Sinus Communication

[Pages:3]Oral & Maxillofacial Surgery

Sinus Communication

drillher | Total Posts: 177 | Member Since: 4/22/2002 | Posted: 12/30/2005 5:09:48 AM | Post 1 of 27

I extracted an upper first molar three weeks ago and had a small sinus communication. I packed it with Gelfoam and sutured it; Rx clindamycin 150 mg QID for a week. The patient reported no problems after a week, but yesterday his wife called and said that his MD has him on antibiotics and he has a whistle in his mouth. He is coming in to see me next week. If it is a sinus/oral communication that has not healed, what should I do? I'm not sure that an OS [oral surgeon] would be happy to see him since I did the extraction. Thanks for any info.

Randy Nolf | Periodontist | Total Posts: 692 | Member Since: 11/5/2001 | Location: Stroudsburg, PA | Posted: 12/30/2005 6:12:10 AM | Post 2 of 27

Drillher, I've opened a few sinuses, never had one stay open. I hear this story from my GP friends occasionally and it seems to sound the same. I wonder about the Gelfoam. I never use it because when I did, I remember it falling out in a disgusting blob after a week or two, and leaving a hole. I routinely get primary closure with extractions, and double especially if I think there is a sinus communication. After some healing, and depending how large, I'd plan to close it with sliding flaps. The trick is to be sure you have no tension on the flaps. I expect you'll get some advice about graft material or barriers from Townies who have treated more OA [oral-antral] fistulas. In my opinion, the success will depend on tension and blood supply. When using materials be sure not to compromise either.

mrfred | Total Posts: 1,273 | Member Since: 6/11/2001 | Location: Pennsylvania | Posted: 12/30/2005 6:34:59 AM | Post 3 of 27

Drillher, if you are not sure what to do, refer the patient to the OS. An informed consent should cover this as a possible complication of maxillary posterior extraction. I have used CollaCote or CollaPlug on very small sinus exposures successfully without primary closure, together with good post-op instruction about not blowing nose, etc. On larger exposures I have used BioMend Extend combined with a no tension primary closure to successfully prevent an oral-antral fistula. Maybe Jay or Jawdoc will chime in on their thoughts.

wizexo | Michael | Total Posts: 206 | Member Since: 7/19/2005 | Location: Connecticut | Posted: 12/30/2005 8:01:19 AM | Post 4 of 27

Drillher, as an OS, I'll tell you that if you referred the patient to me for sinus communication closure??I would say, "thank you." I might tease you a bit, but I'd say "thank you." Keep in mind that your treatment at the time of exposure was "almost" appropriate. Not bad. With a small opening (2-3 mm), I will also pack Gelfoam and suture closed. For something that small I don't sacrifice bone or tissue to get primary closure, they heal fine every time like this (for me).

However, for medications, clindamycin at 150 mg qid is bacteriostatic NOT bacteriocidal. I would also put the patient on decongestants (i.e. Sudafed) and nasal spray (Afrin x three days, then saline x three days), with strict sinus precautions.

jawdoc | Mike Hoffman | OMS | Diplomate, American Board of Oral and Maxillofacial Surgery | Total Posts: 1,137 | Member Since: 9/19/2001 | Location: Cuyahoga Falls, OH | Posted: 12/30/2005 7:47:43 PM | Post 5 of 27

Randy, I gotta tell you, I rarely get primary closure with my extractions. There really isn't a need for it, and you end up creating larger flaps and distorting tissue. Most sockets granulate in and heal fine. For persistant OA fistulas, I usually elevate a buccal flap and release the periosteum to allow passive closure. I close with a vertical mattress to get good raw-edge-to-raw-edge closure. Post-op instructions include no smoking, no nose blowing, and try to sneeze with mouth wide open to decrease intra-sinus pressures. (Not sure if that last one works but it's what I was taught and sounds impressive.)

Post-op meds are usually amoxicillin, and Vicodin along with recommendations for decongestants as long as the patient is not hypertensive.

rrc | Total Posts: 21 | Member Since: 5/5/2005 | Posted: 12/30/2005 8:47:51 PM | Post 6 of 27

I like the buccal advancement flap also. It seems to work well, especially if you score the periosteum to decrease wound tension. Some other options are a buccal fat pad advancement flap with collagen membrane;

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a palatal supraperiosteal rotational flap; and last resort would be a hemi-temporalis pedicled rotational flap with a hemi-coronal approach. Oral-antral communications can be a real pain in the neck!

dhirji | Total Posts: 689 | Member Since: 8/20/2003 | Location: Brampton, Ontario | Posted: 12/30/2005 11:47:54 PM | Post 7 of 27

Hi David, my first sinus exposure was while in dental school over ten years ago, and I struggled with a buccal and palatal advancing flap with the help of a wonderful OMFS [oral maxillofacial surgeon]. I don't sweat them anymore (and these kinds of comments are gonna' bite me in the @$$). The key is that you need a blood clot to form over the opening which is unlikely if you leave it open. Packing Gelfoam is a good idea, but the key is to ensure that you pack it way down there!

I lay a piece of the CollaTape over the exposure and the socket walls. I usually, then, place a mixture of Puros and PerioGlas (50/50) over the area. I close up with another piece of CollaTape and a figure eight suture.

I am sure everybody will chime in with their favorite bone graft mixture. IMHO, I'd rather do a bone graft here (unnecessary or not, who knows) just to aid in the healing of the OA opening. It's been pretty much an easy procedure with really good success in my hands.

Randy Nolf | Periodontist | Total Posts: 692 | Member Since: 11/5/2001 | Location: Stroudsburg, PA | Posted: 12/31/2005 3:40:10 PM | Post 8 of 27

[In response to post by jawdoc on 12/30/2005 7:47:43 PM]: "Randy, I gotta tell you, I rarely get primary closure with my extractions...."

Mike, don't get me wrong, I'm not trying for primary closure on every extraction. If there is any doubt about the sinus, or if it's just a simple procedure, I'll take a few minutes to close the site. I'm not generally in the extraction business, but as of lately, I've been doing more because our oral surgeons are so busy. Most cases I do are grafted or surgical extractions, and primary closure is my goal. Simple extractions I always suture...usually without full closure.

jreznick | Jay B. Reznick, DMD, MD | Diplomate, American Board of Oral and Maxillofacial Surgery | Total Posts: 1,035 | Member Since: 8/17/2003 | Location: Tarzana, CA | Posted: 1/3/2006 9:53:27 AM | Post 15 of 27

David, I agree with all that has been said. Most small sinus perforations will close spontaneously, as long as the patient keeps the area clean, and avoids straws, nose blowing, etc. Do not be embarrassed to call your local OS if you need help. That is what we are there for. He/she will be happy to help you with this patient. If you have not seen/done an OA fistula closure before, it is best not to start on this on your own. Perhaps, the OS will let you watch the procedure, so you can try it yourself on the next one...and there will be a next one.

tjrdds | Thomas J. Ryan Jr., DDS | Total Posts: 426 | Member Since: 1/25/2002 | Location: Tinley Park, IL | Posted: 1/3/2006 11:31:54 AM | Post 17 of 27

I have always found my referring oral surgeons willing to help me out of a difficult situation. Thanks to their teaching and coaching, I find myself in fewer and fewer difficult situations! Thank you Carlo Pagni, Ed Kasper, Bill Heaton and Bob Bosack!

pushpole | Jason | Total Posts: 19 | Member Since: 5/14/2002 | Location: Robertsdale, AL | Posted: 1/6/2006 7:00:32 AM | Post 18 of 27

How long post-op before you open it back up to regain primary closure? I'm going through this same situation right now...upper first molar, large oral-antral communication, fished the distal root tip out of the sinus after it disappeared, etc. I feel like I've been reading a play-by-play of my own surgery during this entire post. (I love this place!) There is; however, one difference to my situation that I feel is unique and must be mentioned...the patient is my wife!

fletch33 | Total Posts: 90 | Member Since: 1/6/2006 | Location: Willis, TX | Posted: 1/7/2006 12:04:24 AM | Post 20 of 27

How large is large? My experience since my AEGD [Advanced Education in General Dentistry] residency is the larger it is, the better it is to get "primary closure," or as close to it as possible. If the communication is present after 24-48 hr recall; what is going to get it closed? The answer is proximation of the tissue. If you

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can't do it, let the OMFS do it. If they give you grief find a new OMFS. I'm not worried about sinus exposures because I know they can be fixed. The question is what can be done to minimize this from happening? Diagnose the extraction if the sinus is pnuematized, and if you are worried about an exposure, section the tooth into three parts. Seperate the palatal root from the buccal roots, then section the buccal roots. I recommend a hp 559 bur (SS White has them) it is the diameter of a 301 elevator and will allow you to seperate the roots. You can then deliver the roots one at a time and preserve the bone. Remember it is always about informed consent. If you tell the patient an exposure is possible, and it happens, they understand and realize they were unlucky. If you don't tell them and it occurs, you are making excuses. If you tell them it may occur and it doesn't you're superman. Best of luck.

Hank Willis, DDS | Total Posts: 199 | Member Since: 10/15/2005 | Location: Bonners Ferry, ID | Posted: 1/7/2006 1:51:21 PM | Post 23 of 27

I had a patient late on Thursday for a simple extraction of # 1. Three distinct roots present. I could look up in the socket and see solid interfurcal bone and the three holes from the roots. Things looked fine. He called back later and said he was pushing air back and forth. I told him to come in Friday (my off day) afternoon when he got off work. On Friday he said he was now only pushing air UP into his sinus by increasing oral pressure, but couldn't push air the opposite direction. I had him do a Valsalva and indeed he wasn't pushing any air. I decided to wait the weekend to see if it closes spontaneously before intervening surgically. Told him not to blow his nose, avoid sneezing, stay on a decongestant, and DON'T intentionally push air!

coatamer | Paul | Total Posts: 22 | Member Since: 7/27/2002 | Location: Rochester, NY | Posted: 1/7/2006 8:41:45 PM | Post 24 of 27

Your surgical handling of the exposure was correct, i.e. sutures and Gelfoam. However, the patient should have been placed on:

1) 300 mg clindamycin TID x 7-10 days 2) Pseudoephedrine 60 mg QID x 7-10 days. You may also consider giving an antihistamine. You should have also issued sinus precautions: sneezing through the mouth and no nose blowing.

fletch33 | Total Posts: 90 | Member Since: 1/6/2006 | Location: Willis, TX | Posted: 1/8/2006 2:05:23 AM | Post 25 of 27

Thanks, sounds like you've got a patient that has a new toy. Do to the fact this guy has created the communication after the extraction, I would be more proactive. I am making the statement because I know he didn't leave your office with the exposure after the surgery. I would have placed Gelfoam and silk suture (I want to follow-up) antibiotic, decongestant, and most importantly written post-op instruction that I verbally explain to the guy. No blowing nose and no sucking on straws. Most likely this pinpoint exposure will heal on its own, but I would rather do a little more early on, than have to refer to ENT for more extensive and expensive tx. Document everything. Best of luck.

Hank Willis, DDS | Total Posts: 199 | Member Since: 10/15/2005 | Location: Bonners Ferry, ID | Posted: 1/8/2006 1:41:26 PM | Post 26 and 27 of 27

I'm going to see him Monday afternoon for a follow-up. He seemed to understand the seriousness of not playing with his new toy and showing off party tricks. My guess is that it'll have closed, but I'll keep you updated. I didn't Gelfoam/suture on Friday because:

1) There wasn't much of a socket to stick Gelfoam into, and I doubted it would hold well, even with a suture??though I could have flapped and created the space.

2) It was a SMALL communication and he was only pushing air unidirectionally, and even then he had to use force.

3) I was the only one in the office??no assistant. I figured a three-day wait wouldn't do any damage. [Posted: 1/9/2006 3:53:45 PM] Just saw my patient. Oral-antral communication appears to be completely closed. He says he hasn't noticed it since Saturday.

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