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Official websites use. Share sensitive information only on official, secure websites. Address for correspondence: Prof. However, the procedure has a well-known impact on the delicate homeostasis of the maxillary sinus: the concomitant presence of systemic, naso-sinusal or maxillary sinus disease may favour the development of post-operative complications particularly maxillary rhino-sinusitis , which can compromise a good surgical outcome. On the basis of these considerations, the management of sinus lift candidates should include the careful identification of any situations contraindicating the procedure and, if naso-sinusal disease is suspected, a clinical assessment by an ear, nose and throat specialist, which should include nasal endoscopy and, if necessary, a computed tomography scan of the maxillo-facial district, particularly the ostio-meatal complex. This first preventive-diagnostic step should be dedicated to detect presumably irreversible and potentially reversible contraindications to a sinus lift, whereas the second preventive-therapeutic step is aimed at correcting mainly with the aid of endoscopic surgery such potentially reversible ear, nose and throat contraindications as middle-meatal anatomical structural impairments, phlogistic-infective diseases and benign naso-sinusal neoplasms the removal of which achieves naso-sinusal homeostasis recovery, in order to restore the physiological drainage and ventilation of the maxillary sinus. The third diagnostic-therapeutic step is only required if mainly infective and sinusal complications arise after sinus lift surgery, and is aimed at ensuring early diagnosis and prompt treatment of maxillary rhino-sinusitis in order to avoid, if possible, implant loss and, in particular, the related major complications. The purpose of this report is to describe these three steps in detail within the context of a multidisciplinary management of sinus lift in which otorhinolaryngological factors may be the key to a successful outcome. The use of dental implants is now an extremely widespread and highly successful means of ensuring oral rehabilitation. Over the last few years, these have been employed for the upper dental arch, which had, for decades, been considered inviolable by implantologists because of the nearness of the maxillary sinus and the unpleasant complications arising from its surgical assault. In this context, the surgical sinus lift introduced by Boyne and James, in 1 , makes rehabilitation of the upper dental arch feasible even in the case of maxillary bone atrophy 2 — 4 due to increased osteoclastic activity and bone resorption following the inferior expansion of the maxillary sinus after the loss of tooth roots 5. Sinus lifting involves creating a mucoperiosteal pocket over the maxillary floor and beneath the Schneider membrane in which to place graft material allograft, xenograft, alloplast capable of promoting bone thickening by inducing osteoinduction and osteoconduction in order to increase alveolar bone height without compromising the inter-alveolar space. However, before undertaking a sinus lift, surgeons need to consider its impact on sinus physiology in order to avoid unwelcome complications that may compromise a positive outcome. The management of candidates for a sinus lift should be shared by a dental surgeon and ENT specialist. Furthermore, the availability of a multidisciplinary surgical team makes it feasible to attempt experimental surgical strategies such as the combined two-steps procedure in which the ENT specialist first restores maxillary sinus ventilation endoscopically by resolving the pathological process or anatomical alteration contraindicating implant surgery, and then after a period of at least weeks the oral surgeon performs the sinus lift and places the implants. As an expert in naso-sinusal physiology, the ENT specialist should also play a useful role in defining, with the implantologist, a prophylactic regimen for the candidate to sinus lift in order to reduce the risk of complications: stop smoking, avoid dehydration, pollutant inhalation, exposure to low temperature or dry air and assumption of atropine-like drugs are only a few examples of the hygienic rules indicated for the patient. This article will concentrate on the role of an ENT specialist in managing candidates for a sinus lift, and include a brief description of the anatomo-physiology of the maxillary sinus and the effect of sinus elevation on maxillary homeostasis. The maxillary sinus is the widest paranasal sinus, pyramidal in shape and varies remarkably in size, although the average in adulthood is: base 35 x 35 millimeters mm and height 25 mm 9 ; its pneumatisation is related to age of the patient and the presence of teeth. The maxillary sinus walls most involved during sinus lift surgery are the mesio-vestibular wall, the inferior wall or floor and the medial wall. Maxillary secretions converge into the middle meatus exclusively through the natural ostium. The maxillary ostium is a mm long and mm wide elliptical opening 11 that does not open directly into the nasal cavity as it is shielded medially by the uncinate process, which represents the medial bony wall of a slit called the infundibulum that extends from its inlet the hiatus semilunaris to the maxillary sinus. The inner layer of the maxillary sinus consists of a 0. Some serous and mucous glands that thicken near the ostial opening are located in the underlying lamina propria. In addition to acting as an immunological barrier, directly exposed to inspired air, the ciliated respiratory epithelium transports, towards the natural ostium of the maxillary sinus, the viscous gel layer Mucous production is influenced by sympathetic and parasympathetic control, neuropeptide release, physical environmental factors, and drugs 15 , and maxillary drainage depends on sinus oxygenation, which is mainly provided by direct gaseous exchange as the amount of blood oxygen is not enough Maxillary secretions can only be removed via the active transport system of drainage because they cannot take advantage of the force of gravity: in fact, the natural ostium, in the adult population, is located high up in the medial wall, several millimeters over the sinusal floor. Findings emerging from some experimental studies suggest that muco-ciliar transport runs along genetically determined star-shaped pathways 16 from the maxillary floor towards the natural ostium, which is the exclusive discharge point even in the presence of other naturally or surgically made openings. The pathophysiology underlying maxillary sinus disease is impaired sinus secretion drainage related to ostial patency, impaired epithelial function or altered nasal secretions This leads to impaired maxillary drainage and ciliar activity, with decreased oxygen and increased carbon dioxide concentrations, and is followed by epithelial dysfunction, which predisposes to infections causing oedema and mucosal hypertrophy of the ostio-meatal complex OMC , with deterioration in sinusal ventilation and drainage Any surgical treatment of the maxillary sinus activates cellular inflammatory mediators and promotes transient sinusitis, and the larger the exposed area, the more likely it is that there will be a post-surgical inflammatory reaction. In the case of a sinus lift, the development of a secondary infection leads to possible bone graft loss In a more recent study that used standard diagnostic ENT criteria, sub-acute maxillary sinusitis developed in 4. Sinus lifting can obstruct physiological maxillary drainage into the middle meatus in various ways. Furthermore, OMC patency may be impaired by:. However, it is well known that the sinusal mucosa can promptly repair tears due to surgery 34 , and, therefore, it must be assumed that every sinus lifting procedure temporarily impairs maxillary sinusal physiology and sometimes prevents the post-operative restoration of normal sinusal homeostasis, which can lead to maxillary bacterial sinusitis and thus compromise surgical outcome and patient well-being. In this regard, and confirming other reports 8 35 , a prospective study by Timmenga et al. The finding, in that study, of a mild post-operative inflammatory reaction, upon the histo-morphological examination of maxillary sinus mucosal biopsies 36 , should, therefore, be interpreted as a physiological expression of the mucosal airway defense system, which can also be seen in healthy subjects who have not undergone surgery 36 The rapid return of the maxillary sinus to a post-operative sterile state is also well known 36 This intrinsic potential of the sinus mucosa to resume its homeostatic status after the surgical trauma caused by sinus lifting is known as sinus compliance: the better the starting conditions high compliance , the lower the risk of complications. On the other hand, an excessive risk should be considered a contraindication to the procedure. Given the above considerations, sinus compliance of each individual patient or the presence of risk factors for post-elevation sinusitis should be evaluated pre-operatively in order to define a relative risk threshold based on the probability of post-operative complications Flow chart. This involves taking a careful case history in order to identify any previous nasal trauma or surgery, nasal respiratory obstruction, or recurrent or chronic naso-sinusal diseases 12 , as well as the presence of any systemic diseases that may interfere with implant integration, such as uncompensated diabetes mellitus, immunodeficient disease, voluptuous habits smoking, alcohol abuse, cocaine use , odontoiatric diseases periapical diseases, parodontopathies , or maxillary irradiation 5 9 15 Furthermore, all patients with radiological or anamnestic evidence suggesting maxillary sinusal dysventilation should undergo otorhinolaryngological examination with nasal endoscopy and, if indicated, computed tomography CT of the maxillo-facial district including the OMC in order to identify any possible contraindications to sinus lifting. This will lessen the risk of post-operative complications, thus providing relief for the patient and a good medico-legal guarantee for the oral surgeon. However, this diagnostic gap has now been filled by the introduction of high resolution axial and coronal paranasal CT 39 , and pre-operative CT of the maxillo-facial district with acquisition of the OMC , especially the new multi-slice CT with sub-millimetric acquisitions, has become almost mandatory in managing implant surgery when naso-sinusal diseases are suspected 40 — CT imaging is extremely useful as it can assess maxillary bone height 41 and thus make it possible to determine the best surgical approach, the timing of implant placement simultaneous vs. It has also been suggested that maxillary sinus volume can be pre-operatively measured by means of the three-dimensional reconstruction of the CT images in order to choose the best donor site when autogenous bone grafts are needed 43 , however, this application does not seem to be routinely practicable Studying sinus morphology, by means of CT scans, provides precious information since when septa are present in the sinus floor, they can complicate sinus elevation by hampering bone plate inversion and lifting of the sinus membrane CT scans with acquisition of OMC also play a primary role in managing sinus lift, from the ENT point of view, as they very precisely indicate the position and patency of the maxillary ostium, and detect any associated middle-meatal anatomical alterations or concomitant sinus diseases 12 that should be corrected before attempting sinus elevation, because the risk of developing post-operative sinusitis is increased in patients with impaired sinus clearance 3. Other radiological investigations that have become increasingly important in assessing sinus diseases include magnetic resonance imaging MRI 49 , although it is not useful for bone evaluation. Nasal endoscopy is a widely accepted means of assessing the middle meatus 3 because, by directly visualising the OMC, it can pre-operatively detect the factors impairing maxillary sinus drainage that may be responsible for a negative surgical outcome. Furthermore, it is particularly useful in managing their surgical correction before attempting sinus elevation. The main purpose of an endoscopic examination is to evaluate the condition of the infundibulo-meatal area, which is sometimes compromised by spatial competition between its foremost components the uncinate process, the ethmoidal bulla and the agger nasi 50 51 and other anatomical structures, such as the septal crests, the concha bullosa of the middle turbinate or its paradoxical bending, or a massive ethmoidal polyp A relationship has been documented between the post-operative development of sinusitis and pre-existing maxillary sinus diseases 22 as well as a correlation between sinusitis and the size of the maxillary ostium On the grounds that the cranial position of the maxillary ostium makes its mechanical blocking unlikely 3 , a number of Authors 3 recommend nasal endoscopy before maxillary sinus elevation only in the case of patients with previous maxillary pathological processes or a documented history of impaired maxillary clearance, and it has also been suggested that an endoscopic finding of mild mucosal inflammation does not strictly contraindicate sinus lifting Any otorhinolaryngological contraindications should be detected pre-operatively and, if possible, corrected before undertaking a sinus lift procedure. These contraindications can be divided into those presumably irreversible and those that are potentially reversible 15 53 The former include:. However, there are many more otorhinolaryngological contraindications that are potentially reversible by means of appropriate medical or surgical treatment:. Many of these potentially reversible otorhinolaryngological sinus lift contraindications are electively amenable to functional endoscopic sinus surgery FESS. The potentially reversible otorhinolaryngological contraindications to sinus lift surgery need to be corrected by means of conservative medical therapy or functional endoscopic sinus surgery — FESS — the current gold standard for many naso-sinusal conditions amenable to surgery in order to restore physiological maxillary sinus clearance and ventilation, after which it is possible to perform the sinus lift procedure to begin oral rehabilitation. However, this cannot be considered a standard procedure, the use of which should be confined to scientific trials as it is still technically demanding and requires considerable additional equipment. Furthermore, although it can promptly visualize perforations of the sinus membrane, it cannot avoid their occurrence Herewith, a brief description of the current therapeutic options for the treatment of some of the potentially reversible otorhinolaryngological contraindications to sinus lifting. This may involve orally administered non-steroidal anti-inflammatory drugs 61 and the use of topical decongestants for a maximum of 3 days in order to restore sinusal ostial patency and provide symptomatic relief 61 If acute viral rhino-sinusitis is suspected, antibiotics are not recommended 63 , and patients with non-severe acute bacterial rhino-sinusitis should be considered candidates for clinical observation if follow-up is guaranteed There is no evidence supporting the effectiveness of systemic steroids for acute rhino-sinusitis, and only weak evidence supports the use of topical nasal steroids in patients with acute viral rhino-sinusitis or allergic rhinitis these may reduce mucosal swelling 61 A number of mainly industry supported clinical trials have shown the efficacy of topical corticosteroids in cases of acute bacterial rhino-sinusitis 71 72 , but the use of decongestants and corticosteroids in addition to saline irrigation and mucolytics has not been approved by the American Food and Drug Administration for acute rhino-sinusitis. The clinical impact of antihistamine therapy on viral rhino-sinusitis has not yet been assessed 61 , but it does not seem to be substantial in non-atopic patients with acute bacterial rhino-sinusitis In addition to eliminating the infection, the current treatment of chronic rhino-sinusitis also involves identifying and correcting the underlying predisposing factor anatomical alterations of the OMC, allergopathy, nasal polyposis. Endoscopic surgery has become the common means of ensuring functional rehabilitation as it allows precise and decisive therapeutic intervention with minimal negative effects on delicate naso-sinusal physiology 73 and good patient outcome. In the most advanced centres, the traditional approaches to maxillary sinus surgery have been replaced by endoscopic uncinectomy, middle meatal antrostomy, and anterior and posterior ethmoidectomy A description of the surgical treatment of the structural anomalies conditioning impaired maxillary sinus drainage is given in the next section. In the case of allergic rhino-sinusitis or concomitant asthma, medical treatment should first be established with topical or systemic antihistamines 74 , disodium chromoglycate and specific immunotherapy 73 and, if necessary, the patient should be referred for an allergy assessment. In the case of recurrent bronchitis, a pneumological evaluation may also be useful. Patients in Stammberger clinical group I with antrochoanal polyposis, ACP 76 should undergo surgery as first-line therapy 77 78 : the ACP is resected using an endoscopic trans-nasal approach, and then a middle meatal antrostomy is performed in order to remove the base from the maxillary sinus 79 The use of powered FESS instrumentation has also recently been described to be effective in completely removal of an ACP including its antral portion 81 When the antral portion cannot be reached trans-nasally, a combined approach through the canine fossa may be used Any other benign naso-sinus neoplasms, such as maxillary mucous cysts, should also be surgically removed or aspirated before 33 or at the time of sinus augmentation Stammberger group III and IV patients with nasal polyposis associated with chronic rhino-sinusitis without or with eosinophilia 76 should undergo endoscopic surgical treatment if complete recovery cannot be achieved by means of medical treatment with antibiotics and systemic steroids 83 , and post-operative topical steroid treatment should be used to avoid recurrences In the case of non-invasive fungal sinusitis, the fungal ball should be removed by means of trans-nasal endoscopy 84 , whereas the current therapy, for allergic fungal sinusitis, is endoscopic sinus surgery with topical administration of corticosteroids and antimycotic drugs In the case of sinus diseases associated with anatomical alterations that impair physiological maxillary drainage and are responsible for sinus dysventilation, FESS should be used to restore OMC patency before the sinus lifting is performed. Nasal septum deviations, which in the general population reach an incidence of In addition to the traditional headlight technique, endoscopic — and now powered functional endoscopic 87 — septal surgery is considered a safe and efficacious approach, especially in the case of posterior and superior deformities which are difficult to access using the traditional technique, and can be performed at the same time as FESS 88 Any other naso-sinusal anatomic variations, such as paradoxical bending of the middle turbinate general population incidence 5. They must, therefore, be treated first by means of surgical correction and adequate medical treatment in order to obtain a disease-free sinus environment The successful long-term closure of an oro-antral fistula depends on the physiological status of the maxillary sinus Once the alveolo-antral areas have stably and completely healed, the possibility of a sinus lift can be considered depending upon the local situation and residual bone gap. Maxillary sinusitis is the most frequent post-operative complication 19 — 26 , although its post-lifting occurrence is not always defined using precise ENT criteria It may be caused by:. Small intra-operative perforations of the sinus membrane do not seem to be responsible for maxillary sinusitis in healthy subjects 18 , but larger perforations expose more of the grafted bone surface to the sinusal environment, and, therefore, lead to a greater risk of penetration of bony fragments into the sinus lumen and the development of post-lifting rhino-sinusitis 18 The pathogenic mechanism may start with the protrusion of debris-covered implants into the sinus lumen where, as foreign bodies, they may give rise to inflammation impairing the muco-ciliar system; the subsequent mucosal swelling leads to maxillary ostial obstruction, infection, and rhino-sinusitis General guidelines for the prevention of transient and chronic maxillary rhino-sinusitis, after sinus lifting, include peri-operative antibiotic prophylaxis and post-operative administration of topical corticosteroids in order to ensure the patency of the maxillary ostium 3 21 25 The use of decongestants is controversial because, by inducing vasoconstriction, they may further compromise the already low oxygen tension in the sinus The role of ENT specialists, in the case of post-elevation maxillary rhino-sinusitis, is to guarantee early diagnosis and treatment. Early medical or in advanced stages surgical treatment, able to promptly restore maxillary sinus ventilation and drainage, would not only avoid the loss of graft and implants, but also prevent major complications, such as venous septic thrombosis, especially in the case of acute purulent events 12 For a correct and prompt diagnosis, in addition to nasal and sinus endoscopy, the ENT specialist can proceed with aspiration of sinus contents for cytological examination and microbiological assessment CT is also an extremely useful means of detecting pathological processes. If medical therapy alone fails to control the sinus infection, the guidelines for the treatment of transient rhino-sinusitis suggest the use of trans-nasal endoscopy to establish maxillary drains for sinus irrigation and, if this fails to bring about complete recovery within three weeks or in the presence of exposed and sequestered endosinusal grafts , surgical curettage, by means of FESS, should be taken into consideration 3 12 35 In the case of chronic maxillary rhino-sinusitis, endoscopic surgical treatment should be used in addition to medical treatment 3 35 Published data and our own experience show that infected graft material and implants should be removed because eliminating the source of infection will avoid recurrences of rhino-sinusitis ; however, some Authors have successfully used alternative treatments consisting of partial resection of the grafts. Inappropriate positioning or accidental displacement of dental implants, inside the maxillary sinus, have been also reported as late complications after sinus lifting 5 If such events are confirmed by means of diagnostic nasal endoscopy and radiology, the migrated implants should be surgically removed in order to prevent the development of rhino-sinusitis due to interrupted muco-ciliary clearance or a tissue reaction — In the case of nasal or sinusal diseases, FESS should be considered the option of choice but, in the absence of sinus infection and if the OMC is normal, the implants can be retrieved using:. New trocar for endoscopic trans-canine approach conceived by M. It is worthwhile pointing out that these surgical approaches can be used under local anaesthesia if the patient is compliant and the surgeon is experienced. All the above-mentioned considerations indicate that the cooperation of an ENT specialist is also useful in the management of this post-lifting complication, as trans-nasal endoscopic retrieval of migrated implants allows the simultaneous treatment of the concomitant mucosal disease related to implant displacement and any associated ostial obstruction with minimal invasiveness and less morbidity than that related to the standard approach Whenever concomitant dysventilatory naso-sinusal diseases are suspected, ENT specialists are primary figures in the management of candidates for sinus lifting. Their involvement in all three preventive-diagnostic, preventive-therapeutic and diagnostic-therapeutic steps makes it possible to identify any presumably irreversible or potentially reversible contraindications to sinus lifting and resolve when possible the pathological processes or anatomical impairments potentially leading to surgical failure, as well as ensure the early detection and treatment of any post-operative complications that may compromise good surgical outcome. The availability of a multi-disciplinary surgical team, including a well-trained ENT specialist, not only increases the likelihood of a better procedural outcome, but also provides a good medico-legal guarantee for the oral or maxillofacial surgeons attempting a sinus lift. As a library, NLM provides access to scientific literature. Acta Otorhinolaryngol Ital. Show available content in en it. ENT assessment in the integrated management of candidate for maxillary sinus lift Il ruolo dello specialista ORL nella gestione integrata del paziente candidato al rialzo del seno mascellare L Pignataro L Pignataro 1 LP and MM contributed equally to this study. Find articles by L Pignataro. Find articles by M Mantovani. Find articles by S Torretta. Find articles by G Felisati. Find articles by G Sambataro. Received Jan 27; Accepted Mar 7. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

ENT assessment in the integrated management of candidate for (maxillary) sinus lift - PMC

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Local anaesthesia plays a useful role in simple or superficial interventions. Lesions can be frozen by refrigerants such as ethyl chloride spray. The same effect may be achieved with liquid nitrogen, but its lower temperature may cause greater post operative discomfort. Local anaesthetics are generally ineffective when applied to intact human skin because they are poorly absorbed. This is a preview of subscription content, log in via an institution to check access. Institutional subscriptions. Unable to display preview. Download preview PDF. Matsui D Pharmacology of local anesthetics. A breakthrough in skin anesthesia. Google Scholar. Eur J Anaesthesiol 7: — Anaestesia — Pediatrics 95 2 : — Doyle E, Freeman J, Im NT et al An evaluation of a new self-adhesive patch preparation of amethocaine for topical anaesthesia prior to venous cannulation in children. Anaesthesia — Am J Health-System Pharmacy — Anaesth Intens Care — CAS Google Scholar. J Am Acad Dermatol — Obstet Gynecol — J Dermatol Surg Oncol — Article Google Scholar. Pediatrics — Contact Dermatitis 11— Download references. You can also search for this author in PubMed Google Scholar. Reprints and permissions. Topical Anaesthetics in Dermatology. In: Katsambas, A. Springer, Berlin, Heidelberg. Publisher Name : Springer, Berlin, Heidelberg. Print ISBN : Online ISBN : Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Policies and ethics. Skip to main content. European Handbook of Dermatological Treatments. Abstract Local anaesthesia plays a useful role in simple or superficial interventions. Access this chapter Log in via an institution. Chapter EUR Tax calculation will be finalised at checkout Purchases are for personal use only. Preview Unable to display preview. References Matsui D Pharmacology of local anesthetics. Authors F. View author publications. Rights and permissions Reprints and permissions. About this chapter Cite this chapter de Waard-van der Spek, F. Copy to clipboard. Publish with us Policies and ethics. Search Search by keyword or author Search. Navigation Find a journal Publish with us Track your research.

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