About Oroantral communication and fistula

Oroantral Communication and Fistula

- Oroantral communication is a pathological communication between the oral cavity and the maxillary sinus.

- An oral antral fistula is an epithelialized, pathological, unnatural abnormal communication between the oral and antral cavities.

Etiology:

- Oral fistula can result from following causes:

1. Extraction of upper molars and premolar teeth (48%)
2. Tuberosity fracture
3. Destruction of the portion of the floor of sinus by periapical lesions.
4. Implant dislodgement into maxillary sinus.
5. Perforation of floor of sinus and sinus membrane. with injudicious use of instruments.
6. Forcing of a tooth or a root into a sinus during its removal.
7. Extensive trauma to face.
8. Surgery of maxillary sinus.
9. Osteomyelitis/ Osteoradionerosis.
10. As a complication of the caldwell - luc surgery.
11. Malignant granuloma

 Predisposing Factors

- During extraction of post maxillary teeth.
- Hypercementosis or ankylosis of the tooth.
- Long standing decay or infected teeth.
- Severe Periodontitis.
- Previous history of oroantral communication.
- Density of the bone and the size of the sinus.

Symptoms of the Recently Created Oroantral Communication (5 E's):

1) Escape of fluid: Fluid regurgitation and escape of air through the nose from the sites of extraction.

2) Epistaxis: Unilateral epistaxis is seen due to escape of blood from the sinus the nose through the ostium.

3) Escape of air: Air escapes into the nose from the mouth during sucking, inhaling.

4) Enhanced column of air: Which causes a change in the vocal resonance and change in voice.

5) Excruciating pain: Severe pain in and around the region of affected sinus.

Sign of Recently Created Oroantral Communication:

1. Disappearance of the root piece of the extracted tooth.
2. Positive nasal blow test.

Symptoms Established Oroantral Fistula (Remember 5 P's)

1) Pain : As the fistula is established by epithellisation, it allows free escape of fluids, so pain is less then seen in early stage.

2) Purudent nasal discharge: When the head is lowered, there is persistent, purulent unilateral discharge from affected side of nostril.

3) Postnasal drip: Unilateral nasal discharge from the posterior nares, down the pharyme.

4) Possible sequence of general systematic toxaemic condition: Fever, anorexia, malaise, parietal and frontal headaches and in extreme cases, anosmia.

5) Popping out of an antral polyp: Opening of long-standing OAF is occluded by an antral polyp.

Signs of Established Oroantral Fistula:

1) Early Signs: Disintegration of blood dot as a result of forceful nose blowing, excessive mouth rinsing and infection. Signs and symptoms of sinusitis and rhinities.

2) Late signs: Escape of fluids on air through nose, development of polyps.

Decision Making in the Treatment of Oral antral communication and antral Fistula:

- if oral antral communication is less than 2 mm in diameter, without epithelialisation and in the absence of sinus infection, there can be spontaneous healing if proper precautions are taken.

- If the defects are larger than 5-6 mm spontaneous healing rarely takes place and will require surgical intervention.

Management of Acute Oroantral Fistula:

Temporary Measure:

1) Whitehead'sVarnish Pack:
- The pack is used over the socket and secured with sutures.
- Whitehead's varnis:

1. Benzoin 10 parts 44g
2. Storax 7.5 parts 33g
3. Balsam of Toke 5 parts 22 g
4. Iodoform 10 parts 55 g
5. Solvent ether to 1flO₂ O₂ 100 parts 

2) Denture Plate:
- Indicated with there is delay in surgical repair of fistula. Denture plate acts as barrier to prevent entry of food particles into the antrum.

Immediate Closure:

- Primary closure of the socket by mucoperiostal flops, is the simplest method which is obtained by reducing the height of the bony socket.
- Antibiotics are prescribed to prevent sinus infection.

Supportive Measure:

- Antibiotics: These are preserbed to prevent secondary infection at the site, to prevent pre existing infection of antrum.
- Based on culture and sensitivity testing, the selection of antibiotic must be done.

Penicillin and its derivatives: 

- Initially i.v route and later switched to oral route.
- Penicillin V 250 - 500 mg six hourly.

Nasal Decongestants:
The encourage the drainage of pus and secretions. for e.g. Ephedrine(0.5 %) or otrivin nasal drops 3 drops TDS for 7 days.

Analgesics: NSAIDs

1. Tablet Aspirin 500 mg OID daily.
2. Tablet paracetamol 500mg TDs daily.
3. Tablet Ibuprofen 400mg TDS daily.

Surgical options for closure of oroantral fistula.

Surgical management for closure of OAF is briefed in flowchart.