Rhinosinusitis associated with post-dental extraction chronic oroantral fistula: outcomes of non-surgical management comprising antibiotics and local decongestion therapy

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Introduction

An oroantral fistula is an epithelium-lined communication between the oral cavity and maxillary sinus. Most commonly, oroantral fistulas are the result of tooth extraction involving posterior teeth of the upper jaw.¹Other causes include: infections such as syphilis, neoplasm, Paget's disease, osteomyelitis, radiation therapy, and trauma. Recently, bisphosphonate-related osteonecrosis of the jaw has also been implicated in its causation.²

The reported incidence of oroantral communications after tooth extraction is low, about 0.31-4.7 per cent for all tooth extractions³and 5.1 per cent in cases of upper third molar extractions.⁴However, given the large number of tooth extractions being performed, oroantral fistulas in clinical practice are not uncommon.

Many oroantral fistulas, especially those less than 3 mm in size, heal spontaneously, while those more than 5 mm in size do not heal without surgical repair.^5-7Oroantral fistulas persisting beyond three weeks are regarded as 'chronic'.⁸Chronic oroantral fistula is associated with a variable degree of rhinosinusitis. In fact, oroantral fistula is one of the most common causes of odontogenic maxillary sinusitis.⁹

Studies have indicated that rhinosinusitis is responsible for non-healing of oroantral fistula.¹⁰Unfortunately, no definitive management protocols have been described in the literature or in guidelines developed by expert groups on rhinosinusitis for this subset of rhinosinusitis patients. In the past, radical surgery in the form of a Caldwell-Luc operation (involving the removal of part of the anterolateral wall of maxilla, the creation of a wide antrostomy in the inferior meatus and the excision of whole mucosal lining of the maxillary sinus) was used to clear the rhinosinusitis. The procedure was associated with significant morbidity and often failed to achieve the desired clearance.¹¹The focus has now shifted to more conservative approaches. A more recent technique for relief of rhinosinusitis is functional endoscopic sinus surgery (FESS) with surgical repair of the fistula. This has been shown to provide equal or even better results than the Caldwell-Luc procedure, with considerably less morbidity, in the management of rhinosinusitis associated with chronic oroantral fistula.^12-14

The reasoning underlying the success of the minimally invasive FESS approach is based on the role of patent sinus ostia in maintaining the ventilation and health of...