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Monday, March 3rd, 2008 | in
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I did a sinus lift on a 23 year old female. She is a non-smoker. I used autogenous bone graft and there were no immediate complications. After 2 weeks post-op she has developed a bad taste in her mouth in her mouth and she has a constant drainage from her nose. The drainage is clear and watery. I am not sure how to manage this patient now. Everything seems within normal limits radiographically. Should I prescribe antibiotics and spray for the nose?
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22 Responses to “ Constant Drainage after Sinus Lift: Protocol? ”
Dear Colleague,
It’s likely your patient has developed a sinus infection due to the sinus lift. I have had a similar experience which I was able to resolve. I would suggest trying an antibiotic. If that doesn’t resolve the infection, your best option is to re-enter the sinus and drain it, you may need to remove your graft (depending on what you find) and re-attempt it a few months later. Good luck.
Did you place a membrane in the sinus area before you packed the bone as an insurance policy if you perforated the membrane?
If not you should do this going forward…it doesn’t cost that much, and I like to have a good mind that I know that I have covered my bases.
Well no doubt you’ve got sinus infection.I would give antibiotics mostly against anaerobs like Zitromax for 10 days.If the situation persists you will have to get in and take the infected graft out.
I would suggest culturing the drainage and base any continuing antibiotic therapy on the culture. If normal flora, then consider some other cause… possibly not related to the graft. Clear and watery is not usual for infection, but bad taste leans toward infection.
Consider asking a colleague with more surgical experience to look at the case.
Always have the patient do the gentle blow in and out nose after the Schneiderian membrane is been clearly separated to make sure there are no perforation., If is no perforation I suggest not to use any nose spray or blow nose by the patient. Put the patient under antibiotic coverage for 15 days and make him/her use a Neti pot for cleaning the sinus with no pressure once a day every two to three days and recall 21 days later for examination.
healthandyoga.com/html/clean/nasal.html
Sounds like an acute case of RhinoSinusitus. Follow the American Academy of Otolaryngology/Head and Neck Surgery Guidelines for the appropriate antimicrobial therapy for this disease with or without re-entry. Zithromax is definitely CONTRAINDICATED due to lack of efficacy against the 3 most common pathogens S. pneumonia, M. Catharralis, and H. Influenzae. High dose Amoxicillin, Augmentin, or a Fluroquinilone would be more appropriate.
Do what Ziv Mazor advised.
Steve Wallace
First administer Augmenmtin, 875 Mg TID for ten days, then ask questions!
Regardless of what you do at this point (my recommendation is using AUGMENTIN 625mg or higher) for 7-10days), it would be a good idea to determine the etiology and try and minimize the risk for this happening again in the future.
Perhaps you could revisit your surgery protocol and especially your postoperative protocol:
Was the appropriate antibiotic used for a sinus lift
Did you confirm that no tear is present or if there was, how was it treated.
Was the lateral window covered by a membrane (studies support its usage).
Have you considered different materials (multiple studies support non-autogenous bone vs. autogenous bone for Sinus Lifts/ for everything else autogenous bone is still the gold standard).
Were anticongestants subscribed immediately postoperatively.
Were anti-inflammatories subscribed?
Was the suturing technique appropriate (includng choice of suturing material & technique)?
T
I would immediately reinvestigate the area of lift. I will bet you have a purulent graft site. You can try the 15 day regimen of antibiotics if you have a great patient/doc relationship,but I’d like to know what the graft site looks like now. We all have to think about the legal side these days. I quick look will go along ways. A wait and see may be questionable. Remember antbiotics won’t resurrect an infected graft. If its infected get it out, culture it, and go back later for another attempt. If its not then you know its a normal sinus inflammation and treat it with the what ever you feel is approriate.
dear dr. i think the picture of acute sinus infection is not complete, first clear watery discharge is not bacterial infectoin.plus you didn’t mention if this patient is suffering from sinus headache or not.also possibility of blocking the sinus opening is not exisiting because the patient has a discharge.
I would do first sinus x ray.check other symptomes related to sinusitis.
prophylactic antiobiotic ( augmentin)is ok to use at least to avoid the secondery infection of the congested mucosa which causing the watery discharge,what ever is the cause.nasal dropes well help decongestion.
I am interested in where the autogenous bone cam from and how large the graft was. The larger the volume, I believe the harder the body has to work to get it to incorporate. There is a limited amount of circulation surrounding the graft, whether a small volume or large. Its a great place to grow bone, but there are variables and limitations and things we can do. What about steroids? premedication, prophylactic ABX coverage? These can have a positive effect on the early survivability. I certainly feel that the use of steroids for a graft improves untoward early inflammatory consequences. Also, incorporating ABX into the graft is a consideration. Thank you for posting this for discussion. Bill
Dear colleague,
I am very satisfied with the following preventive protocol:
The day before and 5-7 days after the surgery augmentin + Flagyl (Methronidasol).
If you started already with the antibiotic, just add Flagyl.
Wish you success!
Dear Dr.
First, if you have used a block bone graft, you must have fixed it to the wall or floor of antral cavity by something like a titanium screw. In my experience, if the block bone graft is mobile inside the cavity, it will surely become infected and continue to discharge until it is resorbed totally. There may always be some invisible micro-tearings in the schneiderian membrane or contamination with oral microbiota during the graft transfer or even a blood-borne retrograde bacterial contamination that may help to develope such an infection.
Second, at this situation, your drug of choice will definitely be Amoxicillin + Clavulanic Acid + Metronidazole.Although azithromycin (Zithromax) is used to treat some cases of sinus infections, it is mostly prescribed when the clinicians are trying to control an antral infection caused by Chlamydia or Mycoplasma, which is certainly not your case.
Hi there,
Good posts. A few questions autograft from where and fixed how??
The antibiotics of choice would be Amox+Clavulanante pot. with Satronidazole.
Even clindamycin would do if patient can’t take Amox.
A clear discharge would be better handled with medication and nasal decongestant drops. If it becomes purulent go in and investigate and if necessary remove the graft.
Sometimes manipulation of the membrane while elevation produces this discharge, as long its sterile on culture it should resovle with medication.
Dr.Ziv and Dr. Wallace
Will you please give your reasons to use zithromax instead of augmantin and why for 10 days instead of routine dose of zithromax 500 mg for 3-5 days for bacterial sinusitis?
What is your opinion about doing C&S.
Incase of resistant organisms proper anibiotics can be prescribed.
Thanks for discussion
Ive just recently had the same problem
It went on for a while ..initially patient complained of bad taste and bad smell ..put of food etc
i went back in (4 weeks post op)and found the site on one side was purulent
the other was not
I cleaned out the site and irrigated copiously
I lost a lot of the graft but some stayed and seemed stable I then closed up and ensured a lot of bleeding
Augmentin and Metronidozole seemed to work very well with the re entry procedure
Why the comments on Zithromax ..??
Everything healed perfectly odours and smells dissapeared in days .
The x ray actually shows 2 good grafts !..Im tempted to go ahead and place implants into the site that the infection was in without another graft.
The Panex actually looks very good
“I am not sure how to manage this patient now”. Sounds like you need to refer the patient to someone you trust and know. That was one week ago, and hopefully you have already done that. Please post an update of her progress.
Dear satish joshi,
Treating upeer respiratory infections- and the sinus cavity is a part of that system -the first drug of choice is Zhitromax followed by Augmentin.This is the advice I got from my ENT which specializes in these infections.I usually add to the Zhitromax metronidazole as well. 10 days for the infected sinus is a must.
Dr S SenGupta,
I would question you being “tempted ” to go in and do the implants anyway…”xrays actually shows two good grafts”. The xrays shows two images. You will know they are grafts that are good when you go back in. I would go back in leary of the grafts until proven otherwise. JMHO. I have learned NOT to whistle in the graveyard too soon, as one of my colleagues put it. Bill
Dear Dr.Mazor,thanks.
Do you do C&S on patient on first visit after complication before starting Zithromax?
Isn’t is medico-legally advisable eventhough zithromax does cover most sinus organisms ?
I would appreciate your input.
Zithromax(Azithromycin) is a macrolide, thus a bacteriostatic agent and Augmentin is Amoxicillin, thus a bacteriocidal agent.Combining these two agents makes both of them ineffective, and if Azithromycin therapy is being followed by Amoxicillin, then the latter is supposed to kill the bacteria that have not been born yet.That highly respected ENT specialist seems to be a pro-choice.
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