Indian J Otolaryngol Head Neck Surg
DOI 10.1007/s12070-017-1167-5
CLINICAL REPORT
Odontogenic Fungal Maxillary Sinusitis: A Case Report
of a Displaced Dental Foreign Body
Swati Kodur1 • H. Y. Kiran2 • A. M. Shivakumar3,4
Received: 1 July 2016 / Accepted: 17 July 2017
Ó Association of Otolaryngologists of India 2017
Abstract Odontogenic etiology accounts for 10–12% of
cases of maxillary sinusitis. Although uncommon, direct
spread of dental infections into the maxillary sinus is possible
due to the close relationship of the maxillary posterior teeth to
the maxillary sinus. An odontogenic infection is a polymi-
crobial aerobic–anaerobic infection, with anaerobes out
numbering the aerobes. Diagnosis requires a thorough dental
and clinical evaluation, including radiographs. Management
of sinus disease of odontogenic origin often requires medical
treatment with appropriate antibiotics, surgical drainage when
indicated, and treatment to remove the offending dental eti-
ology. A 35-year-old, non-smoking woman visited our clinic,
with a history of 6 months of facial pain, purulent nose dis-
charge, and a foul taste in her mouth. The patient was other-
wise healthy. Nasal endoscopy showed purulent discharge
coming from the left middle meatus with a congested nasal
mucosa and with a past history of dental treatments. CT PNS
showed fractured free floating and an impacted foreign body
through the premolar tooth and a right maxillary polyp with
evidence of similar dental procedure done bilaterally. Func-
tional endoscopic sinus surgery with extraction of the affected
& Swati Kodur
drswatikodur@gmail.com
A. M. Shivakumar
amshivakumar1@gmail.com
1
DLO, MO. 3065/2, 8th Main, 4th Cross, MCC B Block,
Davanagere, India
2
Department of Oral and Maxillofacial Surgery, College of
Dental Sciences, Pavillion Road, Davanagere, India
3
SSIMS, Davanagere, India
4 microbial infection via the nasal ostium or oral cavity [4].
ENT Clinic, No. 22/4, Above Ranganatha Hardware, Near
Vijaya Hotel, AVK College Road, P.J Extension, Davanagere
577002, India
tooth and closure of oroantral fistula was done. The associa-
tion between an odontogenic condition and maxillary sinusitis
requires a thorough dental examination of patients with
sinusitis. Concomitant management of the dental origin and
the associated sinusitis will ensure complete resolution of the
infection and may prevent recurrences and complications. A
combination of a medical and surgical approach is generally
required for the treatment of odontogenic sinusitis. An endo-
scopic shaver-assisted approach to is a reliable, minimally
invasive method associated with less morbidity and lower
incidence of complications.
Keywords Unilateral sinusitis
Fungal sinusitis

Odontogenic
Gutta percha
Introduction
Among the four pairs of paranasal sinuses, the maxillary
sinuses are the biggest ones and those most frequently
damaged. The anatomical and clinical significance of the
maxillary sinus was first described by Nathaniel Highmore
(Highmore 1613–1685) in 1651 with a report on the drainage
of an infected sinus through the extraction socket of a canine
tooth. Since that report, dental treatment of maxillary teeth
has played an important part in the pathophysiological
affection of maxillary sinus or antrum of Highmore [1].
Odontogenic sinusitis accounts for approximately
10–12% of maxillary sinusitis cases with the incidence
being higher in women and that younger individuals (3rd
and 4th decade) appearing to be more susceptible [2, 3].
The maxillary sinus is virtually sterile but susceptible to
Sinusitis related to odontogenic causes occurs when the
schneiderian membrane is violated by conditions such as
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infections of the maxillary posterior teeth, pathologic
lesions of the jaws and teeth, maxillary (dental) trauma, or
by iatrogenic causes such as dental and implant surgery
complications and maxillofacial surgery procedures.
Odontogenic maxillary sinusitis, whether chronic or
acute, resulting from endodontic and periodontal infections
represents the most classic and somewhat common scenario.
Nevertheless, odontogenic sinusitis may also result from
extractions, dislocation of foreign bodies into the maxillary
sinus (teeth or tooth fragments), or iatrogenic penetration of
dental materials in the maxillary sinus (as a result of
endodontic treatments). Moreover, the inflammatory process
of the maxillary sinus, initially present in the vast majority of
cases, may extend to other paranasal sinuses as well [5].
Presenting symptoms range from mucopurulent, often
unilateral, discharge; cheek and/or facial pain; perception
of foul smell and/or taste; postnasal dripping and gingival
swelling [6, 7]. An odontogenic source should be consid-
ered in individuals with symptoms of maxillary sinusitis
and a history of dental or jaw pain; dental infection; oral,
periodontal, or endodontic surgery; and in those people
resistant to conventional sinusitis therapy.
Clinical relevance of this variety of sinus disease differs
in pathophysiology, microbiology, and management as
compared to sinusitis of fungal or bacterial origin due to
community acquired disease. Odontogenic sinusitis may
show bacterial or fungal aetiology. Both aerobes and
anaerobes have been associated with odontogenic sinusitis
[8]. Infectious processes are often polymicrobial and drug
resistant, requiring surgery for complete resolution.
The identification and treatment of the underlying dental
condition are mandatory for the proper management
[9, 10]. A maxillofacial conventional computed tomogra-
phy (CT) scan usually allows the surgeon to evaluate the
sinusal involvement, whereas orthopantomograms, den-
tascan CT scans, and, more recently,cone-beam CT scans
are currently used for dental assessment [11, 12].
Modern surgical treatment relies both on dental surgery
addressing the underlying dental condition and functional
endoscopic sinus surgery, which allows for restoration of the
normal sinusal drainage [3]. When present, an odontogenic
foreign body should be surgically removed. Surgical man-
agement of oroantral communication is indicated to reduce the
likelihood of causing chronic sinus disease. The management
of odontogenic sinusitis includes a 3- to 4-week course of
antimicrobials effective against the oral flora pathogens [13].
Case Report
A 35-year-old, non-smoking woman visited our clinic, with a
history of 6 months of facial pain, purulent nose discharge,
and a foul taste in her mouth that did not respond to long-term
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Indian J Otolaryngol Head Neck Surg
antibiotic treatment. The patient was otherwise healthy. Nasal
endoscopy showed purulent discharge coming from the left
middle meatus with a congested nasal mucosa. The patient
denied any other prior nasal problem, infectious or functional;
however the patient confessed to having dental problems, for
which she had undergone various dental treatments, including
endodontic and periodontal treatments, which held little to no
success in treating her dental condition.
An opinion from the orofaciomaxillary surgeon was
sought, which concluded that the gutta-percha stick used
for endodontic restoration of root canals of teeth had been
accidentally pushed into the maxillary sinus by a previous
dentist through left first molar tooth. The gutta percha stick
was seen as a radiopaque material in left maxillary sinus
floor with sinus obliteration confirmed with intra oral
periapical radiograph and orthopantomography (OPG).
In collaboration, radiographic examinations [orthopan-
tomography] and paranasal sinuses computed tomography
(CT)] were performed.
CT PNS was reported as having a possibility of frac-
tured dental implant causing oroantral fistula and sinusitis
of left maxillary sinus (Figs. 1, 2). The same also indicated
presence of right maxillary sinusitis, either reactionary or
owing to similar procedures done on the right molar teeth.
1. Free floating within the left maxillary sinus.
2. Entering into the sinus attached to the tooth (Fig. 3).
A combined approach in collaboration with the dental
surgeon was done.under antibiotic cover, patient was taken
up for functional endoscopic sinus surgery with extraction
of the causative tooth and repair of the oroantral fistula.
Intraoperative Details
Step 1 Thorough decongestion of the nasal cavity.
Fig. 1 CT-PNS showing two foreign bodies one within the left
maxillary sinus and another entering through its floor
Indian J Otolaryngol Head Neck Surg
Fig. 2 OPG
Fig. 3 Intra oral periapical radiograph showing the gutta percha
Fig. 4 Fungal debris (F) evacuated from the left maxillary sinus.
U uncinate, MT middle turbinate
Step 2 Left uncinectomy done after medialisation of the
middle turbinate. Frank mucopus with fungal debris
evacuated from the left maxillary sinus (Fig. 4).
Step 3 Complete uncinectomy with middle meatal
antrostomy done.Foreign body (gutta-percha) seen lying
free on the sinus floor.
Step 4 Removal of the foreign body and sinus explo-
ration done. Wide middle meatal antrostomy achieved
(Fig. 5, 6).
Fig. 5 Free floating gutta-percha (GP) lying on the sinus floor
Fig. 6 Gutta percha after removal
Step 5 Intraoral examination done.Affected tooth
removed with the second foreign body attached to the
tooth.Point of foreign body entry through the tooth noted
(Fig. 7).
Step 6 Buccal mucoperiosteal flap elevated to close the
oroantal fistula (Rehrmann Flap) (Fig. 8).
Step 7 Right sided uncinectomy done with middle meatal
antrostomy. Polyp in the left maxillary sinus cleared
with establishment of an adequate middle meatal
antrostomy.
Step 8 Bilateral merocel packing done and left in situ for
48 h.
Patient was stable post operatively and was discharged
after 2 days of observation in a stable condition.
Post operative 1 month follow up done. Bilateral well
healed middle meatal cavities and the oroantral fistula noted.
Histopathological report of the fungal debri showed
aspergillus.
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Fig. 7 Extracted tooth with the point of entry of the gutta percha
Fig. 8 Buccal mucoperiosteal advancememnt flap raised and closed
over the oroantral fistula
Discussion
Maxillary sinus growth starts at approximately 3 months of
intrauterine life, and by the 5th month, growth extends into
the adjacent maxilla. The final growth of the maxillary
sinus corresponds with the eruption of permanent teeth
between 12 and 14 years of age [14]. The roots of the
second molars are in closest proximity to the sinus floor,
followed in frequency by the roots of the second molar,
first molar, second premolar, and first premolar [14]. The
relative positions of the roots to the sinus are reported in
several studies [14–18]. It was reported that the frequency
of close proximity (0.5 mm or less) of roots of posterior
maxillary teeth to the sinus floor: second molars 45.5%,
first molars 30.4%, second premolars 19.7% and first pre-
molars 0% [16]. Thus,the close anatomical relationship of
the maxillary sinus and the roots of maxillary molars,
premolars and in some instances canines, can lead to sev-
eral endodontic complications. A study carried out in 411
Romanian patients by Albu and Baciut based on a dental
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Indian J Otolaryngol Head Neck Surg
examination and on a computed tomography (CT) analysis,
reported a maxillary sinusitis prevalence of 25.00% [19].
Classically, Odontogenic maxillary sinusitis is consid-
ered in patients with upper tooth pain, dental infection,
dental surgery, unilateral maxillary sinusitis, foul drainage
or smell, and resistance to conventional sinusitis therapy
[20–23]. Recognition of OMS is important because failure
to address the dental pathology can result in failure of
medical and surgical therapies and persistence of symp-
toms [24, 25]. An odontogenic infection is a polymicrobial
aerobic–anaerobic infection, with anaerobes outnumbering
the aerobes.
As a part of dental procedure, the sinus may be invaded
by either sealer or by solid materials such as gutta percha or
silver cones. Mechanical irritation results from overfilling
the root canal, thereby impinging foreign materials on the
vital tissues. The material produces an inflammatory
reaction with an area of rarefaction in the periapical tissues.
Such inflammation is likely to persist until the foreign
object is removed.
Removal of foreign bodies through an endonasal endo-
scopic approach is the treatment of choice. Endoscopically
assisted Caldwell- luc procedure for removal of a dental
foreign body has also been described in literature.
Conclusion
The association between an odontogenic condition and
maxillary sinusitis requires a thorough dental examination
of patients with sinusitis. Concomitant management of the
dental origin and the associated sinusitis will ensure com-
plete resolution of the infection and may prevent recur-
rences and complications. A combination of a medical and
surgical approach is generally required for the treatment of
odontogenic sinusitis. An endoscopic shaver-assisted
approach to is a reliable, minimally invasive method
associated with less morbidity and lower incidence of
complications.
Compliance with Ethical Standards
Conflict of interest The authors declares that they have no conflict of
interest.
Informed Consent Informed consent was obtained from all indi-
vidual participants included in the study.
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