Odontogenic Sinusitis

Odontogenic Sinusitis
Current Concepts in Diagnosis and Treatment
a,b a,b,
Hillary A. Newsome, MD , David M. Poetker, MD *
KEYWORDS
Odontogenic sinusitis Unilateral maxillary sinusitis Dental origin
Periapical abscess Implant
KEY POINTS
Odontogenic sinusitis is most commonly caused by iatrogenic injury to the Schneiderian
membrane from dentoalveolar procedures followed by periapical abscesses.
Although radiographic findings such as periodontal disease, oroantral fistula, and periap-
ical abscesses are often present, they may not be mentioned as a source of sinusitis in
imaging reports.
A combination of medical therapy, dental procedures, and endoscopic sinus surgery is
used to treat odontogenic sinusitis.
The microbial population differs from that of chronic sinusitis, with a higher incidence of
polymicrobial infections and anaerobes.
INTRODUCTION
The overall health cost burden of adult chronic sinusitis has been estimated to be up-
ward of US$22 billion.1 Maxillary sinusitis of dental origin (MSDO), also termed odon-
togenic sinusitis (OS), is a unique cause of sinusitis that requires special attention.
Although the mainstays of chronic sinusitis treatments, such as endoscopic sinus sur-
gery (ESS) and medical therapy, are often used to treat OS, treatment failure can
occur, highlighting the nuances of this disorder.2,3 Care for these patients often falls
to both the otolaryngologist and dental professional to determine an appropriate treat-
ment plan when it comes to diagnosis, timing of surgery, decision to treat the oral cav-
ity source, and type of antibiotics.
a
Rhinology and Skull Base Division, Department of Otolaryngology & Communication Sci-
ences, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA;
b
Zablocki VAMC, Milwaukee, WI, USA
* Corresponding author. Rhinology and Skull Base Division, Department of Otolaryngology &
Communication Sciences, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwau-
kee, WI 53226.
E-mail address: dpoetker@mcw.edu
Immunol Allergy Clin N Am 40 (2020) 361–369

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362 Newsome & Poetker
RELEVANT ANATOMY AND PATHOGENESIS
The description of MSDO has largely been credited to Bauer in 1943 who, through a
series of microscopic cadaveric dissections, helped clarify possible routes of patho-
genesis for this disorder.4 The maxillary sinus and maxillary molar roots are intimately
related. The floor of the maxillary sinus ranges in thickness and can be interrupted with
exposed tooth roots in patients with bone loss or be up to 12 mm thick.5 Even in a
normal maxilla, the periodontal membrane of the tooth roots can be in direct contact
with the respiratory epithelium (also known as the Schneiderian membrane) of the
maxillary sinus, providing a potential source of contamination.4,5 One of the most crit-
ical points from Bauer’s work was the finding that in cases of a thick bony floor, a
network of blood vessels and lymphatics connect the periodontal membrane to the
bone marrow of the maxilla. The resulting inflammatory reaction leads to fibrous tissue
that decreases the efficiency of the sinus cilia.4 Later studies have gone on to confirm
the posterior maxillary teeth, specifically the first and second molars, as the most
commonly offending teeth.6,7 Single or multiple tooth roots can be involved, and the
palatal root of the first molar, followed by the mesiobuccal root of the second molar,
were most frequently associated with OS in a study reviewing cone-beam computed
tomography (CBCT) images of cases with unilateral or bilateral sinusitis.6 It should
come as no surprise that sinusitis of dental origin can also be implicated in cases of
sinusitis beyond the maxillary sinus, considering that obstruction of the maxillary sinus
ostium can cause blockage of the osteomeatal complex and lead to anterior ethmoidal
and frontal sinusitis (Fig. 1).8 In fact, in 2014 Saibene and colleagues9 found that up-
ward of 40% of OS patients had more extensive sinus involvement than the maxillary
sinus alone, and in 2019 Whyte and Boeddinghaus10 noted more than 60% of cases
involving multiple sinuses.
Additionally, trauma to the epithelial cells of the respiratory epithelium, which typi-
cally have gap junctions in between them to form a physical barrier, allows oral cavity
pathogens into the maxillary sinus.5 Natural causes of trauma to the membrane come
in the form of dental disorder such as periapical infections or inflammation (Fig. 2),
periodontal and endodontal disease, and dentigerous cysts; multiple studies have
gone on to cite periapical abscess as a natural leading cause of OS.2,8,11–14 The
Fig. 1. Typical appearance of odontogenic sinusitis on coronal computed tomography scan.

This patient has left unilateral sinusitis (maxillary sinusitis with involvement of ethmoids) as
a result of a periapical abscess (denoted by black arrow).

Odontogenic Sinusitis: Diagnosis and Treatment 363
Fig. 2. Periapical disease can be seen on this computed tomography scan as radiolucency at
the end of the tooth root (denoted by black arrow). A resulting thickening of the sinus mu-
cosa can occur. Periapical abscess is a common cause of odontogenic sinusitis.
term “endo-antral syndrome” was coined by Selden several decades ago to describe
the passage of infection from periapical and antral tissues.15,16 The iatrogenic causes
of OS are many and include fractures from dental implants, foreign bodies in the sinus,
sinus augmentation procedures, and postoperative oroantral fistulas (Fig. 3).5,11,13
Regardless of the cause, MSDO is a problem of increasing clinical significance.
EPIDEMIOLOGY
In most literature regarding OS, the incidence of maxillary sinusitis related to an odon-
togenic source is quoted at between 10% and 12%.2,3,5–9,12,14,17–24 This has histori-
cally been the teaching since a 1968 paper by Maloney and Doku; however, more
recent studies within the past decade have called this number into question for mul-
tiple reasons.17 A 2011 case series by Longhini and Ferguson25 included an in-
depth review of the literature on the incidence of OS. Of note, the investigators found
that the oft quoted 1968 study is actually a secondary source, and the primary sources
of these numbers do not contain any data to support their incidence claims.17,25 Long-
hini and Ferguson go on to say that the real incidence of OS is unknown but is likely
higher than previously thought. In the mid 1980s, Melen and colleagues26 found that
in a cohort of patients with refractory chronic sinusitis, nearly 40% of patients actually
had an odontogenic source of their disease. When specifically considering unilateral
maxillary sinusitis, the incidence of odontogenic origin jumps up to greater than
70% as seen in several studies.5,13,20 The real incidence of this disease is likely un-
known because diagnostic and inclusion criteria vary between studies (e.g., chronic
versus acute sinusitis patients, unilateral versus bilateral maxillary sinus opacification
patients), and imaging technology (panoramic X-ray versus computed tomography
[CT] scans) has greatly improved from early investigations.

Fig. 3. Oroantral fistula with maxillary sinus opacification demonstrated by sagittal

computed tomography. Oroantral fistula is a less common cause of odontogenic sinusitis
than periapical disease.
There may be a slight propensity for OS to affect women over men, as several
larger-scale studies have shown.3,9,11,27 OS usually presents in middle-aged patients
with both case series and reviews giving average patient ages in the 40s to
50s.8,11,19,20 One potential cause of this fairly consistent age of presentation is that pa-
tients at this age have had sufficient time for periodontal disease and maxillary bone
loss to occur. Both dental providers and otolaryngologists treat these patients, and as
such they may present in either setting.
SYMPTOMS AND DIAGNOSIS
A patient presenting with unilateral sinus disease should pique the provider’s interest
and raise the clinical suspicion of OS. However, there remain several other important
causes of unilateral sinus disease on the differential: antrochoanal polyp, inverted
papilloma, squamous cell carcinoma, and allergic fungal sinusitis, to name a few.
Nevertheless, there are important findings to help the clinician yield a diagnosis of OS.
Most studies agree that a distinguishing symptom of OS from other causes of acute
or chronic sinusitis is foul smelling/tasting rhinorrhea.5,19,25 A study by Workman and
colleagues7 and the more recent findings of Simuntis and colleagues24 emphatically
conclude that malodorous secretions are the hallmark of OS, and the significance of
a thorough history taking should not be understated. Other less unique symptoms
include facial pain and pressure, and nasal congestion. Surprising is the consistency
at which less than half of patients report dental pain.21,25 Symptoms can be present
from a few weeks in acute cases to several years in chronic OD.14,25,27 Patients
may report a preceding history of dental procedure such as recent dental implant or
extraction or may have not seen a dental provider in many years.
On clinical examination, even by a dental professional, the identification of the
offending tooth may not be obvious, owing in part to the varied inciting dental

pathologies. This also makes sense considering the relatively low reporting rate of
associated tooth pain. This step, however, should not be skipped, as sometimes
carious teeth or extraction-site oroantral fistulas are readily apparent. Interestingly,
a 2019 retrospective chart review on acute sinusitis patients from an otorhinolaryn-
gology clinic found that only 8.1% of provider notes mentioned examination of the
teeth: a clear opportunity for improvement in the diagnostic value of the physical ex-
amination.27 Similarly to other presentations of sinusitis, endoscopic examination of
OS may yield findings of purulent secretions in the middle meatus, and if the patient
has already undergone surgical antrostomy, findings of foreign bodies or projecting
tooth roots/implants into the maxillary sinus floor may be demonstrated. Given the
subtle findings on clinical examination, a provider must have a high index of suspicion
before ordering imaging studies or the diagnosis of the OS may be missed.
IMAGING
With the advent of improved accessibility of in-office imaging techniques, there has
been increasing awareness of the radiologic features of OS. Two-dimensional (2D) im-
aging studies that can be used—albeit with limited efficacy—include periapical, pano-
ramic, and Waters radiographs.28 All 2D studies have the same limitation in that they
try to portray a three-dimensional (3D) space in a flat image that often compromises
anatomic relationships because of its superimposition, making it difficult to identify
periodontal disease (Fig. 4). In addition, the posterior maxillary teeth are poorly visu-
alized on these studies.29 By far the most common imaging study currently used for
rhinologic evaluation is a noncontrast CT scan of the sinuses, and several published
Fig. 4. (A) Panoramic radiograph and (B) computed tomography scan of the same patient
with left unilateral maxillary odontogenic sinusitis caused by dental implant. Radiograph
utility is limited by overlapping anatomic structures.

works have been dedicated to increasing awareness of the relevant clinical findings
that suggest OS.8,10,29,30
Conventional CT and CBCT are 3D studies that eliminate the superimposition of
anatomic structures and are superior at identifying changing densities in bony struc-
tures. In addition, they provide the potential to image all of the paranasal sinuses rather
than just the maxillaries. Nevertheless, the odontogenic causes of maxillary sinusitis
may be missed by radiologists up to 60% of the time.8,23 For this reason, it is imper-
ative for both dental providers and otolaryngologists to review images themselves and
to supplement with a physical examination. Bomeli and colleagues12 identified 3 key
radiographic findings suggestive of dental etiology in their retrospective review of 101
CT scans of unilateral and bilateral maxillary sinus fluid: (1) oroantral fistula, (2) peri-
odontal disease with periapical abscess, and (3) a projection molar/premolar tooth
root with periodontal disease. Additionally, they found an increasing likelihood of a
dental source with increasing levels of maxillary fluid (mucosal thickening also showed
a similar trend). This finding was supported by a more recent Swedish study with
similar results: patients with unilateral OS had significantly more swelling and conges-
tion of the maxillary sinuses than patients with nonodontogenic cause.3 Another key
point of radiologic studies is that 75% of cases of unilateral maxillary sinusitis (or
more extensive) with a patent ethmoid infundibulum can be attributed to an oral cavity
source.8 Otolaryngologists should thus keep this in mind when considering cases of
failed functional ESS. Although the likelihood of OS increases when radiographic find-
ings are unilateral, Saibene and colleagues9 found that almost 20% of 315 surgically
treated cases of OS were bilateral.
TREATMENT AND MANAGEMENT
Although there is a large role for medical therapy in cases of classic chronic sinusitis,
most studies focus on a combination of medical and surgical treatment for OS. There
does exist controversy, however, on timing and sequence of surgical procedures to
treat the oral cavity source and the paranasal sinus disease. Surgical management
of maxillary sinus disease classically included the Caldwell-Luc procedure, which in-
volves completely stripping the respiratory epithelium of the maxillary sinus, but now
more commonly includes ESS as the gold standard.31 Antibiotics are the mainstay of
medical treatment. Multiple small-sized studies have found that only approximately
15% to 20% of OS cases resolved with antibiotics alone and that an average of 2.6
courses of antibiotics has been trialed before proceeding to surgery in cases of fail-
ure.14,18,19 Dental treatment can include root canals, dental extractions, or buccal
flaps for oroantral fistulas, depending on the pathologic profile. However, if surgical
treatment is necessary, should the tooth or sinus be treated first?
It is not uncommon for OS patients to present to the otolaryngologist’s office only to
be referred for dental evaluation once OS has been suspected.2 In fact, the American
Association of Endodontists recommends treating the primary endodontic infection
before undertaking ESS.32 Tomomatsu and coworkeres33 studied 39 patients with
OS and found that 20 patients improved after dental treatment and a course of antibi-
otics (length of antibiotic treatment depended on chronicity of symptoms). The other
19 patients required ESS for symptom and radiographic resolution. This suggests that
although treatment of the primary source of infection may prevent more extensive sur-
gery, ESS will be necessary in some cases.
In a study of 43 OS patients (22 improved with medical and dental therapy alone),
Mattos and colleagues21 identified involvement of the osteomeatal complex and a
dental procedure before developing OS symptoms as predictive factors for needing

ESS. Other studies have seconded osteomeatal complex involvement as a critical fac-
tor toward requiring surgical management; less commonly, osteomeatal complex
aperture width, increased Lund-Makay score, symptom duration, and condition of
the maxillary sinus floor have been found to be predictive.14,33 In one prospective
study of implant-related sinusitis, 80% of patients failed to improve after a trial of an-
tibiotics and required functional ESS.19 All of the studied patients eventually improved
despite implants protruding into the maxillary sinus, which remained in situ. This is a
reassuring finding for those patients who are reluctant to have costly implants
removed. Moreover, Craig and colleagues18 published a series of 37 patients with
symptomatic OS and allowed patients to choose primary dental treatment (n 5 11)
or ESS (n 5 26). The group undergoing ESS had faster resolution of symptoms based
on the SNOT-22 and endoscopic findings, and the investigators promoted ESS as
first-line treatment in OS. However, that is also not to say that a patient cannot un-
dergo both an intraoral approach for source control and ESS simultaneously, as
was proved feasible by Kende and colleagues.31 Clearly, based on the current state
of the literature, more prospective studies are needed to clarify the optimal surgical
treatment of this disease.
MICROBIOLOGY
Because of the contamination of the maxillary sinus with oral cavity pathogens, OS
requires thoughtfulness in its antibiotic treatments. One study on microbiological
samples from chronic sinusitis and odontogenic sinusitis found that only 60% of
chronic sinusitis samples grew microbes, whereas all of the OS samples had a large
microbial burden and led to bacterial growth.22 Instead of the usual Streptococcus
pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae that regularly cause
most cases of nonodontogenic sinusitis, cultures from multiple studies of OS have
shown an increased incidence of polymicrobial infections. Isolates have grown
oral anaerobes such as Peptostreptococcus and Prevotella spp. as well as aerobic
bacteria such as Staphylococcus aureus.2,5,14,34 As such, respiratory fluroquino-
lones are frequently used to treat OS.14,22 In addition, fungal isolates, namely Asper-
gillus and Candida, have been found in rare cases of OS. Duration of antibiotic
therapy seems to vary anywhere from to 1 week to 3 months and usually correlates
with symptom duration.
SUMMARY
OS is a unique cause of sinus disease that deserves special consideration. An

astute clinician can elicit historical findings such as recent dental work and symp-
toms such as unilateral facial pain and foul drainage, despite a relatively benign
oral cavity examination. Otolaryngologists and dental professionals who work
together to care for these patients must be able to interpret imaging studies for
dental disorder, such as periapical abscesses and periodontal disease, because
radiology reports may fail to comment on these common findings. Treatment is
frequently some combination of antibiotic therapy, dental procedures, and ESS.
More prospective studies on this topic are needed to determine the best direction
of care for this patient population.
DISCLOSURE
The authors have nothing to disclose.

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Odontogenic Sinusitis

Current Concepts in Diagnosis and Treatment

Immunol Allergy Clin N Am 40 (2020) 361–369

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RELEVANT ANATOMY AND PATHOGENESIS

Fig. 1. Typical appearance of odontogenic sinusitis on coronal computed tomography scan.

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Fig. 3. Oroantral fistula with maxillary sinus opacification demonstrated by sagittal

SYMPTOMS AND DIAGNOSIS

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TREATMENT AND MANAGEMENT

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OS is a unique cause of sinus disease that deserves special consideration. An

The authors have nothing to disclose.

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