Oroantral fistula

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Oroantral fistula
Maxillary sinus - medial view.png
Maxillary sinus (medial view)
Specialty ENT surgery

Oroantral fistula (OAF) is an epithelialised oroantral communication (OAC). [1] OAC refers to an abnormal connection between the oral cavity and antrum (or maxillary sinus). [1] The creation of an OAC is most commonly due to the extraction of a maxillary (upper) tooth (typically a maxillary first molar) closely related to the antral floor (floor of the maxillary sinus). [1] A small OAC (up to 5mm wide) may heal spontaneously but a larger OAC would require surgical closure to prevent the development of persistent OAF and chronic sinusitis. [1]

Contents

Classification

Differences between OAC and OAF [1]
OAC   OAF   
Connection between oral cavity and antrum that is not epithelialised.Connection between oral cavity and antrum that has epithelialised.
May develop immediately following the extraction of maxillary tooth that is close to antral floor.Develops from OAC that has  not healed spontaneously, has not been closed surgically, or initial attempts at surgical closure have failed.
Requires surgical closure if large to prevent development of a persistent OAF and chronic sinusitis.Requires surgical treatment to remove and close the fistula.

Signs and symptoms

When looking in the mouth, a communication in the upper jaw (i.e. a hole) can be seen connecting the mouth to the maxillary sinus. [2] Sometimes this can be the only sign, as pain (+/- other symptoms) is not always present.

Symptoms

· Same side nose blockage (unilateral nasal obstruction). [2] When an OAC or OAF is present, the passage to the maxillary sinus can results in infection and inflammation in the maxillary sinus. This subsequently results in mucus build up presenting as a unilateral nasal blockage

· Sinusitis can progress – this can present as a pain in the midface. Pain can be referred to the upper teeth and be mistaken for toothache [3]

· Fluid can flow from the mouth through the communication and into the maxillary sinus. The maxillary sinus is connected to the nose and therefore fluid can come out of the nostrils when drinking [2]

· Change in sounds produced from the nose and the voice – specifically a whistling sound whilst speaking [2]

· Taste can be affected [2]

Signs

· Visible hole between mouth and sinus

· Fracture of the floor of the maxillary sinus creating a communication to the oral cavity (e.g. as seen following trauma). [2]

· Air bubbles, blood or mucoid secretion around the orifice can be seen as air passes from the sinus into the oral cavity through the communication.

Diagnosis

- Patient history - Diagnosis is usually based on clinical examination and reported symptoms. Therefore, a good history and understanding of the patient’s symptoms is key.

- Undertake a complete extraoral and intraoral examination using a dental mirror alongside good lighting. When assessing the socket following an extraction look for granulation tissue in the socket which may represent normal healing. Assess for the presence of visible an opening/hole between the oral cavity and the maxillary sinus.  

- Imaging can be useful. However, radiographs only show if there is a breach in the bony floor of the antrum. Even if there is a breach in the bony floor then the Schneiderian membrane may still be intact. Depending on the size of the potential communication and in what context, a small radiograph inside the mouth may be sufficient (a periapical) to assess for any break in the bone of the sinus floor which may indicate an OAC.

- Panoramic radiographs [2] can also be used to confirm the presence of an OAC. If simple radiographs are deemed not to give enough information, cone beam computed tomography (CBCT) [2] (special x-ray equipment that can scan in 3 dimensions) may be used.  Imaging can help locate the communication, determine the size of it and can give an indication as to whether there is any sinusitis and foreign bodies in the sinus.

- Normally clinicians should be cautioned against probing or irrigating the site a newly formed OAC as this may reduce the chance of spontaneous healing.

- Valsalva test (nose blowing test) [4] The patient is asked to pinch their nostrils together and open their mouth and then blow gently through the nose. The clinician must observe if there is passage of air or bubbling of blood in the post extraction alveolus as the trapped air from closed nostrils is forced into the mouth through any oroantral communication. Gentle suction applied to the socket often produces a characteristic hollow sound. However, there are differing opinions about the appropriateness of carrying out this test.  It can be argued that by performing this test, a small OAC may be made bigger thus preventing spontaneous healing.

Causes

Extraction of maxillary teeth

The maxillary sinus is known for its thin floor and close proximity to the posterior maxillary (upper) teeth. [1] [5] The extraction of a maxillary tooth (typically a maxillary first molar which lies close to the lowest point of antral floor although any premolar or molar can be affected) is the most common cause of an OAC (which can then progress to an OAF as described above). [1] Extraction of primary teeth are not considered a risk of OAC due to the presence of developing permanent teeth and the small size of the developing maxillary sinus. [1]

Other causes

Other causes of an OAC are: maxillary fractures across the antral floor typically Le Fort I, displacement of posterior maxillary molar roots into antrum and direct trauma. [5] An OAC can happen for many other more unusual reasons, such as acute or chronic inflammatory lesions around the tip of a tooth root which is in close proximity with the maxillary antrum, destructive lesions/tumours of the maxilla, failure of surgical incisions to heal (e.g. Caldwell-luc antrostomy), osteomyelitis of the maxilla, careless use of instruments during surgical procedures, Syphilis, implants and as a results of complex surgery (for example removal of a large cysts or resections of large tumours involving the maxilla. [6] [7] [8]

Diagnosis

Clinical examination and x rays can help diagnose the condition. For examples :[ citation needed ]

Complications

OAF is a complication of oroantral communication. Other complications may arise if left untreated. For example:

Therefore, OAF should be dealt with first, before treating the complications.

Prevention

Whilst in some circumstances, preventing development of an OAF following extraction of a tooth can be difficult, careful assessment is important. The following should be considered prior to carrying out any dental treatment: [1]

If the above factors are assessed as increasing the risk of OAC development, the clinician should take appropriate steps to carefully remove the tooth in question, possibly carrying out a surgical extraction and in an appropriate setting. [1] Hence, in such cases:

Treatment

The primary aim of treatment of a newly formed oroantral communication is to prevent the development of an oroantral fistula as well as chronic sinusitis. The decision on how to treat OAC/OAF depends on various factors. Small size communications between 1 and 2 mm in diameter, if uninfected, are likely to form a clot and heal by itself later. Communications larger than this require treatments to close the defect and these interventions can be categorised into 3 types: surgical, non-surgical and pharmacological. [14] [15]

Surgery

Surgical methods are required if a large defect is present or if a defect persists. [16] Surgery involves creating a flap utilising local tissue to close the communication. There are a number of different flaps that can be used such as the buccal advancement flap, the buccal fat pad flap, a combination of the two and a palatal flap. [16] The flap used is dependent on the size and position of the defect.

Buccal advancement flap

The buccal advancement flap is the most commonly used due to its simplicity, reliability and versatility. [16] It involves cutting a broad based trapezoid shaped mucoperiosteal flap with two vertical incisions. [16] The flap is cut buccally, is three sided and extends to the full depth of the sulcus. [1]

Buccal fat pad flap

The buccal fat pad flap is also a popular option due to its high success rate. [17] It is a simple procedure where the buccal extension of the anatomical fat pad is used for closure. [2]  These two flaps can be used in combination where the buccal fat pad covers the communication followed by a further covering via the buccal mucosal flap described above. [2] This double layer flap has advantages over a single layer as it provides stable soft tissue covering, reduces the incidences[ spelling? ] of wound breakdown and defect recurrence as well as reducing the risk of postoperative infection. [2]

Sutures, either non-resorbing or slowly resorbing, are generally used in the surgical repairs of OAC. [1]

Non-surgical interventions

Ultimately, surgery is usually required to close an OAC/OAF. However, if surgery is not immediately available then non-surgical methods can be used to encourage the growth of oral mucosa between the oral cavity and the antrum. [1] The aim of these methods is to protect the blood clot within the socket and help to prevent infection. One option is construction of a denture with an acrylic base plate or extension of the patient’s existing denture to protect the socket and support the clot. [1] These options are particularly helpful in patients who smoke as it provides protection from smoke inhalation. The socket can also be sutured over with mattress sutures if there is adequate soft tissue available. [1]

Medication

Medications may be needed as an adjunct to assist the closure of the defect. Antibiotics can help control or prevent any sinus infections. Preoperative nasal decongestants usage can reduce any existing sinus inflammation which will aid surgical manipulation of the mucosa over the bone. [18]

Postoperative care

Following all methods of OAC/OAF closure, the patients are instructed to avoid activities that could produce pressure changes between the nasal passages and oral cavity for at least 2 weeks due to risk of disruption to the healing process. Nose blowing and sneezing with a closed mouth are prohibited. A soft diet is also often advocated during this period. Following surgery, nasal decongestants and prophylactic antibiotics are often prescribed to prevent postoperative infection.

Related Research Articles

<span class="mw-page-title-main">Sinusitis</span> Inflammation of the mucous membrane that lines the sinuses resulting in symptoms

Sinusitis, also known as rhinosinusitis, is inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include thick nasal mucus, a plugged nose, and facial pain. Other signs and symptoms may include fever, headaches, a poor sense of smell, sore throat, a feeling that phlegm is oozing out from the back of the nose to the throat along with a necessity to clear the throat frequently and frequent attacks of cough.

<span class="mw-page-title-main">Alveolar osteitis</span> Medical condition

Alveolar osteitis, also known as dry socket, is inflammation of the alveolar bone. Classically, this occurs as a postoperative complication of tooth extraction.

<span class="mw-page-title-main">Maxillary sinus</span> Largest of the paranasal sinuses, and drains into the middle meatus of the nose

The pyramid-shaped maxillary sinus is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Pericoronitis</span> Inflammation of the soft tissues surrounding the crown of a partially erupted tooth

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an operculum, an area which can be difficult to access with normal oral hygiene methods. The hyponym operculitis technically refers to inflammation of the operculum alone.

<span class="mw-page-title-main">Sinus lift</span>

Maxillary sinus floor augmentation is a surgical procedure which aims to increase the amount of bone in the posterior maxilla, in the area of the premolar and molar teeth, by lifting the lower Schneiderian membrane and placing a bone graft.

<span class="mw-page-title-main">Dentigerous cyst</span> Medical condition

Dentigerous cyst, also known as follicular cyst is an epithelial-lined developmental cyst formed by accumulation of fluid between the reduced enamel epithelium and crown of an unerupted tooth. It is formed when there is an alteration in the reduced enamel epithelium and encloses the crown of an unerupted tooth at the cemento-enamel junction. Fluid is accumulated between reduced enamel epithelium and the crown of an unerupted tooth. Dentigerous cyst is the second most common form of benign developmental odontogenic cysts.

<span class="mw-page-title-main">Buccal exostosis</span> Medical condition

A buccal exostosis is an exostosis on the buccal surface of the alveolar ridge of the maxilla or mandible. More commonly seen in the maxilla than the mandible, buccal exostoses are considered to be site specific. Existing as asymptomatic bony nodules, buccal exostoses don’t usually present until adult life, and some consider buccal exostoses to be a variation of normal anatomy rather than disease. Bone is thought to become hyperplastic, consisting of mature cortical and trabecular bone with a smooth outer surface. They are less common when compared with mandibular tori.

<span class="mw-page-title-main">Orbital blowout fracture</span> Medical condition

An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall that typically results from the impact of a blunt object larger than the orbital aperture, or eye socket. Most commonly, the inferior orbital wall, or the floor, is likely to collapse, because the bones of the roof and lateral walls are robust. Although the bone forming the medial wall is the thinnest, it is buttressed by the bone separating the ethmoidal air cells. The comparatively thin bone of the floor of the orbit and roof of the maxillary sinus has no support and so the inferior wall collapses mostly. Therefore, medial wall blowout fractures are the second-most common, and superior wall, or roof and lateral wall, blowout fractures are uncommon and rare, respectively. There are two broad categories of blowout fractures: open door, which are large, displaced and comminuted, and trapdoor, which are linear, hinged, and minimally displaced. They are characterized by double vision, sunken ocular globes, and loss of sensation of the cheek and upper gums from infraorbital nerve injury.

<span class="mw-page-title-main">Dental radiography</span> X-ray imaging in dentistry

Dental radiographs, commonly known as X-rays, are radiographs used to diagnose hidden dental structures, malignant or benign masses, bone loss, and cavities.

<span class="mw-page-title-main">Tooth impaction</span> Prevention of tooth eruption by a physical barrier

An impacted tooth is one that fails to erupt into the dental arch within the expected developmental window. Because impacted teeth do not erupt, they are retained throughout the individual's lifetime unless extracted or exposed surgically. Teeth may become impacted because of adjacent teeth, dense overlying bone, excessive soft tissue or a genetic abnormality. Most often, the cause of impaction is inadequate arch length and space in which to erupt. That is the total length of the alveolar arch is smaller than the tooth arch. The wisdom teeth are frequently impacted because they are the last teeth to erupt in the oral cavity. Mandibular third molars are more commonly impacted than their maxillary counterparts.

Mouth infections, also known as oral infections, are a group of infections that occur around the oral cavity. They include dental infection, dental abscess, and Ludwig's angina. Mouth infections typically originate from dental caries at the root of molars and premolars that spread to adjacent structures. In otherwise healthy patients, removing the offending tooth to allow drainage will usually resolve the infection. In cases that spread to adjacent structures or in immunocompromised patients, surgical drainage and systemic antibiotics may be required in addition to tooth extraction. Since bacteria that normally reside in the oral cavity cause mouth infections, proper dental hygiene can prevent most cases of infection. As such, mouth infections are more common in populations with poor access to dental care or populations with health-related behaviors that damage one's teeth and oral mucosa. This is a common problem, representing nearly 36% of all encounters within the emergency department related to dental conditions.

<span class="mw-page-title-main">Coronectomy</span>

When extracting lower wisdom teeth, coronectomy is a treatment option involving removing the crown of the lower wisdom tooth, whilst keeping the roots in place in healthy patients. This option is given to patients as an alternative to extraction when the wisdom teeth are in close association with the inferior alveolar nerve, and so used to prevent damage to the nerve which may occur during extraction.

<span class="mw-page-title-main">Odontogenic infection</span>

An odontogenic infection is an infection that originates within a tooth or in the closely surrounding tissues. The term is derived from odonto- and -genic. The most common causes for odontogenic infection to be established are dental caries, deep fillings, failed root canal treatments, periodontal disease, and pericoronitis. Odontogenic infection starts as localised infection and may remain localised to the region where it started, or spread into adjacent or distant areas.

A cyst is a pathological epithelial lined cavity that fills with fluid or soft material and usually grows from internal pressure generated by fluid being drawn into the cavity from osmosis. The bones of the jaws, the mandible and maxilla, are the bones with the highest prevalence of cysts in the human body. This is due to the abundant amount of epithelial remnants that can be left in the bones of the jaws. The enamel of teeth is formed from ectoderm, and so remnants of epithelium can be left in the bone during odontogenesis. The bones of the jaws develop from embryologic processes which fuse, and ectodermal tissue may be trapped along the lines of this fusion. This "resting" epithelium is usually dormant or undergoes atrophy, but, when stimulated, may form a cyst. The reasons why resting epithelium may proliferate and undergo cystic transformation are generally unknown, but inflammation is thought to be a major factor. The high prevalence of tooth impactions and dental infections that occur in the bones of the jaws is also significant to explain why cysts are more common at these sites.

<span class="mw-page-title-main">Canine space</span>

The canine space, is a fascial space of the head and neck. It is a thin potential space on the face, and is paired on either side. It is located between the levator anguli oris muscle inferiorly and the levator labii superioris muscle superiorly. The term is derived from the fact that the space is in the region of the canine fossa, and that infections originating from the maxillary canine tooth may spread to involve the space. Infra-orbital is derived from infra- meaning below and orbit which refers to the eye socket.

<span class="mw-page-title-main">Impacted wisdom teeth</span> Teeth that do not fully grow out of the gums due to being blocked by other teeth

Impacted wisdom teeth is a condition where the third molars are prevented from erupting into the mouth. This can be caused by a physical barrier, such as other teeth, or when the tooth is angled away from a vertical position. Completely unerupted wisdom teeth usually result in no symptoms, although they can sometimes develop cysts or neoplasms. Partially erupted wisdom teeth can develop cavities or pericoronitis. Removal of impacted wisdom teeth is advised in the case of certain pathologies, such as nonrestorable caries or cysts.

Antral lavage is a largely obsolete surgical procedure in which a cannula is inserted into the maxillary sinus via the inferior meatus to allow irrigation and drainage of the sinus. It is also called proof puncture, as the presence of an infection can be proven during the procedure. Upon presence of infection, it can be considered as therapeutic puncture. Often, multiple repeated lavages are subsequently required to allow for full washout of infection.

Caldwell-Luc surgery, Caldwell-Luc operation, also known as Caldwell-Luc antrostomy, and Radical antrostomy, is an operation to remove irreversibly damaged mucosa of the maxillary sinus. It is done when maxillary sinusitis is not cured by medication or other non-invasive technique. The approach is mainly from the anterior wall of the maxilla bone. It was introduced by George Caldwell(1893)and Henry Luc(1897). The maxillary sinus is entered from two separate openings, one in the canine fossa to gain access to the antrum and other in the naso antral wall for drainage.

Alveoloplasty is a surgical pre-prosthetic procedure performed to facilitate removal of teeth, and smoothen or reshape the jawbone for prosthetic and cosmetic purposes. In this procedure, the bony edges of the alveolar ridge and its surrounding structures is made smooth, redesigned or recontoured so that a well-fitting, comfortable, and esthetic prosthesis may be fabricated or implants may be surgically inserted. This pre-prosthetic surgery which may include bone grafting prepares the mouth to receive a prosthesis or implants by improving the condition and quality of the supporting structures so they can provide support, better retention and stability to the prosthesis.

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