Detection of multidrug-resistant bacteria in the nasal cavities and evaluation of sinus disorders in patients undergoing Le Fort I osteotomy.

INTRODUCTION: Orthognathic surgery can lead to sinus alterations, including sinusitis, attributed to the exposure of maxillary sinuses during Le Fort I osteotomy. Furthermore, being a hospital-based procedure, there is potential risk of complications arising from bacteria prevalent in such environments. This study evaluated maxillary sinusitis occurrence and the presence of multidrug-resistant bacteria in the nasal cavity before and after orthognathic surgery. METHODS: Ten patients with dentofacial deformities underwent Le Fort I osteotomy. Clinical evaluations using SNOT-22 questionnaire were performed, and nasal cavity samples were collected pre-surgery and 3-6 months post-surgery to quantify total mesophilic bacteria and detect Staphylococcus aureus, Acinetobacter baumannii, and Klebsiella pneumoniae. Cone Beam Computed Tomography (CBCT) was performed pre- and post-operatively, and the results were evaluated using the Lund-Mackay system. This study was registered and approved by the Research Ethics Committee of PUCRS (No. 4.683.066). RESULTS: The evaluation of SNOT-22 revealed that five patients showed an improvement in symptoms, while two remained in the same range of interpretation. One patient developed post-operative maxillary sinusitis, which was not detected at the time of evaluation by SNOT-22 or CBCT. CBCT showed a worsening sinus condition in three patients, two of whom had a significant increase in total bacteria count in their nasal cavities. The Brodsky scale was used to assess hypertrophy in palatine tonsils, where 60% of the subjects had grade 1 tonsils, 20% had grade 2 and 20% had grade 3. None of the patients had grade 4 tonsils, which would indicate more than 75% obstruction. Two patients harboured S. aureus and K. pneumoniae in their nasal cavities. Notably, K. pneumoniae, which was multidrug-resistant, was present in the nasal cavity of patients even before surgery, but this did not result in maxillary sinusitis, likely due to the patients' young and healthy condition. CONCLUSION: There was an improvement in signs and symptoms of maxillary sinusitis and quality of life in most patients after orthognathic surgery. However, some patients may still harbour multidrug-resistant bacteria, even if they are asymptomatic. Therefore, a thorough pre-operative assessment is essential to avoid difficult-to-treat post-operative complications.

Clinical Approach to Dental Root Canal Filler-Induced Maxillary Sinus Fungal Mass Using Transnasal Endoscopy.

Accidentally extruded root canal filler within the sinuses may induce maxillary sinusitis with fungal mass. The authors describe 2 cases of gutta-percha-induced fungal masses in the left maxillary sinus of 2 women. The lesions were evaluated preoperatively using both computed tomography and magnetic resonance imaging, providing comprehensive insights into the condition. In one patient, the lesion was located such that it could be resected through the middle meatal antrostomy alone. However, the second patient presented with an anteroinferiorly situated lesion that necessitated not only a transnasal approach but also an endoscopic modified medial maxillectomy. Both patients recovered uneventfully after surgery. This case series is the first published report of 2 cases of gutta-percha-induced maxillary sinus fungal masses, with their imaging findings, successfully treated through different routes through transnasal endoscopic surgery. These reports highlight the need for a collaborative approach between dental practitioners and otolaryngologists. In addition to the patient's wishes, surgical interventions must consider the unique characteristics of each case and the potential for collaboration across different medical specialties.

Is maxillary sinusitis and radiographic maxillary sinus opacification associated with an altered microbiology of MRONJ?

OBJECTIVE: Maxillary sinusitis can be a sequela of medication-related osteonecrosis of the jaw (MRONJ). This study aims to characterize the microbiome of maxillary MRONJ with concurrent maxillary sinusitis and radiographic maxillary sinus opacification to determine if there is a relationship between the microbiome of MRONJ and sinus disease. STUDY DESIGN: This retrospective case series was conducted using electronic health records from the University of Pennsylvania and affiliated hospitals. The target population was surgically managed maxillary MRONJ patients. The primary predictor variables were tissue culture results. The primary outcomes were maxillary sinusitis or maxillary sinus opacification. Statistical analysis was performed using chi-squared tests at the 95% confidence interval. RESULTS: Thirty-nine subjects were selected: 25 had sinus opacification and 11 had sinusitis. Resident bacteria were present in 90% of subjects, nonresident bacteria in 74%, and opportunistic organisms in 15%. There were significantly more subjects with chronic sinusitis microbes (79%) than without. There were significantly more gram-positive anaerobes, specifically Propionibacterium, as well as the gram-negative facultative anaerobe, Capnocytophaga, in subjects with concurrent sinusitis. CONCLUSIONS: Maxillary MRONJ with concurrent maxillary sinusitis may be associated with gram-positive anaerobic species, Propionibacterium, and Capnocytophaga colonization. Maxillary MRONJ patients may benefit from sinus evaluation and concurrent surgical intervention.

Chronic Maxillary Sinusitis Caused by an Aspergilloma in the Context of Inadequately Treated Type II Diabetes Mellitus.

BACKGROUND/AIM: The prevalence of chronic sinusitis (CS) in Europe is greater than 10%. The causes of CS are diverse. In some cases, dental treatment in the maxilla as well as fungal infection, such as aspergilloma, can lead to CS. Inadequately treated illnesses, such as type II diabetes, are known risk factors for atypical infections. CASE REPORT: The present case report describes a 72-year-old female suffering from CS in the maxillary sinus. A few years earlier, the patient received endodontic treatment of a maxillary tooth. For further diagnostics a CT-scan was performed showing an obstructed maxillary sinus on the left due to a polypoid tumor. The patient had been suffering from type II diabetes that had been inadequately treated for several years. The patient was surgically treated with an osteoplasty of the maxillary sinus combined with a supraturbinal antrostomy. Histopathological findings revealed an aspergilloma. The surgical therapy was supplemented by antimycotic therapy. In addition, the patient received antidiabetic treatment leading towards stable blood sugar levels. CONCLUSION: Rare entities, such as aspergillomas, can also be the cause of CS. In particular, patients with previous illnesses relevant to the immune system are predisposed for Aspergilloma after dental treatment leading to CS.

Presence of anaerobic bacteria and symptoms supports diagnosis of odontogenic sinusitis.

PURPOSE: The present study aimed to investigate the diagnostic indicators of odontogenic sinusitis other than computed tomography (CT) findings and the history of dental treatment such as detected bacteria and symptoms. MATERIALS AND METHODS: We performed a retrospective analysis of 87 patients who underwent surgery for unilateral sinusitis between 2016 and 2020 (n = 87). Patients with cysts and fungal sinusitis were excluded from the study. We analyzed the relationship between the presence/absence of CT findings such as periapical lesions and oroantral fistulas; anaerobic bacteria; and symptoms in patients with unilateral sinusitis. RESULTS: There was a significant correlation between the detection of anaerobes and CT findings. Peptostreptococcus sp., Prevotella sp., Streptococcus anginosus group, and Fusobacterium sp. were the most commonly isolated species. Detection of these anaerobic bacteria supports the diagnosis of odontogenic sinusitis. Moreover, ODS often present with symptoms, such as a foul smell and facial pain. CONCLUSIONS: Our results suggest that not only the presence of CT findings such as PAL and OAF, but the detection of anaerobic bacteria, and the presence of any symptoms may aid in the diagnosis of ODS.

[Fungal sinus infection by Schizophyllum commune: Report of two clinical cases]. / Infección fúngica sinusal por Schizophyllum commune: a propósito de dos casos clínicos.

BACKGROUND: Schizophyllum commune is a basidiomycete fungus which is widely distributed in nature. Its role as responsible for disease in humans is not well known, partly due to its difficult identification. The incorporation of mass spectrometry techniques (MALDI-TOF) and molecular biology to the laboratories has allowed the description of a greater number of cases. CASE REPORT: In this paper, we present two cases in which S. commune was identified as the causative agent of disease: in the first case an immunocompetent patient suffered from chronic rhinosinusitis, and in the second one a sphenoid sinus infection was diagnosed in an immunocompromised patient. In both cases, S. commune was isolated. Its identification was possible by means of MALDI-TOF and this was confirmed in both patients by amplification and sequencing of the ITS region. CONCLUSIONS: In conclusion, S. commune should be considered a potential causative agent of fungal disease. Currently, MALDI-TOF and sequencing techniques are necessary for its identification.

Fungal ball of the maxillary sinus and the risk of persistent sinus dysfunction after simple antrostomy.

BACKGROUND: Maxillary sinus fungal ball is a common cause of unilateral maxillary sinusitis. Fungal balls or mycetomas are primarily treated with surgery to remove the fungus. However, this assumes the pre-fungal ball sinus cavity was normal and post-surgery patients may suffer from mucostasis in the sinus cavity with persistent symptoms. It is proposed that fungal balls are potentially a feature of impaired mucus clearance as they are a pathology in their own right. METHODS: A case series of consecutive patients undergoing antrostomy for maxillary sinus fungal ball was performed. Patient factors including age, gender, smoking status, comorbidities (allergy, asthma, and reflux), disease specific factors including duration of symptoms, microbiology (bacterial co-infection, Gram-positive and/or Gram-negative) and preoperative radiologic findings (extent of sinus development, and neo-osteogenesis/bone thickness) were collected. The primary outcome was sinus function defined by evidence of a normal functioning maxillary sinus, with the absence of mucostasis or pooling, on endoscopic exam at three months, six months and last follow-up. Endoscopic evaluation of inflammation was also collected. RESULTS: 28 patients (age 58.5 ± 15.5 years, 64.3% female) were assessed. Mucostasis was present at three months in 39.3%, at six months in 32.1%, and 17.9% at last follow-up. There was no comorbidity or radiologic finding that was associated with failure to normalize. Those patients with mucostasis had a higher modified Lund-Mackay endoscopic score at last follow-up (5.0 ± 0.7 v 0.2 ± 0.6, p < 0.01). CONCLUSIONS: Long term post-operative mucostasis occurred in 17.9% of patients following an adequate maxillary antrostomy for treatment of a fungal ball. Patients with mucostasis had persistent mucosal inflammation and a greater need for further surgery (modified medial maxillectomy).

Diagnóstico y tratamiento de la sinusitis maxilar odontogénica / Diagnosis and treatment of odontogenic maxillary sinusitis

RESUMEN Introducción: La patología sinusal inflamatoria e infecciosa puede comprometer la mucosa sinusal maxilar, etmoidal, esfenoidal o frontal, y su etiología es variada. Se ha observado que la patología odontológica es uno de los factores causales de la sinusitis maxilar, con una incidencia del 10% al 40% según diversas series de casos. El diagnóstico y tratamiento se debe realizar de manera interdisciplinaria entre las especialidades de otorrinolaringología y de cirugía maxilofacial. Se elaboró un documento descriptivo sobre la sinusitis odontogénica y orientador sobre su manejo, de acuerdo a una revisión de la literatura. Se realizaron búsquedas en las bases de datos PubMed, Lilacs y Google Académico, utilizando términos relevantes para la sinusitis odontogénica, con el fin de elaborar el documento. Se utilizaron 43 artículos, todos publicados desde el año 1986 hasta la fecha. Se concluye que la sinusitis odontogénica difiere tanto en la clínica como en la microbiología de otras enfermedades sinusales. El tratamiento se basa en el trabajo interdisciplinario e incluye cirugía endoscópica funcional, realizada por el otorrinolaringólogo, en conjunto con el tratamiento odontológico, siendo fundamental la buena comunicación entre ambos equipos.

ABSTRACT Introduction: Infectious and inflammatory sinus diseases have a varied etiology and can be associated to the maxillary, ethmoidal, sphenoidal and frontal sinuses. Dental pathology can be one of the etiological factors associated to maxillary sinus disease, with frequency rates of 10-40%. Diagnosis and treatment require interdisciplinary work, with participation of otorhinolaryngology and oral and maxillofacial surgery. The development of a descriptive document on odontogenic sinusitis and management guidelines according to literature review. Pubmed, Lilacs and Google Academic database were searched using terms relevant to odontogenic sinusitis, in order to prepare the document. 43 articles were used, all published from 1986 onwards. We conclude that odontogenic sinusitis differs clinically and microbiologically from other sinus pathologies. Treatment modalities are based upon interdisciplinary surgery, including functional endoscopic surgery done by otolaryngologists and dental treatment, being fundamental close communication between the two teams.

The Potential of High-Throughput DNA Sequencing of the Paranasal Sinus Microbiome in Diagnosing Odontogenic Sinusitis.

OBJECTIVE: High-throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high-throughput DNA sequencing to diagnose sinusitis of odontogenic origin. STUDY DESIGN: Case series with chart review. SETTING: Single tertiary care academic medical center. SUBJECTS AND METHODS: A chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high-throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient's computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determined by the presence of a periapical lucency perforating the schneiderian membrane. RESULTS: Seven of the 142 patients enrolled in this study had an odontogenic source based on computed tomography scans. Relative to this reference standard, high-throughput DNA sequencing produced a sensitivity of 85.7% (95% CI, 42.1%-99.6%), a specificity of 81.5% (95% CI, 73.9%-87.6%), a positive predictive value of 19.4% (95% CI, 13.1%-27.7%), and a negative predictive value of 99.1% (95% CI, 94.7%-99.9%). CONCLUSION: This study supports the use of high-throughput DNA sequencing in supplementing other methods of investigation for identifying an odontogenic etiology of sinusitis.

Maxillary fungus balls due to Fusarium proliferatum.

Fungus ball is the most common form of non-invasive fungal rhinosinusitis. Aspergillusfumigatus (between 44.8% and 75%) and Aspergillusflavus (14%) are the two most common species recovered. However, recent advances in mycological laboratory methods have enhanced the detection and identification of fungi within fungus balls. Fusarium species, sometimes recovered from other forms of fungal rhinosinusitis such as allergic fungal rhinosinusitis or acute invasive fungal rhinosinusitis, are poorly associated with sinonasal fungus ball. Here, we describe two further cases of a fungus ball due to Fusariumproliferatum and provide the first description of this fungal pathogen with a fungus ball of odontogenic origin. These case reports demonstrate that uncommon fungal species such as Fusarium spp. might be underestimated as agents of sinusal cavity fungus ball. Enhanced mycological detection and diagnostic techniques might give rise, in the near future, to the emergence of new or rare fungal species associated with this clinical entity.

Burkholderia gladioli sinonasal infection.

INTRODUCTION: Burkholderia gladioli are non-fermenting, Gram-negative, rod-shaped aerobic bacteria that were first identified as a plant pathogen. Most of the B. gladioli infections reported in the literature have involved immunocompromised adults and newborn infants. B. gladioli in humans is often associated with a poor prognosis. CASE REPORT: We describe the first case of sinonasal infection due to B. gladioli and Staphylococcus aureus in an immunocompetent patient who had recently travelled to the Congo. DISCUSSION: As in the few other reported cases involving immunocompetent patients, the appropriate approach to this multidrug-resistant B. gladioli infection was a combination of surgery and antibiotics chosen in the light of an antibiogram.

Sinus Augmentation Failure and Postoperative Infections Associated with Prophylactic Clindamycin Therapy: An Observational Case Series.

PURPOSE: This observational study was based on a series of clinical cases in which failure of sinus augmentations occurred in patients who received prophylactic clindamycin therapy. MATERIALS AND METHODS: Between the years 2006 and 2010, a retrospective observational study was performed. The study consisted of 1,874 patients (723 males and 1,151 females) in whom sinus augmentations were performed prior to placement of dental implants. RESULTS: In nine (0.48%) patients (four males and five females), infection of the graft material inside the sinus floor occurred, and six patients developed an abscess in the site of surgery, 4 to 6 weeks postoperatively. In three patients, a buccal fistula with pus draining was observed 5 to 8 weeks postoperatively. In all patients, the source of infection was from the grafted material within the sinus. A common manifestation in all nine patients was that they had self-reported penicillin allergy and had been prescribed clindamycin (300 mg every 6 hours for 10 days). CONCLUSION: Prophylactic clindamycin therapy following sinus augmentation procedures seems to be a risk factor for infections and loss of grafting material following these surgical techniques.

Bony Changes in a Unilateral Maxillary Sinus Fungal Ball.

OBJECTIVES: In the paranasal sinus fungal ball (SFB), changes that occur in the underlying bone have not been well described. Recently, bacterial coinfection has been reported in patients with paranasal SFB. We evaluated whether bone changes occur in patients with unilateral maxillary SFB, and also how bacteria in an SFB affect the bony wall of the sinus. METHODS: A retrospective study of patients with a unilateral maxillary SFB undergoing endoscopic sinus surgery was conducted from July 2009 to December 2015. Preoperative computed tomography images of the patients were reviewed. Wall thickness (WT) and wall density (WD) of the diseased sinus were measured and compared to the normal sinus. Specimens of the sinus aspirates were obtained during surgery for aerobic and anaerobic cultures. RESULTS: Forty-three patients were included (mean, 55.7 ±â€Š12.8 years). Thirty-one cultures (72.1%) were positive for bacteria. Thickening was evident in the anterior, lateral, and posterior walls of the diseased sinus. The average WT was 1.69 ±â€Š0.45 mm on the diseased sinus and 1.14 ±â€Š0.31 mm on the normal sinus (P < 0.001). In the diseased sinus, the difference in the average WT between the culture-positive and culture-negative groups was not significant (P = 0.44). The average WD on the diseased sinus was higher than that on the normal sinus (P < 0.001). CONCLUSIONS: Osteitic change occurred in most patients with a unilateral maxillary SFB. The presence of bacteria in sinus secretions does not greatly affect the development of osteitic changes in unilateral maxillary SFB.

Odontogenic sinusitis: developments in diagnosis, microbiology, and treatment.

PURPOSE OF REVIEW: Odontogenic causes of sinusitis are frequently missed; clinicians often overlook odontogenic disease whenever examining individuals with symptomatic rhinosinusitis. Conventional treatments for chronic rhinosinusitis (CRS) will often fail in odontogenic sinusitis. There have been several recent developments in the understanding of mechanisms, diagnosis, and treatment of odontogenic sinusitis, and clinicians should be aware of these advances to best treat this patient population. RECENT FINDINGS: The majority of odontogenic disease is caused by periodontitis and iatrogenesis. Notably, dental pain or dental hypersensitivity is very commonly absent in odontogenic sinusitis, and symptoms are very similar to those seen in CRS overall. Unilaterality of nasal obstruction and foul nasal drainage are most suggestive of odontogenic sinusitis, but computed tomography is the gold standard for diagnosis. Conventional panoramic radiographs are very poorly suited to rule out odontogenic sinusitis, and cannot be relied on to identify disease. There does not appear to be an optimal sequence of treatment for odontogenic sinusitis; the dental source should be addressed and ESS is frequently also necessary to alleviate symptoms. SUMMARY: Odontogenic sinusitis has distinct pathophysiology, diagnostic considerations, microbiology, and treatment strategies whenever compared with chronic rhinosinusitis. Clinicians who can accurately identify odontogenic sources can increase efficacy of medical and surgical treatments and improve patient outcomes.

[Pseudo-tumoral invasive fungus infection of the maxillary sinus in Abidjan]. / Infection invasive à champignon filamenteux pseudotumorale du sinus maxillaire à Abidjan.

INTRODUCTION: The invasive fungal infection of the maxillary sinus is a rare and serious disease generally favored by immunosuppression. We report an exceptional case of pseudotumoral invasive fungal infection of the maxillary sinus in an immunocompetent patient. OBSERVATION: A 32-year-old patient consulted for labial and left temporal swelling associated with proptosis and chemosis that has been developing for 18 months. The scanner objectified a filling of the left maxillary sinus, and the ipsilateral orbital cavity, and the surrounding muscles. Histological examination of the surgical specimen revealed invasive fungal infection of the left maxillary sinus. The relevant antifungal therapy, namely voriconazole, could not be administered due to the unavailability of the medicine. However, the patient has received 200mg of itraconazole every 12hours for three weeks. The change proved disappointing with recurrence and significant sequelae, sort of sagging of the right hemifacial, severe limitation of mouth opening and functional loss of the right eye. CONCLUSION: The invasive fungus infections of the maxillary sinus and the orbit are exceptional in immunocompetent patient. Healing is based on early diagnosis and administration of the reference antifungal to face the risk of recurrence.

Fungus Ball of the Maxillary Sinus Presenting With Epiphora.

The authors report a case of fungus ball of the maxillary sinus with bone erosion presenting with epiphora, which was diagnosed after treatment failure using silicone intubation for nasolacrimal duct obstruction. Symptoms of sinus fungus ball are similar to those of chronic bacterial rhinosinusitis, although occasionally asymptomatic. To our knowledge, epiphora has never been reported as a symptom of sinus fungus ball. The purpose of this report is to emphasize the importance of considering sinonasal causes when evaluating epiphora patients, as well as to suggest the use of preoperative CT scans for a more accurate diagnosis and to prevent unnecessary procedures.

Unusual case of bilateral maxillary fungus ball.

An otherwise healthy 34-year-old man was referred to our ear, nose and throat (ENT) clinic for a bilateral maxillary radiologic opacity. This condition was accidentally discovered with a panoramic radiography performed during a follow-up visit after a bilateral endodontic treatment. The patient did not report any specific sinonasal symptom such as purulent nasal discharge, loss of smell and cough, apart from an unspecific sinus pressure. The CT scans showed a bilateral inflammatory process into the maxillary-ethmoidal sinuses and an iron-like density within the maxillary sinuses, while nasal endoscopy showed purulent discharge in the ostiomeatal complex. The patient underwent functional endoscopic sinus surgery under general anaesthesia and the inflammatory material collected was histologically diagnosed as a rare case of bilateral fungus ball. The patient was dismissed the following day with no complications; there were not any sign of recurrence or symptoms during a 4 month follow-up.

[Clinical analysis of chronic invasive fungal rhinosinusitis].

OBJECTIVE: To investigate the clinical features and treatment of chronic invasive fungal rhinosinusitis(CIFRS). METHODS: From June 2006 to August 2011, seven patients were pathologically diagnosed as CIFRS in otorhinolaryngology department of Peking university first hospital and included in this study. The clinical records were reviewed. The clinical features, clinical course, symptoms, clinical signs, CT/MRI scan of the sinuses, surgical approach, postoperative pathology and medications were analyzed retrospectively. These 7 patients received both surgical and systemic anti-fungal treatment. Among them, 2 cases with characteristically clinical features were addressed into further analyses to explore the clinical feature and treatment of CIFRS. RESULTS: Among the 7 patients, 5 were female and 2 were male. The course of diseases were from 2 months to 8 years. All patients had no systemic immune diseases and history of diabetes mellitus, while 1 case had a history of facial trauma, and another 1 case had received antibiotics for long-stay in bed after a car accident. The onset lesions of 6 cases were in unilateral maxillary sinus and 1 in unilateral ethmoid sinus. Aspergillus fungi were detected in 6 cases and mold fungi were detected in 1 case by pathology or fungal culture. After follow-up for 1-5 years, 6 patients were cured, and 1 was died. CONCLUSIONS: CIFRS are often diagnosed in patients with normal immune function. Lesions alwasys occur in single sinus, and maxillary sinus is the most commonly involved.Aspergillus is the most common pathogens. Early clinical manifestation and sinus CT images are lack of specificity. Surgery associated with adequate antifungal treatment might be the best treatment strategy.

Association between maxillary sinus fungus ball and sinus bone grafting with deproteinized bovine bone substitutes: a case-control study.

OBJECTIVE: To evaluate the association between sinus bone graft and the development of fungus ball (FB) of the maxillary sinus. STUDY DESIGN: The charts of all patients seen for surgical treatment of maxillary sinus FB following sinus bone grafting between 2006 and 2014 were reviewed. The charts of 49 participants were selected from our internal registry for comparison as controls. The association between FB and age, gender, smoking habits, associated co-morbidities, and bone grafting material was evaluated. FB of the maxillary sinus was estimated by using an odds ratio with a Yates' correction. P values were computed using Fisher's exact test, and the statistical significance was set at a P value < .05. RESULTS: All 13 cases (100%) with FB of the maxillary sinus had received anorganic bovine bone as the bone substitute (P = .0001). There were significantly more women in the case group than in the control group (84.6% in the cases vs 40.8% in the controls; P = .01). CONCLUSIONS: This study demonstrated a significant association between a specific deproteinized bovine bone substitute use as sinus bone graft material and subsequent development of FB of the maxillary sinus.