Clearance of Bone Substitute in Gel Form Accidentally Dispersed into the Sinus Cavity during Transcrestal Maxillary Sinus Floor Elevation: Two-Case Report

Sinus membrane perforation is the most frequent intraoperative complication occurring during maxillary sinus floor elevation. Although numerous techniques for perforation management are present, grafting material dissemination may still occur, representing a potential trigger factor leading to acute or chronic sinusitis. This case report describes two cases of xenogeneic bone substitute in gel form accidentally dispersed into the sinus cavity during maxillary sinus floor elevation with a transcrestal approach. In both cases, immediately postoperative radiographic imaging showed an important amount of gel graft dislodged into the sinus cavity as a consequence of hidden perforations that remained undetected during surgery. Patients were monitored for 6 months after surgery and reported no signs or symptoms related to possible sinus disease. Control radiographs showed no sinus membrane hypertrophy and/or presence of residual disseminated gel, confirming complete clearance of the accidentally dispersed graft through the ostiomeatal complex. In order to minimize postoperative complications, bone substitutes in gel form could represent an interesting alternative to granular grafts for their easier clearance from the maxillary sinus cavity in case of accidental dissemination during sinus augmentation procedures.

Bilateral ectopic third molar in the maxillary sinuses associated with dentigerous cyst: a case report

A dentigerous cyst is an epithelial-lined odontogenic cyst formed by an accumulation of fluid between the reduced enamel epithelium and the crown of an unerupted tooth. About 70% of dentigerous cysts occur in the mandible and 30% in the maxilla and the most involved teeth are maxillary canines and maxillary third molar. Dentigerous cysts often displace the related tooth into an ectopic position. In the maxilla when the cyst expands into the sinus, usually causes total or partial occupation of the sinus cavity and can extend to the nose. We report a rare case of a 24-year-old female with bilateral maxillary third molars inside the maxillary sinuses attached to a dentigerous cyst and treated with a minimally invasive endoscopic surgery through the middle meatal meatotomy.

An Updated Review on Head and Neck Cancer Treatment with Radiation Therapy

The complexity of head and neck cancers (HNC) mandates a multidisciplinary approach and radiation therapy (RT) plays a critical role in the optimal management of patients with HNC, either as frontline or adjuvant treatment postoperatively. The advent of both definitive and post-operative RT has significantly improved the outcomes of patients with HNC. Herein, we discuss the role of postoperative RT in different subtypes of HNC, its side effects, and the importance of surveillance. The treatment regions discussed in this paper are the oral cavity, nasopharynx, paranasal sinus cavity, oropharynx, larynx and hypopharynx. Multiple studies that demonstrate the importance of definitive and/or postoperative RT, which led to an improved outlook of survival for HNC patients will be discussed.

Conchopexy Suture versus Bolgerization in preventing middle turbinate lateralisation following FESS

Background: Middle turbinate lateralisation is the most common minor post-operative complication following functional endoscopic sinus surgery. This study aimed to compare the outcome between Conchopexy suture and Bolgerization method in preventing middle turbinate lateralisation. Methodology: This was a prospective, comparative and interventional study conducted from May 2018 to November 2019 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A total of 68 patients were divided equally into two groups. Following functional endoscopic sinus surgery, the middle turbinate was medialised either by Conchopexy suture or Bolgerization technique. Postoperative assessment was done on the second and 12th week of surgery, where the position of the middle turbinate and status of the sinus cavity were assessed using perioperative sinus endoscopic (POSE) score. Chi-square test and unpaired t test were used for comparison of postoperative results between two groups taking p value of < 0.05 as statistically significant. Results: Lateralised middle turbinate and mean POSE score was 5/34 (14.8%) and 2.1±1.25, respectively, in Conchopexy group whilst in Bolgerization group it was 6/34 (17.6%) and 2.5±1.46. However, the observed differences were not statistically significant. Conclusion: Conchopexy suture and Bolgerization techniques were equally effective in preventing middle turbinate lateralisation. Hence, either of these techniques could be used as an adjunct to FESS to avoid middle turbinate lateralisation.

Challenging the gold standard: methods of sampling for microbial culture in patients with chronic rhinosinusitis

Purpose Chronic rhinosinusitis (CRS) is a highly prevalent multifactorial disorder. Culture-directed antibiotics are frequently prescribed to patients with CRS and the middle nasal meatus (MM) is traditionally believed to be a representative sampling site of the sinuses as a whole. The purpose of our study was to reevaluate the reliability of the MM as a sampling site in patients with CRS who suffer from impaired drainage from the sinuses to the MM. Methods Swabs and tissue biopsies were collected from the MM, maxillary sinus and frontal sinus from 50 patients with CRS. The results of bacterial culture were compared between sampling methods and sites in relation to the patency of the sinus ostia. Results 782 bacterial isolates were cultured from the samples. Concordant results between the MM and the sinus cavity were noted in 80% of patients for the maxillary sinus, but only 66% for the frontal sinus and 76% for the sinuses a whole. The differences were similarly prevalent in patients with open and occluded sinus ostia. Notably, swabs from all three sites provided representative information in 92% of patients and tissue biopsies did not provide additional information compared to multiple swabs. Conclusion The traditional method of sampling from the middle meatus provides inadequate information in 24% of patients with CRS, which may result in inadequate antibiotic therapy and contribute to increasing antibiotic resistance. Additional sampling from the sinuses should be recommended whenever possible, while invasive sampling is not necessary.

A Numerical Model of the Influence of Maxillary Sinus Ostium Size on the Distribution of Nitric Oxide Concentration in the Nasal Cavity and Sinuses.

ObjectiveUsing a numerical model, we aimed to study the influence of maxillary sinus ostium size variation on nitric oxide (NO) concentration distribution in the nasal cavity and sinuses and to determine the impact of differing sinus ostium size on sinusitis development and recurrence following sinus ostium opening surgery.MethodsWe obtained high-resolution computed tomography images of the nasal sinuses of a volunteer, following which we established a numerical model, determined NO concentration and air volume in the maxillary sinus on one side, then changed the maxillary sinus ostium size on that side, and finally established five models of sinus ostium of different sizes. Two sizes of sinus numerical models were established to determine effect of differing ostium size on the maxillary sinus cavity NO concentration distributions.ResultsA smaller sinus ostia size corresponded to lower NO concentration in nasal cavity and exhaled air; moreover, a concentration gradient was formed from sinus ostium to nasal cavity. A larger sinus ostia size demonstrated a lower NO concentration surrounding sinus ostium in the sinus cavity and formed a concentration gradient from ostium to cavity.ConclusionConstriction of the sinus cavity can lead to changes in NO concentration. Detection of NO concentration in nasally exhaled air can be used as an index to detect the patency of the maxillary sinus ostium. An excessive opening of sinus ostium leads to a decrease in NO concentration around sinus ostium, which is one of the main causes of persistent or recurrent inflammation in the maxillary sinus

Prompt gamma imaging for the identification of regional proton range deviations due to anatomic change in a heterogeneous region

Objectives: Prompt gamma (PG) imaging has previously been demonstrated for use in proton range verification of a brain treatment with a homogeneous target region. In this study, the feasibility of PG imaging to detect anatomic change within a heterogeneous region is presented. Methods: A prompt gamma camera recorded several fractions of a patient treatment to the base of skull. An evaluation CT revealed a decrease in sinus cavity filling during the treatment course. Comparison of PG profiles between measurement and simulation was performed to investigate range variations between planned and measured pencil beam spot positions. Results: For one field, an average over range of 3 mm due to the anatomic change could be detected for a subset of spots traversing the sinus cavity region. The two other fields appeared less impacted by the change but predicted range variations could not be detected. These results were partially consistent with the simulations of the evaluation CT. Conclusion: We report the first clinical application of PG imaging that detected some of the expected small regional proton range deviations due to anatomic change in a heterogeneous region. However, several limitations exist with the technology that may limit its sensitivity to detect range deviations in heterogeneous regions. Advances in knowledge: We report on the first detection of range variations due to anatomic change in a heterogeneous region using PGI. The results confirm the feasibility of using PG-based range verification in highly heterogeneous target regions to identify deviations from the treatment plan.

THE PROBLEM OF DEVELOPMENT OF MAXILLARY SINUSITIS AFTER SINUS-LIFTING SURGERY

Subject. In some clinical cases maxillary sinus lift is a nessesary surgery preparing for dental implantation in the distal parts of the upper jaw. However, despite the widespread using of this type of surgery in clinical practice, the percentage of postoperative complications leading to the development of odontogenic maxillary sinusitis after sinus-lifting surgery does not decrease from year to year. Among the complications of sinus lifting, the following main ones are distinguished: perforation of the maxillary sinus mucosa and nasal cavity; rejection of a previously installed dental implant; migration of the implant and/or bone material to the maxillary sinus; bleeding; acute maxillary sinusitis. The aim is to conduct a systematic analysis of domestic and foreign literature sources to determine the main factors of development of postoperative odontogenic sinusitis, as well as features of diagnosis and prevention of this complication. Methodology. The review of research allows us to consider the etiology of odontogenic maxillary sinusitis after sinus-lifting surgery and the pathogenesis of the disease, to draw conclusions about possible ways to prevent its development. Results. Odontogenic sinusitis that developed after the sinus-lifting operation is very common in clinical practice, despite the widespread use of this type of bone augmentation and proven methods of surgical intervention. The reason for this can be both anatomical prerequisites and iatrogenic factors, as well as insufficient diagnosis of pathologies of the paranasal sinuses in the preoperative period. Conclusions. The development of postoperative sinusitis can be avoided with careful planning of the operation, necessarily with computer tomography (preferably, cone-beam (dental) computed tomography, which is characterized by a relatively low load for optimal visualization of the maxillofacial tissues). Pathological changes in the sinus cavity and paranasal structures should be eliminated as planned before the sinus-lifting operation.

Comparison of Bioabsorbable Steroid-Eluting Sinus Stents Versus Nasopore After Endoscopic Sinus Surgery: A Multicenter, Randomized, Controlled, Single-Blinded Clinical Trial

Objectives: The aim of this study was to compare the efficacy of bioabsorbable steroid-eluting sinus stents versus absorbable Nasopore packs after endoscopic sinus surgery (ESS) for the treatment of chronic rhinosinusitis (CRS). Methods: One hundred eighty-one patients with CRS who underwent ESS were randomly assigned to receive a steroid-eluting sinus stent in one ethmoid sinus cavity, whereas the contralateral control side received a Nasopore pack. Endoscopic evaluations were performed 14, 30, and 90 days after the ESS. Postoperative intervention, polyp formation, adhesions, and middle turbinate (MT) position were assessed as efficacy outcomes. Results: The stents were successfully deployed in all 181 sinuses. Thirty days after the ESS, the stents significantly reduced the need for surgical intervention compared to the Nasopore ( P < .0001). The percentage of cases with polyp formation was significantly lower on the stent sides compared with the Nasopore sides ( P < .0001) at 14, 30, and 90 days after ESS. The percentage of severe adhesion was significantly lower on the stents sides than on the Nasopore sides at postoperative day 90 ( P = .0003), whereas they were not significantly lower at postoperative days 14 and 30. There were no significant differences between the stent sides and the Nasopore sides regarding the frequency of MT lateralization at all end points. No device-related adverse events occurred. Conclusions: Our study demonstrated significant improvement in the early postoperative outcomes by reducing the need for postoperative surgical intervention and polyp formation using steroid-eluting stents when compared with absorbable Nasopore packs. The steroid-eluting sinus stents and the Nasopore packs were each effective in preserving the ethmoid sinus patency and in preventing MT lateralization. A further prospective cohort study with long-term postoperative outcomes is warranted.