Some notes on vertiprep

Today I had an interesting occurrence whereby there was a sinus infection associated with a dental infection. While I was going through routine consent, he responded to the risk of OAC by saying he has had recurrent sinus infections in the past. he has apparently seen his GP who found nasal polyps and has recurrent sinus infections that he is prescribed antibiotics for. On a side note it is important not to take everything the patient reports as a fact. One would hope that the GP offered more investigation i.e referral to an ENT rather than symptomatic relief from antibiotics. Who knows, maybe the patient was offered this but declined or maybe he sees a different GP every time. Additionally, on the PA it did seem as though the palatal root was close to the maxillary sinus with a periapical radiolucency involved. These should be warning signs to get prooper consent form the patient and inform them of the possible adverse outcomes of treatment and the possible follow up strategies including specialist referral.

The extraction was performed and the palatal root was found to be in contact with the sinus floor mucosa. A cyst was removed attached to the palatal root and profuse bleeding originated form the socket. This kind of bleeding would be expected in an area of active infection. Pus started to drain after that and I suspected a hole into the sinus air cavity. However, there was no hole visible through the socket and I found the bravery to try the valsalva technique. I pinched the patient's nose closed and told him to "very very very very gently" blow through his nose and apply pressure. This instruction is important as the patient may feel the need to blow very hard and rupture the sinus lining or make a small hole even larger. No air bubble were produced through the socket so I assumed the lining was intact. This implied that the bleeding and pus originated from under the sinus mucosa. This may indicate the presence of a mucocele or sinus infection of odontogenic origin as a primary sinus infection would have pus and mucous in the air cavity itself. I waited for draiinage and applied a horizontal mattress suture for incomplete closure. Some points to take away are:

-I avoided full closure to allow the pus to drain. Suturing in active infection may be detrimental to the healing of the socket.
-Even if there was an obvious OAC, delayed primary closure may be indicated due to the presence of pus. Antibiotic use is recommended until the active sinus infection subsides and delayed closure can be performed.
-In the future, I would ensure the patient is upright when draining the pus. I had him lying down and the pus had to drain against gravity and I wondered why it was flowing so slowly.