J Periodontol • February 2011
New York State Ear, Nose, and Throat Specialists’ Views on Pre–Sinus Lift Referral Michael T. Cote,* Stuart L. Segelnick,* Amita Rastogi,† and Robert Schoor*
Background: Dental implant surgery in the posterior maxilla often involves the maxillary sinuses. Sinus surgery for dental implants is highly successful, but the preoperative risk is difficult to assess because a routine preoperative evaluation does not include an intranasal examination by an otolaryngologist. The purpose of the present study is to obtain the opinions of ear, nose, and throat (ENT) specialists located within New York state in an effort to establish a referral protocol before performing a maxillary sinus elevation. This study assesses the need to consult an ENT specialist for evaluation and treatment recommendations in the pretreatment workup. Methods: A questionnaire and a stamped, return envelope with an identification number was mailed to 302 physicians who maintained a current ENT-specialty practice or practiced that specialty in a hospital or clinic setting in New York state. The requirement criteria included a valid address and specialty designation. Up to two follow-up phone calls were made, and another questionnaire was mailed 30 days after the initial mailing. The questionnaire included eight computerized tomography (CT)–scan images that represented different sinus configurations. Answers to the five questions were statistically evaluated and analyzed. A total of 63 recipients returned the questionnaire and were included in the study. Results: A majority of 58.7% (95% confidence interval: 46.9% to 71.1%) of respondents recommended that a maxillary sinus CT scan should be routinely prescribed before a sinus-lift surgery. Patient symptoms that ENT specialists suggested indicated referral included nose complications/problems (40.1%) and sinus issues (23.6%). Of the eight CT-scan images, referral suggestions were >50% for the following: an occluded sinus with septum, inflammation at the base of the sinus only, a sinus with a generalized thickened membrane, an oroantral fistula, a thickened sinus membrane in association with teeth that had endodontic and/or periodontic involvement, and a nearly completely occluded sinus that was missing palatal bone. For patients with seasonal allergies, ENT specialists suggested delaying surgery (20.6%) or controlling symptoms before surgery (41.3%). Concerns included a past history of a sinus surgery (87.3%), chronic sinusitis (85.7%), presence of ostium stenosis (68.3%), nasal or sinus obstruction (82.5%), and oroantral fistulation (74.6%). Conclusions: Within the limits of the study, an attempt is made to develop a preoperative protocol, and 63 responses from ENT specialists suggested that the majority (58.7%) would recommend a maxillary CT scan before a sinuslift surgery. Their greatest concerns were a prior sinus surgery, severe sinus inflammation, nasal/sinus obstruction, and oroantral fistulation. J Periodontol 2011;82:227-233. KEY WORDS Internal medicine; maxillary sinus; oral medicine; pathology; radiology.
* Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, NY. † Private practice, Chicago, IL.
I
n the course of routine dental implant surgery, it is often necessary to involve the maxillary sinuses of patients. Pneumatization (size increase) of the sinus is often seen after teeth are extracted, and as a result, dental implant placement in the posterior maxilla is limited by reduced bone quantity and quality. 1 Maxillary sinus surgery to address this limitation is performed in the dental chair, and this procedure has become a routine part of implant dentistry. A number of techniques exist to accomplish sinus lifts; however, the most common procedures include the lateral window antrostomy first published by Boyne and James in 1980,2 localized management of the sinus floor, and the osteotome sinus-floor elevation. Modern surgical techniques allow for sinus elevations and either simultaneous or subsequent implant placement;3 however, doi: 10.1902/jop.2010.100344
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in developing a diagnosis and a treatment plan, there is a paucity of information on Schneiderian-membrane pathosis before a sinus-elevation procedure. More powerful imaging technologies are now available in dental offices and digital x-ray centers that provide the diagnosis of sinus pathologies and abnormalities;4 however, no guidelines exist about when to seek the consultation of an ear, nose, and throat (ENT) specialist. As currently performed, a sinus surgery for dental implants is highly successful, but the preoperative risk among patients is difficult to assess because a routine preoperative evaluation of patients does not include an intranasal examination by an otolaryngologist.5 Postoperative complications can occur with infection, excessive discomfort, swelling, and bleeding, and these are documented complications that can result in the loss of sinus grafts.6 A diagnosis of a preexisting sinus disease or susceptibility to sinus disease in consultation with an ENT specialist could aid in the prevention of these and other complications.7 The purpose of the present study is to attain the opinions of ENT specialists located within New York state to help establish a guideline or referral protocol for dental surgeons before performing a maxillary sinus elevation. Sinus presentations upon examinations included frequent anatomic deviations, clinical symptomatology, early pathosis, and functional impairment. Eight computerized tomography (CT)–scan images that illustrated the range of pathosis seen in the dental office were sent to ENT specialists for their preoperative assessments. This study assesses the need to consult an ENT specialist for evaluation and treatment recommendations in the pretreatment workup. MATERIALS AND METHODS A questionnaire was developed to elicit subjective opinions from individuals listed as ENT specialists in the telephone business directory, an internet search engine,‡ and ENT-specialist listings. All subjects met the inclusion criteria in that all were specialists and all practiced in New York state, and by completing the questionnaire, they consented to participate in this study. Subjects were excluded if a period of >3 months elapsed since the original mailing or the ENT specialist relocated outside of New York state. In an attempt to gain more responses, two follow-up phone calls were made to subjects, and another questionnaire was mailed 30 days after the initial mailing. A stamped, return envelope with an identification number was returned with the completed survey. The 20.9% return rate of 302 questionnaires parallels survey response rates published in the literature.8,9 The dates of the study were from July 2009 to November 2009. The questionnaire included eight CT-scan images that represented different sinus configurations from unidentified patients in the private practice of the au228
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thors and patients seen at the New York University College of Dentistry (NYUCD). These eight images were chosen to represent specific sinus conditions. Image A was a CT scan of a non-pathologic sinus. Image B revealed an occluded sinus with a bony septum. Image C showed inflammation at the base of the sinus only, whereas image D showed a sinus with a polyp growing from the lateral wall of the sinus. Image E was of a sinus with generalized thickening of the membrane. Image F showed an oroantral fistula. Image G showed a thickened sinus membrane in association with teeth that had endodontic and/or periodontic involvement. Image H revealed a nearly completely occluded sinus that was also missing palatal bone. Answers to the five questions were statistically evaluated and analyzed. A total of 63 (20.9%) recipients returned the questionnaires and were included in the study. Data were entered onto study-specific case-report forms and kept in a secure location. Data were transferred into a password-protected computer with backup to a firewall-protected research-dedicated server using software.§ Double entry was conducted to ensure data accuracy, and data queries were conducted before any statistical analyses. All data entry was conducted confidentially with only study-assigned numbers and no reference to any subject name. The institutional review board of NYUCD approved the study. Statistical analyses were carried out using statistical software.i The frequency and proportion of responses and 95% confidence intervals (CIs) were calculated based on 63 returned surveys. Bar and pie charts were also used to show the proportions of responses of interest. RESULTS A majority of 58.7% of respondents recommended a routine maxillary sinus CT scan before a sinus-lift surgery, whereas 38.1% of respondents did not, and 3.2% of respondents did not respond (Fig. 1). In evaluating subjective symptoms, 72 different responses were elicited. These responses were then grouped into five common categories: 1) group A included facial complications (18.1%); 2) group B included nose complications/problems (40.1%) and was further subdivided into group B1, which included abnormal nasal discharges (20.8%), group B2, which included nasal obstructions (11.1%), and group B3, which included breathing/smelling anomalies (8.3%); 3) group C included allergy symptoms (12.5%); 4) group D included specific sinus issues (23.6%); and 5) group E included eye-related issues (5.6%). ‡ Google, Mountain View, CA. § SPSS, SPSS, Chicago, IL. i SAS v9.1, SAS Institute, Cary, NC.
J Periodontol • February 2011
Figure 1. Percentage of ENT specialists that recommend routinely prescribing a CT scan before sinus-lift surgery.
For each of the eight CT-scan images presented in the questionnaire, responses were elicited as to whether a referral was warranted based on the image or not (Table 1 and Fig. 2). For image A, six ENT specialists (9.5%; 95% CI: 2.3% to 16.7%) elected for referral. For image B, 57 ENT specialists (90.5%; 95% CI: 83.9% to 98.1%) elected for referral. For image C, 35 ENT specialists (55.6%; 95% CI: 43.7% to 68.3%) elected for referral. For image D, 20 ENT specialists (31.7%; 95% CI: 20.5% to 43.5%) elected for referral. For image E, 42 ENT specialists (66.7%; 95% CI: 55.4% to 78.6%) suggested referral. For image F, 52 ENT specialists (82.5%; 95% CI: 73.7% to 92.3%) elected for referral. For image G, 47 ENT specialists (74.6%; 95% CI: 64.3% to 85.7%) recommended referral. For image H, there were 56 responses (88.9%; 95% CI: 81.3% to 96.7%) that elected for referral. In evaluating survey question four, which asked what recommendations or precautions should be taken for patients with seasonal allergies, 62 responses were received (Table 2). These responses were then grouped into three common categories: category 1 involved not proceeding with the surgery at that time (20.6%; 95% CI: 10.6% to 30.6%); category 2 included controlling symptoms and/or providing medications (steroids and antihistamines) before surgery (41.3%; 95% CI: 29.1% to 53.5%) and was further subdivided (category 2A) to include taking dust precautions and using humidifiers, air filters, and saline lavage (3.2%; 95% CI: 1.1% to 7.5%); and category 3 included ENT specialists who did not recommend any precautions (38.1%; 95% CI: 26.1% to 50.1%).
Cote, Segelnick, Rastogi, Schoor
Question five was designed to elicit responses on specific, common concerns before sinus augmentation and referral patterns to an ENT specialist (Fig. 3). A past history of surgeries on the sinus was the most common reason that ENT specialists believed a referral before surgery was warranted (87.3%; 95% CI: 79.1% to 95.5%). The presence of bony septae in the sinus was a concern of 15.9% (95% CI: 6.9% to 24.9%) of ENT specialists surveyed, and the presence of chronic rhinitis or sinusitis concerned 85.7% (95% CI: 77.1% to 94.3%) of ENT specialists. Current tobacco use was viewed as the least important risk factor for complications of sinus surgery by ENT specialists surveyed (14.3%; 95% CI: 5.7% to 22.9%). The presence of ostium stenosis was a pathosis that concerned 68.3% (95% CI: 56.8% to 79.8%) of surveyed ENT specialists; in addition, the presence of a nasal deviated septum concerned 28.6% (95% CI: 17.4% to 39.8%) of surveyed ENT specialists. The presence of teeth roots projecting into the maxillary sinus floor concerned 58.7% (95% CI: 46.5% to 70.9%) of surveyed ENT specialists, and nasal or sinus obstructions concerned 82.5% (95% CI: 73.1% to 91.9%) of surveyed ENT specialists. Lastly, the presence of an oroantral fistula warranted a referral for 74.6% (95% CI: 63.9% to 85.3%) of surveyed ENT specialists. DISCUSSION The average response rates to any survey are between 30% to 50%.10 Response rates to surveys for physicians have been on the decline.11,12 An article by Templeton et al.,13 reported that low response rates do not necessarily affect the validity of the study if the effects of the non-response bias are taken into consideration. Indeed, there is no known single acceptable response rate.14 Other postal surveys have been published with similar response rates to ours,8 and a postal survey to all resident members of the American Academy of Otolaryngology–Head and Neck Surgery in 2001 had a 21% response rate; it is possible that our questionnaire had targeted some of these same physicians.9 Our response rate of 20% was based on online survey sites that showed this rate is likely to be achieved when there is no prior relationship to the recipients.15 In retrospect, the envelope, return envelope, and questionnaire, which had on it the affiliation of the authors, may have also led to a lower response rate.16 Because of the small sample size and not being a probability sample, the study cannot be generalized to represent the entire population of ENT specialists of the United States or New York state. A selection bias might exist even when the response rates were higher because this was not a probability sample. Unfortunately, we could not report this in detail because we did not have information on those who had not 229
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Table 1.
Response to the Question Does the CT Image Warrant an ENT-Specialist Referral Before Sinus-Lift Surgery? CT Image
Response
A: Does a non-pathologic sinus warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 2.3% to 16.7%
52 (82.5) 6 (9.5) 5 (7.9)
B: Does an occluded sinus with a bony septum warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 83.9% to 98.1%
3 (4.8) 57 (90.5) 3 (4.8)
C: Does inflammation at the base of the sinus warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 43.7% to 68.3%
23 (36.5) 35 (55.6) 5 (7.9)
D: Does a sinus with a polyp growing from the lateral wall of the sinus warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 20.5% to 43.5%
38 (60.3) 20 (31.7) 5 (7.9)
E: Does a sinus with generalized thickening of the membrane warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 55.4% to 78.6%
16 (25.4) 42 (66.7) 5 (7.9)
F: Does an oroantral fistula warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 73.7% to 92.3%
8 (12.7) 52 (82.5) 3 (4.8)
G: Does a thickened sinus membrane in association with teeth that have endodontic and/or periodontic involvement warrant an ENT-specialist referral? No (n [%]) 11 (17.5) Yes (n [%]) 47 (74.6) Unknown (n [%]) 5 (7.9) 95% CI: 64.3% to 85.7% H: Does a nearly occluded sinus also missing palatal bone warrant an ENT-specialist referral? No (n [%]) Yes (n [%]) Unknown (n [%]) 95% CI: 81.3% to 96.7%
been selected or did not respond to our survey. Therefore, the possibility of a selection/non-response bias exists. Maxillary sinus–augmentation procedures are considered routine and safe when performed to augment posterior bone in preparation for dental implant place230
3 (4.8) 56 (88.9) 4 (6.3)
ment.17 Survival rates of implants that are placed in lateral sinus-lifted areas are >92%.18,19 The risks for complications for this procedure are low; however, there is a dearth of information in the scientific literature that suggests sinus assessment protocols before sinus augmentation. Abnormalities of the sinus and disease
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Figure 2. CT Images A through H.
Table 2.
ENT-Specialist Recommendations for the Management of Patients With Seasonal Allergies (Question 4) Recommendation Category
Yes Response (n [%])
1: avoid surgery during peak allergy season or clearance
13 (20.6)
2: control symptoms/ medication (steroids and antihistamines) before surgery
26 (41.3)
2A: dust precautions, use humidifier and air filter, saline lavage
2 (3.2)
3: no recommendations
24 (38.1)
presence can affect the success of sinus-lift procedures, and there is referenced literature20 that describes the prevalence of post-surgical symptoms as 27%. At the present time, it is the preoperative protocol to prescribe a CT scan before sinus implant surgery in the Department of Periodontics and Implant Dentistry at NYUCD. This protocol is followed to rule out pathology, to assist in the preoperative plan for implant site development, and to teach sinus anatomy. However, according to Zimbler et al.,21 CT scans and nasal endoscopy are not the prescribed routine for the preoperative evaluation of patients. The present study confirms the practice at NYUCD and further indicates that in the absence of symptoms, 60% of respondents to this questionnaire found it necessary to refer patients preoperatively for a CT scan. In a study
by Pignataro et al.,22 the investigators advocated for ENT-specialist referrals and preoperative CT scans to identify potential problems at three specific levels: the preventive-diagnostic step, the preventive-therapeutic step, and the diagnostic-therapeutic step. The benefits of recommended CT scans before surgery when signs and symptoms are present are clear,23 and in these circumstances, pretreatment CT scans are strong predictors of outcomes. 24 However, when presented with symptom-free findings such as a polyp in the sinus or otherwise normal sinus anatomy, the majority of ENT respondents would not recommend a referral. Before this study, the authors at NYUCD were not concerned with asymptomatic chronic sinusitis. The protocol at NYUCD is to perform the sinus surgery in the presence of benign, asymptomatic sinus polyps that are £0.7 cm in size. This is in accordance with the favorable results of a study by Mardinger et al.25 in which the average lesion size was 5.09 cm2 before sinus-lift surgery. A substantial number of ENT specialists (40.1%) that were surveyed in this study would recommend referral for patients who report symptoms that included nose complications/problems such as abnormal nasal discharges, nasal obstructions, and breathing/smelling anomalies. It is important to consider controlling symptoms in patients with chronic sinusitis related to allergies.26 Patients with seasonal allergies may pose a risk for a sinus-lift procedure. Pignataro et al.22 suggested proceeding surgically when symptoms resolve (if seasonal allergy), and 41.3% of the ENT specialists surveyed recommended controlling allergic symptoms with steroids or antihistamines before surgery. A total of 87.3% of questionnaire respondents expressed concerns with patients who present with a history of prior surgery, whereas smoking, boney septae, a thickened membrane, and ostium stenosis were lesser concerns. ENT specialists commented that septae pose slightly higher tearing potentials; however, high apical locations of the ostium usually separate the entrance mechanically during surgery and, therefore, are not likely to be blocked mechanically.27 CONCLUSIONS Within the limits of the study, an attempt is made to develop a preoperative protocol, and 63 responses from ENT specialists suggest that the majority (58.7%) of 231
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Figure 3. Concerns requiring ENT-specialist referral before sinus-augmentation surgery.
ENT specialists would recommend a maxillary CT scan before sinus-lift surgery. Their greatest concerns were a prior sinus surgery, severe sinus inflammation, nasal/sinus obstruction, and oroantral fistulation. ACKNOWLEDGMENTS The authors thank Dr. Amir Ahmadi, NYUCD Department of Periodontology and Implant Dentistry, New York, NY, for his help in choosing the CT-scan slices used in the survey. We also thank Alex Ho, University at Buffalo School of Dental Medicine, Department of Periodontics and Endodontics, Buffalo, NY, for his assistance with the statistical analyses. The authors report no conflicts of interest related to this study.
7.
8. 9. 10. 11.
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23. Gaggl A, Schultes G, Santler G, Ka¨rcher H. Treatment planning for sinus lift augmentations through use of 3-dimensional milled models derived from computed tomography scans: A report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:388-392. 24. Stewart MG, Donovan DT, Parke RB Jr., Bautista MH. Does the severity of sinus computed tomography findings predict outcome in chronic sinusitis? Otolaryngol Head Neck Surg 2000;123:81-84. 25. Mardinger O, Manor I, Mijiritsky E, Hirshberg A. Maxillary sinus augmentation in the presence of antral pseudocyst: A clinical approach. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:180-184. 26. Costa F, Emanuelli E, Robiony M, Zerman N, Politi M. Endoscopic treatment of maxillary sinus disease before grafting. Br J Oral Maxillofac Surg 2008;46:128-130. 27. Krennmair G, Ulm CW, Lugmayr H, Solar P. The incidence, location, and height of maxillary sinus septa in the edentulous and dentate maxilla. J Oral Maxillofac Surg 1999;57:667-671, discussion 671-672. Correspondence: Dr. Stuart L. Segelnick, 1603 Voorhies Ave., Second Floor, Brooklyn, NY 11235. Fax: 718/7439145; e-mail:
[email protected]. Submitted June 6, 2010; accepted for publication July 30, 2010.
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