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CORPI STRAINI

ENDOSINUSALI IATROGENI

Prof. Dr. Codrut Sarafoleanu

Clinica ORL si CCF “SF. Maria” - Bucuresti


Generalitati
 Patologie rara, dar cu incidenta in continua crestere

 Sexul feminin > masculin (57,7% /42,82%)

 Etiologia cea mai frecventa este cea


 Iatrogena (60%)
 Procedee stomatologice, ORL, oftalmologice
 Accidentala (25%)

 Cel mai frecvent afectat sinus


 Maxilar (75%)
 Frontal (18%)
De ce gresim?

 Insuficienta cunoastere a anatomiei regiunii alveolo-sinusale

 Insuficienta pregatire imagistica a pacientului

 Graba……(suprasolicitarea medicului !)

 Superficialitatea medicului

 $$$$$$$
Consideratii anatomice
Procesul aveolar maxilar

Planseul sinusului

Copil Adult

In acelasi plan La 1.5 mm sub


cu planseul planseul
foselor nazale foselor nazale
Consideratii anatomice :
-Marimea sinusului
Raporturi In functie de -Lungimea radacinilor

dento-sinusale -Inaltimea proc.alveolar

PM2

M1

M2

PM1

C
Consideratii anatomice :
 In functie de dintele afectat:
 M1 – cel mai frecvent afectat
(22,51%)
 M2 – 17,21%
 PM2 – 2,2%
 Canin – 0,66%
Corpi straini endosinusali iatrogeni

 Factori favorizanti:
 Interni
 – pneumatizare excesiva
 - procese inflamatorii locale
 - procese degenerative in boli ale tesutului osos
 - procese degenerative in bolile de sistem
 - procese degenerative maligne

 Externi
 - traumatisme
 - interventii multiple asupra dintilor sinusali si arcada dentara
 - manevre agresive in timpul tratamentului
Fiziopatologie
 Patrunderea accidentala/iatrogena a unui corp strain endosinusal

 Inflamatia mucoasei sinusale

 Blocaj ostial

 Stagnarea secretiilor sinusale

 Anaerobioza

 Dezvoltarea germenilor endosinusali (bacterii, FUNGI !!!)

 SINUZITA
Simptomatologie

 Rinoree mucopurulenta unilaterala

 Obstructie nazala unilaterala

 Durere moderata si senzatie de presiune

 Cacosmie

 Exteriorizare la nivelul cavitatii nazale de material dentar endosinusal


Algoritm diagnostic

 Anamneza

 Examen clinic ORL / stomatologic

 Investigatii:
- examen endoscopic
- nazal
- endosinusal – sinusoscopie
- examene radiologice
- Orto-pan-tomografia
- Radiografie SAF
- CT sinusal
Algoritm terapeutic

 Principii de tratament:

 Tratament polimodal

 Colaborare interdisciplinara
 ORL-ist – Medic de Medicina Dentara
Algoritm terapeutic

 Principii de tratament:

 Extractia corpului strain

 Rezolvarea cauzei dentare (in cazul etiologiei odontogene)

 Tratamentul medicamentos/chirurgical al sinuzitei


Manevre de extractie a corpului strain

 In functie de
 Posibilitatile tehnice
 Pregatirea medicului
 Localizarea corpului strain
 Complicatiile produse de corpul strain
 Sinusoscopie

 Chirurgie endoscopica rinosinusala

 Cura radicala Caldwell - Luc


Manevre de extractie a corpului strain
 Sinusoscopia

 Manevra diagnostico-terapeutica ce
permite
 explorarea endoscopica a sinusului maxilar
printr-un trocar introdus endosinusal prin
meatul inferior
 Prelevarea de secretii patologice
 Extractia de corpi straini
 Ablatia/biopsia de mici formatiuni tumorale
intrasinusale (chiste, polipi, etc.)

 Se poate realiza pe cale diameatica / fosa


canina / abord mixt
Sinusoscopia
Chirurgia endoscopica rinosinusala

 Metoda moderna de tratament chirurgical,


 Avantaje certe in ceea ce priveste conservarea functiei rinosinusale
si a calitatii vietii pacientilor
 Permite o buna vizualizare a reperelor anatomice nazale si sinusale
 Permite, in acelasi timp operator
 Extractia corpului strain
 Rezolvarea chirurgicala a rinosinuzitei produse

 Scopul ESS:
 Prezervarea mucoasei sanatoase endosinusale
 Asigurarea unei bune ventilatii/drenaj sinusal
Chirurgia endoscopica rinosinusala

 Tipuri de interventii
chirurgicale

 Meatotomia inferioara

 Meatotomie mijlocie

 Abord mixt
Chirurgia endoscopica rinosinusala
Chirurgia radicala (Cura Caldwell-Luc)

 Chirurgie antifiziologica

 Realizeaza indepartarea in intregime a mucoasei sinusale

 Necesita spitalizare mai indelungata (5-7zile)

 Poate conduce la
 Anestezia tegumentelor obrazului
 Devitalizarea dintilor hemiarcadei dentare ipsilaterale

 Exista si tehnici combinate mini-Caldwell-Luc+ESS


Corpi straini endosinusali iatrogeni

Metoda combinata – abord Caldwell-Luc modificat + endoscopie


Corpi straini endosinusali iatrogeni

Material si metoda
- lot de 37 de pacienti
- prezentati in ultimele 18 luni
- sex ratio : F/B = 20/17
- tipul corpilor straini:
- gutaperca
- freza dentara
- pasta dentara
- ac Kerr
- surub de implant
- fragment de dinte
Corpi straini endosinusali iatrogeni

Tipul materialului Numar de pacienti


Gutaperca 12
Pasta dentara 18
Freza dentara 1
Ac Kerr 2
Surub de implant 2
Fragment de dinte 2
Corpi straini endosinusali iatrogeni

5%
5%
5%
3% 32%

50%

Gutta-percha Pasta dentara Freza dentara

Ac Kerr Surub de implant Fragment de dinte


Corpi straini endosinusali iatrogeni
 Discutii

 Posibile complicatii:
 - Sinuzite fungice
 - Chiste de retentie
 - Granuloame
 - Osteomielita
 - Sinuzite supurate + complicatii
Maxillary sinusitis of odontogenic origin
diagnostic and treatment difficulties
Introduction
 Maxillary sinusitis of odontogenic origin is a well-known condition in both the dental
and otolaryngology communities

 It occurs when the Schneiderian membrane is violated by conditions arising


from dentoalveolar unit.

 This type of sinusitis differs from sinusitis of other causes in its:


 pathophysiology, failure to accurately identify a dental cause lead to:
 microbiology,  persistent symptomatology
 failure of medical and surgical therapies directed
 diagnostics toward sinusitis.
 management,
Introduction

 Historically, 10-12% of maxillary sinusitis cases -


odontogenic infections (*, **).

 In recent publications, up to 30-40% of chronic


maxillary sinusitis cases contributes to dental cause
(***).

*Mehra P, Jeong D. Maxillary sinusitis of odontogenic origin. Curr Allergy Asthma Rep 2009;9:238-43.
**Brook I. Sinusitis of odontogenic origin. Otolaryngol Head Neck Surg 2006;135:349-55
***Patel NA, Ferguson BJ. Odontogenic sinusitis: an ancient but under-appreciated cause of maxillary sinusitis. Curr Opin Otolaryngol
Head Neck Surg 2012;20:24-8.
Etiology (*)
 Meta-analysis (*)
 most common cause of OMS was iatrogenia(55.97%).
 oroantral fistulas and the remaining roots (iatrogenia after tooth extraction) - 47.56%
 the dressings to close these oroantral fistulas and nonspecific foreign bodies - 19.72%,
 extrusion of endodontic obturation materials into the maxillary sinus represented - 22.27%,
 amalgam remains after apicoectomies -5.33%,
 the maxillary sinus lift preimplantology surgery - 4.17%,
 poorly positioned dental implants or those migrated to the maxillary sinus the 0.92%
 periodontitis (40.38%)
 odontogenic cysts (6.66%).

 Patel (**)
 implant related causes - 37%
 dental extraction-related complications - 29.6%
 dentigenous cyst - 11.1%,
 radicular cyst, dental caries, and a supernumenary tooth- each found in 7.4%
*Arias-Irimia O, Barona-Dorado C, Santos-Marino JA,Martinez-Rodriguez N, Martinez-Gonzalez JM. Metaanalysis of the etiology of odontogenic
maxillary sinusitis. Med Oral Patol Oral Cir Bucal 2010;15:e70-3.
**Patel NA, Ferguson BJ. Odontogenic sinusitis: an ancient but under-appreciated cause of maxillary sinusitis. Curr Opin Otolaryngol Head Neck Surg
2012;20:24-8.
Diagnostic
 Patient’s medical history
 ENT examination
 Dental medicine assesment

- Nasal endoscopy
- Sinusoscopy
- Imaging
- Ortopantomography or
dental tomography
- Plain sinus radiologic evaluation
- CT scan (preffered to MRI)
Clinical features
 Classic symptoms suggestive of an odontogenic source can include
sinonasal symptoms such as:
 unilateral nasal obstruction,
 rhinorrhea,
 foul odor and taste

• Dental symptoms - do not reliably predict an odontogenic cause


 pain and dental hypersensitivity – 29% (*)

 No single symptom from the various sinonasal complaints


associated with sinusitis has been shown to predominate in
odontogenic sinusitis

 BUT --- UNILATERALITY – can be pathognomonic!!!


* Longhini AB, Ferguson BJ. Clinical aspects of odontogenic maxillary sinusitis: a case series. Int Forum Allergy Rhinol 2011;1:409-15.
Radiologic imaging (1)
 Panoramic radiograph:
 useful for evaluating
 the relationship of the maxillary dentition to the sinus,
 pneumatization,
 pseudocysts.
 displaced roots, teeth, or foreign bodies in the sinus

 The overlap of the hard palate limits the usefulness of this examination

 It is less accurate than Water‘s view in identifying maxillary sinusitis, but gives
more detailed information about lower part of the sinus
Radiologic imaging (2)
 Dental radiographs
 estimated sensitivity of 60% for caries and approximately 85% for
periodontal disease

 According to Longhini & Ferguson (*), 86% of the dental evaluations on


patients subsequently diagnosed with odontogenic sinusitis failed to identify
the dental disease.

 !!! Negative dental evaluations do not definitively rule out a dental cause
of sinusitis, particularly in the patient with reccurent chronic rhinosinusitis

* Longhini AB, Ferguson BJ. Clinical aspects of odontogenic maxillary sinusitis: a case series. Int Forum Allergy Rhinol 2011;1:409-15.
Radiologic imaging (3)
 CT scan – gold standard in evaluating the patients with OMS

 Case series by Patel (*) revealed that all patients with odontogenic sinusitis
showed signs of dental disease on CT scan, with 95% of patients showing
periapical abscesses on CT.

 Cone beam volumetric CT


 gaining popularity, particularly in the field of implant dentistry
 has a higher resolution than conventional CT which is a good advantage,
especially in challenging cases of OMS

* Patel NA, Ferguson BJ. Odontogenic sinusitis: an ancient but under-appreciated cause of maxillary sinusitis. Curr Opin Otolaryngol Head Neck Surg
2012;20:24-8.
Treatment of OMS
 Concomitant management of the dental origin and the associated
sinusitis =>
 complete resolution of the infection
 prevent recurrence and complications

 Close collaboration between ENT – Dental practitioners !!!


Surgical treatment

 Surgery of odontogenic cause


 Closure of the oro-antral fistulae

 Removal of dental implants, etc.

 Surgery of the OMS


 Endoscopic app.

 External app.

 Combined app.
Conclusions
 The incidence of odontogenic sinusitis is likely underreported in the available
literature.

 The most common causes are iatrogenic and marginal/apical periodontitis.

 Symptoms and exam findings in odontogenic and nonodontogenic sinusitis are


similar

 Dental evaluations with only panoramic or dental radiographs frequently fail to


diagnose a dental disease in patients with OMS

 Evaluation of a patient with recalcitrant CRS, unilateral or associated with foul


smell or taste - sinus CT or CBVCT with thorough inspection for evidence of
periapical abscesses.

 Maximal medical treatment and dental treatment are mandatory prior to surgery

 Because of less traumatic approach, lower rate of complications and better


preservation of antral lining, ESS is the first line surgical treatment