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BackTable / ENT / Podcast / Transcript #126

Podcast Transcript: Odontogenic Sinusitis

with Dr. John Craig

In this week’s episode of Backtable ENT, Dr. Ashley Agan and Dr. Gopi Shah talk with Dr. John Craig, chief of Rhinology and co-director of the Skull Base Center at Henry Ford Health in Detroit, about odontogenic sinusitis (ODS). You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Defining Odontogenic Sinusitis

(2) Odontogenic Sinusitis Patient Presentation & Risk Factors

(3) Physical Exam in Suspected Odontogenic Sinusitis

(4) Imaging Findings in Odontogenic Sinusitis

(5) Collaborating with Dental Colleagues for Infectious Source Control

(6) Treatment of Odontogenic Sinusitis

(7) Surgical Approaches to Odontogenic Sinusitis

(8) Recurrence of Odontogenic Sinusitis

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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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[Dr. Ashley Agan]
This week on the BackTable Podcast.

[Dr. John Craig]
That's why this condition is so fun to manage. Once you identify it, which is the harder part, you should be seeing 90%, 95% success if you've addressed the teeth appropriately and the sinuses adequately. I think it's important, though, that people don't think it's just 100% success because I know some people presume that. There's even some series showing 100% success, but nothing can really be 100%, in my opinion. I've seen, so we just put this out, and we did actually achieve 98% long-term resolution endoscopically and symptomatically, which was awesome.

[Dr. Ashley Agan]
Hi, everybody. Welcome to the BackTable ENT Podcast. We're a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by. My name is Ashley Agan. I'm a general ENT, and I'm pumped to be across the mic from my dear friend, Gopi Shah today. I've been out for a while because I got labyrinthitis. Do you want to tell everybody what happened, like legit vertigo, sensorineural hearing loss, out for the count, and had to do the whole thing? Antibiotic steroids, high T-steroid injections, times three, vestibular rehab, all the things. I'm doing so much better, and I'm so excited to be podcasting again, excited to be here with my dear friend. How have you been, Gopi?

[Dr. Gopi Shah]
I'm good. I'm just happy to have you back and see you. Congratulations on completing and graduating vestibular PT. That's huge. You worked hard.

[Dr. Ashley Agan]
Thank you. All right, let's intro the show. We have a great guest. Dr. John Craig is here today to talk to us about odontogenic sinusitis, or as we'll call it, ODS. Dr. John Craig is Chief of Rhinology and Co-director of the Skull Base Center at Henry Ford Health in Detroit, Michigan. He's here today to talk to us about odontogenic sinusitis. He is the lead author of the international multidisciplinary consensus statement on the diagnosis of ODS, published in 2021 in IFAR and a state-of-the-art review on ODS in the World Journal of Otorhinolaryngology, HNS, in March of 2022. Welcome to the show, Dr. Craig. How are you?

[Dr. John Craig]
Excellent. Thanks so much for having me. Excited for this.

[Dr. Ashley Agan]
Thanks for coming on. Can you first just tell us a little bit about yourself and your practice?

[Dr. John Craig]
Yes, I am currently, of course, in Detroit, but I hail from Northern California, in Eureka, California. I don't know anyone else in Michigan from there and haven't gone back there since, but basically, I've spent most of my time on the East Coast. I went to Cornell for undergrad. I went over to Chicago, Rosalind Franklin for med school, back over to Syracuse, SUNY Upstate for ENT, and then did my rhinology fellowship at the University of Pennsylvania. Then ever since then, I graduated in 2015, started at Henry Ford, and I've been here ever since, and it's been great.

I think from the purpose of why we're talking today, I've taken a research interest in odontogenic sinusitis, amongst other topics too, but this one stuck out to me as one that really needed some extra love if you will. Since the literature really wasn't guiding us a whole lot on the diagnosis and treatment of the condition, and I was seeing it so frequently right out of training, I felt like there was a gap there and collected some data prospectively, and now here we are. My only other thing to, I guess, report about myself is my family, which is extremely important to me, and I wanted to give a quick shout-out to my two children, Liam and Nora, both whom seem somewhat interested in the fact that I'd be on something like radio, so, hey there, guys. Then, of course, shout out to my wife, Devin, who makes all this sort of academic ridiculousness in my life possible. That's me.

[Dr. Ashley Agan]
Awesome. How old are Nora and Liam?

[Dr. John Craig]
Nora is seven, Liam is nine.

[Dr. Ashley Agan]
They're the age where maybe they can at least listen to the shout-out.

[Dr. John Craig]
For sure.

(1) Defining Odontogenic Sinusitis

[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.

There's been more that's come out over the last few years. For instance, we just published a recent study on endotyping with regard to ODS, which is a hot topic in rhinosinusitis, but ODS just got grouped into other forms of rhinosinusitis without being separated out. To simplify that point, it's just that we showed a T1, TH1 skewed endotype, which would, I think, be expected by a lot of researchers, but I think it's important to recognize that so that in future endotype studies, we can separate that out. All right. Then lastly, I would just say, symptomatically speaking, we'll probably hit on this multiple times because of how important it is, patients will often complain of a foul smell in their nose. This is also pretty unique, not specific per se, but most people with rhinosinusitis don't have a foul smell, whereas ODS patients often do. Hopefully, that's not too much.

(2) Odontogenic Sinusitis Patient Presentation & Risk Factors

[Dr. Ashley Agan]
Yes. No, that's great. Do these patients present more an indolent presentation, or are they usually coming in acute, few-day history of this foul smell and they come in acute to you?

[Dr. John Craig]
By far, the majority, overall majority, I should say, is chronic. That's not just my practice, which is definitely true in my practice, but it's in almost all the literature. These patients present with a median of six months of symptoms when they present. Just for some reason, it gets misdiagnosed or missed by all the different providers that have seen them previously, but yes, definitely chronic, most common. Then there are the occasional patients who will present right after a dental procedure, which is interesting. Within the first week even, they'll have full-blown odontogenic sinusitis, but that's less common.

[Dr. Ashley Agan]
You mentioned strep intermedius, I think of complications of acute sinusitis with the eye or intracranial. How common does ODS have a complication to the eye or the orbit?

[Dr. John Craig]
I love it. I love the question because we happen to have published something on this. I don't know if you read this, but absolutely, ODS can cause orbital, intracranial, osseous, as well as systemic extra sinus infectious complications. I was finding it interesting in my practice that most times I was taking patients to the OR emergently or urgently for these complications, they were unilateral cases, and lo and behold, I was seeing dental sources. I approached University of Pennsylvania, my former mentors, and we put together a retrospective study looking at all operative extra sinus complications over 15 years, and what we found was really interesting.

Amongst patients with unilateral sinusitis, if we excluded fungal etiologies, 60% of them, so two-thirds, had odontogenic sources. Amongst patients who get these complications, it is highly prevalent. I think on the whole, most ODS does not cause extra sinus complications, but it's well documented in the literature. We actually put out a systematic review on this topic, and there's, I think, 110 published cases of extra sinus complications from odontogenic sinusitis. I won't get into the weeds too much, but there's also the potential for dental sources alone to cause all these extra sinus complications regardless of the sinusitis. Nonetheless, it's uncommon on the whole, but when you see these cases, unilateral presentations, look down at the teeth because you'll be surprised how often there's a dental source.

[Dr. Ashley Agan]
Yes, just taking us from the beginning, when patients are coming in, can you talk to us about the stereotypical patient that comes in that you're seeing that ultimately has ODS? Obviously, not everybody is the same, but you've mentioned the foul smell. Is there anything else in the history that tips you off to thinking that it could be ODS?

[Dr. John Craig]
Yes, I think first off, people just have to flip a switch in their head that this is more common than most people think, and once you start thinking about or looking for it, you find it more. I know that sounds obvious, but the problem is that all of these patients will have the cardinal sinusitis symptoms to some variable frequency. They're going to have nasal obstruction, they're going to have anterior drainage, posterior drainage, facial pressure, sometimes smell loss, and different permutations of all those symptoms. The symptomatic history by itself doesn't say, oh, it's definitely dental. If you happen to remember to ask about foul smell, which is not one of the cardinal symptoms in all national-international guidelines, then you might pick up on that. The other thing is unilateral. I've noticed, reading a lot of doctors' notes, they're all-or-none symptoms. Instead, you need to know whether that nasal obstruction is one-sided or both sides. Is the colored drainage one-sided or both sides? It's just been interesting to me noticing that not everyone asks that simple question. Try to focus in on what's unilateral or bilateral, and then that foul smell will be a little extra in terms of suspicion.

[Dr. Ashley Agan]
How common is it for a patient to have associated tooth pain, jaw pain, gum pain?

[Dr. John Craig]
Intuitively, you'd like to hear that was a predictive symptom. Unfortunately, the studies that have included dental pain in symptomatic history in their data collection, it's been about 20% to 40% of these patients have dental pain. Now, I would argue, unfortunately, I don't think most people ask for one. Then the other problem is these teeth are usually necrotic or absent. They may have had their tooth pulled. For multiple reasons, either people aren't asking or they're just not painful etiologies, that symptom is not helpful. I actually always do ask because I collect as a data point, but unfortunately, it's not hugely helpful.

[Dr. Ashley Agan]
When you're asking, are you asking broadly, "Do you have dental issues, pain in your teeth? Have you had a recent extraction? Do you have dental implants?" How specific are you?

[Dr. John Craig]
I try to be pretty methodical. I'll, for one, ask about upper dental pain. Sometimes people just write, "dental pain," and it could have been their lower teeth. That's not going to cause odontogenic sinusitis. I try to get then, into like, "Well, show me which teeth hurt." Then prior dental procedures are a great one, but interestingly, it hasn't been studied as a predictive variable. Have they had a prior filling, for instance? A lot of people have had fillings. Those fillings break down over time. It would be very interesting to know what percentage of ODS patients had a prior filling that's not published.

Root canals definitely put a patient at risk, not necessarily because of the procedure, but because they probably had endodontic pathology that caused a sinusitis.

Knowing that definitely increases my suspicion. Then, yes, extraction, dental implants, bridges. I didn't know much about basically any of the procedures I just said, but bridges actually put people at pretty significant risk for dental disease because they drill down a tooth. It's not an insignificant percentage of people who get endodontic pathology from that down the road. Yes, I try to delve into dental history, but frankly, I don't think we're trained in ENT residency, what questions to even ask, so it feels like almost too much to ask in a very busy clinic if that makes sense.

[Dr. Ashley Agan]
Yes. A question for you for the prior filling history or root canal. Is there a certain timeframe because fillings can break down 10, 20 years later, or is the filling within 6 months? Does that tip you off at all? I would say 100% of people have had fillings.

[Dr. John Craig]
I think it needs to be studied. It just hasn't been studied, so I wouldn't be able to tell you, but it would probably be a long-term thing. Maybe 10, 20 years ago, they had a filling, but that's totally speculation. I know root canals are another one where, depending on what source you read, it might say that they fail 10 years down the road or further, and so that can be a source for bacteria from the mouth to get through into the apex of the tooth.

[Dr. Ashley Agan]
Most of the time, the patients are coming to you without that suspicion. It's not like the dentist is sending them to you thinking, oh, they have odontogenic sinusitis, and there's some dental disease. It's usually you finding it and then sending them to a dentist. Yes?

[Dr. John Craig]
Yes. No, you're totally right. I think a lot of people, this is just a funny side point, they think that because I study this, that I must be getting a lot of referrals for it, but it's not the case. We actually just published a paper showing that 85% of ODS cases that I've seen over the years have all been identified by me. We can talk about this probably with treatment, but I've made some networks with different dental specialists around here, and I still found it interesting that they don't send me very many patients. It's usually me sending my patients to them. It's the onus of the ENT surgeon to recognize this.

[Dr. Ashley Agan]
Are there any other risk factors? A broken tooth or a loose tooth? Maybe there wasn't a dental procedure that preceded this. Are there any other groups that you have noticed that, hey, these people are at higher risk or anything like that?

[Dr. John Craig]
I think those types of dental procedures we talked about are higher risk, but it hasn't been studied specifically. We don't know if certain dental treatments are specifically putting patients at more risk. I think that because we know endodontic disease, a condition called apical periodontitis, where you get infection of the pulp space, spreads out the apex of the tooth, that's the most commonly reported type of odontogenic sinusitis. I think it's safe to presume that if you hear they've had a prior root canal, that means they had endodontic disease, that would make sense.

A prior extraction, also, you would think, has to put a patient at risk, but it just hasn't been studied. I wouldn't want to say anything definitive, but I have not seen any immunocompromised patients with ODS, so we can't blame their immune system on this. No, other than that, nothing sticks out to me.

[Dr. Ashley Agan]
Or trauma or anything like that?

[Dr. John Craig]
Facial trauma or dental trauma?

[Dr. Ashley Agan]
Yes, both.

[Dr. John Craig]
Yes. I've seen those cases after Le Fort fractures and a nasty sinusitis that's growing oral bacteria, but that's sort of a different ballgame altogether. We're not even really calling that odontogenic sinusitis. Yes, if you have a fracture through a tooth socket, that's got to put you at risk. I guess, nothing quantitative out there.

[Dr. Ashley Agan]
What about sinus lifts? You have these patients that get these procedures so that they can be a candidate for implants called a sinus lift. Do you see that they are at increased risk?

[Dr. John Craig]
This would require a good collaboration with dental implant specialists to truly know what this risk is because if you read their literature, it says 1%. Patients who get a sinus lift with bone grafts, augmentation to the sinus floor for that eventual implant, 1% risk of sinusitis. Here's the thing. Every study I've read on that doesn't collaborate with ENT. They're not scoping patients. We don't know if they've developed infectious purulent sinusitis after said procedures. I will say just all I can speak to is my practice, of all the ODS cases I treat, they are the minority.

From a phenotypic standpoint, they're just the same as all the others. They're nasty, purulent infections. What's interesting is sometimes the bone graft needs to be removed, but then other times, it's mucosalized in the sinus. There's no fistula in the mouth, and we just address the sinusitis and don't have to take out that bone graft. This just gets to the point of really needing that collaboration between dental providers and ENT to really know if that bone graft did cause a sinusitis. Does that make sense?

(3) Physical Exam in Suspected Odontogenic Sinusitis

[Dr. Ashley Agan]
Yes. Moving on to your exam, I assume you have typical rhinology exam where you're looking in the nose and you do endoscopy. When it comes to your exam, your oral exam, what are you thinking when you're looking at teeth? I know when I look in the mouth, I'm like, "Oh, that tooth looks kind of funny," or maybe I can't say that I feel very confident about what I see.

[Dr. Gopi Shah]
Are you tapping on any of the teeth with a tongue blade like checking for loose – feeling the gums?

[Dr. John Craig]
These are all really important questions and we don't have answers for them yet. Again, I'm going to go to my anecdotal oral exam process, but I can tell you it does not predict ODS in either direction. If I see a diseased tooth, frankly, necrotic, horrible-looking tooth, totally clear sinuses. Then the flip side is true, really healthy-looking dentition, we get the scan, and oh my gosh, it's a huge periapical abscess, bone erosion into the sinus. Unfortunately, for me so far, I just haven't studied it methodically, but I don't think there's a clear correlation between the oral exam and the sinuses.

What do I actually look for? I do look for prior dental work because it just makes sense to me that if they've had something done that affects the possible spread into the pulp chamber, then that's going to increase the risk for sinusitis down the road. If they've had a prior extraction, I'm looking at that. I should mention that the molars are the main culprits here. It's actually going to be a cool study that we haven't put out yet, but looking at the relationship of the tooth sockets to the sinus, the first and second molars are generally closest to the sinus floor.

They're the highest-risk teeth basically regardless of dental pathology. Either endodontic pathology with intact teeth or prior extractions causing a fistula, those are your biggest bang for your buck. I tend to look at the posterior dentition. That said, we've all seen a first or second premolar also cause disease and in a very rare situation, a canine. I'm looking at all those teeth mainly just to try to correlate to what I'm going to see on my endoscopy. I mentioned prior dental work. Overt dental disease obviously is suspicious. Necrotic tooth that's fractured, black looking, and then don't forget to look at the gum line.

Right above the tooth roots, if there's a raging dental process, there will be fullness there. You also might see pus straining through the tooth socket. I think those are the main things I'm looking for. Then, like you mentioned, the scope. The scope is huge.

[Dr. Ashley Agan]
What do you see on it? Tell us.

[Dr. John Craig]
Yes. Once again, unilateral comes to mind. We've shown, and it's not just our studies, other studies have shown this too, 80% to 90% of true ODS, infectious sinusitis, is going to show pus. You look for pus coming from the middle meatus, and then you're comparing it to the other side. If you see unilateral pus, it's just such a simple thing to identify for us, but we've got this really cool study that showed, in a prospective cohort fashion, that finding in patients with unilateral maxillary sinus opacification on a CT scan, 17 times more likely to have an odontogenic source.

It just gets back to this unilateral point. If you see unilateral pus on scope, be suspicious for ODS. If you see unilateral opacification on a CT scan, be suspicious for ODS. Then the only other point I'd say about scope is that polyps are actually not that uncommon for ODS. It's the minority. About 20% to 30% in two studies from us, and it's been shown in other studies too, have severe, I think most physicians would call them polyps, whether it's polypoid edema or legit multilobulated polyps, could be seen in odontogenic sinusitis. I know that there's a study in the past that suggested ODS was a non-polypoid condition. I think that is not a good way to think about it. These cases can have severe edema and sometimes, frankly, look like a tumor, by the way.

[Dr. Ashley Agan]
Like IP or something?

[Dr. John Craig]
Exactly.

[Dr. Ashley Agan]
Potentially confused for—

[Dr. John Craig]
Yes. I just presented this at a recent ARS meeting, but I mistakenly, early on in my practice, took a person to the OR for almost certainly an IP. It looked papillomatous. There was pus, but did a medial maxillectomy to remove the tumor and came back negative for IP. I know there are others out there that have had this happen to them too. My point there is just that pus unilaterally should tip you off to potential ODS. Then if you see polyps, don't presume that it's not ODS.

[Dr. Ashley Agan]
When you're looking in the mouth, again, I'm thinking about a particular patient one time that had a fistula, but it was so tiny. I remember trying to find it in the OR and having to have a tiny little probe and just gently probing around in there to finally even find it because I couldn't see it. Do you poke around at all in the clinic or how—

[Dr. John Craig]
Yes.

[Dr. Ashley Agan]
How much in the mouth?

[Dr. John Craig]
That's the thing. I don't know how many people will do that, but I agree. That is one way. In our consensus, we had a bunch of dental providers on that consensus, and consensus was that there are two ways to assess for a fistula. One is what you said. You could probe for it. Simpler method that's pretty reliable is have patients plug both nostrils and with an open mouth, blow. I've definitely seen the bubble effect coming through a tiny pinpoint fistula. That's one simple way. If you have a little probe though, that is also a great way.

I've seen some, just like you said, really creepy ones where it's not even a pinpoint, but I sent them to a dental provider. I've got this great video where he takes this really fine probe, and he's scraping along the gingiva and then slides into this hole, and goes straight through the sinus. You definitely couldn't see it on exam. Yes, when you see somebody with a prior extraction, I'm not saying you don't necessarily have to repair these tiny pinpoint non-visible openings, but they do exist.

[Dr. Ashley Agan]
Yes. Take home points for while you're seeing these patients in clinic are foul smell, unilateral, ask about unilateral. There's going to be unilateral exam findings like pus and could be polyps and an angry-looking endoscopy. Then I suppose, I bet a lot of patients come to you with a CT scan already, but if not, then that's the next step.

[Dr. John Craig]
Yes.

[Dr. Gopi Shah]
Can I step back for one second? Do you ever culture the pus? Do you ever do that?

[Dr. John Craig]
I do. I used to do it on everyone. The thing I was finding tricky in some of these, you've got this little stream of pus, despite it being floridly infected. Just because of endoscopic access issues or the amount of pus you can get, sometimes that the culture results in the office aren't particularly helpful. I usually try to, because here's the scenario that's tricky. What if you don't have that CT scan and you've got somebody with unilateral pus? I know a lot of people out there will treat that as maybe even a recurrent or chronic infectious sinusitis and keep treating because some people lean on, you've got to try multiple courses before you do anything more.

Then they won't get a CT scan because some people would say you don't get the CT scan unless you're planning surgery. I guess that my point is, if you get that culture, if you can, adequate access, adequate pus, get it because, if it shows you oral bacteria, that'll tip you off and say, okay, we actually should get the CT scan. Does that make sense?

[Dr. Ashley Agan]
Yes.

[Dr. Gopi Shah]
Yes.

(4) Imaging Findings in Odontogenic Sinusitis

[Dr. Ashley Agan]
When you're getting a CT scan, do you guys have a scanner in the office or do you have to send them out for their CT?

[Dr. John Craig]
We have them in the hospital. Each clinic site that I work at Henry Ford, they have a radiology department at each spot. Not in the office, but it's pretty easy to get the scans expedited.

[Dr. Ashley Agan]
Yes, but they're not sitting. It's not like, "Oh, go get your CT and then come back into the exam room, and then we'll talk about it." There's,-

[Dr. John Craig]
No.

[Dr. Ashley Agan]
-they go across the, across the way and get it.

[Dr. John Craig]
Yes, and then I just call them.

[Dr. Ashley Agan]
Then I would assume that CT is your big workhorse. Is there any reason to get any other imaging? Do you ever think about MRI-

[Dr. John Craig]
Oh, right.

[Dr. Ashley Agan]
-or contrasted or Panorex?

[Dr. John Craig]
Ah, yes, the dental imaging effect. Okay. First, from the sinus standpoint, I just get a non-contrasted sinus CT. As far as contrast or any kind of other modality like MRI, that's going to be more in the setting of extra sinus spread, or maybe you're not sure if this is a tumor and there's bone erosion with possible extension of the orbit, face, brain, something like that. That's going to be, I probably wouldn't be getting MRIs on most of these people.

[Dr. Ashley Agan]
Before we get to Panorex, what are your typical CT findings? Is it a hyper-expanded max that's blown out or in the uncinate, it's going to be sucked in laterally to the lamina? What is your typical findings for this on the unilateral and the max?

[Dr. John Craig]
Yes. Subtotal to total opacification of the maxillary sinus is going to be most common. This actually is a nice segue into the mucosal thickening dilemma. One point I want to hit on a couple of times during this today is that mucosal thickening adjacent to dental pathology or dental work is not what we're talking about with odontogenic sinusitis. Unfortunately, the literature lumps it in there sometimes. That's a problem. That's just reactive mucosal inflammation to underlying dental pathology responds very well to dental treatment.

A true infectious ODS, like we're focusing on for the most part, you won't see an atelectatic sinus. You'll definitely see bulging out of the uncinate process. There's actually a nice study by Alberto Saibene, out of Milan, actually. He published a study showing that the angulation of the uncinate bulges out more in ODS. You'll see that in the maxillary. Then, in my practice, you usually see some extension of the ethmoids plus or minus frontal. I think this is an important point. You usually see relative sparing of the posterior ethmoid and sphenoid sinuses. Infection drains in the middle of the meatus, presumably then can access the anterior ethmoid. Some patients, it's like the 5% range for my practice, get into the posterior ethmoid and sphenoid. It's possible, it's just a lot less common.

[Dr. Ashley Agan]
Any bony changes? Like, does anything look more osteotic or—

[Dr. John Craig]
Yes. I would say the majority, I actually have this data, I just haven't looked at it in depth, but majority have thickened hyperostotic walls. The weird thing is not an inconsequential number of people have bone erosion. Like creepy spots, like the pterygopalatine fossa, they'll read it as possible invasive fungal sinusitis or tumor extension into the pterygopalatine or infratemporal fossa. We see erosion into the orbit, skull base, and not necessarily presenting with those extra infectious complications. It's another reason why that IP that I mentioned had bone erosion, and I'm like, "All right, this has got to be a tumor. The imaging findings can be variable, but I think the biggest things are maxillary, it's got to have maxillary opacification. Then more, like you said, alluded to the bulging of the uncinate, ethmoid or frontal disease, much less likely sphenoid and posterior ethmoid.

[Dr. Ashley Agan]
Yes, and is a Panorex helpful?

[Dr. John Craig]
On the whole, not so much. If you have networks or dental specialists you can work with, I would defer to them for the most part, but it's well-established in their literature that cone beam CT scan outperforms Panorex or periapical x-rays. The x-ray modalities like Panorex and periapicals, they're just not great resolution. The benefits is they do show the whole height of the tooth, including the apex. That is better than nothing, but due to things like facial and zygomatic arch superimposition and the haziness of the maxillary sinus mucosa and edema, it's just sort of a messier study, but not all dental providers have a cone beam CT scanner.

You're going to find mostly those are going to be in dental specialist offices, endodontists, periodontists, oral surgeons. If you can get them to get that, it's better. I used to wonder, a sinus CT scan shows the teeth actually pretty nicely, but they've shown me some cases where there was barely any finding on the sinus CT scan. Then they get the zoomed-in higher resolution cone beam and sure enough, there's a little more bone erosion around the tooth socket that I couldn't see. I think there is some benefit there.

[Dr. Ashley Agan]
How often do you not have a positive dental finding on a CT scan with ODS that you're concerned for?

[Dr. John Craig]
Yes, it's important. The majority, fortunately, do show what I'd call overt dental pathology on the CT. Nice, raised periapical lesion with bone erosion, maybe other bone erosion around the tooth socket, absent tooth, dental implant, all the really obvious findings. Unfortunately, there's not great studies yet. There's two studies that I'm aware of. One was from Rod Tataryn. He published a series showing that almost 30% of ODS due to endodontic disease had no dental findings on the sinus CT. Then we showed similarly almost 30% of my patients with endodontic disease have subtle to absent dental pathology on a sinus CT scan when there's endodontic disease causing odontogenic sinusitis. The problem is that one of the studies was retrospective and none of the studies followed all patients with unilateral maxillary sinus opacification, and so we don't really know what the true incidence is of patient has no overt dental pathology on a sinus CT scan. What's the likelihood of that patient actually having dental pathology? I think it's an important study to do in the future. I think the take-home point is just that not all patients with odontogenic sinusitis will have overt dental pathology on a sinus CT. You need to keep that in mind if you're taking that patient to surgery. Get that sinus culture, see if it shows oral organisms. If so, get that dental workup. Alternatively, if you have a close relationship with dental specialists, you could get that patient's teeth assessed with appropriate endodontic testing, which should we go into endodontic testing?

(5) Collaborating with Dental Colleagues for Infectious Source Control

[Dr. Gopi Shah]
Sure, so we actually have an idea of what the conversation should be if we have to call referring providers.

[Dr. John Craig]
I think one helpful thing is when a patient that came back from their dental evaluation and says, "The dentist said it was fine, there's no dental disease." If you know about endodontic testing, you can at least ask, "Did they do the following?" Putting a cold stimulus on the tooth, it's called the cold pulp test, it's one of the simplest but most predictive tests for assessing whether a tooth is necrotic. As in the pulp chamber is infected and dead, a lack of response to cold stimulus is suggestive of that. I won't go into all the different types of pulp testing.

There's cold pulp, hot pulp, electric pulp, but you want to hear that the patient got some form of pulp or endodontic testing, not just they got a dental x-ray, and they tapped on my tooth. The tapping on the tooth is not as predictive. Then I guess I didn't mention this earlier, I just said dental x-ray. I want to clarify that point. There are what they call routine bitewing dental x-rays like we all get when we get a dental cleaning. That is not showing the apex of the tooth. It is extremely common for patients to go to their general dentist in this situation and get routine bitewing dental x-rays.

That is not going to help the workup. That's why it keeps, I don't know if I've stressed it enough yet, but if you could work with dental specialists, endodontists, periodontists, or oral surgeons, they're more likely to do appropriate endodontic testing and get appropriate higher-resolution cone beam CT scan imaging.

[Dr. Ashley Agan]
Usually, the patient has seen their dentist. Do you ever call the dentist? When are you in your own mind like, "maybe I need to refer to an oral surgeon or an endodontist?

[Dr. John Craig]
Right.

[Dr. Ashley Agan]
Does that come up?

[Dr. John Craig]
Oh, yes. I spent years identifying, I must have called 100 different dental providers, and I had to learn what an endodontist does versus a periodontist, versus an oral surgeon versus a general dentist. I, therefore, have a bias perhaps, but I just see the difference in the thoroughness of the examination, the imaging, the treatment success, and all these things. That's why I prefer interacting with dental specialists on this topic. There are no publications on this topic in the general dentistry literature. Endodontists are more in tune with it, oral surgeons have published on it.

I just feel like there's a better awareness of the condition. For me, I don't send patients to general dentists anymore. I have a few people that I can refer them to or I ask them if they have their own endodontist, periodontist, oral surgeon. If they do, that's totally fine by me. I will get their contact information and that does become a very tricky thing. If you don't have a network set up of some sort, contacting these dental offices are very challenging. It's honestly, in my mind, one of the most important parts of making progress on this condition long-term. We need to find a better way for rhinologists and general ENTs who are managing this condition to connect with dental specialists. I definitely refer directly to them.

[Dr. Ashley Agan]
Yes, that's interesting because in rhinology, we have such good contacts and partnership with ophtho, we have great partnership with neurosurgeons we don't think about, just given how common, now that we are more aware of ODS, the importance of having our endodontic/OMFS colleagues. That's interesting.

[Dr. Gopi Shah]
The other tricky thing is that dentistry as a specialty exists outside of health care. It's a different insurance for patients. Not all patients have dental insurance. How does that come into play? Correct me if I'm wrong, does medical insurance cover an endodontist because the diagnosis is odontogenic sinusitis, does that help at all? Does that ever come up?

[Dr. John Craig]
Did you guys secretly read my other paper?

[Dr. Gopi Shah]
No.

[Dr. John Craig]
I swear that I'm not trying to be weird about these publications.

[Dr. Gopi Shah]
No, but apparently there's-

[Dr. Ashley Agan]
I have a paper. Right.

[Dr. Gopi Shah]
-a list of these papers, and so we're going to need all of the references that we're going to put on their show notes to our listeners so we can actually all read them, so I can actually read them.

[Dr. John Craig]
I'm not making this stuff up, I swear. I agree. I was finding some very interesting trends with regard to patients' decisions on dental versus sinus surgical treatment based on their financial means, either their insurance or dental insurance versus medical insurance, looking at their deductibles versus their dental insurance coverage. They were actually changing their management plan. We looked at this, and I worked with an economics guru here at Henry Ford that I could not have done this analysis without him and basically looked at, based on diagnostic and therapeutic codes for all types of ODS, as in root canals, extractions, dental implants, bone grafts, and then sinus surgery codes, and I won't go through it all, but we found that just raw cost-wise, a root canal and dental extraction cost about the same actually on the whole when you consider rates of failure and all these different things.
It was about half the cost of, say, upfront sinus surgery followed by appropriate dental treatment, which makes sense in the sense that it should be more expensive. The whole problem here is how variable people's insurance is. Some dental insurances cover more of these specialty dental procedures. Some patients' deductibles for sinus surgery are high versus low. I guess my point here is just that, that is something that I think we should try to take into account for patients when we consider types of dental treatment and the order sometimes in which you do dental treatment versus sinus surgery.

[Dr. Ashley Agan]
As you're referring patients for that evaluation if you have a patient that doesn't have dental insurance, who's evaluating the teeth?

[Dr. John Craig]
What I do is I try to ask them what their preference would be, but I don't think most ENTs would want to go through this. I do ask if they have dental insurance, and if they say no, I explain to them that if they have an intact tooth, the cheapest treatment is going to be an extraction, okay, if that's all they want to do. The tricky thing is, and this is why it's important to have dental collaborations to explain all these downstream effects, if you pull a first or second maxillary molar, there's a good chance you're going to have issues with occlusion, biting, chewing, sometimes aesthetic concerns.

A lot of those patients are going to need some form of reconstruction. That could come in the form of a partial denture, a bridge, or a dental implant. Those are obviously very expensive. As opposed to, say, a root canal up front, you might preserve that tooth, and it'll be just the cost of that root canal. I actually do have that discussion with people, and it guides me to refer them to either an endodontist or an oral surgeon/periodontist. It's sort of a nuance-y discussion, and it's based somewhat on my knowledge now of the cost of all these procedures.

(6) Treatment of Odontogenic Sinusitis

[Dr. Gopi Shah]
As we're moving on to talking about the management, after you have that suspicion for ODS, and you're talking to the patient about, okay, this is probably an infection that's coming from a tooth, what do you do next as far as like medical management and the evaluation from oral surgery, endodontist, periodontist? What's the order of operations?

[Dr. John Craig]
I think one thing that's going to be helpful over time is if we start grouping these patients into treatable versus non-treatable dental pathology, which sounds obvious, but there's actually a number of different conditions from the teeth that won't be treatable if they already had a prior treatment, for instance. Once you identify them, then you have a better idea of, where am I sending this patient. We'll start with the more straightforward thing. If they have a treatable dental source, so you know they have an untreated tooth that has a periapical abscess or they have an oroantral fistula that's draining pus through the tooth socket that you see, these things won't resolve until you address the dental source. We talk about maybe we saw the sinusitis endoscopically. You can treat that patient with antibiotics to temporize their symptoms, but if you didn't recognize that there was a dental source, that patient is going to recur. That gets back to the point of you've got to recognize that there's a dental source or you're going to treat this like recurrent infectious sinusitis. Point there is just that for treatable dental pathology, antibiotics are not curative, so you'd need to get that patient to a dental provider. Now, if we move on to non-treatable situations, it gets a little more interesting. What if you have a patient who has odontogenic sinusitis, had an extraction, so there's no infectious dental source anymore, they still have purulent sinusitis, what do you do there?

I think it makes sense to at least try an antibiotic if there's no treatable dental source. What's interesting is how infrequently they resolve. We've actually got a prospective study going, it's multi-centered right now, looking at the rate of success of antibiotic use after dental extraction. It's very low and we don't know all the reasons why. In any case, as far as antibiotic therapy, I don't think we should think of this as curative. It's usually temporizing symptoms, but probably worth a trial in situations where there is no treatable dental pathology.

[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 ever think about steroids with, you mentioned sometimes that you see polyps, do you ever think about adding some steroids just to help with all that big inflammatory response?

[Dr. John Craig]
When I do see those patients, sometimes, but I got to say most of the time I don't. I think my problem is I've seen such infrequent resolution with medical therapy for this condition that I personally haven't seen a robust response with steroids, but you're right, if you had severe edema, you could definitely make that argument.

[Dr. Ashley Agan]
Do you ever get fungus on culture or anything weird like that?

[Dr. John Craig]
Yes, fungus definitely needs to be explored more with regard to dental pathology because there are a few studies showing some relationship between fungal balls and prior dental implants, for instance. I personally don't send fungal cultures in purulent sinusitis when I don't see any fungal debris unless I was concerned about invasive fungal or something, immunocompromised patients, for sure. There's not much out there on fungal cultures for this. There also is not much on next-generation bacterial DNA sequencing, which would be interesting. We might look into that, but you're right, we probably should figure out what the fungal contribution is. It seems anecdotally to be low, but can't say with certainty.

[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.

[Dr. Ashley Agan]
That's actually my next question. How long do you give the patient, after they've had a dental treatment, to say, "Oh, the dental treatment worked?" How long? You said about one to two months, and then you when do them back and how long do you give them before you start thinking surgery?

[Dr. John Craig]
This is also arbitrary, but it's based on international consensus, a mix of national consensus. In our study, it was one to two months before the successfully treated dental patients got better. Then some other oral surgeons and endodontists felt that that was sometimes too short a duration. Somewhere between one to three months, we agreed on, and therefore, I took the middle ground and said, "All right, I'll see my patients back in two months." If they're miserable, within a few weeks of that dental procedure, they can totally call me, and we can actually, either see them back in the office sooner or depending on the situation, maybe just book the surgery. Does that make sense?

[Dr. Ashley Agan]
Yes.

[Dr. John Craig]
I aim for two months. I think that seems pretty reasonable. If it's not better by two months, they're not getting better.

(7) Surgical Approaches to Odontogenic Sinusitis

[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]
Given that we've just said how inflamed these sinuses can be, do you do most of these or all of these in the OR? Do you ever do these in the office, and do you always use navigation, or does it just depend on what the patient has?

[Dr. John Craig]
Yes, me personally, I've never needed to do these cases in the office. I can get them on my OR schedule pretty quickly, and they're relatively short. People doing a lot of in-office procedures have a nice system set up. I've talked to some people doing these cases in the office, so I think it all comes down to your comfort level. If you're comfortable controlling pretty significant oozing, and you have a team in your office, I think that's totally fine. If you feel it's safe, that's great. Me personally, I want to make that opening really wide, deal with any arterial bleeding that might pop up, and so I do in the OR.

We usually have navigation protocol CTs ordered whenever we order the CT, so it's almost always available for a maxillary antrostomy, really using that navigation. I think if you're going up along the skull base and frontal sinus regions, if you don't do a lot of those cases, it's probably wise to have navigation.

[Dr. Ashley Agan]
After surgery, as far as post-op instructions for patients, I assume you have them rinsed. 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.

[Dr. Gopi Shah]
Are you always culturing in the OR as well?

[Dr. John Craig]
Oh, yes, absolutely. I presume everyone does it this way, but sterilely obtained culture, essential. We had 100% culture growth rate in our microbial culture study. My infectious disease person was very happy about that. Just me personally, I use a 2.5-millimeter malleable curved suction attached to a Lukens trap, collect that pus directly from the maxillary sinus. I feel like that's been a great way to do it. Just, I would hesitate if people are using swabs and just swabbing the inside of the nose as they go in. Sterile acquisition is good.

[Dr. Gopi Shah]
You're suctioning that after you've created your antrostomy and you can actually put your suction down into the sinus as opposed to suctioning the stuff that's coming out.

[Dr. John Craig]
Yes. I found that the middle meatal pus is not enough. When you get into that maxillary, there's so much pus and ODS. It's a large reservoir.

[Dr. Gopi Shah]
Yes, culturing the heart of it, like the middle.

[Dr. John Craig]
Yes, got it.

[Dr. Gopi Shah]
As far as outcomes go, once you've drained the abscess basically, success rates are pretty high.

[Dr. John Craig]
Very high. That's why this condition is so fun to manage. Once you identify it, which is the harder part, you should be seeing 90%, 95% success if you've addressed the teeth appropriately and the sinuses adequately. I think it's important, though, that people don't think it's just 100% success because I know some people presume that. There's even some series showing 100% success, but nothing can really be 100% in my opinion. I've seen, so, we just put this out and we did actually achieve 98% long-term resolution endoscopically and symptomatically, which is awesome, but there's that 2% to 5% group that who knows?

There's just so many variables with sinusitis, whether they're forming biofilms. I've had to do a medial maxillectomy on one patient that comes to mind. It actually wasn't odontogenic bacteria when I finally got in there. They actually started growing MRSA. We open these sinuses to the outside world, different bacteria can get in there, set up shop. Maybe you have some surgical scarring. The bottom line is these patients usually do fantastic, but you just have to be aware some of these patients will either recur or in my experience, it's been more a different sinusitis has occurred after.

(8) Recurrence of Odontogenic Sinusitis

[Dr. Ashley Agan]
When you say recur, like having another tooth have problems or the same area having issues again, something like that?

[Dr. John Craig]
Yes, that's a good point. I didn't specify that. If you didn't get the two, there's two situations there. If the tooth wasn't appropriately treated, so maybe an incomplete root canal or fractured root when they extracted the tooth or something, then yes, that would be a recurrence. I personally haven't seen this yet, but I'm waiting for it to happen. Another tooth to pop up and cause a second odontogenic sinusitis. Seems to be pretty unlikely on the whole, but that could happen as far as recurrence goes.

[Dr. Ashley Agan]
As we start to round things out, any final pearls that you want to leave our listeners with, John?

[Dr. John Craig]
For one, we just need to all be aware that this is more common than we previously thought and we have to look for it. Other dental providers, radiologists, other medical providers, they're not going to identify this for you. That's actually been shown in a bunch of studies too, that radiologists, unfortunately, miss the odontogenic pathology in the majority of cases. Again, ENTs, we have to be looking for it. The things that should tip us off, unilateral symptoms, scope findings, CT findings, especially maxillary opacification. We should be looking down at the teeth on that CT and looking for dental pathology.

I mentioned this earlier, but I think we're going to start pushing this message more. Opacification on that CT is what's critical. Mucosal thickening is very common, can be just a random anomalous finding or it's very common adjacent to dental pathology or dental treatment. Scope that patient, make sure it's infectious sinusitis. That's what we should be considering odontogenic sinusitis.

[Dr. Gopi Shah]
Perfect. Thank you so much. I learned so much.

[Dr. Ashley Agan]
Yes, thank you for taking the time. This was great.

[Dr. John Craig]
Excellent. Thanks so much, guys.

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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