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.

About 3 months ago I did a graft on a SA-4 sinus. Used the Misch Institute's layered approach: Bovine cortical/50-50 mix mineralised + demineralized with autogenous/ autogenous,covered with a collagen membrane. This graft went about as smooth as one could ask for! Postop Rx 300 mg Clindamycin qid since the patient was allergic to amoxicillin. She developed the same symptoms described in this post, with some pain. I changed to Flagyl and things settled down. On suture removal thongs looked super but the patient still complained of a discharge, which I thought may have been allergenic or seasonal but transient. About 2 weeks later she called again with the same complaint so I Rx'd Zithromax zpac and she told us that the z pac did the job! About another month I got a call from an ENT MD who had seen her for a sinusitis involving the maxillary frontal and ethmoid sinuses on the right side. They also said the patient had an "Ostemyelitis" but without any symptoms of pain tenderness or swelling over the sinus. I explained to him that perhaps the dender HA content of the graft gave that appearance and he agreed with me. An infectious disease specialist was called into the case and started the patient on IV Ertapenem and oral Moxifloxicin for 10 days, the patient also had the sinuses irrigated and patentcies checked. Ive kept in touch with the patient and she tells me she thinks she is getting some relief finally and the ENT thinks the graft can be salvaged. Seems bizarre! So there's my story with two additional antibiotics thrown in. Any comments??

Back in the early 90's, it was strongly suggested to have an ENT evaluate the sinuses if we thought anything was out of order, prior to surgery (sinus lift). Perfaps we should go back to this? One has to wonder, the sinus in an adult or child is far from sterile. However, the grafts are not vascular at first so bacteria can grow and replicate and untill they develop a blood supply things are at risk. Ceftin is also a great broad spectrum, 3 rd generation cephalosporin and is bacterialcidal, not static like erythromycin, biaxin, azrithromycin, tetracyclines etc.

The use of Xenograft materials may be the factor that makes the infection more severe and difficult to treat. I have been shown a number of cases where this has occured and all have used these materials. There are bactreia everywhere ,intra-oral, adjacent tooth etc but it is how the body copes post-op and these materials seem to "prolong" the infection. This is just an observation and not evidence based. Maybe more research in this area .

This is not a material issue. Review your protocol, and technical level, and your problems will be limited.

Dear Dr, The history and information about the case is very limited and is not enough to disscuss, but: If the graft became infected, the systemic antibiotic alone will never fully penetrate a graft, even the graft is autogenous. So, if you are sure about the infection, you must remove the graft. You can administer antibiotics as an adjunct. Antibiotic alone will not resolve the problem, as other experiences show. Please be sure about no history of past sinusitis or systemic conditions like uncontrolled/undiagnosed diabetes. Hope you success

I usually mix clindamycin or lincomycin with the graft material. This helps. Also scrub down the oral cavity and face with betadyne or hebiclens, prior to the procedure. I'm not going to say this will prevent all the infections but it will help keep the infections down. Remember an infection is a sinus augmentation can be very bad.

Dr. Neda-Moslemi is correct. An ounce of prevention is worth a pound of cure.