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SINUS INFECTION AFTER SINUS LIFT PROCEDURE • ALMAGHRABI
ET AL
Treatment of Severe Sinus Infection After
Sinus Lift Procedure: A Case Report
Bandar Abdulrahman Almaghrabi, BDS, MS,* Michael N. Hatton, DDS, MS,† Sebastiano Andreana, DDS, MS,‡
and Mark A. C. Hoeplinger, MD§
T
he maxillary sinus is an airfilled cavity located on both
sides of the maxilla. It is pyramidal in shape and is the largest of the
sinus cavities. Sinuses communicate
to the nasal cavity via small bone
channels called ostea.1,2 The biological
role of the sinuses is debated,2– 4 but a
number of possible functions have
been proposed:
• Decreasing the relative weight of
the front of the skull, especially
the bones of the face
• Increasing resonance of the voice
• Providing a buffer against blows
to the face
• Insulating sensitive structures
such as dental roots and eyes from
rapid temperature fluctuations in
the nasal cavity
• Humidifying and heating of inhaled air because of slow air turnover in this region3,5,6
This cavity is frequently reinforced
with internal vertical septae that can create further intrasinus cavities. The size
*Research Instructor, Postgraduate Periodontal Resident,
Department of Periodontics and Endodontics, SUNY at
Buffalo, Buffalo, NY.
†Clinical Associate Professor, Department of Oral Diagnostic
Sciences; Clinical Assistant Professor, Department of Oral and
Maxillofacial Surgery SUNY at Buffalo, Buffalo, NY.
‡Associate Professor, Director of Implant Dentistry,
Department of Restorative Dentistry, SUNY at Buffalo,
Buffalo, NY.
§Private Practice, Clinical Instructor, Department of
Otolaryngology, University of Buffalo School of Medicine;
Medical staff of Mercy Hospital of Buffalo, Women and
Children’s Hospital and Millard Filmore Gates Circle Hospital at
Buffalo, NY.
Reprint requests and correspondence to: Bandar
Abdulrahman Almaghrabi, BDS, MS, SUNY at
Buffalo, 250 Squire Hall, Buffalo, NY 14214, Phone:
716-907-8444, Fax: 716-829-6840, E-mail:
baa8@buffalo.edu
ISSN 1056-6163/11/02006-430
Implant Dentistry
Volume 20 • Number 6
Copyright © 2011 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e318236525c
Maxillary sinus floor augmentation
may have a variety of postoperative
complications including infection,
sequestration of bone, and maxillary sinusitis. Complications can
also occur due to a preexisting sinus condition called ostium stenosis. This case report presents a
complication after sinus lift and
grafting procedure due to an unrecognized ostium stenosis.
Case Report: A 50-year-old male
patient had sinus augmentation on his
right side. However, postoperatively,
his symptoms were protracted. A CT
scan showed thickening of the Sch-
neiderian membrane and scattered
graft material. Management included
endoscopic nasal examination and ostium enlargement, antibiotic coverage,
and full enucleation of the graft and
diseased tissue.
Conclusion: Patency of the sinus
ostium should be carefully evaluated
before sinus lift/grafting procedure using CT technology. Radiology and
otolaryngology consultations may be
necessary to rule out ostium stenosis
before surgery. (Implant Dent 2011;
20:430 – 433)
Key Words: ostium, stenosis, otolaryngologist, sinus lift complications
of the sinus can vary on individual basis.
Adults have a mean width of 35 mm at
the base and a mean height of 25 mm.7
After tooth extraction, bone remodeling
of the alveolus occurs, which often leads
to an inadequate alveolar height and
width for dental implant placement. A
frequently performed clinical technique,
the “sinus lift,” was published by Tatum.8
He described a modified CaldwellLuc approach from the lateral aspect of
the maxillary sinus and elevation of the
Schneiderian membrane. This, in turn,
provided a closed space for hard tissue
grafting procedures. Tatum’s technique,
however, has potential complications. A
common intraoperative complication is
perforation of the Schneiderian membrane during dissection.9 –11 Postoperative sinus floor augmentation may
consist of complications that may include, infection, sequestration of bone,
and maxillary sinusitis.12 Loss of the
grafting material may also occur. Previous investigations have reported that
complications can occur in up to 20% of
patients after sinus floor augmentation.6,8 The literature suggests that complications tend to be associated with
preexisting sinus disease or documented
susceptibility to sinus disease.13–15 Ostium stenosis is a narrowing of the ostium size due to chronic sinus disease or
congenital factors. It is a defect not previously described as being responsible
for complications following sinus lift
operations, and about 24% of patients
who present for sinus lift procedures
may have this finding.16 This case report
presents an unforeseen complication after sinus lift and graft procedure.
CASE REPORT
A 50-year-old white male patient
came to the University at Buffalo
School of Dental Medicine (Buffalo,
NY) to seek dental replacement of previously extracted teeth in the areas of
teeth 3 and 14. The patient’s medical

2. IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011
Fig. 1. Preoperative pictures during initial examination.
Fig. 2. Presurgical CT scan showing some remnants of the grafting material with thickened
Schneiderian membrane and ostium stenosis.
Fig. 3. Instrumentation: fiberoptic probe and inflatable device.
history included an allergy to penicillin. At this time, the patient was taking
multivitamins, Diazepam (SigmaAldrich, St. Louis, MO), Asmanex
(Merck & Co., Whitehouse Station,
NJ), Symbicort (AstraZeneca Pharmaceuticals, Wilmington, DE), and Albuterol (Mylan Pharmaceuticals Inc.,
Morgantown, WV). The latter three
medications were used to control reactive airway disease, whereas Diazepam was prescribed to control anxiety
and insomnia. A panoramic x-ray of
the patient showed alveolar atrophy
and sinus pneumatization in the areas
of teeth 3 and 14 (Fig. 1).
Treatment options were discussed
with the patient, and a mutual decision
was made to undergo sinus lift/
mineralized tissue graft procedures,
before implant placement. We decided
to provide care starting on the patient’s right side. The left side was
planned to be done at a future appointment. Risks, benefits, and alternatives
of the proposed procedure were discussed with the patient. All questions
were answered. The patient signed a
standard surgical consent form. Local
anesthesia was administered using one
carpule of 2% lidocaine, with epinephrine (1:50,000). A full-thickness flap
was reflected over the lateral aspect of
the right maxillary wall. An osseous
window was created in a standard
fashion using both rotary and piezoelectric surgery techniques. During the
procedure, the Schneiderian membrane was torn (Ͻ5 mm), and it was
closed using a collagen membrane
(Colla Tape; Zimmer, Carlsbad, CA)
with dimension of 1 ϫ 2.5 ϫ 7.5
mm.17 The intact side of the membrane
was fully reflected to achieve an ideal
space for grafting. Before graft placement (irradiated cancellous particulate
allograft bone; Rocky Mountain Tissue Bank, Aurora, CO), the membrane
perforation was checked for complete
coverage. Four grams of bone graft
material (irradiated cancellous particulate allograft bone; Rocky Mountain
Tissue Bank) was placed into the sinus lift
cavity. A collagen membrane (Conform,
Ace Surgical Supply, Brockton, MA)
was placed over the lateral aspect of the
bone window. The flap was replaced,
and 4.0 nonresorbable suture material
(Cytoplast PTFE; Osteogenics Biomedical, Lubbock, TX) was used to stabilize
the flap. This patient was prescribed 150
mg clindamycin four times per day for
10 days and 0.75 mg dexamethasone
four times per day for 6 days. The
patient started these medications one
day before surgery.
The first postsurgical week was uneventful. However, 2 weeks after the
431
surgery, the patient reported pain and
discomfort, with drainage from his nasal
cavity on the operative side. A periapical radiograph was taken which showed
that grafting material was intact.
Yellow mucus discharge from the
right nostril was cultured in standard
transport media. A mixture of aerobic
and anaerobic bacteria was noted. The
patient was prescribed clindamycin
300 mg along with metronidazole 250
mg to reduce the possibility of having
anaerobic bacterial infection. The patient showed no improvement, and he
was then prescribed tetracycline 500
mg, for 10 days. On the second day of
taking tetracycline (21 days after the
surgery), the patient reported swelling
in the right maxillary sinus area. There
was also pain on palpation, malaise,
and fever. Surgical intervention was
done via incision and drainage under
local anesthesia. Four days later, the patient reported that the swelling subsided,
with a decrease in nasal discharge. The
patient was monitored on a frequent basis. A CT scan was obtained which revealed that the bone graft was scattered
in the anterior and floor regions of the
right sinus area with most of the pieces
adhering to the soft tissue lining. Of
special note was that thickened soft tissue which completely blocked the right
maxillary sinus ostium. The treatment
plan was discussed. He agreed to have
the graft material removed from the
right maxillary sinus.
After several weeks, the intraoral
soft tissue stoma had closed. Under
local anesthesia, a full-thickness flap
was reflected over the right maxillary
sinus wall, and access was made
through the previous lateral window.
Findings included showed frank pus
accumulation and unattached bone
grafting material. The area was curetted and irrigated with saline. Suturing
was done using a 3.0 PTFE with interrupted technique.
After soft tissue healing of the
site, the patient noted discomfort and
tenderness over the right maxillary
sinus. A yellow nasal discharge persisted from the right nostril. We referred the patient for consultation with
an otolaryngologist. CT scans were
obtained, which revealed remnants of

3. 432
SINUS INFECTION AFTER SINUS LIFT PROCEDURE • ALMAGHRABI
ET AL
DISCUSSION
Fig. 4. Nasal endoscopy: ethmoid thickening with ostium stenosis.
Fig. 5. Sinus ostium after enlargement using inflatable device and shaving the ethmoid thickening.
Fig. 6. Polyps removed along with bone grafting material after maxillary sinus membrane
enucleation.
Fig. 7. Postsurgical radiographic image.
the grafting material and stenosis of
the right maxillary ostium (Fig. 2).
The otolaryngologist performed an
endoscopic examination under general
anesthesia (Fig. 3). Findings were consistent with stenosis of the right maxillary
sinus ostium (Fig. 4). Balloon catheterization and widening of the ostium were
completed (Fig. 5). Cultures were taken
during the surgery, and the sinus was
examined using a fiberoptic probe.
These cultures had shown presence of
Prevotella species and were identified
as Prevotella melaninogenica. The base
of the Schneiderian membrane on the
other hand appeared intact. No other abnormalities were noted.
The patient did improve after the
procedure and was less symptomatic.
Two months later, the patient developed copious clear mucus discharge
from the right nasal cavity and also
noted tenderness of the right maxillary
sinus. In addition, he reported intermittent blockage of the right nasal airway and difficulty with air flow
through the right nasal passage. Based
on the persistent symptoms and consultation with his otolaryngologist,
surgical exploration by an oral and
maxillofacial surgeon was offered to
the patient. The consulting otolaryngologist was not experienced in removing dental material from a grafted
sinus and asked that a dental surgeon
perform the procedure. Standard surgical consent was obtained. Under
local anesthesia, the oral and maxillofacial surgeon elevated a fullthickness mucoperiosteal flap over the
right lateral aspect of the maxilla. The
previous lateral window was used to
gain access into the base of the sinus.
The window was enlarged, and a thorough curettage of the graft material
was done. Multiple sinus polyps and
grafts material attached to the thickened Schneiderian membrane were
removed (Fig. 6). The sinus was thoroughly irrigated, and the osseous
window was covered with a collagen
membrane. The flap was brought
again to its original position and
closed with interrupted sutures. The
patient showed remarkable improvement (Fig. 7) and was symptom free on a
1-year follow-up.
Alveolar atrophy and maxillary sinus pneumatization after tooth extraction can create a significant challenge
for dental implant placement in the
posterior maxilla. To increase the
bone height of the posterior alveolar
areas of the maxilla, “sinus lift” procedures have become commonly used
in dental implant surgery.6 This communication describes a persistent postoperative maxillary sinusitis, which
can be traced to stenosis ostium of the
maxillary sinus.
Anatomical variation of the osteomeatal complex (which can include
narrowing of the ostium) can have
deleterious effects on sinus drainage.13,18 –20 Narrowing of the sinus
ostium can arise from congenital, inflammatory, or neoplastic sources.
Stenosis ostium has a prevalence of
24%16,21 and can be associated with
acute and chronic sinusitis where the
permeability of the ostium is altered.21–24 Mucosal edema can obliterate the ostium, along with nasal polyp
formation.25,26 A patient’s medical history is an important factor before
undertaking a sinus lift procedure, especially in regard to nasal symptoms.
This patient did have a history of reactive airway disease. He also had a
history of nasal problems, which were
not active at the time of the original
procedure. In fact, he had seen the
same treating otolaryngologist in the
past to stabilize the sinus symptoms
before proceeding with the sinus lift
procedure. Chronic sinusitis is more
prevalent among patients with reactive
airway disease.16 Although this patient
had an intraoperative tear of the Schneiderian membrane during the graft
procedure, we believe that the persistent sinusitis was indeed related to stenosis ostium. The patient had adequate
pre- and postoperative antibiotic coverage for the procedure. The incidence
of membrane perforation varies
widely in the literature.27,28 It is not
uncommon and is usually dealt with as
described above.3,27,29
Schneiderian membrane perforation can be associated with postoperative complications, such as acute or
chronic sinus infection, wound dehiscence, loss of the graft material, and a

4. IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011
disruption of normal sinus physiologic
function.3,30 –33 Becker et al,27 however,
found that sinus perforation per se did
not necessarily result in implant loss,
displacement of graft material, or infectious complications. The authors believe
that this patient’s protracted course was
indeed due to ostium stenosis.
CONCLUSION
Ostium stenosis cannot be visualized on intraoral dental radiographs or
panoramic films. On the basis of this
case, we now strongly recommend the
use of a CT scan before proceeding
with sinus lift procedures. Patency of
the ostium should be carefully evaluated, along with any preexisting sinus
disease or other aberrant anatomical
factors of the sinus. All of these issues
must be taken into account before
commencing a sinus lift/grafting
procedure. If the dental clinician is
unfamiliar with reading a CT of the
paranasal sinuses, we recommend a
radiologist review the scan. An otolaryngologist should be consulted preoperatively if there are issues with the
CT or the patient has a history of sinus
ailments. On the basis of this case, we
now strongly believe that a patent ostium should be verbally included in
any consultant’s report.
DISCLOSURE
The authors claim to have no financial interest in any company or any of
the products mentioned in this article.
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