Do I refer a patient whose CT scan showed a completely blocked maxillary sinus?

From the Guidelines

Yes, you should refer a patient whose CT scan shows a completely blocked maxillary sinus to an otolaryngologist (ENT specialist) for further evaluation and management. This finding may indicate significant sinus disease such as chronic rhinosinusitis, a mucus retention cyst, polyp, fungal ball, or potentially a tumor that requires specialist assessment 1. The presence of a completely blocked maxillary sinus, as shown on the CT scan, suggests ostiomeatal obstruction, which is a key indicator for referral to an otolaryngologist, as stated in the practice parameter update on the diagnosis and management of sinusitis 1.

While waiting for the referral, you can start the patient on initial medical therapy including a topical intranasal steroid spray and saline nasal irrigation. If acute bacterial sinusitis is suspected based on symptoms like facial pain, purulent discharge, and fever, consider prescribing an antibiotic. However, it's crucial to note that the patient's condition may require more advanced treatment approaches, including endoscopic evaluation, culture-directed antibiotics, or possibly surgical intervention to restore normal sinus drainage and function, as outlined in the guidelines for the management of chronic sinusitis 1.

Key considerations for the referral include:

• The presence of significant nasal septal deviation or obstruction of the sinus outflow tracts caused by middle turbinate deformity or accessory structures that block sinus drainage 1
• The presence of obstructing nasal polyps, after an appropriate course of treatment that might include a trial of oral corticosteroids 1
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management 1
• The need for evaluation, including coronal sinus CT with extra cuts through the ostiomeatal complex to clarify the extent of disease and specific location or locations 1

From the Research

Referral Considerations for a Patient with a Completely Blocked Maxillary Sinus

• A completely blocked maxillary sinus, as shown on a CT scan, may require referral to an ear, nose, and throat (ENT) specialist for further evaluation and treatment recommendations 2.
• ENT specialists suggest that referral is indicated for patients with symptoms such as nose complications/problems and sinus issues 2.
• A study found that 58.7% of ENT specialists recommended a maxillary sinus CT scan before sinus-lift surgery, and referral suggestions were >50% for certain CT-scan images, including an occluded sinus with septum and a nearly completely occluded sinus 2.
• Another study found that unilateral opacity of the maxillary sinus on CT scan can be indicative of neoplastic disease, and nasendoscopic examination is important for accurate assessment of sinonasal disease 3.
• CT scan of the paranasal sinuses can be an effective presurgical planning tool in patients with nasal obstruction, and can help identify significant abnormalities that may alter surgical planning 4.
• Preoperative sinus CT can help identify anatomic variants that predispose patients to major surgical complications, and the use of a mnemonic such as "CLOSE" can help radiologists quickly recall and incorporate critical variants and landmarks into the preoperative imaging report 5.
• Patients with symptomatic unilateral maxillary sinusitis may benefit from a dental evaluation to rule out odontogenic maxillary sinusitis (OMS), and low awareness of OMS can delay diagnosis and treatment 6.