Sinuzită odontogenă la un adolescent – prezentare de caz şi mini-review de literatură

Introduction

The definition of sinusitis is the inflammation of the sinuses – in our case, the maxillary sinuses – as a direct consequence of a bacterial or fungal infection. When the pathogens involved in this infection are from the oral cavity, more specifically from a dental infection, the disease is called odontogenic sinusitis. The latter is a frequently overlooked cause for acute or chronic sinusitis. Identifying this disease at the optimal time and correctly treating it are two very important aspects for the remission of sinusitis and for the complications’ prevention. Conventional symptomatic treatment that does not involve treating the etiological cause is often ineffective in the long term, with various serious complications⁽¹⁾.

In this paper, we present the case of an adolescent with right maxillary sinusitis of odontogenic cause and we briefly review the recent literature on the epidemiology and treatment of odontogenic sinusitis.

Case report

A 17-year-old male adolescent presented to the emergency department (ED) for a three-day onset fever (maximum 39.9 degrees Celsius) with associated headache and nasal obstruction predominantly on the right side. At the time of evaluation in the ED, the general condition was altered, the patient was febrile (39.4 degrees Celsius), with heart rate 84/minute, blood pressure 126/77 mmHg, O₂ saturation 99% in room air, the physical examination being normal, except for predominantly right nasal obstruction, right-sided nasal pyramid edema and tenderness on palpation of the right maxillary sinus point. On evaluation of the oral cavity, extensive caries with integral destruction of the crown at the level of the 16^th premolar could be identified.

The laboratory investigations revealed an increased white blood cell count (20.9x10³/µL) with predominance of neutrophils (79.4%, 16.6x10³/µL) and the presence of a significant inflammatory syndrome (CRP=11.6 mg/dL; normal range: below 0.5 mg/dL). We performed a sinus X-ray which showed the total opacification of the right maxillary sinus. The patient received outpatient treatment with amoxicillin 875 mg/clavulanate 125 mg, being referred to the dentist for dental evaluation.

After seven days of treatment, he was reassessed. He had the complete remission of symptoms, with no nasal pyramid edema, no nasal obstruction and no maxillary sinus point tenderness. The patient was referred to the dentist who started an oral rehabilitation program for the adolescent.

Discussion

The etiological spectrum of the odontogenic sinusitis ranges from air allergens, bacterial or fungal infections to foreign bodies⁽²⁾. Odontogenic sinusitis tends to be more prevalent in female population, with a ratio of 1/1.33 between males and females. The most frequent affected tooth is the first molar, followed by the third molar and the second molar. The two most frequent direct causes involved in this disease are iatrogenesis and periodontitis⁽³⁾. Although odontogenic sinusitis affects a large part of the population, there is still no international consensus for the diagnosis of this condition⁽⁴⁾. In the medical literature, the incidence of odontogenic sinusitis is somewhere between 10% and 40% of all cases. Moreover, the most common cause for this condition is iatrogenic infection. Also, this particular disease has to be treated very carefully by both otolaryngologists and dentists⁽⁵⁾.

The main cause for odontogenic sinusitis is the bacterial infection originated from the oral cavity. The bacterial pathogens involved in this infection are mostly represented by anaerobes, with most of them (70%) having an amoxicillin/clavulanate susceptibility. On the other hand, all the isolated pathogens are susceptible to levofloxacin, teicoplanin and vancomycin. This finding highlights the importance of the antibiotic therapy associated to the dental or/and sinus surgery⁽⁶⁾.

The odontogenic sinusitis is taken in consideration as a potential diagnostic when there is a history of recent dental work and symptoms and signs which include unilateral facial pain and improper drainage in association with or without an obvious sign of dental infection at the oral cavity examination⁽⁷⁾. However, the clinical presen­tation of odontogenic sinusitis is very similar to the rhinogenic sinusitis, with the three main symptoms that are common for both of them. These symptoms include, as mentioned before, facial pain, postnasal discharge and congestion⁽⁸⁾.

The gold standard diagnostic tool for odontogenic sinusitis is the computed tomography. Although the conventional radiography is still being used in some countries, this method cannot identify and subsequently diagnose this particular pathology⁽⁹⁾. The literature also mentions the cone beam volumetric CT as a good diagnostic tool for odontogenic sinusitis⁽¹⁰⁾.

The main treatment options for odontogenic sinusitis include – but are not limited to – dental treatment alone or combined with endoscopic sinus surgery personalized for every patient⁽¹¹⁾.

Odontogenic sinusitis can cause a series of complications, ranging from moderate to severe and even life-threatening ones. These complications include orbital, intracranial and osseous extension of infection⁽¹²⁾. As mentioned before, the treatment for the odontogenic sinusitis is represented by medical treatment that includes antibiotics and the surgical treatment which includes endoscopic sinus surgery. One study from literature concludes that the majority of patients with odontogenic sinusitis can fully recover with medical and dental treatment alone, these patients being the ones with dental caries and periapical abscess. The patients with severe findings at the sinus CT scan, with additional risk factors (e.g., tobacco smoke) are the candidates for endoscopic sinus surgery⁽¹³⁾.

Conclusions

Odontogenic sinusitis is a disease with a sudden clinical impact and possible severe complications. It is therefore important to diagnose and treat this disease early. The possible polymicrobial character must be taken into account, therefore antibiotic therapy must have a spectrum of action that includes anaerobic pathogens. The management of these pathologies must be individualized for each case, and multidisciplinary collaboration is very important and must include, among others, a dentist and an ENT doctor.  

Consent: Written informed consent was obtained from the patient and his parents for the publication of this case report.

Conflict of interests: The authors declare no con­flict of interests.

Funding: None to declare.

Acknowledgements: All authors have same con­tri­­bu­­tion.