Post-Operative Infection after Sinus Lift: Causes?

Dr. A. asks:

I have had excellent success with direct sinus lifting using mineralized corticocancellous allograft, soaked in Ancef [cefazolin]. I also use a collagen membrane soaked in Ancef as well, and a membrane over the window prior to closure. The patient is put on a Augmentin 875mg , as well a Dexamethsone protocol, Sudafed, and Chlorohexidine rinse.

However I had a couple of cases recently, where the patient was healthy without systemic disease, with no allergies, where the surgery was uneventful. The patient returned two weeks post-operative and the surgical site looked great. Then at 3.5 to 4 weeks patient returns with a moderate size swelling in the upper side where the sinus lift was performed. Intraorally, everything is normal and incision lines are closed. Radiograph shows the graft still completely intact. Obviously an infection has occurred, however anyone know why, and what is the best course of treatment?

34 thoughts on “Post-Operative Infection after Sinus Lift: Causes?

  1. It could be a secondary infection due to the use of systemic glucocorticoids. What kind of “Dexamethasone protocol” are you using? You should probably treat this like a “normal” orofacial infection, eg. drainage, bacterial sampling, antibiotics and close observation of the site and the patient.

  2. Is patient a smoker? That can cause serious problems in a healthy patient. Also, if patient is abusing cocaine can cause problems. Very fine line in asking these questions but may take a little bit of the mystery out of the puzzle.

  3. are you sure the site is infected? You only mentioned swelling. I have seen moderate to severe swelling (which was only inflammatory in nature) in some otherwise healthy patients. Hid you see the patient for post ops in the 4 week period. I assume your dex protocol was 3 days or less.

  4. Have you ever used PRP instead of using Ancef? Additionally, I am a big advocater of using autogenous bone. I never do sinus lifts that aren’t at least 50% autogeonous bone. I mix my bone/allograft with prp and place patient on abx for 1 week after surgery and I rarely if ever see sinus infections with this technique that includes the times when I have a membrane perforation. I would also recommend that you not place patients on extended doses of steroids as this can intefere with healing and expose your patients to higher risk of infection. PRP does a nice job with helping with post-op inflammation for me. I have seen a big difference in how well my patients do with and without PRP. Smoking, holes in the membrane, incomplete lifting of the membrane, excessive steroid, prior exsisting sinus diseases, infected extraction sites, age of the patients can all contribute to post-op sinus lift infections. Check your technique first.

  5. First I would place them On a combo of Amox500mg with Flagyl250mg for 7-10 days. Take a Cat Scan. Get an ENT to see what he or she thinks. It may be unrelated. It would be odd for this much time to elapse adn now have an infection.

  6. Do yourself and your patient a favor and make an ENT refferal. It is a good thing to have an ENT doc who can check the sinus prior to surgery also. If there is any question about sinus health you will know. Get to know some of the specialists in your area don’t wait until you are in real trouble.

  7. Dear resident( grasshopper) , you have a lot to learn. 3-5 days of preop steroids is not going to effect the immune system In most healthy patients. It is always important to appreciate that large steroid dosing can cause immune system compromise and even an addisons type crisis, but soon you will be tx life threatening infections with this drug. You will ultimately have an infection where the airway is so comprised in a “true Ludwigs infection” that while considering the emergent cricothyroidotomy or trach. , you will need to give high dose steroids to reduce soft tissue inflammation. Entensive studies have proven , that infection rates are not increased in this scenario, and you see first hand the amazing effect of membrane stabilization, first hand. I have routinely used preop steroids for the last fifty sinus lifts with no infections . I use prp / autogenous bone mixed with demin. Or min. Bone. I don’t use a membrane in a true sinus lift, even though a lot of literature suggest it. I feel like the periosteum and the vascularized intact bony wall is more than adequate, thus leaving another foreign body out of the picture. I agree with some of the earlier entries that suggest referring it out to an ent, especially if you can’t handle the complications. Almost all boarded omfs trained in the last two decades are very comfortable treating these issues ,in that functional endoscopic sinus surgery is something most of us do on a routine basis . Here is where the continued interdiscilplinary turf wars starts to hurt the patients, however. The majority of well trained ent’s are very uncomfortable with the traditional caldwell luc approach, and some even suggest it’s malpractice. So, if you really think it’s in the best interest of your patient to bypass your omfs colleques , I might reconsider! Obtaining a high quality ct preop is important , assuming you know how to asses the osteomeatal complex. If not ,send your scan off to get it read. I have seen infections of this area resolve with po abx and wound care. Cover the anaerobes . Bon chance! Bv

  8. Ancef is not best antibiotic choice here. Wrong spectrum. If you need a liquid to soak in, ampicillin is a cheap and better alternative.
    Baker Vinci, less preach, more teach.

  9. Really sb, these are day to day facts. Do you think the ent is the appropriate route to take in managing this problem. If so , I’m going to encourage some intensive ce. Some spiritual advice would not hurt some of the scenarios we see on this sight. Good day. Bv

  10. Shame on the maxillofacial community for not educating our colleques as to what we do. The reason I have such an issue with referring a dental problem to a non dental surgeon, is because most ent’s have no concept of what we are doing. Let’s take the nasal lift scenario for example. Yes, ent’s do more nasal surgery than I do, that’s the nature of the referral pattern, but I can promise you, not one of the ent doctors that I know, could show anyone how to do a true nasal lift. If you have a dental surgeon down the street that is better suited to handle the problem, why wouldn’t you use their service. Do you think an ent could perform a sinus lift???? Sorry for the preaching, but all of us spent a lot of time getting here, do what’s best for the patient. Bv

  11. I agree fully with BV here most ENT surgoens have no or very little idea what we are and have been doing in the sinus . It is enlightenning to speak to them about issues such as infection , tears in the lining etc as there are some very ususal answers ( after a major tear close and re-enter at 2 weeks ! ).
    But another area that must be a bigger help than I initially thought is the use of bacterio-static synthetic graft materials where even in difficult situations spread of infection is controlled .
    As it is the anaerobes not the usual respiratory aerobic bacteria that are the main cause of issues in our case , a different approach is needed.

  12. When an infecion starts after a sinus lift i tend to treat the infection with augmentin then Levaquin or Avelox.
    If the infection persists more tha a couple of weeks the only treatment is to open the sinus and remove the graft and all foreign bodies rinse it and to do an anthrostomy to permit adequate drainage of the sinus.
    It is important when one grafts the sinus to have a sterile technique and to cover the patient with antibiotics a few days prior to the surgery and at least 7 days post.
    I think adding PRP, PRGF , PRF, PDGF or autogenous bone or BMPs can help accelerate healing.(Bottle bone is more prone to infect)
    After reading an article by Choukroun in triple O I have been adding metronidazole ( a good way to target anaerobic bacteria) to any allogenic bone and have been getting good results.
    It is also important to screen the patient prior to surgery . Is the infudilum patent ? Is the mucosa thickened ? Are there polyps ? Is there a concha bullosa ? Does the patient have allergies or chronic problems ?
    A scan is mandatory prior to surgey.
    In my area I have seen ENT’s send me infected patients because they did not feel confortable treating grafted cases

  13. My ENT did not understand why my dentist did not remove my implants with the infected bovine grafting material. Unbearalbe pain. This ENT told me that everything must be removed as soon as possible and prescribed me Clindamycin without any results. There was definitively an infection with bovine graft material. More than 2,5 month after the suggestion of my ENT I found an oral surgeon who removed the infected area. My bone was destroyed. Pain… But not all infected bovine graft material could get out with that operation. After it I needed another one with histological results of the infection. Etc.

  14. I am constantly amazed at the different combinations of graft materials, membranes, and pharmaceuticals used in sinus graft surgery, most bereft of any type of biologic rationale. Going back to the original post, the first part of the protocol is the use of a collagen membrane. Collagen had been proposed as a liner because of the high incidence of perforation. While it does cover small perforations and acts to prevent extravisation of graft into the sinus, it has one unacceptable consequence. It prevents osteogenic cells in the Schneiderian membrane from participating in early bone growth and angiogenesis. Soaking the membrane in an antibiotic has no advantage as it is in the periphery only. A better choice is a PRF membrane. Viable leukocytes within the membrane will have a bacteriocidal effect while the growth factors contained in the platelets will potentiate early angiogenesis and bone growth.
    Next, we are so keen to reference literature on this website as support for our thesis. Therefore, the only published split mouth studies (Choukroun, et al and Simonpieri, et al) for sinus grafts show the efficacy of aqueous metronidazole. Short of additional similar studies with other antibiotics, this should be the standard of care at this time.
    The use of corticosteroids and Sudafed similarly makes no sense. We were taught 15 years ago to use these meds to reduce post-op swelling and dry up the sinus. For the past decade I have solely used COX-1 or -2 antiinflammatories post-op with outstanding post-operative outcomes. Corticosteroids have dramatic effects distant from the surgical site and suppress the immune response. The only time you should use Sudafed post-operatively is in the presence of a rhinovirus or other flu related outcome to prevent sinus congestion. If the otherwise healthy patient, you unnecessarily dry out the mucosal lining. If you have a small perforation, you will actually DELAY clearing of the sinus.
    Last is the use of chlorhexidine. The use of CHX immediately post-op is contraindicated because it is inhibitory to fibroblast growth. This will delay closure of the incision site and potentially lead to post-op leakage through the flap into the window. Similarly, we should use an additional PRF membrane on the outside of the grafted area to prevent epithelial ingrowth in the graft area.
    RJM

  15. Dear damaged patient, don’t think you are supposed to be dropping comments, but since you have, I ask you to believe little of what a ent might suggest has occured ,in that he probably has no experience in management of these scenarios. To suggest everything had to come out before incision / drainage/ and wound care is a little aggressive. for some one to suggest some of the bone couldn’t be taken out, maybe, because the graft took . Hopefully the omfs is giving you an honest shake. A lot of doctors that find themselves tx other doctors complications, find themselves saying things they wouldn’t say if they were tx there own. If you had to have a bone graft and a sinus lift, then you were in pretty bad shape to start. I hope you get good care! Bv

  16. Dr. Miller, doesn’t this study base Its conclusion on subjective ct scan findings( post op). Not sure if we can conclude anything other than the fact that metronidazole is safe. That maybe all they were trying to prove. I’m fearful that we have generated a lot of misconception regarding the use of steroids, just as we have about the utilization of clindamycin and subsequent c. Dif. Infections. There are no studies that support the statement that short duration steroids have any effect on immune system function and we know for a fact that membrane stabilization is crucial In the management of connective tissue disorders, autoimmune disorders and traumatic neurologic injuries. We have yet to even ” cut our teeth” with steroids. We can’t discount what we don’t know. Bv

  17. Good comments Dr Millar , with the advent and use of Dask our occurence of tears in the lining has been dramatically reduced from about 15- 20% to now less than 5 % ( only 2 visible tears in the last 100 lifts ). But with the use of synthetic graft materials that set and are thus stable , soft tissue cell occlusive and bacterio-static yet are vascular nano-porous this is less of an issue .
    This can be taken to the extreme when removing objects from with-in the sinus where the lining in the site of the similtaneously placed implant is destroyed with a currette and the implant placed and grafed ( by adhering a ball of graft material over the implant )through the lateral window . This is then loaded at 4 to 5 months , whilst only 20 cases have been done in the last 4 years ( thus of no scientific benefit whatsoever ) it shows the bodies ability to heal.
    Infection can always be an issue as we are working in the mouth ( all patients have a pre-op CHX mouthwash ) but some graft materials a better at not becoming infected themselves ( As was the case in Damaged patient )thus reducing the severity of the outcome.
    Another case of interest was 4 mopnths ago after a routine LW sinus augmentation( 3 mm residual bone) the flap was sutured up with Vicryl rapide and despite being told not to used corsadyl , alas 3 days later he was in to proudly demonstrate a flapping flap , and how could open it with his tongue.
    Needless to say the graft was lost , but then merely injected another graft ( Easygraft 400 ) into the sinus which then set ( due to the pol-lactide coating ) and the flap was resutured .
    Now 4 months later all loaded ( great Ostell reading ). Never mixed and Ab with a graft material again possibly a benefit of synthetics materials.
    Just an opinion ….
    Now back to work..
    Peter

  18. BV, you do not place a membrane on the lateral window? Are you aware of the study by the NYU group led by Stephen Wallace that shows enhanced bone quality by using a membrane? It is definitely a foreign body, however we use foreign bodies all the time, whether it is graft materials, membranes, etc. without any negative sequalae.

  19. I am very sure that BV knows about the NYU research as we all are but that is using Bovine Ha products and very different to what we are dicussing .Foriegn body response is a very interesting area where there is little research but a very experienced colleague has done numerous bi-lateral cases where he has used Xenografts in one side and Synthetics in the other and there a markedly different reaction in the synthetics side ( less pain nad swelling etc )
    Again just an opinion…
    Peter

  20. I am familiar with that study and others that suggest using the membrane at the lateral window, and every time I respond with this suggestion. Not only does the periosteom act as a suitable membrane , it may very well be the biggest nutrient source to the graft. Foreign bodies aside, If you access the sinus lift via crestal incision, the chance of mucosal in growth is nill(sp). Just a preference . Understand I use 7-8 membranes a week. So I’m not opposed. Bv

  21. Dr. B. One thing I Try to do on all sinus lift cases, is to keep the lateral wall attached to the schn. Membrane creating an essential random pattern vascularized bone flap. The larger the window the more succes I have keeping the bony wall attached and the better access , obviously. If there is greater than 3 mm of implant to be grafted in the sinus, I use prp and make every effort to make sure the palatal aspect of the implant has every bit as much bone as the buccal. I really do think any barrier placed at the buccal is inhibitory. I agree we do place foreign materials In our patients, with great success, with the most biocompatible being titanium. I am a strong believer in placing as few foreign materials as possible, hence the reason , autogenous bone is still the gold standard. The way I understood gtr , when it was introduced, it’s primary function was and still is a barrier to prevent soft tissue In growth . If the sinus is ovegrafted , with the intact bony wall, I think you will be ok. Some surgeons suggest removing the buccal wall and plating back into position . I have never done this while placing and implant. Good luck . Bv

  22. I too keep the bony wall attached, although I’ve seen different approaches, all with reasonably good results.

  23. An oral surgeon knows several failed cases.

    david salzman says:
    September 13, 2009 at 10:38 pm

    I have bio oss attaching and spreading everywhere. Some has been taken out, the implant was taken out. I now have a glob of this garbage attached above #16, some in the soft palate by 16. Salty bitter taste coming from there as well. Do any of you folks know of someone who can remove some of these particles. My
    ENT just removed several pieces from my upper lip. The bio oss was originally placed in #14, obviously did not stay there. Cannot believe anyone in good conscience would use this stuff. Please let me know if any of you know of someone in your profession who would take this on.

  24. Not sure if I understand the question. Are you asking if anyone would tx this complication. The answer is a big yes. I will , have and will continue to treat these abortions of dentistry, with a smile. I truly do enjoy tx complications and failures. I would never use bioss, primarily, because I don’t need to and secondarily because I don’t know that much about it. I have read up on it a couple of times, when I was trying to assist one of my colleques, when he ran into trouble. Bv

  25. I think you are all starting to sway away from the original question. There are many approached and ways to perform direct sinus lifts and many of these methods work well. The technique of placing a membrane soaked in an antibiotic acts as an antibiotic carrier in the grafted site, and this is a technique taught by Carl Misch.
    The bottom line is, the patient was perfectly fine, healing fine, and surgical site fine for the first 4 weeks, and then a buccal space swelling occurred. Since the post, the patient was put on Augmentin 10 day course, and the swelling has completely resolved, and intra-orally tissue looks normal. The question was what you think maybe the cause, and how you would treat it??

  26. I thought I said wound care and po abx! The cause could be a multitude of things. if the membrane wasn’t violated, then you can throw out sino- nasal dz. . Why do third molar sights get infected ? A mouth full of the most virulent bugs in the body is going to lend itself to the occasional graft/implant infection. It’s just a matter of when! Glad the infection resolved. Had you gone to the ent treating the damaged pt., You would have been advised to take everything out. Getting my point?? ???? Bv

  27. Dr. Miller, I would have to see some proof that chx inhibits soft tissue closure, in that I have used it exclusively for two decades without any problems that I’m aware of. As of late , I have started to receive a lot of “flack”, because the substance stains the dentition. I always respond with, can’t u just polish it off. This recieves mixed responses, with one gp asking me to polish it off myself. Aside from hurting my feelings, I’m confused that maybe he wasn’t getting the big picture. I would have obliged , but I haven’t either a high speed or low speed handpiece. Secondly, I have seen one study that proved the ciliary clearance of the respiratory epithelium Is stunted after the schn. Membrane is lifted from the floor of the sinus. With this in mind , in cases where the infindibulum is unusually large or the ostium is obstructed , I will quickly correct this intranassaly, before proceeding with the sinus lift. There is also a fair study that suggest preop steroids toughens the inflammed schn. Membrane thus improving our ability to lift it without creating the dreaded rent. Just some suggestions based on loose science. One thing that I think is important to reiterate , is that a lot of what we do has no scientific studies to support it , leaving the artistic part to the surgeon. I’m seeing an obgyn surgeon tomorrow that I tx for osteoradionecrosis some 14 years ago, with bmp. This was considered off label then and it still is today, but he is 94 and doing beautifully. So why am I seeing him? So I can have a cbct record, for educational purposes .By the way ,this pow of the Korean war, did not get implants, and he has perfect oh. Just saying!!! Bv

  28. Dr. A , I’m going to encourage a cbct, in the face of the infection or resolve. If the scanner has a high definition mode use it. Then I think it would be wise to perform a simple incision over the buccal wall to see if any larger than normal specs of bone maybe trying to sequester. Something caused the infection, and it’s possible that it may re- occur, once off the abx.. I hope it doesn’t . Good luck. Bv

  29. Here is a representative paper on the cytotoxicity of CHX in early wound healing. All the papers on this subject agree that it should NOT be used in early wound healing if it is a clean surgical wound.
    RJM

    Chlorhexidine-Induced Changes to Human Gingival Fibroblast Collagen and Non-Collagen Protein Production
    Mariotti AJ, Rumpf DA.
    Journal of Periodontology
    December 1999, Vol. 70, No. 12, Pages 1443-1448 , DOI 10.1902/jop.1999.70.12.1443
    (doi:10.1902/jop.1999.70.12.1443)

    Section of Periodontology, College of Dentistry, The Ohio State University, Columbus, OH.
    Conclusions: These results suggest that chlorhexidine will induce a dose dependent reduction in cellular proliferation and that concentrations of chlorhexidine that have little effect on cellular proliferation can significantly reduce both collagen and noncollagen protein production of human gingival fibroblasts in vitro. Hence, the introduction of commercially available concentrations (0.12%) or diluted commercial concentrations (as low as 0.00009%) of chlorhexidine to surgical sites for short periods of time prior to wound closure can conceivably have serious toxic effects on gingival fibroblasts and may negatively affect wound healing. J Periodontol 1999;70:1443-1448

  30. If the patient is taking post-op antibiotics, there really is no need for early antimicrobial rinses. Anything that is bacteriocidal by contact is generally inhibitory to fibroblasts. We do the opposite; the use of an aloe vera/chlorine dioxide gel over the incision site is both angiogenic and bacteriostatic. You can give a tube to the patient and have them apply it during the first week of healing. When the course of antibiotics is completed, we can then segue to CHX more safely. The material is sold by the Oxyfresh Corporation in California and is called Oxyfresh. There are several peer-reviewed journal articles on it’s use and benefits.
    RJM

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