Despite significant progress in dental care for the population, in recent years there has been an increase in the incidence of odontogenic maxillary sinusitis (OMS), which is associated with the rapid development of interventional dentistry [1, 2]. RFS occupies one of the leading places among inflammatory processes of odontogenic etiology [1–4]. The connection between RFS and dental disease is often underestimated by specialists, especially if it is not obvious, and often RFS is considered to be rhinogenic, which can lead to improper patient management. First of all, this concerns chronic forms of odontogenic sinusitis with its relatively asymptomatic course [4-8].
According to domestic and foreign researchers, PFS accounts for at least 5-8% of the total number of inflammatory diseases of the maxillofacial area [9, 10]. This is explained by the fact that foci of chronic odontogenic infection cannot always be identified by visual examination of the oral cavity. They can also be concomitant with the rhinogenic form of sinusitis and aggravate its course. Often, chronic TFM is detected by chance during an X-ray examination of the bones of the facial skull for another pathology [5, 7].
A common cause of the development of AFM is errors in endodontic treatment of teeth and dental implantation - passing instruments for root canal treatment (root needles, drills, canal fillers, pulp extractors), as well as filling material and implant beyond the apex of the tooth root into the sinus cavity. Less commonly, foreign bodies in the sinus cavity are fragments of tooth roots [1, 2, 5, 12]. The reasons for the development of AFM also include infection of the sinus during surgery with perforation of the bottom of the cavity of the maxillary sinus: most often (up to 80%) with accidental opening of the sinus during extraction and curettage of the hole after extraction of the first and second molars of the upper jaw, less often - during resection of the root apex, cystectomy, removal of impacted teeth, sequestrectomy, placement of a dental implant, removal of tumors in this area [1, 10, 15].
The leading role in the diagnosis of HFRS still remains with radiation research methods. Traditionally, to assess the paranasal sinuses, including the maxillary sinuses, radiography in the nasal-mental projection, survey radiographs of the skull in direct and lateral projections are used. To visualize teeth, orthopantomography or intraoral contact radiography are used, which do not allow reliably assessing the condition of the maxillary sinuses [11-14]. With the introduction of modern high-tech methods of radiological diagnostics - multislice computed tomography (MSCT), cone beam computed tomography (CBCT), magnetic resonance imaging (MRI) - many doctors began to abandon classical radiological techniques due to their low information content [12-14]. At the same time, the protocols for describing the paranasal sinuses do not always include data on the condition of the alveolar process and the teeth of the upper jaw [11, 13]. This can lead to untimely diagnosis and various local and general complications in such patients [15, 16].
The purpose of the study is to determine the capabilities of modern radiological research methods - MSCT and CBCT - in the diagnosis of inflammatory changes in the maxillary sinuses (MSS) of odontogenic etiology.
What does a sinus x-ray show?
An x-ray shows the human skull with bone structures, cavities and septa. The method is used at the preparatory stage in surgery.
What can be seen on a sinus x-ray:
- Foreign object in the nasal passages.
- Inflammatory process, thickening of the mucous membrane of the infected area.
- Consequences of injuries to the face and head.
- The presence of exudate (mucous, blood, purulent) in the paranasal and frontal cavities.
- "Airiness" of the sinuses.
- Neoplasms: polyps, tumors, cysts.
- Anomalies in the structure of the facial skeleton.
X-rays help to correct the diagnosis in case of fever or headache of unknown etiology.
Results and discussion
Analysis of the results of radiological diagnostic methods revealed signs of RFS in 110 (66.2%) of 166 cases. 66 (39.7%) patients had characteristic clinical symptoms of the disease (headache, low-grade fever, sleep disturbance, a feeling of heaviness in the corresponding half of the face when tilting the head anteriorly, nasal congestion on one side only); these patients were referred for radiation examination by otorhinolaryngologists. The remaining 44 (26.5%) people did not have complaints from the maxillary sinuses; Previously, they were sent for examination by dentists and maxillofacial surgeons for the following reasons: 22 (13.2%) patients - to clarify their dental status, 12 (7.3%) patients - before dental implantation, 10 (6%) patients - for postoperative control after surgical interventions on the upper jaw. In these cases, the identified inflammation of the maxillary sinus was a diagnostic finding.
As is known, acute odontogenic inflammation of the maxillary sinus develops within 1-3 days. Quite often the cause is an inflammatory process of the upper jaw (acute or exacerbation of a chronic one). Such conditions include complications of dental caries, periodontitis, periostitis, osteomyelitis, as well as suppuration of dental cysts or granulomas [7, 8].
Typical complaints of patients with acute maxillary sinusitis were: difficulty in nasal breathing, rhinorrhea, loss of smell, headache and facial pain, a feeling of heaviness in the corresponding half of the face when tilting the head forward, low-grade fever, as well as night cough and sleep disturbances. Odontogenic sinusitis, in contrast to rhinogenic sinusitis, has the following distinctive features: isolated damage to one of the maxillary sinuses, pain in the tooth or in periodontal tissues that precedes the disease, disruption of the facial configuration as a result of swelling of the soft tissues of the cheek and pain on palpation of the anterolateral wall of the maxillary sinus.
In acute sinusitis, x-rays showed thickened mucous membranes, darkening, and fluid levels. In chronic sinusitis, a decrease in sinus transparency was noted.
When assessing and analyzing diagnostic images, the criteria for odontogenic sinusitis were the following: the presence of a foreign body of metallic density corresponding to a filling material or implant in the sinus cavity; deep caries and signs of periodontitis of premolars and molars of the upper jaw; destruction of the lower bone wall of the maxillary sinuses in the area of pathologically changed teeth, as well as partial adentia of the upper jaw in the area corresponding to changes in the maxillary sinus.
During an X-ray examination, in 44 (26.5%) patients with acute maxillary sinusitis, a thickened mucous membrane and/or subtotal darkening with a horizontal fluid level was detected on a plain radiograph. In 78 (47%) patients, there was a total decrease in sinus transparency, of which 38 (22.8%) patients had foreign bodies of metal density (corresponding to filling material) found in the sinus cavity. However, the low contrast of liquid and soft tissues and the summation of shadows made it difficult to objectively assess the obtained radiographs. For additional assessment of the condition of the teeth of the upper jaw, all patients underwent orthopantomography, which did not allow reliably assessing the condition of the maxillary sinuses, and in 13 (7.8%) patients, accurately interpreting changes in the area of the apexes of the teeth of the upper jaw (due to the reflection of the projection layering of complex anatomical structures ).
According to the results of our study, 24 (14.5%) patients showed signs of chronic periodontitis in the area of premolars and molars of the upper jaw (Fig. 1). Deep caries was diagnosed in 4 (2.4%) patients, maxillary cysts in the area of the roots of premolars and molars were visualized in 6 (3.6%) cases.
Rice. 1. CBCT. Panoramic (a) and multiplanar reconstructions of the right (b) and left (c) maxillary sinuses of patient M., 37 years old. Diagnosis: bilateral odontogenic chronic maxillary sinusitis. CT signs of chronic granulomatous periodontitis of teeth 1.8, 2.7, 2.8 are noted (in the form of foci of destruction at the apices of the roots, round in shape, with clear, even contours). The lower bone walls of the sinuses are thinned and cannot be traced in the periodontal area of teeth 1.8 and 2.8 (indicated by arrows). In the lower part of the right maxillary sinus, a parietal soft tissue formation of a homogeneous structure with a polycyclic upper contour is determined. The left maxillary sinus is subtotally filled with soft tissue contents of a homogeneous structure with a rounded upper contour.
Filling material was found in 38 (22.8%) patients (Fig. 2). Of these, in 34 (20.4%) patients in the submucosal layer of the lower wall of the sinus, in 4 (2.4%) - in the upper section near the medial wall of the sinus (Fig. 3). 8 (4.8%) patients were diagnosed with dental implantation errors: the tip of the implant was immersed in the sinus cavity, which caused the development of chronic odontogenic maxillary sinusitis, as well as complications in the form of chronic polysinusitis ( n
=4; 2,4%).
Rice. 2. MSCT. Coronal (a) and sagittal (b) reconstruction of the right maxillary sinus of patient K., 29 years old. Diagnosis: right-sided odontogenic chronic maxillary sinusitis. The roots of teeth 1.6, 1.7 and 1.8 are immersed in the cavity of the maxillary sinus. Condition after endodontic treatment of teeth 1.6 and 1.7, with removal of the filling material beyond the apex of the palatal root 1.7. In the area of the roots of teeth 1.6 and 1.7, there is a rarefaction of bone tissue with fuzzy, uneven contours (radiological signs of granulating periodontitis). In the lower part of the sinus, a parietal soft tissue formation with a polycyclic contour is determined; the bony walls of the sinus are not traced in this area.
Rice.
3. CBCT. Sagittal reconstruction, right maxillary sinus. Patient U., 48 years old. Diagnosis: right-sided odontogenic chronic maxillary sinusitis. Teeth 1.6 and 1.7 after endodontic treatment, the filling material is removed from the apex of the roots of tooth 1.6 (the material is located in the bone tissue of the alveolar process and in the submucosal layer of the sinus). A loss of bone tissue is determined in the area of roots 1.6 and 1.7; the bone wall of the sinus is not visible in this area (arrow). In the lower part of the sinus, thickening of the mucous membrane up to 10 mm is determined, in the superomedial part of the sinus an irregularly shaped foreign body of metal density is visualized (corresponding to fragments of filling material). In our study, 30 (18.1%) patients had absence of maxillary teeth in the area corresponding to changes in the maxillary sinus, which also made it possible to judge the odontogenicity of maxillary sinusitis.
In all cases, computed tomography (MSCT or CBCT) made it possible to accurately diagnose the form of the disease, determine the extent of damage to the sinuses, assess the condition of the lower bone wall of the sinus (identify a violation of its integrity and the communication of the tooth socket with the sinus), determine the source of inflammation in the periodontium, and also identify the presence of foreign bodies in the maxillary sinus. At the same time, the data from MSCT and CBCT were completely comparable with each other, significantly superior to traditional X-ray techniques in terms of diagnostic information content and had such advantages as the absence of superposition, high contrast resolution and the ability to obtain higher-quality reconstructions of images in various planes and 3D images of the area of interest, and also a significant reduction in patient examination time and a reduction in radiation exposure. After computed tomography, treatment tactics were adjusted in 38 (22.9%) patients.
How is a sinus x-ray performed?
The procedure is not painful and does not require preparation. Receive a referral at an appointment with an otolaryngologist, infectious disease specialist or surgeon.
How to do a sinus x-ray:
- The patient removes metal jewelry, glasses, and dentures.
- To protect against radiation, he wears a lead apron or vest with a collar.
- The laboratory assistant indicates how to position yourself correctly relative to the apparatus. Depending on the required projections, the position is changed at the command of a specialist.
- While taking the photo, you should not move and hold your breath.
- After development and decoding, the film with the description is given to the patient.
The conclusion is not considered a final diagnosis, but provides clarifying information for the treating specialist.
Treatment
In the process of treating chronic maxillary sinusitis, it is necessary to restore the drainage and ventilation function, remove pathogenic discharge and stimulate recovery processes. To achieve success, broad-spectrum antibiotics (amoxicillin, augmentin, panclave, etc.), anti-inflammatory drugs, vasoconstrictor nasal drops, antihistamines, puncture of the maxillary sinuses to clean rinsing water, or rinsing the paranasal sinuses by moving fluid (vacuum) are prescribed. drainage). If the effect of the prescribed treatment does not occur within a week, treatment should be continued up to surgery in the ENT department of the hospital.
If the rinsing water during puncture of the maxillary sinus is white, dark brown or black, a fungal infection can be suspected. In this case, it is necessary to discontinue antibiotics and carry out antifungal treatment. If you suspect the anaerobic nature of the process, which is characterized by an unpleasant odor of the discharge, a negative result in bacteriological examination of the contents, oxygenation (a high-pressure oxygen treatment method) of the sinus lumen should be carried out.
If long-term drainage is necessary, you need to install a drainage in the sinus and rinse it through it daily (up to 3 times a day). In case of severe local pain, which is confirmed by X-ray examination, and the ineffectiveness of conservative treatment within 3 days, as well as if signs of complications appear, immediate referral to an ENT hospital is indicated to carry out surgical debridement.
Darkening of the sinuses on x-ray
The method is based on the different permeability of hard and soft tissues by electromagnetic waves. Bones block radiation and appear white in the picture. Specialists are interested in blackouts, which determine the nature of the disorder.
Darkening of the sinuses on an x-ray indicates fluid accumulation. This is a sign of inflammation with the release of mucous or purulent secretion. Sometimes, the picture shows thickening of the walls of the mucous membrane lining the sinuses.
New growths stand out as clear dark spots with shadows. Polyps look like peas on a “pedicle”, and cysts have a cavity filled with fluid inside.
Location and functions of the maxillary sinuses
The maxillary sinus is also called the maxillary sinus. It is a paired paranasal sinus of the nasal cavity. It is located almost throughout the entire space of the maxillary bone, inside the upper jaw. The sinuses consist of the nasal, facial and orbital, posterior and inferior walls.
The maxillary sinuses are lined from the inside with a mucous membrane, which is represented by ciliated epithelium.
There are few nerves and blood vessels in this area. Therefore, inflammatory diseases of the paranasal sinuses remain undiagnosed for a long time, as they occur without severe pain. Pain usually appears during the height of the disease.
Functions of the maxillary sinuses:
- Humidification of inhaled air.
- Participation in the formation of voice.
- Regulation of intracranial pressure.
- Lightening the weight of the skull bones.
- Air filtration and protection against pathogenic microorganisms.
X-ray of the sinuses during pregnancy
The radiation dose during the study is 20 μSv and is considered safe even when performed repeatedly for an adult. The fetus is susceptible to ionizing radiation, which causes intrauterine developmental defects. Carrying a child is a contraindication to the procedure.
X-rays of the nasal sinuses during pregnancy and breastfeeding are done exclusively for health reasons. The potential benefit of the research must outweigh the harm to the child. After the procedure, a pregnant woman needs an ultrasound of the fetus, and a nursing woman needs to transfer the baby to artificial nutrition for a day.
X-ray of the sinuses for children
Pediatricians try to protect preschool children from the harm caused by X-ray radiation to the fragile skeletal system. The procedure is allowed to be performed on patients over 7 years of age.
Before this period, a clear justification for the importance of intervention is necessary - for example, severe facial trauma or severe sinusitis with a risk of inflammation of the meninges.
It is difficult for a young child to sit or stand still during an x-ray. To distract him, they use toys, sedatives, and in emergency cases, anesthesia. At an older age, you can captivate your child with a game in which you should freeze for a short time.
Sign up for the study
Patients and methods
In the period from 2013 to 2015 in the Department of Radiation Diagnostics of Clinical Hospital No. 1 of the First Moscow State Medical University named after. THEM. Sechenov examined 166 patients with maxillary sinusitis of various etiologies. In 110 patients (66.2%) the odontogenic etiology of the disease was confirmed. An analysis of the distribution of patients according to age and gender showed that of the examined patients with TFS, the majority - 91 (54.8%) people - were young and mature, from 21 to 60 years of age. There were 19 (11.4%) patients over 60 years of age; the average age of patients was 48 years (from 21 to 81 years). The majority were female (62 (37.3%) women and 48 (28.9%) men) of working age.
A comparison of the clinical manifestations of odontogenic HFS and the X-ray picture made it possible to conditionally group patients into two groups: 66 (39.7%) patients with an acute inflammatory process in the maxillary sinus had corresponding clinical symptoms of the disease, and 44 (26.5%) patients had complaints from the maxillary sinus no sinuses were presented (the inflammatory process in the maxillary sinus was chronic).
A comprehensive X-ray examination was performed in all cases. All patients underwent computed tomography (MSCT or CBCT): MSCT - 76 (45.8%) patients, CBCT - 90 (54.2%) patients. 122 (73.5%) patients underwent radiography of the paranasal sinuses in the nasomental, semi-axial projections. To clarify the condition of the teeth of the upper jaw, orthopantomography was performed ( n
=166, 100%) and intraoral contact radiography (
n
=12, 7.3%).
When assessing and analyzing diagnostic images, the criteria for odontogenic sinusitis were the following: the presence of a foreign body of metallic density corresponding to a filling material or implant in the sinus cavity; deep caries and signs of periodontitis of premolars and molars of the upper jaw; destruction of the lower bone wall of the maxillary sinuses in the area of pathologically changed teeth.
