Odontogenic Sinusitis Management: Insights From a Retrospective Analysis

Unilateral maxillary sinus disease is a presentation frequently encountered in rhinology clinics, and it requires a thorough consideration of potential aetiologies. Tumours, fungal balls and notably, odontogenic sinusitis (OS) emerge as significant differential diagnoses in individuals presenting with unilateral sinus conditions. Notably, OS accounts for an estimated 30% of such cases [1]. OS is characterised by maxillary sinus infection linked to adjacent dental pathologies or procedures. The prevalence of OS has increased, attributed to the rise of invasive dental implant procedures [2]. The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 guidelines [3] recommend considering OS in patients with localised rhinosinusitis, particularly those with a history of dental infection, surgeries or resistance to conventional sinusitis therapy. Diagnosis necessitates comprehensive dental and clinical evaluations, including appropriate imaging. While medical and dental care are crucial for managing OS, there is ongoing debate about the appropriate surgical approach and timing of dental, surgical and medical treatment. The lack of a gold standard practice raises conflicting opinions among clinicians on the need for surgery, the timing of dental treatment in relation to sinus surgery, and the extent of surgical intervention. This retrospective study aims to share the experiences concerning the treatment of patients affected by OS. This was an audit of local practice and therefore ethical approval was not required. The CARE checklist was adhered too in reporting. The retrospective study scrutinised the management protocols for OS at Portsmouth University Hospital trust which is a district general hospital in the United Kingdom (UK). The focus of the study was on patients who underwent unilateral functional endoscopic sinus surgery (FESS) in the ear, nose and throat (ENT) department over a 32-month period; January 2020 to September 2022. A systematic approach was employed to collect data. The inclusion criteria required confirmation of chronic OS, defined as the persistence of symptoms for more than 12 weeks despite optimal medical treatment, through clinical examination or computerised tomography (CT) imaging. To maintain the study's focus on OS, exclusion criteria were applied to omit cases unrelated to this condition, including acute or chronic rhinosinusitis of non-odontogenic origin. Cases without clinical or imaging findings on CT that supported a diagnosis of OS were also excluded. Table 1 provides a summary of the inclusion and exclusion criteria. Post-operative information was gathered via telephone consultations at 6-to-12-months following surgery. The study included 50 patients, comprising 24 males and 26 females, with a mean age of 58 years. Of these, 48 surgeries (96%) were performed as day-case procedures. Preoperative clinical examinations revealed mucopus in 27 cases, polyps in 8 cases, and a combination of pus and polyps in 5 cases. Erythema or congestion was noted in three cases, and five cases showed no abnormalities. In two cases, documentation of clinical findings was unavailable. All patients underwent CT imaging of the sinuses, which confirmed unilateral maxillary sinus disease with associated dental pathology in all cases. One patient exhibited an oroantral fistula, although none had dental implants within the affected sinus. CT findings also revealed partial frontal sinus opacification in 22 cases, complete frontal sinus opacification in 5 cases and no frontal sinus opacification in 21 cases. Treatment modalities varied widely preoperatively, ranging from antibiotics alone to combinations of intranasal corticosteroids, oral steroids and sinus rinses. (Table 2) Postoperative management commonly involved a combination of sinus rinses, intranasal corticosteroids and oral antibiotics (Table 3). Surgical intervention consisted exclusively of FESS without formal frontal dissection. The predominant form of FESS performed in our unit was characterised by uncinectomy with middle meatal antrostomy (MMA). Further insights into the extent of surgical procedures are provided in detail in Table 4. Dental evaluation and treatment played a critical role in outcomes. Of the 23 patients referred to maxillofacial teams or dentists, 19 underwent preoperative dental work. Among these, 90% reported significant improvement or resolution of symptoms following FESS. In contrast, 76% of patients who did not receive preoperative dental work reported similar outcomes, highlighting the importance of addressing dental pathology in managing OS. Postoperative follow-up, conducted via telephone consultations 6–12 months after surgery, revealed that 39 patients (78%) experienced significant improvement or resolution of symptoms. However, eight patients reported persistent symptoms or no improvement, with six of these cases lacking preoperative dental treatment. Of these eight patients, five were awaiting revision surgeries. Detailed analysis of these cases suggested a variety of contributing factors to the lack of symptom resolution, as summarised in Table 5. Three patients were unresponsive to follow-up attempts. This study has revealed that most patients experience resolution following limited FESS surgery, in the form of uncinectomy with MMA without formal frontal dissection even in the presence of frontal opacification. Dental management can be undertaken either prior to or following FESS; however, our data indicate that outcomes are improved when it is performed beforehand. This study underscores the importance of expedited limited surgery, rather than delaying surgery for further medical management (intranasal corticosteroids and antibiotics) in patients with established OS. It offers a high likelihood of symptom resolution, particularly in those motivated to address their underlying dental cause. As this study was conducted as a retrospective audit, post-operative scanning was not possible. It focussed on patients necessitating surgery and therefore may have missed some patients managed purely through medical therapy or dental treatment alone. There was no standardisation of pre-operative therapy prior to this study, however since this study, a departmental algorithm has been implemented to standardise care. The strength of this study lies in its ability to assess a large cohort of patients and provide a comprehensive overview of OS management. It has highlighted the importance of pre-operative dental management which increased the resolution of symptoms from 76% to 90%. It reveals the ineffective nature of oral antibiotic or topical therapy to resolve established OS. It highlights the benefit of limited FESS surgery, aimed at opening the maxillary sinus and clearing the middle meatus, as a means of decompressing and resolving infection, restoring normal function without the need for more complex frontal sinus dissection, which is often technically demanding in acutely inflamed and infected sinus cavities. The literature reports varying success rates with medical and dental treatment alone, ranging from 21% to 72%, with a notable portion of patients ultimately necessitating endoscopic sinus surgery [4]. The effectiveness of FESS in managing OS is well-established [5-7]. Several studies suggest the potential effectiveness of endoscopic sinus surgery as a standalone treatment for managing OS; however, these findings are limited to retrospective cohort studies, with reported success rates as low as 33% [4, 6, 8]. FESS is generally recommended when the osteomeatal complex is blocked and the thickened mucosa's height exceeds one-half of the maxillary sinus on CT [6]. Dental input remains crucial for addressing underlying dental pathology, and there are studies which explore this as the primary mode of treatment. Yoo et al. [9] conducted a study noting that 67% were effectively treated with dental procedures alone, while the remaining required FESS. Another retrospective study by Bacci et al. [10] concludes that the therapeutic efficacy of a minimally invasive intraoral approach alone is comparable to a combined endoscopic and intraoral approach for managing chronic OS. However, when endoscopic sinus surgery is combined with targeted dental treatment, the disease is expected to resolve in 90%–100% of patients [5, 7]. The specific extent of sinus surgery required for symptom relief remains uncertain and there is insufficient evidence on this topic. Our findings, demonstrate successful alleviation of symptoms in patients who underwent limited FESS without formal frontal dissection or prior dental treatment, which is more relevant recently due to the limitations in accessing community dental care. Undertaking all odontogenic cases jointly with maxillofacial is not feasible in our institution, therefore we take a pragmatic approach of advising community dental management whilst awaiting FESS surgery, with maxillofacial referral only in those with persistent severe dental disease, dental implant-related OS, or in the development of a draining oroantral fistula, which in our experience is rare. In summary, our retrospective analysis provides valuable insights into the role of limited FESS in the management of OS, especially in contexts where access to dental care is delayed. Our findings reaffirm the effectiveness of limited FESS, without frontal dissection, in managing OS, particularly when combined with preoperative dental treatment. Looking ahead, it is evident that personalised treatment strategies and a multidisciplinary approach are crucial for improving outcomes in patients with OS. Shayan Shahidi made substantial contributions to the design of the study, analysis, interpretation of the data. Musharrat Tasnuva Zaman Mim and Lima Gharbawi contributed to data curation. Tim C Biggs, Stephen M Hayes and Harish Viswanathan made substantial contributions to the conceptualisation, design of the study and interpretation of the data. All authors have read and approved the final version of the manuscript. All authors contributed to drafting the work, revising it critically for important intellectual content and approved the final version. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Shayan Shahidi affirms that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.