How to treat odontogenic sinusitis?

Odontogenic sinusitis is one of the most atypical forms of maxillary sinusitis. Its peculiarity is that it has nothing to do with the respiratory and, in general, the cold pathway of penetration of the pathogen. The infection enters the sinus not through the anastomosis, but through a thin bridge between the paranasal chamber and the oral cavity. Treatment of odontogenic sinusitis is performed jointly by an otolaryngologist and a dentist.

The causes of the development of the disease and its types

Odontogenic sinusitis is an inflammatory process of the mucous membranes of the adnexal chambers of the nose, which develops as a result of the transition of infection from a diseased tooth in the upper jaw. There may be several reasons:

Dentist error while placing the filling. The roots of the chewing teeth of the upper jaw are often located close to the maxillary sinus, sometimes even protruding into it. Sometimes an inexperienced doctor, while cleaning and filling the dental canal, can bring a part of the filling material into the air pocket through it. A filling outside the tooth is identified by the body as a foreign body, and a defense mechanism is triggered, which provokes an inflammatory process.
Unsuccessful extraction of a diseased tooth. During tooth extraction, part of the root can break off and penetrate into the accessory pocket. If the root protrudes into the sinus, then after removal a fistula is formed, which becomes a gateway for the spread of pathogens from the oral cavity. Poor-quality implant installation can end the same way.
Insufficient oral care. Most people do not pay enough attention to dental care, limiting themselves to daily brushing. Because of this, dental diseases develop, which can worsen at any time. The desire, when unpleasant symptoms appear, to delay the trip to the dentist until the last can end in sinusitis, especially if the nerve is affected.

Diseases of the teeth that can cause odontogenic sinusitis:

deep advanced caries or pulpitis of the upper premolars and molars;
suppuration of a dental cyst;
periodontitis;
periodontal disease;
osteomyelitis;
a tumor that destroys the sinus wall.

The causative agent is mainly a mixed microflora of the oral cavity (streptococci, enterococci, staphylococci, diplococci, various bacilli). The disease can be acute, subacute and chronic. Dental sinusitis with or without perforation of the sinus wall is also distinguished.

The disease may not develop immediately after the unsuccessful intervention of the dentist; the process can start both in a few days and six months after the extraction of a tooth or the installation of an implant.

Development stages and main symptoms of the disease

Dental sinusitis affects adults, since the dental roots in children are small and do not reach the lower wall of the sinus. Most often, this type of sinusitis is unilateral, only the cavity in contact with the diseased tooth is affected. Before the onset of the disease, a person often feels pain or inflammation in the area of the alveolar ridge, which may indicate the spread of pathogenic bacteria.

This type of maxillary sinusitis goes through two stages of development:

serous, in which there is acute inflammation, vasodilation, tissue edema and fluid filling of cells;
purulent, when mucus accumulates, pus and intoxication of the body appear.

An ailment in an acute form is distinguished by the following characteristic symptoms:

Congestion (usually one-sided) and difficult nasal breathing.
Discharge from the nose is at first watery and transparent, later - with an admixture of pus, has an unpleasant odor.
The pain can cover both the entire head and its individual parts (gum, eye, tooth, cheek), it is aching dull in nature.
Fever, high temperature (up to 39 degrees), sometimes photophobia, lacrimation.
General weakness, sleep disturbances, lack of appetite.
Sore teeth when chewing food.
Inflammation of the gums, the presence of small ulcers on them.
Putrid odor from the mouth.
Swollen lymph nodes.
Smell disorder.
Swelling of the cheeks in the area of the affected chamber.

In the case when the treatment was insufficiently qualified, and the source of infection (affected tooth, filling material) was not removed, then a chronic form of sinusitis develops. It is characterized by frequent pain in the infected tooth, increased fatigue, and decreased performance. Sometimes headaches, purulent discharge from the nasal passages, deterioration of smell, a feeling of congestion are manifested. This type of disease can recur from hypothermia, respiratory diseases, and other pathologies. Often the chronic form of dental sinusitis is almost asymptomatic.

Dental sinusitis diagnostics

Both an otolaryngologist and a dentist who detects signs of periodontitis, a cyst of the tooth root, or the presence of inflamed tissue around the implant can identify signs of sinusitis, which is a consequence of problems in the oral cavity.

After interviewing the patient and collecting anamnesis, the ENT performs a series of actions to establish an accurate diagnosis. In doing so, he chooses procedures based on the indications and the availability of the necessary equipment in the hospital.

Palpation of the cheeks in the area of the affected sinus causes severe pain.
Rhinoscopy shows swelling of the lower and middle part of the nasal cavity from the side of the affected accessory pocket, sometimes pus mixed with mucus is seen.
Radiography (sighting or panoramic) shows darkening in the affected chamber and a diseased tooth.
Computed tomography allows you to make out the presence of foreign objects in the sinus.
Endoscopy is used in cases where computer methods do not allow to recognize the true picture of the disease. A thin endoscope is inserted through the anastomosis or perforated sinus floor and provides detailed information about the ongoing process.
Puncture (therapeutic and diagnostic or diagnostic) with the subsequent direction of the contents of the chamber for bacteriological analysis.
A blood test (general) indicates an increased ESR and neutrophilic leukocytosis.

Sanitation of the oral cavity as the first stage of treatment

Treatment of odontogenic sinusitis consists of two main mandatory stages: elimination of the primary source of infection and subsequent treatment of inflammation in the air pocket. This requires constant cooperation of specialists from the otolaryngology and dental departments of the hospital. If there is no such cooperation, then it may happen that not all the necessary measures are taken, and the threat of re-development of the disease remains.

First, the oral cavity is sanitized, which may include:

Excision of a cyst or granuloma from a tooth root.
Removing the implant.
Removal or treatment of a diseased tooth. Most often, despite the patient's desire to save the tooth, it is removed, since even the most modern treatment cannot guarantee the complete destruction of pathogens in the root canals, nerves and surrounding tissues. Unsuccessful treatment will cause new outbreaks of infection and long-term retreatment.
Opening the abscess and providing the necessary drainage for osteomyelitis or periostitis.

If there is a perforation after tooth or implant extraction, it must be closed to prevent bacteria from crossing between the voids. As a rule, such fistulas are closed with mucous membranes from the oral cavity.

Conservative therapy for dental sinusitis

After the completion of the oral cavity sanitation process, further treatment is carried out by an otolaryngologist. If the inflammatory process in the accessory pocket is limited to swelling of the mucous membranes, then with such odontogenic sinusitis, treatment is carried out with antibiotics, injection of drugs and regular washing.

Antibiotic therapy. Antibiotics are selected by the attending physician on the basis of bacteriological culture data or empirically, taking into account data on the main pathogens noted in the region. Most often, the choice comes down to respiratory fluoroquinolones or protected penicillins. Generally acting drugs such as Amoxicillin, Augmentin, Sumamed, Ceftriaxone are prescribed. Topical antibiotics are usually given during a puncture.
Decongestants. With nasal congestion, local vasoconstrictor agents are prescribed in the form drops and sprays (Galazolin, Naphtizin, Rinazolin, Tizin, Oxymetazoline). They are injected only into the nasal passage that is laid.
Antihistamines. They are used in systemic therapy to reduce swelling of the mucous membrane (Loratadin, Suprastin, Diazolin).
Antiseptic and antibacterial agents in the form of drops and irrigation of the nasal passages (Miramistin, Bioparox, Izofra, Polydex).
Flushing of the nasal cavity and air pockets using the method of intermittent pressure (YAMIK catheter) or the movement of fluids ("cuckoo"). These procedures are carried out in medical institutions under the supervision of specialists. The only exception is the presence of a foreign object in the sinus. The usual home rinses do not work well.
Physiotherapy procedures promote faster and more effective recovery of epithelial tissues. UHF therapy, electrophoresis, salt and phototherapy are used.

Surgical treatments for odontogenic sinusitis

Often, conservative therapy for dental sinusitis does not give the desired effect. It is for this form of sinusitis that surgical intervention is characteristic to cleanse the mucous membranes and remove foreign objects.

Maxillary sinus puncture for dental sinusitis it is necessary in most cases. The puncture ensures the removal of the accumulated purulent exudate and the delivery of the necessary therapeutic solution from the antibiotic, antiseptic and enzymes directly to the address. Despite the notoriety, a puncture using a Kulikovsky needle under local anesthesia is practically painless. The patient feels only a short-term unpleasant feeling of fullness from the inside of the chamber during the injection of fluid into it. Fluid with mucous accumulations is removed through the mouth.

In most cases, several punctures in combination with drug therapy are enough to overcome the disease. However, the puncture also has its weaknesses, so a number of specialists are skeptical about its capabilities. With it, it is impossible to remove altered tissues (cysts, polyps), fungal masses or foreign bodies (breakaway parts of the root, filling material) from the sinus. Puncture followed by flushing helps only if the mechanisms of natural sinus cleansing are preserved, otherwise a more serious operation has to be done.

Radical surgical intervention. Removal of pathological tissues and foreign objects is performed using an operation from the oral cavity. This method has been used in various variations for over a century, but it is very traumatic and has many complications. At the same time, the patient falls out of the usual rhythm of life for a long time.

An incision is made under the upper lip from the second molar to the lateral incisor. After opening the mucous membranes, part of the sinus wall is removed. Through the resulting hole, a foreign body is removed, and the pathologically altered mucous membrane is scraped out with special surgical instruments. A hole is made through the nose in the front wall of the chamber to drain the contents, a gauze turunda soaked in an antiseptic is inserted into it. After completing all the manipulations, the doctor applies stitches.

Endoscopic surgery has a number of advantages over the radical method. It is carried out through the natural connecting canal (anastomosis) or through the hole formed when the affected tooth is removed. Both local anesthesia and general anesthesia can be used. Thin endoscopes and special instruments make it possible to cleanse the sinus, practically without damaging healthy tissue, through tiny accesses. As a result, they are safer than open surgeries and are much easier to tolerate by patients. Hospitalization for endoscopic surgery lasts one day, after which the patient is only regularly monitored by a doctor.

Refusal of surgery for odontogenic sinusitis can threaten with serious complications, such as:

inflammation of the frontal and sphenoid sinuses;
gum abscess;
the appearance of abscesses in the soft tissues;
phlegmon of the orbit of the eye;
proliferation of tissues (polyps and cysts) in the accessory pocket with their possible degeneration into malignant neoplasms;
meningitis;
purulent brain damage.