for close collaboration among implantologists, maxillofacial/oral surgeons, and otorhinolaryngologists.

To the best of our knowledge, no published studies have clearly demonstrated the treatment outcome of ODS based on the phase of infection, and this is the first analysis of the clinical utility of dental treatment or ESS as primary treatments according to the acute and chronic phases of ODS.

The present study has several limitations. First, it had a retrospective design, leading to possible information bias, inaccurate recall, and an inability to control variables. Hence, further randomised prospective studies are needed. Second, the heterogeneity within our sample might have limited comparability between patients. Moreover, given our relatively small sample size, the rate of patients lost to follow-up is notable (19 of 172 patients, 11%) and might have influenced our study outcomes. Further multicentre studies are needed to more accurately evaluate the utility of different treatment modalities for ODS in a clinical setting. Research is also required on racial and cultural influences on the incidence of ODS and treatment regimens. In addition, our study did not collect detailed information on the medication type or steroid use, and we did not employ established assessment tools like visual analogue scale or SNOT-22 scale to evaluate symptom improvement. Lastly, we adopted the terms “acute” and “chronic” based on duration of symptoms, according to standard rhinogenic sinusitis terminology. However, this distinction is not universally accepted in the broader ODS literature ^11,12 and should be interpreted in the context of our study.

Conclusions

In our study, the clinical utility of dental treatment and/or ESS depended on the morbidity period of ODS. For chronic ODS, combined ESS and dental treatment seems to be an effective first-line treatment. Classification of ODS according to the acute or chronic phase may be useful for treatment, as it is for rhinogenic sinusitis.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

KWK: data curation, methodology, analysis, interpretation, visualization, writing – original draft. JWG: data curation, analysis. Y-SC: methodology, project administration, writing – review and editing.

Ethical consideration

This study was approved by the Institutional Ethics Committee of Asan Medical Center (2021-0922). The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.

Figures and tables

Figure 1.CT findings (A) and nasal purulent discharge (B) upon nasal endoscopy suggestive of left maxillary odontogenic sinusitis.

Figure 2.Treatment outcomes of acute and chronic ODS.

Figure 3.Kaplan-Meier curves representing (A) time to resolution in the acute ODS group (p = 0.012*); (B) follow-up periods in the acute ODS group (p = 0.92); (C) time to resolution in the chronic ODS group (p = 0.45); and (D) follow-up periods in the chronic ODS group between patients receiving dental treatment and those receiving ESS (p = 0.99).

Figure 4.Time to resolution of acute and chronic ODS.

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