Calcifications afloat: bad omens in maxillary sinus augmentation.

To cite: Di Pasquale D, Saibene AM, Bebi V, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-201581 DESCRIPTION A 60-year-old patient was referred to our ear nose and throat (ENT) clinic for facial pain, bilateral midface swelling and purulent nasal discharge. The patient had undergone a bilateral maxillary sinus augmentation procedure 3 weeks before. A nasal endoscopy showed purulent material from both the middle meati, while oral examination revealed a left oroantral fistula. The head CT scan (figure 1) showed both maxillary sinuses occupied by flogistic material with disperse calcifications and confirmed the left oroantral fistula. These calcifications hint towards a diagnosis of odontogenic sinusitis: multiple calcifications in a completely opacified maxillary sinus most likely represent infected grafts dislodged from the maxillary floor. In some cases, the fragments even tend to align to the mucociliary clearance flow. Maxillary augmentation is considered a safe and predictable answer to vertical maxillary bone atrophies. Grafting the particulate bone and covering the lateral window access with a collagen membrane has been shown to increase implant survival. The use of piezoelectric tools has gained popularity to reduce damage to the Schneiderian membrane. According to the classification of sinonasal complications following dental treatment, the patient showed a class 1a complication (condition following maxillary sinus augmentation). The patient was consequentially treated with an association of functional endoscopic sinus surgery and an intraoral approach as suggested by Chiapasco et al. A bilateral antrostomy restored the maxillary drainage and allowed the removal of bony fragments resulting from the prior sinus augmentation. The intraoral approach on the other hand was required to completely remove the grafting material and close the oroantral fistula with local rotation flaps. The patient was intravenously administered levofloxacin 750 mg for 2 days followed by oral levoxacin 500 mg for 7 days. Endoscopic follow-up at 1, 2, 4 and 12 weeks confirmed complete healing of the sinonasal complex.