How Do I Manage Oroantral Communication? Key Points
This Urgent Care Scenario (USC) is presented by the JCDA Oasis Team in collaboration with Dr. Archie Morrison and is also available through the JCDA Oasis Mobile
Oroantral Communication (Oroantral Fistula)
Oroantral Communication (OAC) is an abnormal communication between the maxillary sinus and the oral cavity. It may be the result of different pathological processes and often occurs following an extraction. Other causes for OAC include: infection, inflammatory conditions, neoplasm, Paget’s disease, iatrogenic injury, and trauma.
- Individuals who recently underwent maxillary posterior tooth extractions.
- Individuals presenting for extraction of a long-standing lone posterior maxillary molar.
- Individuals presenting with a radiographic signs of large maxillary molar roots or close root proximity to the sinus floor.
- Elderly people presenting with large bulbous roots with more bone expansion and possible fracture of the thin sinus floor.
- Individuals with the loss of lamina dura on the maxillary posterior teeth to be extracted.
- Bulbous expansion of the alveolar bone from large roots with increased risk of root and alveolar bone fracture
- Fracture of the antrum floor
- Attachment of sinus lining and associated fractured bone and roots upon extraction
- Dark opening into the sinus visualized with appropriate lighting
- Loss of the socket blood clot in the days immediately following extraction
- Patient complains of fluid going from mouth to nose when drinking.
- Patient feeling a sensation of air rushing through the socket as they breathe.
- Pain severity: Usually not painful unless secondary sinusitis develops.
- Ask the patient about fluid rush to the nose while drinking.
- Perform a complete extra- and intra-oral examination as well as radiographic examination to rule out local pathologies.
- With appropriate lighting, rule out the loss of the blood clot or granulation tissue in the socket.
- Confirm the suspected small openings into the antrum.
- Perform a gentle Valsalva test, if there is still question of an opening after taking a history and examining the patient and not finding a definitive opening.
Based on clinical examination and radiographic findings, a diagnosis of oroantral communication (oroantral fistula) is determined.
Common Initial Treatment: Estimate the fistula diameter
- 1-2 mm: No treatment required as it will usually naturally heal.
- 2-4 mm: Carefully follow the patient after 1-2 weeks and advise to avoid straining the area (no holding back sneezes, no smoking, no use of straws, no pressure on the sinus).
- 6 mm or larger: Follow up at 2-4 week intervals for 3-4 months prior to referring for surgery. Consider referral to an Oral & Maxillofacial Surgeon for further evaluation.
- Amoxicillin (500 mg/adults) 3 times daily for at least 1 week and maybe 2 from the outset.
- Use Clindamycin in penicillin-allergic patients.
- For resistant infections consider using levofloxacin 500 mg once daily.
- Use over-the-counter sympathomimetics, such as Otrivin or Sudafed to control sinus congestion for a maximum of 3 days.
- Consider a nasal steroid spray, such as Flonase to limit inflammation of the sinus lining.
- Debride the socket and pack with Gelfoam to help form a blood clot.
- Close with a buccal advancement flap: advance some buccal soft tissue over onto the palate and secure it with sutures.
- In case of a large opening: swing a palatal pedicle finger flap into the area and cover it with a buccal advancement flap.
- For very large chronic defects, consider using a buccal fat pad graft into the socket before covering with your flaps.
- Chronic sinusitis
- Osteomyelitis with maxillary bone loss although less common.
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