Maxillary sinus mucous retention cyst removal: thoughts?
I have a 31-year old healthy male with recent history of extracted maxillary right first molar due to failed root canal treatment. The patient rejects removable and fixed partial denture options but agreed to augmenting the sinus in preparation for implant placement. CBCT revealed large maxillary sinus mucous retention cyst. Treatment plan was to remove cyst with delayed graft. The sinus was exposed, cyst enucleated and sinus chamber thoroughly flushed and evacuated with sterile saline. Clinically, I could visualize the medial and inferior sinus walls. The access was tacked closed with Mem-Lok membrane and tissue sent for biopsy. Patient was prescribed short-term steroids and Flagyl/Augmentin combo. 4-day post-evaluation patient is asymptomatic and surgical site is healing well.
The immediate post-surgical CBCT still exhibited radiopaque density in the inferior sinus half. My thoughts are these are remnants of the thickened inflammatory mucosal lining. Am I correct to expect that this will gradually subside over time? I plan to rescan and hopefully graft in 4 months. Any comments or thoughts are appreciated.
11 Comments on Maxillary sinus mucous retention cyst removal: thoughts?
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Ninja
6/15/2017
In my opinion thickening of mucosa never goes away. Swelling due to inflammation obviously does go away. This observation is consistent with biological principles. Thickening of the mucosa may not be a pathological reason for not lifting the sinus floor for augmentation. A thick mucosa lack cells that could interfere with bone graft.
Gene
6/15/2017
Ninja, I agree. I expect that, given time, future scans will show dramatically reduced inflammation like I've experienced in cases prior.
My hope was that someone could reaffirm my thinking that "yes, the sinus is supposed to look that way immediately after cyst enucleation."
ZORAN STAJCIC
6/15/2017
HI there, I should draw your attention to the book Atlas of Implant Dentistry and Tooth Preserving Surgery. Prevention and Management of Complications, chapter: Sinus Floor Elevation with Simultaneous Cyst Evacuation page 136 as well as the video clips: "Surgical Removal of Maxillary Sinus Mucous Cyst, Sinus Floor Elevation, Insertion of Implants" as well as "Dual Lateral Window Approach for the Removal of the Maxillary Sinus Cyst...." that can be found on VIMEO.
I have been performing simultaneous removal of the Maxillary Sinus cysts and pseudocysts with the Sinus Floor Elevation and bone augmentation, frequently associated with insertion of dental implants for over seven years now and it seems to be a predictable procedure providing a proper technique is used.
Best regards.
Peter Fairbairn
6/19/2017
Agree
CRS
6/15/2017
Probably easier to graft at same time. Decongestants? Hopefully this won't open up or recurr? Is the OMC patent? You may want to consult an ENT orOMS unless you are comfortable managing a Caudwell-luc with antrostomy and closure of a O-A communication. Please post outcome.
Gene
6/15/2017
I realize I could've saved the patient a second procedure by simultaneously grafting, however, I decided to proceed conservatively as this was the largest cyst I've attempted to date and would have regretted having to manage a post-graft infection. If this were simply a large membrane tear I would've grafted "a la Pikos".
The OMC is patent both pre- and post-surgery. The path report came back as benign inflammatory tissue. Patient was prescribed Afrin decongestant and dexamethasone.
I'll definitely post results as hopefully others can benefit from this.
Wesley Haddix
6/16/2017
Dr. Mike Pikos has addressed this very issue in his advancements of sinus augmentation procedures. I was fortunate to have Dr. pikos as a classmate when I attended the Misch Institute and later classes developed by Dr. Pikos himself. Based on this experience, I have treated similar cases with cyst removal, aggressive curretage of all bony surfaces (yes, there will be no membrane, or at l ast a large fenestration), placement of a "tent" using a long term collagen membrane to contain graft material, and placement of the graft. I have only encountered three cases (relative to the hundreds Dr. Pikos has encountered) and all healed uneventfully and later implants placed integrated well. Dr. Pikos might be a helpful reference for future cases. That being said, your approach was commendable in its caution and well done. Best to both you and your patient.
F. DuCoin
6/18/2017
It sounds like you are very familiar with these procedures, competent and experienced. I would suggest that the cyst removal as part of a grafting procedure could certainly be considered as one procedure. However performing the cyst removal itself, it seems to me, could be pushing the scope of practice and more within the realm of an ENT MD. As long as it all goes well, it will be well, but if it went south, say a severe infection or a oral-antral fistula, then you could be opening yourself up to a difficult defense. That does not mean that you don't have the skills to do this, merely that maybe you shouldn't.
Wesley Haddix
6/20/2017
Quite possibly. Let me offer another point of view: if we are going to treat the sinus, we need to be competent in managing normal conditions such as this. If not, perhaps we should not be performing subantral procedures at all. Even "uncomplicated, textbook" subantral augmentations can fail; the line of "opening ourselves up" becomes blurred. Personally, I do not concern myself with that question, preferring for 30 years to focus on what is best for that individual patient and focusing on thorough preop workup and patient consultation and consent. If I tell my patient about the cyst and how I propose to manage it as well as alternatives, I feel I have served their interest well; in fact, this scenario is part of my consent form. My main point is that as surgeons, we evolve our skills and judgments with education and experience. This doctor's decision to defer graft placement was prudent and commendable. Perhaps, as a result of this discussion, he may choose to broaden his knowledge and thus manage the next case in a different manner. I am not implying there is only one approach, only offering another possibility for consideration...or not. Interestingly, Dr. Pikos developed the collagen tent technique to deal with cases such as this, and to my knowledge uses them on nearly all subantral augmentation cases even when there is no visible tear in the membrane out of concern for unrecognized tears, estimated to be present in 12 and 25% of SA cases. It can be very useful in the occasional patient who has an extremely friable membrane, or patients who have a seeming complete absence of a membrane and has proven a very useful technique in my cases, and I hope it is so for others as well. All the best to everyone and our patients.
CRS
7/12/2017
We learn this in oral surgery residency. you have a valid point, well said!
ZORAN STAJCIC
6/19/2017
Hi F.DuCoin,
Your comment is very much appreciated. I would like to point out that implant dentistry can be a very challenging therefore, an implant dentist can either refer the patient (the question whether a maxillofacial surgeon or ENT surgeon is familiar with procedures that should comply to further implant treatment) or invite a competent maxillofacial or oral surgeon to form a team and provide the best possible treatment that is doable in a dental office.
I enclose two sentences from the book I have already mentioned that address this issue.
Epilogue, p.333.
"Offer the treatment that you sincerely think is the best option under
given circumstances, not the surgical procedure you can
perform."
"After a sound explanation of the
complexity of the procedure that should match patients
requirements has been presented, any involvement of the
external surgeon, who is more skilful in the particular
manoeuvre, is certainly appreciated by the patient."
One should take SAC classification seriously before contemplating a new procedure.
Best regards.
