10.14639/0392-100X-N2648
Objectives. To investigate the clinical efficacy of dental treatment and endoscopic sinus surgery (ESS), each primary/combined treatment modality, in patients with odontogenic sinusitis (ODS), according to its phase, acute or chronic. Materials and methods. We retrospectively reviewed clinical data on 172 patients diagnosed with ODS. They were divided into two groups: acute (≤ 3 months; 90 patients) and chronic (&gt; 3 months; 82 patients) ODS. The success rate and time to resolution of each primary/combined treatment modality were compared between the two groups. Results. In both ODS groups, the success rate was highest with combined ESS and dental therapy, followed by ESS alone and dental therapy alone. ESS outperformed dental therapy (96.6% vs 65.5% for acute ODS, p = 0.011; 80.6% vs 56.5% for chronic ODS, p = 0.046) and led to quicker resolution of symptoms for acute ODS than dental therapy (0.9 vs 1.7 months, p = 0.012). In the comparison between ESS alone and combined therapy, no significant difference was observed for acute ODS, whereas combined therapy demonstrated a superior success rate for chronic ODS (100% vs 80.6%, p = 0.046). Conclusions. In our study, the clinical utility of dental treatment and/or ESS depended on the morbidity period of ODS. For chronic ODS, combined ESS and dental treatment seems to be an effective first-line treatment.
text/xml
1827-675X
2648
en
Yoo-Sam Chung
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
endoscopic sinus surgery
Retrospective comparison of first-line treatments for odontogenic sinusitis based on duration of symptoms
Text.Serial.Journal
https://www.actaitalica.it/
44
Rhinology
2024-02-29
2023-05-19
2024-04-23
2024-04-23
91-99
1
Yoo-Sam Chung
2024/02/29
10.14639/0392-100X-N2648
91
Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Corrisponding author - entysc@gmail.com
1827-675X
endoscopic sinus surgery
en
99
Retrospective comparison of first-line treatments for odontogenic sinusitis based on duration of symptoms
https://www.actaitalica.it/article/download/2648/1083
44
ACTA OTORHINOLARYNGOLOGICA ITALICA 2024;44:91-99; doi: 10.14639/0392-100X-N2648




Rhinology


Retrospective comparison of first-line treatments for
odontogenic sinusitis based on duration of symptoms
Kyung Won Kwon1,2, Jang Wook Gwak1, Yoo-Sam Chung1
1
  Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; 2 Department of
Otolaryngology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea



SUMMARY
Objectives. To investigate the clinical efficacy of dental treatment and endoscopic sinus
surgery (ESS), each primary/combined treatment modality, in patients with odontogenic
sinusitis (ODS), according to its phase, acute or chronic.
Materials and methods. We retrospectively reviewed clinical data on 172 patients diag-
nosed with ODS. They were divided into two groups: acute (≤ 3 months; 90 patients) and
chronic (> 3 months; 82 patients) ODS. The success rate and time to resolution of each
primary/combined treatment modality were compared between the two groups.
Results. In both ODS groups, the success rate was highest with combined ESS and dental
therapy, followed by ESS alone and dental therapy alone. ESS outperformed dental therapy
(96.6% vs 65.5% for acute ODS, p = 0.011; 80.6% vs 56.5% for chronic ODS, p = 0.046) and
led to quicker resolution of symptoms for acute ODS than dental therapy (0.9 vs 1.7 months,
p = 0.012). In the comparison between ESS alone and combined therapy, no significant differ-
ence was observed for acute ODS, whereas combined therapy demonstrated a superior success
rate for chronic ODS (100% vs 80.6%, p = 0.046).
Conclusions. In our study, the clinical utility of dental treatment and/or ESS depended on
the morbidity period of ODS. For chronic ODS, combined ESS and dental treatment seems
to be an effective first-line treatment.
KEY WORDS: odontogenic sinusitis, rhinosinusitis, maxillary sinusitis, endoscopic sinus
surgery


Introduction                                                                                   Received: May 19, 2023
                                                                                               Accepted: September 6, 2023
Odontogenic sinusitis (ODS) is an inflammatory condition of the maxillary or                   Published online: February 29, 2024
extended paranasal sinuses that has a dental aetiology 1. The causes and mech-
                                                                                               Correspondence
anisms of ODS are diverse. Major predisposing factors include periapical and                   Yoo-Sam Chung
periodontal lesions, such as cysts or abscesses, as well as iatrogenic causes,                 E-mail: entysc@gmail.com
such as tooth extraction, oroantral fistula (OAF), other dental procedure-relat-
ed infections, implant use, or foreign bodies 2-5.                                               How to cite this article: Kwon KW, Gwak
Dental infection can spread from a tooth that is close to the floor of the maxilla               JW, Chung Y-S. Retrospective comparison of
                                                                                                 first-line treatments for odontogenic sinusitis
into the sinus chamber through the adjacent maxillary alveolar bone 6. ODS
                                                                                                 based on duration of symptoms. Acta Otorhi-
frequently occurs when the sinus mucosal lining (Schneiderian membrane) is                       nolaryngol Ital 2024;44:91-99. https://doi.
injured during dental procedures 7. The ODS diagnosis is often overlooked be-                    org/10.14639/0392-100X-N2648
cause of its relatively varied clinical course, non-specific symptoms, and lack
                                                                                               © Società Italiana di Otorinolaringoiatria
of information on radiological characteristics. Untreated ODS may progress                     e Chirurgia Cervico-Facciale
to pansinusitis or cause severe complications that are intractable or difficult to
treat 3,8-11. In an international consensus statement on ODS 12, diagnostic crite-                            OPEN ACCESS
ria were proposed based on the clinical and microbiologic features of ODS. A                   This is an open access article distributed in accordance with
                                                                                               the CC-BY-NC-ND (Creative Commons Attribution-Non-
strong consensus was reached regarding a multidisciplinary approach involv-                    Commercial-NoDerivatives 4.0 International) license. The
ing both otolaryngologists and dental providers.                                               article can be used by giving appropriate credit and mentio-
                                                                                               ning the license, but only for non-commercial purposes and
The number of ODS cases is on the rise, reportedly owing to the increase in                    only in the original version. For further information: https://
dental procedures, which is associated with the aging population 13. However,                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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K.W. Kwon et al.




there is no consensus on first-line treatment for ODS 14.           Exclusion criteria were previous sinus surgery or trauma,
Rhinologists and dental care providers differ in opinion in         definite OAF, or fungal sinusitis. In our cohort, 7 patients with
terms of the optimal sequence of dental care and endoscop-          previous surgery or trauma, 24 with an OAF, and 7 with con-
ic sinus surgery (ESS) 15,16. In our institution, there have        comitant fungal sinusitis were excluded, as these factors may
been several cases in which primary dental or ESS treat-            have caused recalcitrance to treatment, which may have af-
ment alone failed, requiring secondary treatment.                   fected the outcome. A total of 172 patients were analysed for
ODS treatment can pose distinct challenges compared to              demographics, symptoms, physical examination results, CT
rhinogenic sinusitis because the histopathological inflam-          imaging characteristics, treatment modality, clinical course,
matory changes in ODS are more severe 17, and the pre-              and follow-up period. Based on the diagnostic criteria for si-
dominant bacterial cultures in ODS tend to be anaerobic             nusitis 26, the patients were divided into two subgroups: acute
and polymicrobial 6,12,18-23. Notably, Brook et al. 20,23,24 have   and chronic ODS. Chronic ODS was diagnosed when symp-
revealed that the predominance of bacteria in the acute and         toms or objective results suggestive of sinusitis persisted for
chronic phases of ODS differs considerably. In acute ODS,           more than 3 months, whereas acute ODS was defined as a
aerobic bacteria predominate, whereas, in chronic ODS,              morbidity duration of ≤ 3 months. Although the conventional
anaerobes outnumber aerobic bacteria 6,23,25. Therefore, we         classification of sinusitis 21 designates 4 to 12 weeks of mor-
deemed it worthwhile to consider treating ODS accord-               bidity as the subacute phase, we assigned this period to the
ing to its duration, as is common practice for rhinogenic           acute phase in our study to investigate the overall tendency
sinusitis. Generally, acute sinusitis is defined as signs or        of treatment outcomes in a large cohort. ESS was performed
symptoms of inflammation having lasted less than 4 weeks,           to decrease inflammation and open the natural drainage path-
and chronic sinusitis as those having lasted more than 12           ways of the sinuses that were opacified on CT. For antibiotic
weeks 26,27.                                                        therapy, either amoxicillin-clavulanic acid (1250 mg/day) or
To our knowledge, there have been no attempts to clas-              levofloxacin (500 mg/day) was prescribed.
sify ODS according to its duration or to apply different            Endoscopy was performed in all patients, and physical ex-
treatment options in acute and chronic subgroups 1,27. We           amination outcomes included endoscopic findings, such as
supposed that irreversibly blocked sinus drainage or path-          the presence of nasal purulent discharge, mucosal inflam-
ologic changes could be a possible mechanism in the devel-          mation, nasal polyps, dental inflammation or pus, cheek
opment of recalcitrant ODS. We hypothesised that chronic            swelling, and cheek tenderness, which were evaluated by a
ODS tends to be resistant to treatment and requires radical         rhinologist or dentist. The severity of sinusitis was assessed
treatment or a combination of treatments. The purpose of            using the Lund-Mackay (LM) score on CT. After dental or
the present study was to investigate the treatment outcomes         sinus surgery, physical examinations and clinical progress
of dental treatment or ESS as first-line therapy for patients       evaluations were performed at follow-up outpatient visits
with ODS and to compare the clinical utility of each treat-         every 1-3 weeks until complete recovery.
ment in the acute and chronic phases of ODS.

Materials and methods
We retrospectively reviewed the medical records of patients
diagnosed with ODS, periodontitis, unilateral sinusitis, or
peri-implantitis at the Departments of Otolaryngology or
Dentistry at our tertiary Hospital from January 2001 to De-
cember 2020. Based on CT scan analysis and clinical his-
tory, 210 patients were confirmed to have ODS by two spe-
cialists in otolaryngology, dentistry, or radiology (Fig. 1).
The primary radiological characteristics included unilateral
maxillary sinus opacity with one or more of the following:
1. periapical lucency (soft tissue density around the dental
   root), including loss of the lamina dura;
2. maxillary alveolar bone defect;
3. maxillary sinus floor elevation;
4. dental material, implant graft, or tooth displaced into the      Figure 1. CT findings (A) and nasal purulent discharge (B) upon nasal endos-
   maxillary sinus.                                                 copy suggestive of left maxillary odontogenic sinusitis.



92
                                                                                  Treatment for acute and chronic odontogenic sinusitis




Treatment outcomes were assessed in terms of the success        maxillary sinus floor elevation (27%), and an implant or
rate of each treatment modality and compared between the        tooth displaced into the sinus (34%). Dental therapy per-
two ODS subgroups. Treatment success was defined as a           formed to treat ODS included extraction of the implant
complete resolution of referred symptoms, no signs of in-       graft or causative tooth (87%), root canal treatment (12%),
flammation upon follow-up physical examination including        surgical curettage (7%), and Caldwell-Luc surgery (7%).
nasal endoscopy, and clear results from radiologic exami-       The time to resolution of ODS for all patients who were
nations such as CT/X-ray imaging. In cases in which the         cured was 1.3 ± 1.4 months. The total follow-up period was
clinical course revealed no improvement or symptom re-          3.4 ± 2.1 months. No recurrences or serious complications
currence throughout the follow-up period, or lesions were       were observed during the follow-up period for any patient.
aggravated within 1 month after primary treatment, the          In this study, 90 (53%) patients with acute ODS and 82
treatment was considered a failure and second-line treat-       (48%) with chronic ODS were included. There were no
ment was attempted. The clinical utility of the treatment       significant differences in sex, age, history of smoking, or
modality was evaluated based on the overall success rate,       underlying diseases, including hypertension, diabetes mel-
resolution time, and total follow-up period.                    litus, allergic rhinitis, and asthma between the two groups.
Statistical analysis was performed using IBM SPSS (ver-         Regarding treatment outcomes, the overall success rate
sion 20.0). Specifically, the chi-square test was utilised      was higher in patients with acute ODS than in those with
for the comparison of dichotomous data (treatment suc-          chronic ODS (91.1% vs 85.4%). In the acute ODS group,
cess, symptoms, clinical factors, examination findings), the    18 patients had 4-8 weeks of full antibiotic medication
Mann–Whitney U test for non-parametric continuous data          alone, among whom the disease was resolved in 13 (72%);
(age, symptom duration, CT score), and the independent          however, 5 (28%) patients were lost to follow-up after fail-
t-test for parametric continuous data (resolution time, to-     ure of the first treatment. In the acute ODS group, 29 pa-
tal follow-up period). Using Kaplan-Meier curves, clinical      tients received dental therapy as primary treatment along
outcomes were analysed between the different treatment          with 1-3 weeks of medication, among whom the disease
modalities used in each group. Differences between the          was resolved in 19 (66%). Among the 10 (34%) patients
Kaplan-Meier curves were assessed using the log-rank test.      who had persistent disease despite dental treatment, 2 were
A difference with a p value < 0.05 was considered statisti-     lost to follow-up, and the disease was resolved in the re-
cally significant.                                              maining 8 after undergoing ESS as a secondary treatment.
                                                                Another 29 patients with acute ODS underwent ESS with
                                                                1-3 weeks of medication, among whom the disease was re-
Results
                                                                solved in 28 (97%); the remaining patient (3%) exhibited
A total of 172 patients with ODS were included in our study     no improvement and was lost to follow-up. The remaining
for analyses on medical history, clinical course, and follow-   14 patients with acute ODS were all cured with concurrent
up imaging characteristics (Tab. I). The mean age was 54.1      ESS and dental treatment. In the chronic ODS group, 16
years, and 110 (64%) patients were men. The average dura-       patients were treated with medication alone, among whom
tion of symptoms was 3.4 weeks in the acute ODS group           the disease was resolved in 10 (63%); however, the treat-
and 17.9 months in the chronic ODS group. The LM score          ment failed in 6 (38%) patients who were subsequently lost
for all patients was 4.73 ± 2.09.                               to follow-up. Among the 23 patients with chronic ODS
The most common aetiological factors of ODS were dental         who received dental therapy as primary treatment along
implants and graft material (45%), followed by periodonti-      with medication, the disease was resolved in 13 (57%),
tis/periapical disease, including cysts and abscesses, tooth    while the treatment failed in 10 (43%), 3 of whom were lost
extraction, and root canal treatment.                           to follow-up, 6 of whom were cured with ESS as secondary
Presenting symptoms varied, with purulent rhinorrhoea           treatment, and 1 of whom was not cured despite secondary
(55%) being the most common, followed by post-nasal             ESS. Among the 31 patients with chronic ODS who un-
drip, nasal obstruction, facial pain, foul odour, headache,     derwent ESS as the primary treatment modality, 25 (81%)
dental pain, cheek swelling, and hyposmia.                      were cured and 6 (19%) had to undergo dental treatment
The distribution of objective findings was as follows: nasal    after ESS; among those 6, 4 were cured while the other
purulent discharge (73% of patients), mucosal inflamma-         2 were lost to follow-up. The remaining 12 patients with
tion (34%), and nasal polyps (6%) upon nasal endoscopy,         chronic ODS were cured with concurrent ESS and dental
dental inflammation or pus (23%), and cheek swelling (5%).      treatment (Fig. 2).
The CT findings included the following: periapical abscess      Regarding subjective symptoms, the most common in pa-
(84% of patients), alveolar maxillary bone defect (31%),        tients with acute ODS was purulent discharge (58%), while



                                                                                                                                   93
K.W. Kwon et al.




Table I. Demographic and clinical characteristics of the study sample.
 Variables                                                        All patients   Acute ODS    Chronic ODS   p value
                                                                 N = 172 (%)     N = 90 (%)   N = 82 (%)
 Gender (%)
   Male                                                            110 (64)      52 (57.7)     58 (70.7)
   Female                                                           62 (36)      38 (42.3)     24 (29.3)
 Mean age (years)                                                    54.1          52.2          58.3
 Underlying conditions
   Hypertension                                                    42 (24.4)     22 (24.4)     20 (24.4)     0.6
   Diabetes mellitus                                               33 (19.2)     13 (14.4)     20 (24.4)    0.374
   Asthma                                                            1 (0.5)      1 (1.1)        0 (0)        1
   Allergic rhinitis                                                 7 (4.0)      6 (6.6)       1 (1.2)     0.156
   Smoking                                                          14 (8.1)      7 (7.8)       7 (7.8)     0.573
 Symptoms
   Purulent rhinorrhoea                                            94 (54.7)     52 (57.8)     42 (51.2)    0.574
   Postnasal drip                                                   86 (50)      40 (44.4)     46 (56.1)    0.129
   Nasal obstruction                                               70 (40.7)      36 (40)      34 (41.5)    0.736
   Facial pain                                                     50 (29.1)     37 (41.1)     13 (15.9)    0.002*
   Foul odour                                                      40 (23.3)     20 (22.2)     20 (24.4)    0.888
   Headache                                                        40 (23.3)     25 (27.8)     15 (18.3)    0.089
   Dental pain                                                     18 (10.5)     10 (11.2)      8 (9.8)     0.811
   Cheek swelling                                                   8 (4.7)       5 (5.6)       3 (3.7)        1
   Hyposmia                                                         8 (4.7)       5 (5.6)       3 (3.7)      0.82
 Physical examination
   Nasal purulent discharge                                       126 (73.3)     70 (77.8)     56 (68.3)    0.375
   Mucosal inflammation                                            59 (34.3)     34 (37.8)     25 (30.5)     0.5
   Nasal polyp                                                      11 (6.4)      7 (7.8)       4 (4.9)     0.642
   Dental inflammation                                             39 (22.7)     25 (27.8)     14 (17.1)    0.319
   Cheek swelling                                                    8 (4.7)       5 (5.6)      3 (3.7)        1
   Cheek tenderness                                                   5 (3)        2 (2.2)      3 (3.7)      0.31
   Non-specific findings                                            15 (8.7)       6 (6.7)      9 (11)        1
 Cause of ODS
   Dental implant                                                  77 (44.8)     42 (46.7)     35 (42.7)    0.71
   Periapical lesion                                               53 (30.8)     24 (26.7)     29 (35.4)    0.159
   Tooth extraction                                                35 (20.3)     22 (24.4)     13 (15.9)    0.157
   Canal root treatment                                            27 (15.7)     17 (18.9)     10 (12.2)      1
 CT findings
   Periapical abscess                                             144 (83.7)     76 (84.4)     68 (82.9)    0.804
   Maxillary floor bone defect                                    53 (30.8)      28 (31.1)     25 (30.5)    0.95
   Maxillary floor elevation                                       47 (27.3)      27 (30)      20 (24.4)    0.771
   Implant displaced into sinus                                    58 (33.7)     34 (37.8)     24 (29.3)    0.386
   CT Lund-Mackay score                                             4.7 ± 2       4.8 ± 2      4.5 ± 2.1    0.562
 Dental treatment
   Implant/tooth extraction                                        71 (86.6)     36 (83.7)     35 (89.7)
   Root canal treatment                                            10 (12.2)       6 (14)       4 (10.3)
   Surgical curettage                                               6 (7.3)       5 (11.6)       1 (2.6)
   Caldwell-Luc operation                                           6 (7.3)       2 (4.7)       4 (10.3)
   Time to resolution                                              1.3 ± 1.4      1.2 ± 1      1.5 ± 1.8
   Total follow-up (months)                                        3.4 ± 2.1      3 ± 1.8      3.8 ± 2.4
ODS: odontogenic sinusitis.




94
                                                                                Treatment for acute and chronic odontogenic sinusitis




post-nasal drip (56.1%) was the most common in patients       with ESS suggests that it is the better option among the
with chronic ODS. Notably, more patients with acute ODS       two, considering that there was no significant difference in
(41%) reported facial pain than those with chronic ODS        the total follow-up period (2.9 vs 2.8 months in the acute
(16%) (p < 0.05). The distribution of physical findings was   ODS group, p = 0.92; 3.9 vs 4.3 months in the chronic ODS
similar in the two groups, and the most common finding        group, p = 0.99; 3.3 vs 3.4 months overall, p = 0.93) (Fig.
was purulent discharge upon nasal endoscopy. In addition,     3). Notably, in the comparison between ESS alone and ESS
the distribution of the cause of ODS, CT results, and LM      combined with dental therapy, there was no significant dif-
score were similar in the two groups.                         ference in the acute ODS group, while concurrent ESS with
Dental treatment was provided to 43 patients in the acute     dental therapy yielded better results in the chronic ODS
ODS group and 39 in the chronic ODS group. Of note, sau-      group than ESS alone, with a higher success rate and no
cerization and simple dental curettage were performed in      significant difference of resolution time (100% vs 80.6%,
five patients (12%) in the acute ODS group and one pa-        p = 0.046 and 1.1 vs 1.4 months, p = 0.523 respectively)
tient (3%) in the chronic ODS group. On the other hand,       (Figs. 2, 4).
Caldwell-Luc surgery, which requires general anaesthesia,
was performed more frequently in the chronic ODS group
                                                              Discussion
(10%) than in the acute ODS group (5%).
For patients who underwent successful treatment, the dura-    In our study, we assessed the clinical utility of dental
tion to complete cure was 1.2 ± 1 months in the acute ODS     treatment and ESS in acute and chronic ODS, and treat-
group and 1.5 ± 1.8 months in the chronic ODS group. The      ment outcomes were dependent on morbidity periods and
mean total follow-up for the acute ODS group was 3 ± 1.8      treatment modalities. The overall success rate was higher
months, and that for the chronic ODS group was 3.8 ± 2.4      with acute ODS than with chronic ODS, and the overall
months. There was no significant difference in the overall    success rate was highest with concurrent ESS and dental
resolution and follow-up times between the two ODS groups.    therapy, followed by ESS alone, dental therapy alone, and
In the present study, in both ODS groups, the success rate    medication alone. Compared to dental treatment alone,
of treatment was highest with concurrent ESS and dental       ESS alone was associated with a higher success rate,
therapy, followed by ESS, dental therapy, and medication      shorter resolution time, and shorter follow-up period. No-
alone. In particular, in the comparison between ESS and       tably, in the chronic ODS group, the combination of ESS
dental therapy, the higher success rate (96.6% vs 65.5% in    and dental treatment exhibited the best clinical utility as
the acute ODS group, p = 0.011; 80.6% vs 56.5% in the         a first-line treatment, followed by ESS alone and dental
chronic ODS group, p = 0.046; 88.3% vs 61.5% overall)         treatment alone. In patients with acute ODS, on the other
and faster resolution time (0.9 vs 1.7 months in the acute    hand, we suggest ESS as the initial treatment, because
ODS group, p = 0.012; 1.4 vs 2.2 months in the chronic        there was no significant difference in success rate be-
ODS group, p = 0.45; 1.2 vs 1.9 months overall, p = 0.041)    tween patients who underwent ESS alone and those who




Figure 2. Treatment outcomes of acute and chronic ODS.



                                                                                                                                 95
K.W. Kwon et al.




underwent concurrent ESS and dental treatment, with the                           al. 29, among 33 patients with ODS, two-thirds were cured
latter having a longer mean follow-up period (4.3 vs 2.9                          with dental treatment and medical management without
months) and the disadvantage of multiple surgical sites                           ESS. Patients who were smokers and had severe CT results
involved.                                                                         tended to require ESS because of failure of dental treat-
There are no established guidelines and no standard treat-                        ment. However, their study design was limited to patients
ment protocols for ODS. Previous reports vary in terms of                         with ODS caused only by periapical abscess or dental car-
treatment regimens and preferences 12,15. Many previous re-                       ies, excluding other causes such as dental implants, trauma,
searchers have recommended dental surgery as the primary                          surgery, or tooth extraction.
treatment for ODS, based on the theory that removal of the                        In contrast, several recent studies have revealed that ESS
source of infection should be prioritised. Longhini et al. 15                     may be a more effective first-line treatment for ODS. Two
conducted a case series of 21 patients with ODS and report-                       meta-analyses 30,31 demonstrated a high overall success rate
ed successful treatment with dental surgery alone for 19. In                      for ESS in treating ODS, consistent with our results. Craig
a study by Wang et al. 28, of the 21 patients cured, 7 (33%)                      et al. 16 conducted a prospective study of 37 patients with
had undergone ESS alone and 7 (33%) had undergone con-                            ODS. In their study, primary ESS resulted in faster resolu-
current ESS and dental therapy. However, as the authors                           tion of the 22-item sinonasal outcome test (SNOT-22) re-
speculated that patients with ODS that resolved without                           sults, sinusitis symptoms, and endoscopic findings than did
dental surgery may have had a lower grade of sinusitis, they                      primary dental treatment. However, they did not evaluate
still recommended dental surgery as the first-line surgical                       the overall success rate for different treatment sequences,
treatment. The authors suggested performing ESS as subse-                         because of the limited sample size. Our study differs from
quent treatment if the patient failed to improve sufficiently                     previous studies in that we subdivided patients with ODS
after dental surgery. In another study, conducted by Yoo et                       according to the duration of morbidity and aimed to ana-




Figure 3. Kaplan-Meier curves representing (A) time to resolution in the acute ODS group (p = 0.012*); (B) follow-up periods in the acute ODS group (p = 0.92);
(C) time to resolution in the chronic ODS group (p = 0.45); and (D) follow-up periods in the chronic ODS group between patients receiving dental treatment and
those receiving ESS (p = 0.99).



96
                                                                                      Treatment for acute and chronic odontogenic sinusitis




                                                                   In our clinical experience, the treatment outcome of ODS
                                                                   may be unpredictable and it is commonly intractable, requir-
                                                                   ing a multidisciplinary approach and an efficient treatment
                                                                   regimen that differs from that for non-odontogenic sinusi-
                                                                   tis. The ability to predict which patients with ODS would
                                                                   benefit from ESS, dental treatment, or both, may increase
                                                                   the clinical efficacy of ODS treatment, assisting clinicians in
                                                                   decision-making and consultation with the patient. Felisati
                                                                   et al. 33 examined a multidisciplinary approach to address
                                                                   sinonasal complications arising from dental procedures.
                                                                   Those were subdivided into three groups: preimplantologi-
                                                                   cal, implantological, and classic dental treatments. Subse-
                                                                   quently, they introduced a new classification system based
                                                                   on sinonasal conditions and dental pathogenesis. The major-
Figure 4. Time to resolution of acute and chronic ODS.             ity of patients (254/257 or 98.8%) responded successfully
                                                                   to the proposed surgical treatment protocols. Fadda et al. 8
                                                                   employed that classification system and protocol in the treat-
lyse the clinical efficacy of either dental surgery or ESS as      ment of sinonasal complications resulting from dental dis-
the primary treatment for ODS in each subgroup.                    ease and procedures. In their study of 31 patients, 16 (52%)
Furthermore, regarding the initial treatment in the acute          were treated with ESS, 3 (10%) with an intraoral approach,
phase of ODS, we observed differences in treatment out-            and 12 (39%) using a combined approach. Their study un-
comes for non-odontogenic acute sinusitis. Guidelines for          derscored the importance of a combined approach when the
acute rhinosinusitis 26 generally advocate a policy of ‘watch-     maxillary alveolar process is affected by infectious diseases
ful waiting’ combined with symptomatic therapy as an initial       such as osteitis, osteomyelitis, peri-implant pathology, peria-
management strategy, and antibiotic therapy is recommend-          pical lesions, maxillary sinus lift complications, or oroantral
ed if symptoms worsen or persist for more than 7 to 10 days.       fistula/communication 8-10. Their research also revealed that
In a large prospective study of patients with acute sinusitis      51% of patients exhibited maxillary sinusitis associated with
by Blin et al. 32, initial treatment was successful in 96.2%       anterior ethmoid sinusitis and 13% with anterior ethmoid si-
of the patients in which antibiotics had been prescribed, and      nusitis and frontal sinusitis, highlighting the need for close
the disease spontaneously resolved in 88.7% of patients who        collaboration among implantologists, maxillofacial/oral sur-
were not prescribed antibiotics, which is contrary to our          geons, and otorhinolaryngologists.
relatively low treatment success rate with antibiotic therapy      To the best of our knowledge, no published studies have
alone for ODS. Several studies have emphasised the unique          clearly demonstrated the treatment outcome of ODS based
microbiological features of ODS. Belibasakis et al. 21,22 re-      on the phase of infection, and this is the first analysis of the
ported that ODS tended to be polymicrobial owing to its den-       clinical utility of dental treatment or ESS as primary treat-
tal origin, and anaerobes outnumber aerobes in many ODS            ments according to the acute and chronic phases of ODS.
cases. Zirk et al. 18 analysed the harvested bacteria from 121     The present study has several limitations. First, it had a
patients with ODS who underwent surgery and discovered             retrospective design, leading to possible information bi-
that Pseudomonas aeruginosa infection was significantly            as, inaccurate recall, and an inability to control variables.
associated with misplaced foreign bodies (root filling, aug-       Hence, further randomised prospective studies are needed.
mentative dental material), as well as anaerobic dominance,        Second, the heterogeneity within our sample might have
with 45 anaerobes versus 19 aerobes. However, there has            limited comparability between patients. Moreover, given
been little research on the change in the profile of microbio-     our relatively small sample size, the rate of patients lost to
logical flora of ODS according to the phase; Brook et al. 20,23-   follow-up is notable (19 of 172 patients, 11%) and might
25
   reported that the ratio of anaerobes and aerobes in ODS         have influenced our study outcomes. Further multicentre
cases indeed depends on the phase of the ODS infection.            studies are needed to more accurately evaluate the utility
We supposed that the period of morbidity is positively cor-        of different treatment modalities for ODS in a clinical set-
related to the formation of a bacterial biofilm or pathological    ting. Research is also required on racial and cultural influ-
changes, as well as blockage of natural drainage pathways,         ences on the incidence of ODS and treatment regimens. In
which could be a possible mechanism in the development of          addition, our study did not collect detailed information on
recalcitrant ODS.                                                  the medication type or steroid use, and we did not employ



                                                                                                                                       97
K.W. Kwon et al.




established assessment tools like visual analogue scale or                   5
                                                                                  Elwany S, Ibrahim A, Hussein W, et al. Ten-year experience with
                                                                                  multidisciplinary diagnosis and treatment of odontogenic sinusi-
SNOT-22 scale to evaluate symptom improvement. Lastly,                            tis. J Laryngol Otol 2021;135:987-992. https://doi.org/10.1017/
we adopted the terms “acute” and “chronic” based on dura-                         S0022215121002310
tion of symptoms, according to standard rhinogenic sinusi-                   6
                                                                                  Saibene AM, Vassena C, Pipolo C, et al. Odontogenic and rhinogenic
tis terminology. However, this distinction is not universally                     chronic sinusitis: a modern microbiological comparison. Int Forum
                                                                                  Allergy Rhinol 2016;6:41-45. https://doi.org/10.1002/alr.21629
accepted in the broader ODS literature 11,12 and should be
                                                                             7
                                                                                  Cordero GB, Ferrer SM, Fernández L. Odontogenic sinusitis, oro-
interpreted in the context of our study.                                          antral fistula and surgical repair by Bichat’s fat pad: literature review.
                                                                                  Acta Otorrinolaringol Esp (Engl Ed) 2016;67:107-113. https://doi.
                                                                                  org/10.1016/j.otorri.2015.03.001
Conclusions                                                                  8
                                                                                  Fadda GL, Berrone M, Crosetti E, et al. Monolateral sinonasal com-
In our study, the clinical utility of dental treatment and/or                     plications of dental disease or treatment: when does endoscopic en-
                                                                                  donasal surgery require an intraoral approach? Acta Otorhinolaryngol
ESS depended on the morbidity period of ODS. For chron-                           Ital 2016;36:300-309. https://doi.org/10.14639/0392-100X-904
ic ODS, combined ESS and dental treatment seems to be                        9
                                                                                  Lee KC, Lee SJ. Clinical features and treatments of odontogenic
an effective first-line treatment. Classification of ODS ac-                      sinusitis. Yonsei Med J 2010;51:932-937. https://doi.org/10.3349/
cording to the acute or chronic phase may be useful for                           ymj.2010.51.6.932
treatment, as it is for rhinogenic sinusitis.                                10
                                                                                  Workman AD, Granquist EJ, Adappa ND. Odontogenic sinusitis:
                                                                                  developments in diagnosis, microbiology, and treatment. Curr Opin
                                                                                  Otolaryngol Head Neck Surg 2018;26:27-33. https://doi.org/10.1097/
Conflict of interest statement                                                    MOO.0000000000000430
The authors declare no conflict of interest.                                 11
                                                                                  Craig JR, Dai X, Bellemore S, et al. Inflammatory endotype of od-
                                                                                  ontogenic sinusitis. Int Forum Allergy Rhinol 2023;13:998-1006.
Funding                                                                           https://doi.org/10.1002/alr.23099
                                                                             12
                                                                                  Craig JR, Poetker DM, Aksoy U, et al. Diagnosing odontogenic sinus-
This research did not receive any specific grant from fund-
                                                                                  itis: an international multidisciplinary consensus statement. Int Forum
ing agencies in the public, commercial, or not-for-profit                         Allergy Rhinol 2021;11:1235-1248. https://doi.org/10.1002/alr.22777
sectors.                                                                     13
                                                                                  Ly D, Hellgren J. Is dental evaluation considered in unilateral max-
                                                                                  illary sinusitis? A retrospective case series. Acta Odontol Scand
Author contributions                                                              2018;76:600-604. https://doi.org/10.1080/00016357.2018.1490966
                                                                             14
                                                                                  Craig JR, Tataryn RW, Aghaloo TL, et al. Management of odontogen-
KWK: data curation, methodology, analysis, interpretation,
                                                                                  ic sinusitis: multidisciplinary consensus statement. Int Forum Allergy
visualization, writing – original draft. JWG: data curation,                      Rhinol 2020;10:901-912. https://doi.org/10.1002/alr.22598
analysis. Y-SC: methodology, project administration, writ-                   15
                                                                                  Longhini AB, Ferguson BJ. Clinical aspects of odontogenic maxillary
ing – review and editing.                                                         sinusitis: a case series. Int Forum Allergy Rhinol 2011;1:409-415.
                                                                                  https://doi.org/10.1002/alr.20058
                                                                             16
                                                                                  Craig JR, McHugh CI, Griggs ZH, et al. Optimal timing of en-
Ethical consideration
                                                                                  doscopic sinus surgery for odontogenic sinusitis. Laryngoscope
This study was approved by the Institutional Ethics Com-                          2019;129:1976-1983. https://doi.org/10.1002/lary.28001
mittee of Asan Medical Center (2021-0922). The research                      17
                                                                                  Raman A, Papagiannopoulos P, Kuhar HN, et al. Histopatho-
was conducted ethically, with all study procedures being                          logic features of chronic sinusitis precipitated by odontogenic
                                                                                  infection. Am J Rhinol Allergy 2019;33:113-120. https://doi.
performed in accordance with the requirements of the
                                                                                  org/10.1177/1945892418811210
World Medical Association’s Declaration of Helsinki.                         18
                                                                                  Zirk M, Dreiseidler T, Pohl M, et al. Odontogenic sinusitis maxil-
                                                                                  laris: a retrospective study of 121 cases with surgical intervention.
                                                                                  J Craniomaxillofac Surg 2017;45:520-525. https://doi.org/10.1016/j.
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