Osteoradionecrosis of the Posterior Maxilla: A New Approach Combining Erbium: Yttrium Aluminium Garnet Laser and Bichat Bulla Flap.

Osteoradionecrosis (ORN) of the jaw is a complication of radiation therapy for head and neck cancers. We report a case of ORN of the posterior maxilla treated with Er: YAG laser and a pedicled buccal fat pad (bichat bulla adipose) flap. A 69-year-old man presented complaining of pain on left maxilla. He had received high-dose radiotherapy (90 Gy) for squamous cell carcinoma of the left soft palate 2 years earlier. Clinical and radiographic examinations revealed ORN of the left maxillary molar region and maxillary sinusitis. Daily home care consisted of 0.9% saline irrigation and 0.8% H2O2 gel application. Sequestrectomy and tooth extraction were followed by debridement with Er: YAG laser and repair with a pedicled buccal fat pad flap. Complete resolution of ORN and maxillary sinusitis was established one year postsurgically. The excellent clinical outcome suggests that Er: YAG laser debridement and pedicled buccal fat pad flap are a viable option to treat ORN of the posterior maxilla.

Chronic oroantral fistula: combined endoscopic and intraoral approach under local anesthesia.

OBJECTIVE: To evaluate the outcome of combined surgical treatment of oroantral communications associated with chronic maxillary sinusitis. PATIENTS AND METHODS: 8 consecutive patients affected by complicated oroantral fistula were included in the study. The protocol consisted of: clinical, endoscopic and radiological preoperative evaluation (panoramic tomogram and computed tomography); systemic antibiotic and steroid therapy 2 weeks before surgery; one-stage surgical procedure under local anaesthesia consisting in uncinectomy with enlargement of the osteomeatal complex through endoscopic nasal approach associated with the closure of the oroantral communication by means of a mucoperiosteal flap; postoperative antibiotic and cortisone-based therapy. Follow-up consisted of weekly clinical evaluation during the first month, and nasal endoscopy at 3, 8 and 24 weeks after surgery. RESULTS: After surgical treatment, all patients were symptom-free and had no endoscopic and radiological evidences of maxillary sinusitis at the 6-month follow-up. No recurrent oroantral fistulas were found. CONCLUSIONS: The current prospective study showed that a one-stage, combined endoscopic and intraoral approach under local anaesthesia represents a feasible and minimally invasive procedure for the long-term effective treatment of chronic complicated oroantral communications. Moreover, it represents an easily applicable approach also in outpatient clinics with minor patient discomfort.

Sinusitis due to Stenotrophomonas maltophilia.

This is the first report of a patient diagnosed with sinusitis due to Stenotrophomonas maltophilia. Despite the organism being resistant to trimethoprim-sulfamethoxazole, the infection was cured by drainage and treatment with intravenous piperacillin, followed by oral ciprofloxacin.

Local anesthesia with EMLA cream for maxillary sinus puncture.

Maxillary sinus puncture is traditionally carried out through the lateral wall of the inferior nasal meatus under local anesthesia. One problem with it is that the insertion of a cotton-tipped applicator soaked in local anesthetic is painful. Patients also dislike waiting for the anesthetic effect with the metallic applicators in the nose. In this study, we present a new, well-tolerated method of topical anesthesia for maxillary sinus puncture via the inferior meatus of the nose. Twenty adult patients with maxillary sinus infection who were undergoing bilateral maxillary sinus puncture were studied. One side of each patient's nose was anesthetized with a cotton-tipped applicator moistened with a lidocaine-adrenaline solution (LA), and the other side was anesthetized with EMLA cream instilled with a suction needle and syringe; the sides were chosen randomly. The mean "application of anesthesia" pain score on a 100-mm visual analog scale was 39.2 for the LA side and 9.1 for the EMLA side (p < .01). The anesthesia required for puncture was reached more quickly on the EMLA side than on the LA side (p = .02). The mean puncture pain score was 25.1 with LA and 8.6 with EMLA (p = .01). Fourteen patients out of the 20 (70%) found EMLA more tolerable, 3 patients (15%) found no difference, and 3 patients (15%) preferred LA (p < .01). We conclude that EMLA is better-tolerated and quicker-acting than LA for local anesthesia in maxillary sinus puncture.

Microbiology and management of chronic maxillary sinusitis.

OBJECTIVE: Assessment of the microbiology and management of patients who suffered from chronic maxillary sinusitis was studied retrospectively. DESIGN: Retrospective analysis of microbiology and antimicrobial therapy of 68 patients who underwent the Caldwell-Luc procedure for chronic sinusitis had not received antimicrobials before surgery and whose cultures showed bacterial growth. SETTING: This study was performed at the Naval Hospital in Bethesda, Md. INTERVENTION: Amoxicillin-clavulanic acid was given to 18 patients, amoxicillin or ampicillin to 25, cefaclor to 17, and erythromycin to eight. RESULTS: A total of 183 isolates (123 anaerobic and 60 aerobic) were recovered. Anaerobic organisms only were recovered from 35 (51%), specimens, and aerobic or facultative bacteria only in 12 (18%), and mixed aerobic and anaerobic flora in 21 (31%). Thirty-four aerobic and anaerobic beta-lactamase-producing bacteria were isolated from 28 patients. The 18 patients who received amoxicillin-clavulanic acid had the most rapid and complete response to therapy, none required a change in therapy, and surgical drainage was required in one case. Of 25 patients who received amoxicillin or ampicillin, eight required a change of therapy due to clinical failure (32%), including three who also had surgical drainage. Of 17 that received cefaclor, five had an antibiotic change (29%), one with surgical drainage. Of the eight who were treated with erythromycin, three needed antibiotic change (38%), two with surgical drainage. Resistant organisms were recovered from most of the patients that required therapeutic change. CONCLUSIONS: These findings indicate the major role of aerobic and anaerobic beta-lactamase-producing bacteria organisms in the polymicrobial etiology of chronic maxillary sinusitis and illustrate the superiority of therapy effective against these bacteria.