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Odontogenic Sinusitis Treatment

Author Julia Casazza covers Odontogenic Sinusitis Treatment on BackTable ENT

Julia Casazza • Nov 8, 2023 • 37 hits

Treatment of odontogenic sinusitis (ODS) reflects the disease’s interdisciplinary nature. A combination of tooth extractions, antibiotics, and sinus surgery are needed to treat odontogenic sinusitis. ODS is one of the most satisfying sinus pathologies to treat; appropriate diagnosis and management will resolve 95% of cases. BackTable contributor and rhinologist Dr. John Craig shares how he manages this unique condition.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Odontogenic sinusitis is not a subtype of chronic rhinosinusitis. Rather, it is sinusitis that results from dental infection or dental procedures.

• Patients with an identifiable source of infection should undergo tooth extraction, which, in cases of isolated maxillary disease, can be curative. Patients without an identifiable source of infection are started on sinus rinses and a short antibiotic course.

• Unilateral maxillary antrostomy is indicated in patients whose symptoms persist following dental extraction or antibiotic treatment. Upfront sinus surgery is also appropriate in patients with an elevated symptom burden.

• Amoxicillin-clavulanic acid (or clindamycin for patients with penicillin allergies) is Dr. Craig’s antibiotic of choice for odontogenic sinusitis treatment.

Odontogenic Sinusitis Treatment

Table of Contents

(1) Odontogenic Sinusitis Definition

(2) First-Line Management of Odontogenic Sinusitis

(3) Surgery for Odontogenic Sinusitis

Odontogenic Sinusitis Definition

Odontogenic sinusitis (ODS) is maxillary sinus disease arising from dental infection or as a consequence of dental procedures. 90-95% of the time ODS is unilateral. ODS can extend into other sinuses, most commonly the frontal and anterior ethmoid sinuses. The posterior ethmoid and sphenoid sinuses are less commonly involved.

Though sometimes mistakenly linked, chronic rhinosinusitis (CRS) and ODS represent two distinct disease processes. Unlike CRS, in which cultures grow respiratory flora, ODS is associated with oral flora, such as oral anaerobes and alpha-hemolytic streptococci. Further, ODS is not associated with defective mucociliary transport.

[Dr. Ashley Agan]
Starting out, let's just set the stage with terminology overview, when you're speaking of odontogenic sinusitis, comparing it to other forms of chronic rhinosinusitis or acute sinusitis, and how do you think about that?

[Dr. John Craig]
Yes, it's so critical, but until recently, we didn't have just a simple definition. What we've tried to be consistent with in recent studies, both consensus statements, there's a treatment consensus and a diagnostic consensus out there. Here's the definition. Bacterial maxillary sinusitis, with or without extension to other paranasal sinuses, secondary either to adjacent infectious dental pathology or following complications from dental procedures. It's a mouthful, but it covers all the different etiologies that cause dental-related sinusitis. We're trying to be all-inclusive and make sure we're not forgetting about all the different types.

Now, I believe you said how to compare it or contrast it to rhinosinusitis. It is distinct. It is not chronic rhinosinusitis. I think this is a problem in older literature. It almost talks about it like it's a subtype of rhinosinusitis. This is completely different. It's a secondary sinusitis caused by, like we said, dental pathology or dental complications from procedures. We really just have to keep distinguishing it. What are some clinical differences? For one, this is a condition that's almost always unilateral. Very simple distinguishing point. Most rhinosinusitis is bilateral.

90% to 95% of ODS is going to be unilateral. We mentioned that it's distinct from the standpoint of it being from oral or dental bacteria. Another distinct point is that there's no deficiency in mucociliary function. It's been shown in multiple histopathologic studies. The mucociliary function is presumably intact as opposed to some forms of rhinosinusitis where it might be distorted. We know that there's different microbiology behind this. We mentioned dental and oral bacteria. That's been shown in multiple studies, including one from us, just that oral anaerobes and oral alpha hemolytic strep species, for instance, like strep intermedius, strep constellatus, are definitely more common in ODS.

Listen to the Full Podcast

Odontogenic Sinusitis with Dr. John Craig on the BackTable ENT Podcast)
Ep 126 Odontogenic Sinusitis with Dr. John Craig
00:00 / 01:04

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First-Line Management of Odontogenic Sinusitis

Odontogenic sinusitis treatment includes a combination of sinus rinses, antibiotics, and procedural/surgical intervention. All patients with ODS benefit from sinus rinses to flush out pus. Patients without a treatable dental pathology (e.g. a diseased tooth) need antibiotic therapy. Dr. Craig likes to treat these patients with a ten day course of amoxicillin-clavulanic acid (or clindamycin for patients with penicillin allergies). Patients with treatable dental pathology should see a dental provider for tooth extraction as appropriate. When disease is limited to the maxillary sinus, symptoms should resolve within two months of the dental intervention. For patients with disease beyond the maxillary sinus, dental work alone will not resolve disease and surgery should be considered following tooth extraction.

[Dr. Gopi Shah]
What antibiotics do you like?

[Dr. John Craig]
It's awesome when they don't have penicillin allergies, then it's simple, it's Augmentin all the way. I work with infectious disease as well as dental providers on this point, and we all agree that's a great go-to. If they have a penicillin allergy, you'd like to think clindamycin. Great, covers anaerobes, gram-positives. Unfortunately, at least at Henry Ford, we have a pretty high rate of clindamycin resistance. If you don't have that, then I would go to clinda. If you do have a concern about clindamycin resistance, a lot of places will give Flagyl, but then you usually have to combine that with something that covers gram-positives. That's why I'm saying it's nice when they don't have a penicillin allergy because I've talked to ID and they're between azithromycin, for instance, plus Flagyl, or maybe a tetracycline sometimes, but I won't give any more information on that.

[Dr. Ashley Agan]
Is this like a 10 to 14-day type of course, or do you need to do like a 21-day that we think of with CRS because most of these are pretty indolent?

[Dr. John Craig]
I know. We don't have that answer either, but I know for our study, we're doing 14 days. There are some studies showing that three weeks is usually futile in CRS, so we just shortened it to two, but relatively arbitrary there.



[Dr. Gopi Shah]
Do you have them do sinus rinses because there's sinusitis there and that's what we do is to tell patients to rinse?

[Dr. John Craig]
Yes, I usually do. Just symptomatic relief. Pretty much, everybody with sinus issues, I'll offer sinus irrigations. Again, for this problem, there's usually such edema and pus in that middle meatus. I don't think you're doing anything more than just flushing out temporarily the pus that's straight into the nose, but it's not penetrating the sinus.

[Dr. Ashley Agan]
When you know that this is an odontogenic sinusitis, you're talking to your patients and you're like, "we're going to do antibiotics and we're going to have you do some rinses and we're going to have the endodontist," do you go ahead and talk about surgery? Because as you alluded to, especially these patients that have non-treatable sinusitis or they don't have a disease tooth anymore, it sounds like the likelihood of having surgery is very high. Are you already talking about that because you are anticipating that this isn't going to get better with antibiotics alone?

[Dr. John Craig]
Yes, I'm also sort of biased because of what I've been studying, but I have extensive convos with them about whether they have treatable or non-treatable dental pathology. Then we talk about the benefits and risks of upfront sinus surgery versus dental treatment. I think the tough thing is, in the literature, if you look at the largest studies, the average success rate for resolving odontogenic sinusitis with a dental extraction, on average, there's some higher, some lower, but it's about 60%. One negative predictor in four studies that I'm aware of, that have looked at that, has been extra maxillary disease extension.

If you've got ethmoid frontal or sphenoid disease, that upfront dental treatment is probably going to be even less successful. I know in my practice and talking with colleagues, it's probably less than 50% success, so I just talk to patients about that potentially high likelihood that they're going to need a subsequent sinus surgery. The other variable is their symptom burden. I think this is really important to gauge because it's not black and white, like you said, whether you do dental treatment or you do sinus surgery. I think one huge decision modifier is, are they miserable?

I keep alluding to studies, but we showed in a nice prospective study that upfront sinus surgery, fairly intuitively, led to faster symptom, quality of life, and endoscopic resolution of past edema, all the findings, compared to the upfront dental treatment. If you get that tooth treated, yes, for me, flip a coin, it might get better. It's going to take longer to get better usually. Every once in a while, you'll get somebody that gets their tooth pulled and they feel amazing the next day or within a week. In our study, it was one to two months before they had symptomatic relief.

If they're miserable, if you send them off for dental treatment, unless you have a system set up, they're going to have to find a dentist, they're going to have to get teed up for a procedure. Bring them back to the office, get that tooth treated, and then hopefully you've arranged somehow to see that patient back. My point here is that the time can get drawn out quite a bit with upfront dental treatment, and it might not even work. For my really miserable patients, I explain to them that we can get you in on average within about a month to get this quick, pretty low-risk surgery, get you feeling better faster.

In the interim, I usually get them seen by their dental provider. Sometimes they'll get the tooth treated upfront, and then it comes into not only how miserable they are, but their insurance status. If they can't afford sinus surgery because of their deductible, they're going to not do that. Maybe they'll elect some dental procedure. Again, so the permutations of different reasons to choose upfront dental surgery versus sinus surgery is real for patients. There's different reasons that they decide to do one or the other. I'll try to bring this all home now with just the simple, ask patients how miserable they are.

If they're really miserable, we can at least offer upfront sinus surgery. They can always get their teeth treated first, but we need to see those patients back because if that sinusitis doesn't resolve, they're going to have a long-term risk of things like extra sinus complications.

Surgery for Odontogenic Sinusitis

Odontogenic sinusitis patients whose symptoms significantly affect their lives and those who fail to improve following dental treatment require unilateral maxillary antrostomy for pus drainage. Patients typically do not benefit from more extensive sinus surgery, and, given the high rates of frontal sinus stenosis in ODS, more extensive surgery can be detrimental. Though no literature exists on the role of post-operative antibiotics for ODS, Dr. Craig reports success treating his post-surgical patients with ten days of amoxicillin-clavulanic acid. When possible, intra-operative cultures should be obtained, as patients with long-standing disease can be cultured with bacteria besides typical oral flora.

[Dr. Ashley Agan]
When you're doing sinus surgery, are you just doing a maxillary antrostomy, or are you treating every sinus that's diseased on the scan?

[Dr. Gopi Shah]
Also, can you just do balloons, or how big does antrostomy have to be?

[Dr. John Craig]
Balloons, we agreed on in our management national consensus to not be appropriate for most cases of odontogenic sinusitis, largely because there's usually significant edema in the middle meatus, might even be tough to cannulate the maxillary sometimes, very friable edema. Then you need a wide enough opening to clear out-- The whole point of surgery is to clear out all the pus. It's almost like draining an abscess. You really want to clear that out. With a balloon dilation, I know I've heard some people say, "Well, you could flush the sinus after," but I don't know. I've seen the inside of a lot of maxillary sinuses with this condition, and there's so much polypoid edema in there, I don't know that you could reliably flush out all that pus. I don't know, for me, and I know other colleagues studying this, we want a wide maxillary antrostomy, clear out the pus. Now, the next question you ask is an intriguing one. How much sinus surgery do you then need to do? A group, they looked at this, so, Ahmad Safadi, he and his group looked at 45 patients prospectively. They had maxillary, ethmoid, and frontal disease, and they did only a maxillary antrostomy and showed 100% resolution of the disease, presuming the dental source is treated.

It's only one study so far, and we're going to look at this too, but it is intriguing that maybe you don't need to open all disease sinuses like we do with other forms of rhinosinusitis. I would say that that's in the non, or uncomplicated ODS situation, where you don't have spread outside into the eye, brain, other areas. If you have complicated ODS, I think it makes sense, if you're going in, you should drain all the purulent sinusitis potential source of that infectious complication, but if you're wondering what I do, I've evolved, I say, or migrated over time, I used to address all disease sinuses, but I admit, I had a frontal stenosis after one of those cases. I had to do a Draf Ⅲ for that patient to resolve that, and then I saw Dr. Safadi's paper, and it got me thinking maybe we don't have to open all sinuses.

We don't have the perfect answer yet, but I do think it's reasonable based on what's been published, and then just what I've seen, that if you're not comfortable opening a frontal sinus, you shouldn't go up into an ODS frontal sinus especially. It's very inflamed, probably higher risk for stenosis. We don't have that answer yet, but I think maxillary only is an intriguing option.




[Dr. Ashley Agan]
Do you do any post-operative antibiotics, or any other special medications or treatment?

[Dr. John Craig]
Yes, I'm still doing antibiotics after these cases. I think I usually do 10 days of post-op antibiotics. It comes down to it's a raging, purulent sinusitis, can I be confident I got every last bit out of the infection? Maybe not, and so that's what I've been doing. Not to say that that's evidence-driven, but there's nothing on post-operative antibiotic use for ODS. There's some studies showing no benefit in rhinosinusitis, but I think this is different and just needs to be studied better.

[Dr. Ashley Agan]
Do you ever wait for a culture from the OR before you call something in and get sensitivities, or do you say, "Listen, this is going to be oral flora and Augmentin is going to be fine?"

[Dr. John Craig]
I love when I can give Augmentin. That's my favorite. Yes, I usually start empirically. If it's somehow resistant to that, then I'll call the patient and switch the antibiotic.

Podcast Contributors

Dr. John Craig discusses Odontogenic Sinusitis on the BackTable 126 Podcast

Dr. John Craig

Dr. John Craig is the chief of Rhinology and co-director of the Skull Base Center at Henry Ford Health in Detroit, Michigan.

Dr. Ashley Agan discusses Odontogenic Sinusitis on the BackTable 126 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses Odontogenic Sinusitis on the BackTable 126 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, August 29). Ep. 126 – Odontogenic Sinusitis [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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