01 Giugno 2020

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Odontogenic sinusitis in immunosuppressed patient: a clinical case and literature review

Clinical case

Christian Bacci, Vlatko Prosenikliev, Sara Munari, Mariagrazia Boccuto, Carmela Gurrieri, Marco Pizzi, Enzo Emanuelli

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Objectives  Objectives is to describe a com­plex multidisciplinary case.

Materials and methods  Odontogenic sinusitis accounts for about 10% of all cases of si­nusitis. The incidence of sinusitis rises dramatically in immunosup­pressed patients, frequently re­quiring a combination of medical and surgical therapy. To the best of our knowledge, this is the first case report to be published re­garding the management of od­ontogenic maxillary sinusitis in an immunosuppressed patient. A 72-year-old female came to our tertiary referral hospital with pro­found asthenia and slowly-resolv­ing hematomas of the lower limbs. Neutropenia was also present. She was diagnosed with acute my­eloid leukemia (AML) on bone mar­row examination, showing matura­tion arrest of the medullary series, and consequent neutropenia, mye­loid blasts were 33% of total cellu­lar amount. A paranasal sinus CT scan performed for nasal obstruc­tion revealed complete obliteration of the left maxillary, frontal and ethmoidal sinus, with obstruction of the ostiomeatal complex, and the presence of a dental implant in the left alveolar bone. Nasal endos­copy confirmed ostiomeatal ob­struction with purulent secretions in the medial meatus. An OPT and odontoiatric assessment led to the diagnosis of peri-implantitis.

The mandatory treatment for her AML was chemotherapy, which could only be performed in the absence of widespread inflammatory or in­fectious conditions. The patient therefore underwent a combined simultaneous surgical treatment under general anesthe­sia involving functional endoscop­ic sinus surgery (FESS) performed jointly by an ENT surgeon and an oral surgeon who implemented an intraoral approach. During the intraoral part of the surgical procedure, a maxillary nerve blockage was performed through the greater palatine ca­nal, under paraperiosteal local an­esthesia of teeth 2.4, 2.5 and 2.6. A full-thickness trapezoidal flap was incised and elevated, reveal­ing that two of the three implants were not osteointegrated, while the third was partially osteointe­grated. All three implants were re­moved with a minimal osteotomy. Granulation tissue was also re­moved and sent for histological examination. Bichat’s bulla was isolated, left pedicled and rotated to form the deep first layer. After periosteal incision, a mucosal flap was advanced and used to form the second layer, using an absorb­able suture. Complete left uncinectomy, medi­al antrostomy, dranage of the pu­rulent secretions from the sinus, frontal sinusotomy and ethmoid­ectomy were performed. Granula­tion tissue was also removed from the maxillary sinus and sent for histological examination.

Histology of the surgical specimens showed mucosal edema with lym­phoplasmacytic cell inflammation of the subepithelial connective tis­sue associated with the aggrega­tion of myeloid blasts. PAS-D stain­ing showed no growth of fungal spores, and microbiological exami­nation revealed growth of a mul­tiresistant Klebsiella pneumoniae. Postoperative antibiotic therapy was administered and, 10 days after surgery, the patient started chemotherapy. A combined, multidisciplinary, en­doscopic and intra-oral surgical treatment was adopted, aiming to avoid any severe complications and any need to delay the initiation of chemotherapy.

Results and conclusions  The outcome of our surgical ap­proach was excellent, proving an appropriate solution for managing odontogenic sinusitis in this im­munosuppressed patient.

Clinical significance  It is fundamental a team coopera­tion treating complex patients.

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doi: https://doi.org/10.19256/d.cadmos.06.2020.08