Odontogenic sinusitis: A state-of-the-art review

Abstract

Odontogenic sinusitis (ODS) is more common than historically reported, and is underrepresented in the sinusitis literature. ODS is distinct from rhinosinusitis in that it is infectious sinusitis from an infectious dental source or a complication from dental procedures, and most commonly presents unilaterally. ODS clinical features, microbiology, and diagnostic and treatment paradigms are also distinct from rhinosinusitis. ODS evaluation and management should generally be conducted by both otolaryngologists and dental providers, and clinicians must be able to suspect and confirm the condition. ODS suspicion is driven by certain clinical features like unilateral maxillary sinus opacification on computed tomography, overt maxillary dental pathology on computed tomography, unilateral middle meatal purulence on nasal endoscopy, foul smell, and odontogenic bacteria in sinus cultures. Otolaryngologists should confirm the sinusitis through nasal endoscopy by assessing for middle meatal purulence, edema, or polyps. Dental providers should confirm dental pathology through appropriate examinations and imaging. Once ODS is confirmed, a multidisciplinary shared decision-making process should ensue to discuss risks and benefits of the timing and different types of dental and sinus surgical interventions. Oral antibiotics are generally ineffective at resolving ODS, especially when there is treatable dental pathology. When both the dental pathology and sinusitis are addressed, resolution can be expected in 90%-100% of cases. For treatable dental pathology, while primary dental treatment may resolve the sinusitis, a significant percentage of patients still require endoscopic sinus surgery. For patients with significant sinusitis symptom burdens, primary endoscopic sinus surgery is an option to resolve symptoms faster, followed by appropriate dental management. More well-designed studies are necessary across all areas of ODS.

Keywords: apical periodontitis; chronic rhinosinusitis; endoscopic sinus surgery; maxillary sinusitis; odontogenic sinusitis.

Figure 1

Diagram highlighting the two central tenets of diagnosing odontogenic sinusitis (ODS): suspecting and confirming the condition (as described in international multidisciplinary consensus). The diagnosis of ODS is made by confirming sinusitis through nasal endoscopy by otolaryngologists and confirming adjacent maxillary dental pathology through various forms of diagnostic testing and imaging by dental specialists. AP, apical periodontitis; CBCT, cone beam computed tomography; CT, computed tomography; OAF, oroantral fistula; OP, orthopantogram; PAR, periapical X‐ray

Figure 2

(A) Computed tomography demonstrating right‐sided odontogenic sinusitis due to apical periodontitis that arose from dental caries and pulpal necrosis in a maxillary molar (yellow arrow pointing to the carious molar). (B) Right‐sided nasal endoscopy demonstrating an edematous bulging uncinate process (UP), with purulence draining posteriorly in the middle meatus. MT, middle turbinate

Figure 3

Computed tomography demonstrating left‐sided odontogenic sinusitis with maxillary and ethmoid sinus opacification, but no overt maxillary molar pathology. However, the periapical bone around the palatal molar root was remodeled or absent (yellow arrow). Due to an odontogenic sinusitis suspicion, the patient was referred to an endodontist who confirmed pulpal necrosis and apical periodontitis

Figure 4

(A) Computed tomography illustrating a case of confirmed left maxillary molar endodontic and periodontal disease causing periapical bone erosion, and adjacent maxillary sinus mucosal thickening on computed tomography. However, the patient had a (B) normal left‐sided nasal endoscopy with no purulence or edema in the middle meatus (yellow asterisks). Therefore this patient was not diagnosed with odontogenic sinusitis. MT, middle turbinate

Figure 5

Example of odontogenic sinusitis causing an orbital subperiosteal abscess, resulting in left orbital pain and proptosis but no vision loss. (A) Sagittal noncontrast computed tomography demonstrating complete maxillary and frontal sinus opacification and a maxillary premolar root with a periapical lesion and bone erosion (yellow arrow). (B) Coronal computed tomography with contrast demonstrating left frontal sinus opacification and sinus floor erosion, and a superiorly based rim‐enhancing subperiosteal orbital abscess (yellow arrow)