43-year-old male smoker with a history of anemia, previous upper GI bleed, peptic ulcer disease (and more specifically to this case) chronic sinus congestion, excessive post nasal discharge, and foul smell in nasal passages. Had been seeing ENT doctor approx 3 months who was conservatively treating with nasal sprays and PPI's. Eventually diagnosed with chronic rhinosinusitis, chronic inflammation and ordered CT.
PRE OP CT Sinus on 6/14/23
FINDINGS: There is near complete occlusion of the left maxillary sinus. There is occlusion of the left ossicular complex. Minimal mucosal disease is seen within the ethmoid sinuses causing narrowing of the frontal ethmoidal recess. Remainder of the paranasal sinuses are clear.
There is a 1.4 cm lesion near the root of the left maxillary first molar which protrudes into the floor of the left maxillary sinus. No overt osseous erosion though there is thinning near the lingual aspect of the maxilla. General dentition is poor with scattered dental caries.
The nasal cavities are normally developed. The nasal septum is intact. There are no signs of nasal masses. The globes and orbits are within normal limits. There is no acute osseous abnormality. The visualized portions of the brain parenchyma are normal in appearance for patient's age.
Impression:
Advanced left maxillary sinus mucosal disease with occlusion of the ostial complex. Nonspecific low-attenuation 1.4 cm lesion in the floor of the left maxillary sinus protruding into the maxilla near the root of the first molar. No overt osseous erosion. Differential considerations include a mucocele or mucous retention cyst or cyst of a odontogenic origin. Interval follow-up suggested.
After multiple discussions, ENT eventually performed left total endoscopic ethmoidectomy with frontal sinus exploration, left maxillary antrostomy with removal of contents and nasal septoplasty.
OPERATIVE NOTE: PLEASE SEE ATTACHED PHOTOS.
He was treated 2 times post op with debridement and ABX treatment.
CT PARANASAL 6 MONTHS POST OP
FINDINGS:
Paranasal sinuses:
Maxillary:
1.4 cm circumscribed low-attenuation lesion with chronic expansile bony reactive change extending from left maxilla into floor of left maxillary sinus associated with the left first maxillary molar tooth and chronic remodeling of the root of the left first molar tooth and extensive dental caries (24-40 4/5, 29/1001, 55/1002).
This lesion would correspond to the 1.4 cm lesion described on outside CT sinus
report 6/14/2023. Minimal mucomembraneous reactive change left maxillary sinus. Minimal mucomembraneous reactive change right maxillary sinus. Defect medial wall left maxillary sinus and a few adjacent ethmoidal air cells compatible with left maxillary and partial ethmoidectomy, correlate with surgical history.
Ethmoid: Minimal mucomembraneous reactive change ethmoid sinuses.
Sphenoid: Clear. Frontal: Clear. Visualized Mastoids: Clear No air-fluid levels. Ostiomeatal units: Right osteomeatal units patent. Postsurgical change left ostiomeatal unit. Nasal turbinates: Unremarkable Nasal septum: near the midline. Visualized Orbits: Unremarkable. Limited intracranial evaluation: Unremarkable Osseous Structures: Unremarkable. Dental caries involving multiple maxillary teeth, correlate with dental exam. Mandibular teeth not included in field of imaging.
IMPRESSION:
1. Minimal mucomembraneous reactive change maxillary and ethmoid sinuses compatible with minimal chronic sinusitis. 2. 1.4. cm circumscribed lowattenuation lesion with chronic circumscribed bony expansion left maxilla extending from left first maxillary molar tooth into the floor left maxillary sinus. Chronic remodeling root of first left maxillary molar tooth and extensive dental caries. Differential considerations include but are not limited to sequelae of subacute or chronic apical dental abscess, chronic dentigerous cyst, atypical mucocele amongst other etiologies. Recommend correlation with maxillofacial surgical consultation for further workup and management. 3. Postsurgical changes. 4. Extensive dental caries incompletely assessed on this exam.
Our potential client states that he obtained a second opinion and was told multiple times that this procedure was “not necessary” based on his condition and symptoms. In addition, symptoms have not resolved completely and PC feels as no progress so we included the OP note to ensure that was performed properly. His current diagnosis is laryngopharyngeal reflux.
We are seeking the opinion of an ENT experienced with these procedures and could speak of the validity of our potential clients plan of care.
We appreciate your time and opinions in advance.
Files:
No questions yet!
Do you believe there might have been medical error?
Patient should have been referred to an oral surgeon/dentist for the dental issue to address the possible odontogenic cause of the sinus infection. That being said, frequently sinus disease does not clear completely despite resolving the dental origin.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The sinus disease is cleared by imaging. No injury has occurred to the patient. Frequently all the sinuses on that side need to be opened to prevent scarring which would necessitate repeat surgery to open the remaining sinuses
What makes you a good expert for this case?
Skull base fellowship trained Advanced endoscopic surgeon ENT advisor/consultant for state medical board
How often do you encounter cases similar to this one in your practice?
Frequently. I see patients with this type of condition often.
Do you believe there might have been medical error?
In reading the history provided, along with two CT SCAN reports, clearly read by different r adiologists given style, pt had successful endoscopic nasosinus surgery, i.e. the diseased L max sinus mucosa was treated, and clear 6 mos pot op. Very common for CT to not truly indicate septal deflection as often septopasty needed for access. Anterior ethmoid also indicated to prevent maxillary ostia occlussion post op. The dental description not import as bone intact. And, there was no mention of "medical error' in summary. Was the concern the extent of the surgical procedure? If so, I cannot find the indication for Left frontal procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
no injury or post op complication noted.
What makes you a good expert for this case?
Performed thousands of FESS/SINUS CASES in academic(MEEI; UMASS) and community settings.
How often do you encounter cases similar to this one in your practice?
this case presentation, assessment, and treatment are everyday seen in my practice.
Do you believe there might have been medical error?
I don't see any obvious evidence of a medical error in this description. The patient was followed for some time and managed medically, but had persistent symptoms of "chronic sinus congestion, excessive post nasal discharge, and foul smell in nasal passages." With the diagnosis of chronic sinusitis and nasal obstruction and findings on CT including "advanced left maxillary sinus mucosal disease with occlusion of the [ostio-meatal complex]", I believe the recommended surgery was appropriate. It is certainly possible that some symptoms may have persisted and may be due to underlying dental disease, though the surgery would still seem appropriate for other symptoms and findings. If the small mass of the left floor of the maxillary sinus represented a mucous retention cyst (rather than a peri-apical dental abscess or cyst), it would be important to realize that these are common, often asymptomatic, and can recur.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I don't think having symptoms "not resolved completely", especially when it comes to chronic rhinosinusitis (CRS) is uncommon at all and is certainly not consistent with any permanent damage or injury. In fact, it sounds more like successful treatment (to which the patient consented) from an ENT perspective and a good next step in addition to ENT follow-up would be referral to a dentist or oral-maxillofacial surgery to address any dental component of the patient's symptoms.
What makes you a good expert for this case?
I am board-certified in Otolaryngology-Head & Neck Surgery (ENT) and have practiced in an Academic setting for just under 21 years following my fellowship at Johns Hopkins Hospital in Baltimore, MD. My primary area of clinical practice is rhinology, allergy, and sinus surgery. I see hundreds of patients each year with nasal congestion and symptoms of chronic rhinosinusitis and perform about 100 sinus procedures annually including functional endoscopic sinus surgery (FESS). I am also a fellow of the American Rhinologic Society (ARS).
How often do you encounter cases similar to this one in your practice?
As stated above, I take of hundreds of patients each year with nasal obstruction and similar symptoms due to CRS. I would say I see this more specific issue (sinus disease vs. dental disease as a cause of symptoms) about 5x per month or 60 or so times per year.
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