Extraction of a tooth root accidentally removed into the maxillary sinus using middle and inferior meatotomy: a case report

¹Otorhinolaryngology Department of the Military Training Hospital Mohamed V of Rabat, Rabat, Morocco, ²Otorhinolaryngology Department, 5^th Military Hospital, Guelmim, Morocco

^&Corresponding author
Marouane Balouki, Otorhinolaryngology Department of the Military Training Hospital Mohamed V of Rabat, Morocco

Introduction    

The maxillary sinus belonging to the nasal and oral cavity is the most susceptible of all sinuses to invasion by pathogenic bacteria, either through their communication with the nasal cavity or the product of odontogenic infection established their home via nasal (carcinogenic), allergic, or tooth root. Chronic maxillary rhino sinusitis can be caused by several etiologies. The dental origin constitutes 10 to 24% of the known causes [1], it could be a bucco sinus communication (BSC), migration of foreign bodies (ductal paste, roots, teeth), granulomas, cysts, and impacted teeth [2]. It is possible for small foreign materials to spontaneously be expelled, but in most cases, they require removal [3]. We present a case of maxillary sinusitis of dental origin, where the imaging examinations were crucial in establishing the diagnosis. A dental scan is the chosen test for studying dental damage [4]. Treatment involves both treating the sinuses and the tooth that caused the infection. It will therefore be carried out jointly by the otorhinolaryngologist and the dentist [5]. The purpose of this paper was to present an unusual case of a large foreign body of endodontic origin (tooth roots) removed from the maxillary sinus.

Patient and observation     

Patient information: a 68-year-old female patient was treated for allergic rhinitis. She suffered from orbital and buccal pain on the right side of the face and headaches in the preceding 2 months, without nasal obstruction or rhinorrhea nor fever. The symptoms were associated with the end of endodontic treatment of the 17^th tooth.

Clinical findings: on clinical examination, it is observed that there is no increase in the volume of the surrounding tissue. The examination also demonstrated a facial pain caused by palpation over the right maxillary sinus.

Diagnostic assessment: CT of the sinuses in the axial section 2.5 mm thick showed mucous thickening in the frame of the right sinus on an intrasinus foreign body measuring 4 to 5 mm, the root of the 17^th tooth was also included intrasinus (Figure 1).

Diagnosis: at the end of the clinical and paraclinical examinations, the diagnosis adopted in this patient was: hyperalgesic right maxillary sinusitis due to a dental part pushed back into the sinus during an extraction.

Therapeutic interventions: initially, the patient received medical treatment by antibiotic (amoxicillin + clavulanic acid) and nasal washes. Then she underwent endonasal surgery under general anesthesia; the combination of middle and lower right meatotomy first allowed extraction of the foreign body and then wide ventilation of the maxillary sinus. The use of the lower maxillary sinusotomy was necessary to facilitate the extraction because the dental piece was embedded in the bottom of the sinus, and difficult to mobilize in the polypoid mucosa (Figure 2). The two approaches allowed the extraction of an intra sinus tooth root (Figure 3).

Follow-up and outcome of interventions: the patient was followed regularly in otorhinolaryngology consultation every 15 days for 3 months, she reports a clinical improvement after the surgical extraction of the dental material.

The patient's perspective: after the complete extraction of the dental root of the maxillary sinus, the patient expressed great joy, he was very satisfied with the functional results, and he even expressed his gratitude because she got rid of her chronic debilitating headache.

Informed consent: informed consent was obtained from the patient.

Discussion     

Rhino sinusitis of dental origin is not uncommon. The maxillary sinuses are the most affected during dental manipulations at the roots of the first molar and the second premolar (even other molars, the first molar, and the canine) if the sinuses are large. During tooth extraction, there may be migration of dental pieces in the sinuses or communication between the oral cavity and the sinuses. Therefore, when there is recurrent or chronic unilateral maxillary sinusitis, it is necessary to think of a dental origin [4]. The clinical presentation can be variable: patients may present a nasal obstruction, foreign body sensation, facial pain, headaches, recurrent epistaxis, rhinorrhea, rhinitis caseosa, oronasal fistula, and cacosmia [5]. The dental scan is a revealing examination. The scanner confirms the diagnosis, specifies the size of the foreign body, and allows a preoperative assessment [6]. The treatment includes an antibiotic therapy adapted to the germs most often encountered in oral infections: amoxicillin-clavulanic acid (6 to 10 days) in the first line. A macrolide or a 3^rd generation cephalosporin in case of allergy is possible. Dental treatment consists of extracting the offending tooth or treating its root, and closing oral-sinus communication when it exists [4]. Once the sinus infection has been treated and the dental cause has been removed, sinus surgery may be considered with an (ear, nose, and throat).

An endoscopic approach with reopening of the ostium by middle meatotomy is the first choice. It allows the ostium to be enlarged and the sinus to be ventilated without destroying the sinus mucosa. The lower meatotomy, Isolated or associated with the middle meatotomy, offers an approach to the lower half of the maxillary sinus and in particular of the alveolar groove which facilitates the extraction of foreign bodies strongly embedded in the bottom of the sinus mucosa, especially when it´s altered by an inflammatory process during allergic rhinitis (the case reported). The maxillary sinus can also be approached by an anterior mini-antrostomy. It uses the principle of the Caldwell-Luc method by adapting it to minimally invasive surgery [7]. It is a penetration of the maxillary sinus through the canine fossa. Likewise, it is ardently defended in maxillary aspergillary sinusitis, but it can be offered as a complement to an endonasal approach when the latter proves to be insufficient [7]. However, it is the source of many complications: fistulization, late maxillary mucoceles, devitalization of the maxillary teeth, paresthesia of the suborbital nerve territory, and prolonged absence of aeration of the sinus [8]. The Caldwell Luc technique is a very invasive and dilapidating surgical intervention, currently, it is rarely used. It causes bone (maxilla) and mucous membrane (sinus mucosa) lesions and carries a risk of infection of the surgical site from germs commensals of the oral cavity (strongly septic cavity) [9].

Conclusion     

When faced with recurrent chronic unilateral rhinosinusitis, one must think of a dental cause. Nasal endoscopy has revolutionized other classic invasive and decaying techniques. It allows the extraction of the intrasinus foreign body and the drainage of the sinuses via a medium meatotomy. The lower meatotomy can be associated with removing the dental pieces enclosed in the bottom of the sinuses.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Marouane Balouki wrote the article. Noureddine Errami and Bouchaib Hemmaoui have reviewed the literature. Ilyas Benchafai, Ali Jahidi and Fouad Benariba are responsible for the corrections. All authors have read and approved the final manuscript.

Figures     

Figure 1: coronal CT of the sinuses. Migration of dental material during an extraction attempt with inclusion of tooth root n° 17

Figure 2: intraoperative endoscopic view showing a right lower meatotomy (yellow arrow: inferior meatotomy, blue arrow: inferior horn)

Figure 3: extraction of an intra-sinus tooth root

References