Endoscopic Treatment of Perforated Maxillary Sinusitis

For many decades, the problem of odontogenic sinusitis, particularly perforative sinusitis, has been actively discussed among otolaryngologists, dentists, and maxillofacial surgeons. During this time, a wealth of clinical experience has been accumulated, knowledge of normal and pathological physiology of the nose and paranasal sinuses has significantly advanced, and numerous surgical treatment methods for this pathology have been proposed, yet the number of patients with perforative sinusitis is not decreasing, and treatment outcomes leave much to be desired.

When analyzing the reasons for such a high frequency of this pathology, and according to various authors, perforative sinusitis accounts for 40-80% of all odontogenic sinusitis cases (V.M. Bezrukov, T.G. Robustova, 2000; V.M. Uvarov, 1962; et al.), the first reason cited is the unsatisfactory organization of dental care for the population, and consequently, the catastrophic prevalence of complicated forms of caries (A.G. Balabantsev, V.V. Bogdanov et al., 2000). The second reason is the pneumatic type of sinus structure, which is present in most people, where the roots of the teeth are separated from its lumen by a thin bony wall or only by the mucous membrane. Perforations often occur as a result of rough medical manipulations (V.M. Bezrukov, T.G. Robustova, 2000; S.M. Kompaniets, 1949; A.G. Shargorodsky, 1985; G.A. Vasilyev, 1963; et al.).

As for unsatisfactory treatment outcomes, they are primarily due to its inadequacy. This opinion is expressed in most modern publications (A.G. Balabantsev, V.V. Bogdanov et al., 2000; N.D. Tsepilova, D.M. Fazlynurova et al., 1998; and others), and we fully agree with this statement. It can be said that the question of the necessary volume of intervention today raises the main discussions, and the methods used in the clinic are sometimes polar opposites, ranging from widespread radical maxillary sinusotomy to complete abstention from interventions on the sinus.

In our opinion, the available data on the pathomorphology and pathophysiology of the process allows us to answer the question of the necessary volume of intervention. Statements about changes in the sinus after the formation of its communication with the oral cavity have been present in publications since the beginning of the century. Their nature was described in detail by V.A. Kozlov et al. in 1982. The author experimentally proved that the formation of a perforation leads to a reactive inflammatory process in the mucous membrane and bone structures of the intact sinus. He identified three phases of this process – the alternative, productive, and fibrous phases. This conclusion, by the way, helps to resolve some confusion that exists in the modern literature, where some authors refer to this pathology as perforation, which may or may not be complicated by sinusitis, while others immediately call it perforative sinusitis. The latter are undoubtedly correct; the discussion can only be about the clinical signs of the pathology, whether obvious or hidden, and the presence of inflammation in the sinus is proven.

Like any experiment, it did not fully reflect the clinical picture, as the perforation was applied to intact teeth and sinus. In reality, perforation often occurs against the background of already existing odontogenic etiology sinusitis. The fact is that teeth are removed due to exacerbation of chronic, and less often acute, periodontal inflammation. This process is accompanied by bone destruction in the area of the root apex, i.e., in the case of a pneumatic type of sinus structure, the thin bony wall (which sometimes is completely absent) separating the tooth from the sinus is destroyed. The sinus becomes infected, and the periapical granuloma fuses with its mucous membrane. These sinusitis cases are mostly localized, affecting the sinus only in the area of the alveolar recess, and they progress slowly and asymptomatically, which is why they are not always diagnosed (A.V. Buskina, V.H. Gerber, 2000; A.M. Shevchenko et al., 2000; A.G. Balabantsev et al., 2000; et al.). The formation of perforation in such cases is inevitable, and consequently, as a result, there will be no acute sinusitis observed, but rather an exacerbation of chronic sinusitis, which is also of considerable importance. The presence of preceding sinusitis sometimes becomes the reason for late diagnosis of perforation, as polypoid growths can obstruct it, clinical signs are blurred, and the diagnosis is established only after the formation of a fistula.

As our experience and data from other researchers (F.A. Tyshko, O.P. Dyadchenko et al., 2000; V.M. Bezrukov, T.G. Robustova, 2000; V.V. Luzina, O.E. Manuilov, 1995; A.G. Balabantsev, V.V. Bogdanov et al., 2000; N.D. Tsepilova, D.M. Fazlynurova et al., 1998; etc.) show, perforative maxillary sinusitis is not characterized by an acute course, which is logically explained by the good drainage of exudate into the nasal and oral cavities. The acute phase quickly subsides, peaking at 2-7 days, after which, in most cases, the process localizes in the area of the alveolar socket. Total changes in the sinus are observed less frequently. The perforative opening gradually narrows due to the growth of granulation tissue, its walls become epithelialized, and a fistula forms, through which liquids and food enter the sinus, irritating its mucous membrane.

The process is more active in the presence of a foreign body (tooth root, filling material, tampon, etc.). In such patients, there is a constant purulent discharge from the sinus, with periodic exacerbations. Changes in the sinus are total in nature, with a predominance of the proliferative, less often destructive component, i.e., pronounced polyposis, or necrosis of the mucous membrane and destruction of the underlying bone.

Another important factor that has a direct impact on the course of perforative maxillary sinusitis is the condition of the anthrochoanal communication. This factor was significant even before the formation of the perforation, in terms of the sinus's resistance to odontogenic infection. After the formation of the perforation and the free communication of the sinus with the oral cavity, its role becomes less noticeable, but after the obturation or surgical removal of the perforation, the drainage function of the fontanelles again becomes of primary importance; the failure of the anthrochoanal communication will lead to exacerbation of sinusitis.

Based on the information provided above, a theoretical concept for the treatment of perforative maxillary sinusitis can be developed. Treatment should be aimed at eliminating the oroantral communication and suppressing the inflammatory process. The oroantral communication should be eliminated against the background of inactive sinusitis, i.e., in the case of perforation of an intact sinus within 1-2 days or 1-2 weeks after its formation, and in the case of perforation against the background of chronic sinusitis – during its remission stage.

Treatment of sinusitis itself should include the removal of polyps, granulations, foreign bodies, etc. from the sinus, elimination of oroantral communication, and restoration of the natural anthrochoanal connection. The intervention should not be accompanied by trauma to healthy tissues. As with the elimination of perforation, sinus sanitation should not be performed during active inflammation, as this will lead to its progression.

To date, we have managed to find almost three dozen original proposals in the literature regarding methods for eliminating oroantral communication. Essentially, they can be divided into 4 groups: isolation of the perforation from the oral cavity with its independent healing; perforation plastic surgery using artificial material; plastic surgery with soft tissue flaps; and a combination of flap operations with filling using artificial materials.

Proponents of the first option (Yu.I. Bernadsky, 2000; V.I. Lukyanenko, 1976; et al.) believe that the isolation method is indicated for acute perforation (up to 48 hours). For this purpose, a iodoform tampon is used, fixed with ligatures to adjacent teeth, or a plastic protective plate. This measure prevents the washing out of the blood clot from the socket, which subsequently organizes and is replaced by connective tissue. The method was popular, but frequent complications and recurrences with such narrow indications limited its use.

Plastic surgery with artificial materials is proposed as a method for eliminating acute perforations and oroantral fistulas (R.G. Anyutin…, Bogatov et al.). The authors used oxycellulose, hemostatic sponges, collagen-based preparations, hydroxyapatite, and demineralized bone matrix, etc. There are only a few publications available, without long-term follow-up, making it impossible to conduct an objective assessment of these methods.

The best results to date have been achieved through plastic closure of oroantral communication using soft tissue flaps. The variety of proposed grafts is quite rich, many of which are of only historical interest, such as the transplantation of Filatov's stem or other flaps from distant parts of the body (…). Local tissues are unanimously recognized as the optimal plastic material. In everyday practice, mucoperiosteal flaps from the vestibular surface of the alveolar ridge and cheek are most widely used. They are convenient from a technical standpoint and highly viable, but their use often leads to scar deformation of the vestibule of the oral cavity and cheek, which is detrimental not only from an aesthetic perspective but also for subsequent dental prosthetics. A solution to this problem may be palatal flaps. Their harvesting and transfer are technically more complex, but in terms of viability, they are comparable to vestibular flaps and do not cause scar deformations of the vestibule of the oral cavity.

Turning to the methods of sanitation of the maxillary sinus in cases of perforated sinusitis, we note that radical surgeries, proposed more than a century ago, still hold a leading position today. According to V.V. Luzina and O.E. Manulov (1995), the percentage of complications after such a treatment option for odontogenic sinusitis reaches 80%. Similar figures are provided by other researchers (M.M. Solovyev et al., 1974; V.A. Sukachev et al., 1996; and others). The list of observed complications is quite impressive: recurrence of sinusitis, anesthesia in the area of innervation of the infraorbital nerve, neuritis of the second branch of the trigeminal nerve, scar deformation of the tissues in the infraorbital region, tearing, osteomyelitis of the maxilla and zygomatic bone with loosening of teeth, etc. (percentages, authors, etc.). The reason for such unsatisfactory results is the non-physiological nature of the intervention and its traumatic nature. The extensive defect of the mucous membrane of the sinus and the bone of the anterior wall, the formation of an unnatural communication between the sinus and the inferior nasal meatus, trauma to the nasolacrimal canal and infraorbital nerve – these are not all, but the main flaws of the technique. Various modifications of the surgery have not significantly affected the quality and quantity of complications.

More progressive are the proposals to sanitize the sinus through perforation. This idea has been discussed for a long time, but it has not gained widespread acceptance due to the inability to visualize the intervention with the naked eye and the inconvenience of the manipulations. Some researchers believe that the sinus can be sanitized without visual control by performing apodactyl curettage of the alveolar bay and extracting foreign bodies with tampons (similar to nets) (Bogatov, Semenyuk et al.). Others, understanding that visual control is still necessary, suggest expanding the perforation, but even expanding it to 1.5-2 cm, the sinus remains not fully accessible to the eye, and such an increase in the bone defect significantly worsened the results of its plastic surgery (...). Therefore, researchers became interested in optical devices, and publications on the use of bronchoscopy and cystoscopy in the treatment of perforative sinusitis appeared in the literature. The use of endoscopic techniques brought this intervention to a fundamentally new level, as it became possible to revise the sinus without additional trauma and objectively determine the volume of necessary intervention. Nevertheless, the unsuitability of the equipment and instruments used largely negated the positive aspects of the method (Bogatov, 1991).

The real basis for the implementation of the endoscopic method opened up with the emergence of specialized rhinological endoscopic equipment. Rigid endoscopes with diameters of 1.7 mm and 4 mm with viewing angles of 0°, 30°, and 70° allow for the examination of perforation in all sections of the sinus, determining the condition of the antrochoanal communication, the presence and location of foreign bodies, polyps, etc. Based on this data, the question of further tactics is resolved. If the antrochoanal communication is intact, it is optimal to perform sinus sanitation through the perforation, but unfortunately, its size and location do not always allow for the introduction of the endoscope and instruments and their manipulation. Moreover, the size of the foreign body is often larger than the size of the perforation. In such cases, the oroantral communication can be expanded, but only by excising the granulation tissue in the socket. In our opinion, expanding the bony defect is not advisable, as it would worsen the wound healing process, sharply increase the risk of recurrence of the oroantral fistula, and complicate subsequent dental prosthetics. If performing the intervention through the perforation is not possible or if correction of the antrochoanal communication is required, an additional endonasal endoscopic opening of the maxillary sinus through the middle nasal passage is performed. The simultaneous use of two approaches (through the perforation and the middle nasal passage) resolves any technical problems of the operation.

In the presence of accompanying pathology in the nasal cavity (deviated septum, turbinate hyperplasia, etc.), simultaneous correction is performed under video-endoscopic control.

Thus, the endoscopic technique allows for complete sanitation of the sinus with minimal or no additional trauma in accordance with the principles of functional surgery.

We have been using the described endoscopic method for treating perforated sinusitis since 1997. During this time, nearly 100 patients with this pathology have been treated. The majority were patients with chronic sinusitis (up to 2 years since the formation of the perforation), and only 18 patients were admitted to the hospital in the first days after perforation.

Almost all patients with a chronic process had previously undergone multiple (up to 6 attempts) repairs of perforations and oroantral fistulas before being admitted to our department. About a third of them had also been previously operated on using radical methods. We faced the greatest challenges in treating them, as the previous surgeries had completely destroyed the mucous membrane of the sinus, its lumen was filled with granulations soaked in pus, the ostium to the inferior nasal meatus was usually obstructed by scar tissue, and the natural ostium was blocked by polyps or granulations. In such cases, we had no choice but to widely open the sinus into the middle nasal meatus, remove as much granulation and polyps as possible, and plastically eliminate the oroantral fistula.

In most patients with chronic perforating maxillary sinusitis who had not previously undergone radical interventions, there was a local (in the area of the alveolar recess), and less frequently diffuse polypoid mucosa of the maxillary sinus, along with accompanying pathology of the nasal cavity. In cases of prolonged presence of a foreign body in the sinus, necrosis of the tissues around it and active purulent discharge were observed.

We eliminated the perforations using vestibular and palatal flaps.

The results of endoscopic surgical treatment of perforating maxillary sinusitis showed the effectiveness of this technology. We observed isolated cases of recurrence of oroantral fistula (8 patients) and sinusitis (13 patients), almost all of these were previously operated patients by radical methods. In 2 cases, as a result of surgical trauma to the paper plate of the medial wall of the orbit, we obtained orbital hematomas, which resolved successfully. No other complications were recorded.

The hospitalization period for endoscopic surgical treatment was 3-4 days, and further treatment was conducted on an outpatient basis.

Thus, our clinical experience fully confirms the correctness of the principles of functional surgery of the maxillary sinus. The prospects of this direction are beyond doubt, and it will be fundamental in the treatment of sinusitis in the near future. Today, the need for further development of the technological foundation, namely endoscopic techniques and special instruments, is also evident. Nevertheless, even today, physiological endosurgery should gain more clinical prevalence, displacing outdated traumatic technologies.