Diagnostic value of spect bone scintigraphy for odontogenic maxillary sinusitis

Osteitis in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Osteitis is recognized as a common factor in recalcitrant chronic rhinosinusitis (CRS). There is evidence for the association of osteitis with revision surgeries and CRS severity, in terms of higher Lund-Mackay scores. This is a narrative review on the osteitis in CRS patients.

RECENT FINDINGS

Evidence to date is inconclusive with regard to the etiology and pathogenesis of this bony thickening. Histopathology of osteitis in primary CRS is likely a process of neo-osteogenesis and bone remodeling. For better understanding, various associating factors have been studied including an inflammatory pattern of rhinosinusitis. Recent studies have associated osteitis with nasal polyps and tissue eosinophilia with the increase in periostin expression and P-glycoprotein mucosal expression. There is no association of osteitis to symptoms or quality of life. Osteitis is an outcome of neo-osteogenesis rather than inflammatory processes in CRS patients without a prior history of surgery. While CT has become a staple in osteitis assessment, the standards for grading osteitic severity remain in an experimental stage. There is no association between the presence or severity of osteitis at the time of surgery and clinical outcomes at 1 year after surgery. This review provides a comprehensive overview of the pathogenesis, epidemiology, and correlation with clinical and biological factors of osteitis in CRS patients.

The significance of osteitis in rhinosinusitis

Rhinosinusitis is a disease of multifactorial aetiology. As a profession our insight into this pathological process has progressed enormously over the last few decades. The contribution from environmental, host immunity, microbiology and anatomical factors is well recognised, if not completely understood. The involvement of underlying bone in rhinosinusitis was first recognised experimentally in animals and has subsequently been highlighted as a potentially significant finding in humans with CRS. In this review, the role of bone in chronic rhinosinusitis and the evidence behind that role are discussed. Both histological and radiological findings are presented and the subsequent potential clinical impact and relevance of osteitis in rhinosinusitis patients. Future pathways for research to add to the current knowledge of the impact of bony involvement are also discussed.

Osteitis in chronic rhinosinusitis: a review of the literature

BACKGROUND

The role of osteitis, or inflammation involving bone, is 1 potential reason for disease recalcitrance in chronic rhinosinusitis (CRS) and is not extensively studied. This review article will discuss osteitis in CRS, including pathophysiology, diagnostic methods, clinical significance, and treatment modalities.

METHODS

A systematic review of the literature was performed using PubMed search terms osteitis, osteomyelitis, bone involvement, hyperostosis, neo-osteogenesis, osteoneogenesis, remodeling, single positron emission computed tomography (SPECT), and nuclear scintigraphy, with each term cross-referenced with chronic rhinosinusitis. This search was then narrowed to English language articles, which were reviewed for relevance. Cited references of relevant articles were also examined.

RESULTS

The PubMed search identified 231 articles, which after reviewing for inclusion criteria resulted in 26 articles that were included in the current review. Pathophysiology, including current understanding of molecular mechanisms contributing to osteitis, is discussed. Histology, computed tomography (CT), and SPECT have been used to establish a diagnosis. Radiographic staging systems exist but are not standardized. Osteitis has been treated both with intravenous antibiotics and surgery. Five articles involved assessment of outcomes in patients with osteitis.

CONCLUSION

Osteitis involves inflammatory changes in the underlying bone that may lead to recalcitrant CRS. Osteitis is associated with worsened measures of disease severity such as CT, endoscopy, and olfactory scores, and affects the degree of improvement in quality-of-life measures after both medical and surgical treatment. Future studies directed at characterizing the underlying molecular mechanisms including earlier and precise identification may improve our ability to treat this significant aspect of CRS.

[Correlation of mucosal involvement as evaluated by computed tomography and bone single-photon emission tomography findings SPECT in patients with chronic rhinosinusitis]

Osteitis has been proven to play important role in patophysiology of chronic rhinosinusitis (CRS). Computed tomography (CT), a standard diagnostic technique used to evaluate the extent of the sinus disease, fails to show the bone involvement in patients with CRS. In contrast single-photon emission tomography (SPECT) yields adequate information on remodeling and bone turnover. Persistent osteitis may be one of the reasons of failure of adequate medical and surgical therapy for CRS and discrepancies between extent of the disease as evaluated by CT and symptom scores.

THE AIM OF THE STUDY

is to evaluate correlation between the results of CT and SPECT in patients with CRS.

MATERIAL AND METHODS

29 patients with CRS (15 with nasal polyps and 14 without nasal polyps) were evaluated with CT and SPECT. The mucosal involvement of CRS graded on Lund-Mackay Scale (LMS) was compared to degree of bone involvement evaluated by SPECT with the use of modified LMS.

RESULTS

The mean LMS grade was 13,3 for CT and 9,8 for SCPECT (modified LMS). A positive correlation between the results of two imaging methods was found r = 0.72 (p < 0.0001).

CONCLUSIONS

The bone involvement as evaluated by SPECT correlates with the degree of mucosal changes showed by CT.

Correlation between computed tomography and bone single photon emission-computed tomography scintigraphy in patients with chronic rhinosinusitis

BACKGROUND

Computed tomography (CT) has been the imaging study of choicefor evaluating chronic rhinosinusitis (CRS). 99mTc-MDP bone single photon emission-computed tomography (SPECT) has proven useful at identifying inflammation of bone and its use in CRS has been discussed recently. No studies, however, have documented the correlation between these two imaging modalities in CRS.

METHODS

A retrospective analysis was performed of 30 patients with CRS who underwent CT and SPECT scan of the paranasal sinuses. Increased radiotracer uptake during SPECT scan was compared with CT findings graded on the Lund-Mackay score (LMS). The findings of the two imaging modalities were compared and evaluated for standard correlative statistics for diagnostic tests.

RESULTS

SPECT imaging was abnormal in 25/30 patients, and CT was abnormal in 27/30 patients. Correlation between the two was highest for the ethmoid sinuses at 73.3%. SPECT had a high positive predictive value for mucosal inflammation on CT of 84.1%. Approximately 25% of individual sinuses with a positive SPECT in patients without prior surgery were not positive in corresponding sinuses onl CT. There was a positive correlation between the LMS and the number of SPECT positive sinuses within the same patient (r = 0.486; p = 0.006).

CONCLUSION

99mTc-MDP SPECT scan in patients with CRS is shown to be a useful indicator of bone involvement. The relatively high rate of bone involvement in the absence of mucosal inflammation as seen in this study warrants additional research and the potential need for different therapies than are currently available.

Correlation of bone SPECT scintigraphy with histopathology of the ethmoid bulla: preliminary investigation

OBJECTIVES

Reports in the rhinology literature suggest that osteitis of the ethmoid bone may be responsible for refractory and/or recurrent sinusitis. If so, bone scanning technologies capable of detecting osteitis may be useful in diagnosing this condition and its response to treatment. The objective of this prospective cohort study was to determine the correlation of single photon emission computed tomography (SPECT) bone scintigraphy with the histopathology of the ethmoid bulla.

METHODS

Thirty-six patients with a diagnosis of chronic sinusitis who were scheduled to undergo sinus surgery underwent a presurgical SPECT bone scan using technetium 99m-methylene diphosphonate. All bone scans were done within 5 days of surgery. During the procedure, bone samples from the face of the ethmoid bulla were obtained and examined by a pathologist blinded to the bone scan result. In this study, histopathology consistent with osteitis was defined as a change from lamellar to woven bone. A positive bone scan was defined by the presence of increased radiotracer uptake in the ethmoid sinuses.

RESULTS

Thirty-two of the 36 patients had a positive bone scan on SPECT imaging, and 31 specimens demonstrated histopathologic bone changes consistent with osteitis, for a sensitivity of 93.9%. An additional 4 patients had a negative bone scan on SPECT imaging, and osteitis was identified in 2 of the 4. The specificity was 66.7%, and the positive predictive value was 96.9%.

CONCLUSIONS

We found that SPECT bone scanning with technetium 99m-methylene diphosphonate is a highly sensitive test for identifying osteitis in patients with chronic rhinosinusitis. It may be a useful tool in the armamentarium of the otolaryngologist to better define this disease process.

[The most often causes of odontogenic maxillary sinusitis]

In the period 2000-2002, 40 patients with odontogenic sinusitis were examined at the Institute for ENT and Maxillofacial Surgery, Clinical Centre of Serbia. Oroantral communication was detected in 40% of the patients, oroantral fistula in 35%, sinus foreign bodies in 15% and other conditions in 10% of the cases. The extraction of the upper lateral teeth was the cause of odontogenic sinusitis in 65% of the cases. Given the specific tooth, the first upper molar was the most often cause of the condition, i.e., in 40% of cases. Odontogenic sinusitis as the complication of the oral cavity surgery was found in 85% of the patients.

[Variations in the surgical treatment of maxillary sinusitis]

From September 2001. to February 2004. in the Institute for ENT and Maxillofacial Surgery were investigated 107 patients with the inflammatory diseases of the maxillary sinuses. Patients with sinusitis were separated into group of patients with rhinogenic (72) and patients with odontogenic maxillary sinusitis (35). We found that the etiology of odontogenic sinusitis was mostly artificial caused after some dental surgery (88%), what is totally opposite to the spontaneous etiology of rhinogenic sinusitis. Surgical treatment of rhinogenic sinusitis mostly was endonasal polypectomy with operation by Caldwell-Luc or FESS. Odontogenic sinusitises were mostly treated by FESS and surgical "closing" of oral-antral fistula by local mucogingival flap (51%).

Evaluation of odontogenic maxillary sinusitis after conservative therapy using CT and bone SPECT

Fifteen patients with odontogenic maxillary sinusitis examined using computed tomography (CT) and single photon emission computed tomography bone scintigraphy (bone SPECT) were reviewed. The changes in bone activity associated with causative maxillary alveolitis, evaluated by bone SPECT, before and after conservative therapy were correlated with the pathologic changes in the maxillary sinus mucosa and ostium demonstrated on CT images following conservative therapy. This combination of imaging methods is valuable for predicting the prognosis and selecting appropriate treatments for the disease.