Acute Post Nasal Drip After Sinus Augmentation Case: Proper Protocol?

Dr. T asks:

I recently placed 4 implants as shown in the OPG 5 weeks ago (please see images below). Since the surgery my patient has had watery nasal discharge (a runny nose). The discharge is colorless and he has no symptoms of sinusitis, no sneezing or congestion. He reports his nose running occasionally 2 or 3 times a day for short durations. He notes it is getting less but still not gone away.

Details of the surgery: Healthy patient being a former smoker 10 years ago. CT showed no sinus pathology. Sinus was elevated. The bone graft was a mix of autogenous bone, and harvested from the patient’s hip, mixed with Cerasorb [Curasan], a synthetic bone material and metronidazole. A small perforation was evident and covered with collatape (Zimmer). Implants 16 and 17 were placed at the same time with excellent stability. 14 implant has been angled away from the anterior wall. Tooth 15 will be extracted later. Patient placed on Augmentim 625mg bidx10days.

My question: Should this runny nose be indication to restart antibiotics now? Have other Drs seen acute/chronic post nasal drip or watery discharge occurring after sinus lift augmentation? If so, what can be done? Should this just be referred to an ENT?

Before Surgery

After Surgery

15 thoughts on “Acute Post Nasal Drip After Sinus Augmentation Case: Proper Protocol?

  1. David Lambert says:

    Should you start antibiotics? Not necessarily. A preop OPG (pre-implant) would be helpful, as I can currently see some suggestion of opacification over the right posterior sinus overlying the implants placed there. Any number of factors could cause this. Did you ask the patient if he/she has ever had this before? Does the pt have any pain, premaxillary tenderness in the pyriform area? Any fever? I would suspect none of these since the drainage is clear. Barring any findings suggesting infection, I would suspect, especially this time of year, this could potentially be allergic (does pt have allergies) and consider placing him/her on an antihistamine with decongestant (Zyrtec-D). I might also consider a brief course of steroids.

  2. Tiago Marques says:

    In case of being an oroantral fistula should the graft be removed or can it still be saved, I have a similar case that I did 2weeks ago the patient doesn’t have pain or fever just the discharge. I put him on strong antibiotics but I’m not sure if it’s an oroantral fistula.

  3. Renato says:

    it could be a oroantral fistula, you should start with antibiotics as son as possible,just in case of infection it can “protect¨ the graft and postpone the surgery for clean the sinus eand close the oroantral fistula,and preserv part of graft,you must see the patient 3 times a week,and a cat scan

  4. prof.dr.Hossam Barghash says:

    in ur report you mention that there was a small perforation and covered with collatape .but did you notice ant blood come from the pt. nose?
    also you should have notice the membrane mobility afer this perforation did the membrane movment stopped?
    when we come to tthe point should we give antibiotic or not.I think as you mentioned there was perforation so should give antibiotic & also nasal dropes,small perforation usually heal well especially if it is not on the top of the implant.

  5. Carlos Boudet, DDS says:

    Dr. T
    Did you look at the nares?
    I can’t see the panoramic very well but, could the floor of the nose be irritated or compromised with the anterior implant.
    It sounds like you have covered your patient appropiately immediately post surgery.
    A volumetric conebeam CT scan might be a good idea.
    Good luck!

  6. DR. M.Ali DDS, MS says:

    Dear DR.T , You put 4 implants 2 in the anterior region, and 2 in the posterior region, upper right side (molars region) with sinus lift and bone graft. You stated that there was a perforation in the membrane during the surgery and you covered it with collatepe membrane, then after surgery patient started to have discharge from the nose (runny nose). Few questions will be asked: 1-is there any difference in the right side or the left side of the nasal openings in term of the discharge? 2- Is there any bone particles coming with the nasal discharge 3- Is this a first time for the patient to have( runny nose ) ,or if the patient has any type of allergy? .To eliminate sinus fistula, the discharge should be examined for any bone particle. This is concerning the posterior part of your implant, in the anterior part: some implant numbers have been reported to perforate the nasal cavity ,however, they still functioning in the patient’s mouth(1,5mm or less ).Anyway you can feel if the implant is perforating the nasal cavity RT.or LT , by palpation .Patient should be inform by that if it exists. Now steps should be taken : 1-antibiotic is recommended as a prophylactic course. 2-antihistamine agent(Decongestants)should be given to stop the runny nose. 3- X ray should be taken to evaluate the location of all implants( Cone Beam CT scan, etc. ) In general ,initial implant stability should be achieved during implant placement, even in sinus elevation. Then you can determine your treatment planning based on your new findings . Good luck DR.Ali,DDS.MS, New York

  7. Dr. T says:

    Thanks for the responses. To answer some questions raised

    1) the discharge is clear from both nostrils without any particles
    2) patient has no allergies / history with runny nose
    3) the perforation measuring 5mm and was well covered with collatape
    4) patient experiencing no pain, tenderness
    5) the anterior implant is bicortically stable however, I wonder if this could be due to nasal floor trauma

    Her runny nose is differenct tims of the day. Especially when she bends over.

    I am considering to restart antibiotic course of Augmentim 625mg bid for 10days with decongestant.

    Any further comments appreciated

  8. Ron Neff says:

    If it is posteral, then the sinus is the source of the fluid. I would rule out the nose and associated nasal region implants as the source. Focus on implants in sinus, and vitality of remaining tooth. Clear discharge doesn’t convince me of the need for antibiotics, but then I am liberal about antibiotic use.

  9. Dr P van Rooyen says:

    Dear Dr,
    Having briefly read some of the replies, I don’t for one moment think that the sinusses are giving you the discharge. To me it appears that the 2 most anterior implants are defenitly impeding on the base of the nose and therefor causing an inflammatory reaction in the least. I also think this is the least of your problems, What are you planning from the restorative point of view. For your sake,I hope the patient has a VERY low smile line. I would immediately remove those two implants, consider proper bone reconstruction and new restoratively driven implant positioning. You should bactrack on this case as early as you possibly can, it will only get worse and cost you more to recover in the end. Best of luck to both you and the patient. Dear colleague, I do not mean to be arrogant or aggressive towards your presentation, but in all fairness, did you really feel that your implant positioning in the anterior region is presentable, without attracting some hefty response.

  10. cory c. says:

    it’s tough to tell from the pix, but how much graft material did you use? it looks kinda’ like you obliterated a good part of the right side sinus cavity.any sinus headaches since placement?

  11. Dr.T says:

    Dear Dr P van Rooyen,

    Thanks for your comment. The case is designed for low smileline. We agreed to forego vertical bone grafting due to cost, more delay and having to deal with a troubling period with denture on the graft.

    The patient is fine now. The post nasal drip is infrequent. Your assessment has led me to believe you are correct- this a case of rhinosinusitis due to the anterior implant. I recognize now that driving the anterior implant in has led to pressure on the cortical plate. I could not find much literature regarding post operative effects with nasal floor lifts.

    I have not done any nasal floor lift before (until now). I don’t think I’ll be doing any again-

  12. dr. pirtpal says:

    please g0 for culture sensitivity test. if negative nothing to worry. in case positive, start antibiotic orally and nasal drops

  13. Dr. Alan Samit says:

    My wife had maxillary segmental surgery 30+ years ago without apparent complications and with an excellent cosmetic result. However, over the last several years she has developed signs and symptoms that I think are related to her surgery and may have a bearing on the case being discussed.
    While eating, she will occasionally have a clear discharge from one nostril (typically on the left). Within 5-10 minutes after eating, particularly if she moves around, starts to talk or bends over, she will develop a severe gagging cough that frequently progresses to the point of regurgitation. These episodes occur only when she eats or immediately thereafter. Numerous, upper GI radiographs and endoscopies have yielded no positive findings, including a barium swallow study during which an attack was precipitated and documented, again with no diagnostically useful findings.
    I suggest that, akin to Frye’s Syndrome (Gustatory sweating), an unknown number of patients undergoing maxillary surgery involving the sinuses will develop unintentional and inappropriate nerve anastomoses, such that impulses intended to stimulate the palatal minor salivary glands will instead stimulate the sinus mucosa. The resulting salivary outflow produces a rhinorrhea and voluminous post nasal drip.
    It might be very interesting and enlightening for centers and practitioners who performed large numbers of maxillary orthognathic or implant procedures involving the maxillary sinuses to complete a long-term follow-up review of their cases to determine if Gustatory Rhinorrhea and/or Gustatory PND should be included as sequelae of such procedures.


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