Treatment of Severe Sinus Infection AfterSinus Lift Procedure: A Case Report

Bandar Abdulrahman Almaghrabi, BDS, MS,* Michael N. Hatton, DDS, MS,† Sebastiano Andreana, DDS, MS,‡and Mark A. C. Hoeplinger, MD§

The maxillary sinus is an air-filled cavity located on bothsides of the maxilla. It is pyra-

midal in shape and is the largest of thesinus cavities. Sinuses communicateto the nasal cavity via small bonechannels called ostea.1,2 The biologicalrole of the sinuses is debated,2–4 but anumber of possible functions havebeen proposed:

• Decreasing the relative weight ofthe front of the skull, especiallythe bones of the face

• Increasing resonance of the voice• Providing a buffer against blows

to the face• Insulating sensitive structures

such as dental roots and eyes fromrapid temperature fluctuations inthe nasal cavity

• Humidifying and heating of in-haled air because of slow air turn-over in this region3,5,6

This cavity is frequently reinforcedwith internal vertical septae that can cre-ate further intrasinus cavities. The size

of the sinus can vary on individual basis.Adults have a mean width of 35 mm atthe base and a mean height of 25 mm.7After tooth extraction, bone remodelingof the alveolus occurs, which often leadsto an inadequate alveolar height andwidth for dental implant placement. Afrequently performed clinical technique,the “sinus lift,” was published by Tatum.8He described a modified Caldwell-Luc approach from the lateral aspect ofthe maxillary sinus and elevation of theSchneiderian membrane. This, in turn,provided a closed space for hard tissuegrafting procedures. Tatum’s technique,however, has potential complications. Acommon intraoperative complication isperforation of the Schneiderian mem-brane during dissection.9–11 Postopera-tive sinus floor augmentation mayconsist of complications that may in-clude, infection, sequestration of bone,and maxillary sinusitis.12 Loss of thegrafting material may also occur. Previ-ous investigations have reported that

complications can occur in up to 20% ofpatients after sinus floor augmenta-tion.6,8 The literature suggests that com-plications tend to be associated withpreexisting sinus disease or documentedsusceptibility to sinus disease.13–15 Os-tium stenosis is a narrowing of the os-tium size due to chronic sinus disease orcongenital factors. It is a defect not pre-viously described as being responsiblefor complications following sinus liftoperations, and about 24% of patientswho present for sinus lift proceduresmay have this finding.16 This case reportpresents an unforeseen complication af-ter sinus lift and graft procedure.

CASE REPORT

A 50-year-old white male patientcame to the University at BuffaloSchool of Dental Medicine (Buffalo,NY) to seek dental replacement of pre-viously extracted teeth in the areas ofteeth 3 and 14. The patient’s medical

*Research Instructor, Postgraduate Periodontal Resident,Department of Periodontics and Endodontics, SUNY atBuffalo, Buffalo, NY.†Clinical Associate Professor, Department of Oral DiagnosticSciences; Clinical Assistant Professor, Department of Oral andMaxillofacial Surgery SUNY at Buffalo, Buffalo, NY.‡Associate Professor, Director of Implant Dentistry,Department of Restorative Dentistry, SUNY at Buffalo,Buffalo, NY.§Private Practice, Clinical Instructor, Department ofOtolaryngology, University of Buffalo School of Medicine;Medical staff of Mercy Hospital of Buffalo, Women andChildren’s Hospital and Millard Filmore Gates Circle Hospital atBuffalo, NY.

Reprint requests and correspondence to: BandarAbdulrahman Almaghrabi, BDS, MS, SUNY atBuffalo, 250 Squire Hall, Buffalo, NY 14214, Phone:716-907-8444, Fax: 716-829-6840, E-mail:baa8@buffalo.edu

ISSN 1056-6163/11/02006-430Implant DentistryVolume 20 • Number 6Copyright © 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e318236525c

Maxillary sinus floor augmentationmay have a variety of postoperativecomplications including infection,sequestration of bone, and maxil-lary sinusitis. Complications canalso occur due to a preexisting si-nus condition called ostium steno-sis. This case report presents acomplication after sinus lift andgrafting procedure due to an un-recognized ostium stenosis.

Case Report: A 50-year-old malepatient had sinus augmentation on hisright side. However, postoperatively,his symptoms were protracted. A CTscan showed thickening of the Sch-

neiderian membrane and scatteredgraft material. Management includedendoscopic nasal examination and os-tium enlargement, antibiotic coverage,and full enucleation of the graft anddiseased tissue.

Conclusion: Patency of the sinusostium should be carefully evaluatedbefore sinus lift/grafting procedure us-ing CT technology. Radiology andotolaryngology consultations may benecessary to rule out ostium stenosisbefore surgery. (Implant Dent 2011;20:430–433)Key Words: ostium, stenosis, otolar-yngologist, sinus lift complications

430 SINUS INFECTION AFTER SINUS LIFT PROCEDURE • ALMAGHRABI ET AL

history included an allergy to penicil-lin. At this time, the patient was takingmultivitamins, Diazepam (Sigma-Aldrich, St. Louis, MO), Asmanex(Merck & Co., Whitehouse Station,NJ), Symbicort (AstraZeneca Pharma-ceuticals, Wilmington, DE), and Albu-terol (Mylan Pharmaceuticals Inc.,Morgantown, WV). The latter threemedications were used to control re-active airway disease, whereas Diaze-pam was prescribed to control anxietyand insomnia. A panoramic x-ray ofthe patient showed alveolar atrophyand sinus pneumatization in the areasof teeth 3 and 14 (Fig. 1).

Treatment options were discussedwith the patient, and a mutual decisionwas made to undergo sinus lift/mineralized tissue graft procedures,before implant placement. We decidedto provide care starting on the pa-tient’s right side. The left side wasplanned to be done at a future appoint-ment. Risks, benefits, and alternativesof the proposed procedure were dis-cussed with the patient. All questionswere answered. The patient signed astandard surgical consent form. Localanesthesia was administered using onecarpule of 2% lidocaine, with epineph-rine (1:50,000). A full-thickness flapwas reflected over the lateral aspect ofthe right maxillary wall. An osseous

window was created in a standardfashion using both rotary and piezo-electric surgery techniques. During theprocedure, the Schneiderian mem-brane was torn (!5 mm), and it wasclosed using a collagen membrane(Colla Tape; Zimmer, Carlsbad, CA)with dimension of 1 " 2.5 " 7.5mm.17 The intact side of the membranewas fully reflected to achieve an idealspace for grafting. Before graft place-ment (irradiated cancellous particulateallograft bone; Rocky Mountain Tis-sue Bank, Aurora, CO), the membraneperforation was checked for completecoverage. Four grams of bone graftmaterial (irradiated cancellous partic-ulate allograft bone; Rocky MountainTissue Bank) was placed into the sinus liftcavity. A collagen membrane (Conform,Ace Surgical Supply, Brockton, MA)was placed over the lateral aspect of thebone window. The flap was replaced,and 4.0 nonresorbable suture material(Cytoplast PTFE; Osteogenics Biomed-ical, Lubbock, TX) was used to stabilizethe flap. This patient was prescribed 150mg clindamycin four times per day for10 days and 0.75 mg dexamethasonefour times per day for 6 days. Thepatient started these medications oneday before surgery.

The first postsurgical week was un-eventful. However, 2 weeks after the

surgery, the patient reported pain anddiscomfort, with drainage from his nasalcavity on the operative side. A periapi-cal radiograph was taken which showedthat grafting material was intact.

Yellow mucus discharge from theright nostril was cultured in standardtransport media. A mixture of aerobicand anaerobic bacteria was noted. Thepatient was prescribed clindamycin300 mg along with metronidazole 250mg to reduce the possibility of havinganaerobic bacterial infection. The pa-tient showed no improvement, and hewas then prescribed tetracycline 500mg, for 10 days. On the second day oftaking tetracycline (21 days after thesurgery), the patient reported swellingin the right maxillary sinus area. Therewas also pain on palpation, malaise,and fever. Surgical intervention wasdone via incision and drainage underlocal anesthesia. Four days later, the pa-tient reported that the swelling subsided,with a decrease in nasal discharge. Thepatient was monitored on a frequent ba-sis. A CT scan was obtained which re-vealed that the bone graft was scatteredin the anterior and floor regions of theright sinus area with most of the piecesadhering to the soft tissue lining. Ofspecial note was that thickened soft tis-sue which completely blocked the rightmaxillary sinus ostium. The treatmentplan was discussed. He agreed to havethe graft material removed from theright maxillary sinus.

After several weeks, the intraoralsoft tissue stoma had closed. Underlocal anesthesia, a full-thickness flapwas reflected over the right maxillarysinus wall, and access was madethrough the previous lateral window.Findings included showed frank pusaccumulation and unattached bonegrafting material. The area was curet-ted and irrigated with saline. Suturingwas done using a 3.0 PTFE with in-terrupted technique.

After soft tissue healing of thesite, the patient noted discomfort andtenderness over the right maxillarysinus. A yellow nasal discharge per-sisted from the right nostril. We re-ferred the patient for consultation withan otolaryngologist. CT scans wereobtained, which revealed remnants of

Fig. 1. Preoperative pictures during initial examination.Fig. 2. Presurgical CT scan showing some remnants of the grafting material with thickenedSchneiderian membrane and ostium stenosis.Fig. 3. Instrumentation: fiberoptic probe and inflatable device.

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the grafting material and stenosis ofthe right maxillary ostium (Fig. 2).

The otolaryngologist performed anendoscopic examination under generalanesthesia (Fig. 3). Findings were consis-tent with stenosis of the right maxillarysinus ostium (Fig. 4). Balloon catheter-ization and widening of the ostium werecompleted (Fig. 5). Cultures were takenduring the surgery, and the sinus wasexamined using a fiberoptic probe.These cultures had shown presence ofPrevotella species and were identifiedas Prevotella melaninogenica. The baseof the Schneiderian membrane on theother hand appeared intact. No other ab-normalities were noted.

The patient did improve after theprocedure and was less symptomatic.Two months later, the patient devel-oped copious clear mucus dischargefrom the right nasal cavity and alsonoted tenderness of the right maxillarysinus. In addition, he reported inter-mittent blockage of the right nasal air-way and difficulty with air flowthrough the right nasal passage. Basedon the persistent symptoms and con-sultation with his otolaryngologist,

surgical exploration by an oral andmaxillofacial surgeon was offered tothe patient. The consulting otolaryn-gologist was not experienced in re-moving dental material from a graftedsinus and asked that a dental surgeonperform the procedure. Standard sur-gical consent was obtained. Underlocal anesthesia, the oral and maxillo-facial surgeon elevated a full-thickness mucoperiosteal flap over theright lateral aspect of the maxilla. Theprevious lateral window was used togain access into the base of the sinus.The window was enlarged, and a thor-ough curettage of the graft materialwas done. Multiple sinus polyps andgrafts material attached to the thick-ened Schneiderian membrane wereremoved (Fig. 6). The sinus was thor-oughly irrigated, and the osseouswindow was covered with a collagenmembrane. The flap was broughtagain to its original position andclosed with interrupted sutures. Thepatient showed remarkable improve-ment (Fig. 7) and was symptom free on a1-year follow-up.

DISCUSSION

Alveolar atrophy and maxillary si-nus pneumatization after tooth extrac-tion can create a significant challengefor dental implant placement in theposterior maxilla. To increase thebone height of the posterior alveolarareas of the maxilla, “sinus lift” pro-cedures have become commonly usedin dental implant surgery.6 This com-munication describes a persistent post-operative maxillary sinusitis, whichcan be traced to stenosis ostium of themaxillary sinus.

Anatomical variation of the os-teomeatal complex (which can includenarrowing of the ostium) can havedeleterious effects on sinus drain-age.13,18 –20 Narrowing of the sinusostium can arise from congenital, in-flammatory, or neoplastic sources.Stenosis ostium has a prevalence of24%16,21 and can be associated withacute and chronic sinusitis where thepermeability of the ostium is al-tered.21–24 Mucosal edema can obliter-ate the ostium, along with nasal polypformation.25,26 A patient’s medical his-tory is an important factor beforeundertaking a sinus lift procedure, es-pecially in regard to nasal symptoms.This patient did have a history of re-active airway disease. He also had ahistory of nasal problems, which werenot active at the time of the originalprocedure. In fact, he had seen thesame treating otolaryngologist in thepast to stabilize the sinus symptomsbefore proceeding with the sinus liftprocedure. Chronic sinusitis is moreprevalent among patients with reactiveairway disease.16 Although this patienthad an intraoperative tear of the Sch-neiderian membrane during the graftprocedure, we believe that the persis-tent sinusitis was indeed related to ste-nosis ostium. The patient had adequatepre- and postoperative antibiotic cov-erage for the procedure. The incidenceof membrane perforation varieswidely in the literature.27,28 It is notuncommon and is usually dealt with asdescribed above.3,27,29

Schneiderian membrane perfora-tion can be associated with postoper-ative complications, such as acute orchronic sinus infection, wound dehis-cence, loss of the graft material, and a

Fig. 4. Nasal endoscopy: ethmoid thickening with ostium stenosis.Fig. 5. Sinus ostium after enlargement using inflatable device and shaving the ethmoid thickening.Fig. 6. Polyps removed along with bone grafting material after maxillary sinus membraneenucleation.Fig. 7. Postsurgical radiographic image.

432 SINUS INFECTION AFTER SINUS LIFT PROCEDURE • ALMAGHRABI ET AL

disruption of normal sinus physiologicfunction.3,30–33 Becker et al,27 however,found that sinus perforation per se didnot necessarily result in implant loss,displacement of graft material, or infec-tious complications. The authors believethat this patient’s protracted course wasindeed due to ostium stenosis.

CONCLUSION

Ostium stenosis cannot be visual-ized on intraoral dental radiographs orpanoramic films. On the basis of thiscase, we now strongly recommend theuse of a CT scan before proceedingwith sinus lift procedures. Patency ofthe ostium should be carefully evalu-ated, along with any preexisting sinusdisease or other aberrant anatomicalfactors of the sinus. All of these issuesmust be taken into account beforecommencing a sinus lift/graftingprocedure. If the dental clinician isunfamiliar with reading a CT of theparanasal sinuses, we recommend aradiologist review the scan. An otolar-yngologist should be consulted preop-eratively if there are issues with theCT or the patient has a history of sinusailments. On the basis of this case, wenow strongly believe that a patent os-tium should be verbally included inany consultant’s report.

DISCLOSURE

The authors claim to have no finan-cial interest in any company or any ofthe products mentioned in this article.

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