The study, published in Frontiers in Oral Health, examined patients treated between December 2020 and November 2025 at the Department of Integrated Therapies in Otolaryngology. Of 165 consecutive patients evaluated for suspected sinonasal disease, 111 had sinusitis without any foreign body, 6 carried a maxillary foreign body without sinusitis, and 48 presented the combination that formed the core of the analysis: odontogenic maxillary sinusitis accompanied by a foreign object in the sinus. The male-to-female ratio in the overall cohort was almost exactly even, at 1.01, and 129 of the patients suffered the chronic form of the disease, defined by symptoms persisting for more than three months, while 26 presented acutely.

Odontogenic sinusitis, as the condition is known, occupies a distinctive position in sinus pathology. Under the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 classification, it is categorized as a secondary chronic rhinosinusitis, a localized disease with an anatomically unilateral distribution. The dominant mechanism is periapical or periodontal infection arising from a maxillary posterior tooth, in which inflammatory exudate erodes through the bone separating the dental apex from the sinus floor and drains into the cavity. Periapical lesions account for roughly 73 percent of cases, oroantral fistulae for 23 percent, and retained teeth for 4 percent, according to figures cited in the literature. The disease develops unilaterally in over 90 percent of cases, and between 85 and 90 percent of patients experience symptoms on the same side as the dental problem.

Recognizing the condition remains a diagnostic challenge. The most frequent complaints are facial pain or pressure, postnasal drip, nasal obstruction, and unilateral purulent discharge often accompanied by a foul odor or taste, yet dental pain is frequently absent, which can steer clinicians away from the true cause. Computed tomography typically shows partial to complete opacification of the maxillary sinus in 70 to 100 percent of cases, but dental pathology is reportedly overlooked in 60 to 70 percent of scans by radiologists unless a targeted dental assessment is performed. This blind spot is precisely why the Roman team insists on a multidisciplinary diagnostic pathway: preoperative CT scans were independently reviewed by at least three specialists, a radiologist, an otolaryngologist, and an oral surgeon, while endoscopic findings were evaluated jointly by at least two specialists before any surgical decision was made.

The foreign bodies themselves vary widely in composition and origin. Tooth roots, root canal filling materials, fractured tooth fragments, dental implants, and impression substances can all enter the sinus through apical migration, traumatic manipulation during dental procedures, or an oroantral fistula. Dental implants deserve particular attention. Accidental displacement usually occurs intraoperatively, linked to excessive site preparation, insufficient primary stability, or inadequate planning, but delayed migration years after placement has also been documented, potentially driven by peri-implantitis or bone resorption from improper occlusal load distribution. Resorption of the alveolar ridge combined with progressive pneumatization of the sinus reduces the available bone height in the posterior maxilla, which is both a major predisposing factor for displacement and a contraindication to implant placement in that region.

The surgical toolkit described in the paper centers on three routes of access. The nasal approach, an endoscopic middle meatal antrostomy, involves removing the uncinate process and enlarging the natural sinus ostium to clear diseased mucus while preserving healthy mucosa and its basement membrane, thereby maintaining mucociliary function; the widened opening can also serve as the corridor for foreign body extraction, though the proximity of the orbit and infraorbital nerve demands considerable expertise. The oral approach is a modified mini Caldwell-Luc procedure, in which a full-thickness mucoperiosteal flap is elevated over the canine fossa, a bony window is created in the anterior sinus wall, and the Schneiderian membrane is incised to access the cavity; the antrostomy typically exceeds 3 to 4 millimeters to admit a pediatric endoscope. This modification reduces the facial swelling and paresthesia associated with the traditional Caldwell-Luc operation and speeds recovery. Where an oroantral communication or fistula exists and the foreign body is small enough, the fistulous tract itself can serve as the removal route, after which the defect is closed with local flaps for small to medium gaps of 5 to 8 millimeters, or with cortico-cancellous grafts covered by resorbable collagen membranes, sometimes reinforced with a heterologous cortical lamina, for larger defects.

What distinguishes the Roman algorithm is its explicit integration of three variables that previous flowcharts treated more loosely: the status of the ostiomeatal complex, the size and position of the foreign body, and the presence or absence of an oroantral defect. The decision logic runs roughly as follows. In patients without ostiomeatal obstruction and without an oroantral defect, foreign bodies smaller than 1 to 2 centimeters are approached nasally if they sit superiorly or adhere to the sinus roof, and orally via the mini Caldwell-Luc if they lie inferiorly or are embedded in inflammatory tissue in the deep recesses; bodies larger than 2 centimeters require an endoscopically assisted lateral approach. In patients without sinusitis but with an oroantral fistula, the fistular route is preferred when the foreign body fits through the tract, with simultaneous fistula closure. When odontogenic sinusitis is present, signaled by ostiomeatal complex obstruction, the calculus shifts decisively toward combined surgery: small foreign bodies without a fistula are managed with a combined or purely nasal approach, large ones demand a simultaneous endoscopic and lateral procedure, and the coexistence of a fistula adds a fistular step for closure after nasal removal. For tiny foreign bodies under 1 to 2 millimeters, the team even endorses a wait-and-see policy when clinically appropriate, sparing the patient an operation altogether.

The outcomes lend the algorithm considerable weight. Among the 48 patients with sinusitis and a foreign body, 32, or 67 percent, underwent the combined oral and nasal approach in a single operative session, 12, or 25 percent, were treated orally alone, and 4, or 8.33 percent, nasally alone. Complete removal of the foreign body and complete resolution of symptoms were achieved in all cases, with no major complications and no revision surgeries over a mean follow-up of six months and a minimum of three. Within the broader cohort, ostiomeatal complex obstruction was observed in 77 cases, and 73 patients carried an oroantral defect alongside the foreign body. Under Felisati’s classification, 8 cases were pre-implantological complications, 37 were implantological complications, and 115 were classical complications, reflecting how heavily dental procedures and implant surgery feature in the origins of this disease.

The findings align with a growing international consensus that odontogenic sinusitis is best managed jointly by otolaryngologists and oral surgeons. Felisati and colleagues previously reported a 98.8 percent success rate across a prospective series of 257 patients using a cause-specific algorithm, while a prospective study by Kocum and colleagues found that a one-stage combined ENT and dental approach was used in 94 percent of 364 patients with a 97 percent success rate. The Roman team acknowledges the limitations of its own design: the analysis is descriptive rather than comparative, no formal statistical superiority testing was performed given the small size of subgroups such as the four nasal-only patients, and follow-up relied on clinical symptom resolution rather than systematic radiologic assessment or patient-reported outcome measures. Even so, the authors argue that the relatively large number of patients with maxillary sinus foreign bodies and the consistent application of a predefined algorithm make the results directly applicable to routine practice.

The broader message for patients and clinicians alike is that a displaced dental material in the maxillary sinus is rarely a trivial finding. Surgical removal is recommended when the foreign material causes or contributes to sinusitis, and the choice of route, nasal, oral, fistular, or a simultaneous combination of these, should be dictated by the anatomy of each case rather than by habit or specialty allegiance. As the authors put it in their conclusion, the simultaneous combined approach overcomes the anatomical and technical limitations of each individual access, providing wider visualization and more comprehensive access to the sinus cavity, reducing the risk of recurrence or complications, and representing, in their view, a new frontier in the management of foreign bodies in patients suffering from odontogenic sinusitis. Larger prospective and multicenter studies will be needed to confirm which patient subgroups benefit most, but for now the Rome algorithm offers one of the most detailed roadmaps available for a problem that sits, quite literally, at the intersection of two surgical disciplines.

Subject of Research: Surgical management of maxillary sinus foreign bodies in odontogenic sinusitis using a multidisciplinary treatment algorithm

Article Title: Maxillary foreign body management in odontogenic sinusitis: an algorithm based on a single centre experience

Article References: Sabatino, L., Lopez, M. A., Valentini, M., Mattaroccia, M., Iafrati, F., Di Giovanni, S., Moffa, A., & Casale, M. (2026). Maxillary foreign body management in odontogenic sinusitis: an algorithm based on a single centre experience. Frontiers in Oral Health, 7, Article 1945885. https://doi.org/10.3389/froh.2026.1945885

Image Credits: AI Generated

DOI: 10.3389/froh.2026.1945885

Keywords: odontogenic sinusitis, maxillary sinus, foreign body, dental implants, middle meatal antrostomy, Caldwell-Luc, oroantral fistula, endoscopic sinus surgery, multidisciplinary surgery, ostiomeatal complex, treatment algorithm, oral and maxillofacial surgery

The operation at the center of the report is called extended resection of thymic tumor combined with artificial bypass between the innominate vein and the right atrial appendage. In essence, surgeons remove the thymic tumor together with the segment of superior vena cava it has invaded, then restore venous outflow by sewing a synthetic vascular graft between the innominate vein and a small pouch-like structure on the heart called the right atrial appendage. Since March 2016, the Shanghai group has explored this approach systematically. A published study from their institution covering fifty-seven patients treated between January 2016 and June 2021 found that the procedure substantially improved quality of life and prolonged survival. Among those cases, twenty-five patients required resection of the left innominate vein alone, two underwent partial resection and repair of the superior vena cava, and thirty received full artificial vessel reconstruction between the innominate vein and the right atrial appendage before the tumor and the vein were removed.

What makes the new commentary valuable is its focus on the anesthetic discipline that underpins the surgery. The authors, anesthesiologists YuanYuan Ma and ShengJin Ge and thoracic surgeon JianYong Ding, emphasize that the operation demands general anesthesia with a single-lumen endotracheal tube, because access is gained through a median sternotomy, the vertical division of the breastbone. Notably, they deliberately avoid combining general anesthesia with an epidural block, a technique often used for pain control in major chest surgery. The reason is practical and unforgiving: these patients require strict anticoagulation around the time of surgery to keep the artificial graft from clotting, and an epidural catheter in a heavily anticoagulated patient carries a risk of spinal bleeding that no surgical benefit can offset.

Preparation begins long before the first incision. The team insists on a mandatory preoperative assessment of both the airway and the great vessels. In their experience, airway integrity is rarely compromised in patients selected for planned surgery, but the vascular assessment is critical: anesthesiologists and surgeons must map precisely where and how extensively the tumor invades the superior vena cava and the brachiocephalic veins, and they must judge whether collateral circulation, the network of smaller veins that develops to bypass a chronically obstructed great vessel, has already been established. The anatomy itself offers a helpful clue for planning. The left innominate vein crosses in front of the aortic arch and follows a long, accessible course, which makes it relatively easy to separate and expose when the tumor has not completely engulfed it. That is why the left innominate vein to right atrium reconstruction is the team’s preferred configuration.

Once the patient is in the operating room, the monitoring strategy reads like a checklist for protecting two vulnerable organs at once: the brain and the heart. The team tracks body temperature and measures the activated clotting time of whole blood, or ACT, at three key moments: before anesthesia induction, fifteen minutes after giving intravenous heparin at a dose of one milligram per kilogram, and thereafter as needed to guide anticoagulation. Depth of anesthesia is monitored with the bispectral index, including the burst suppression ratio, or alternatively with cerebral oxygen saturation, so that any fall in brain perfusion is caught in real time. A catheter is placed retrograde into the cranial segment of the right internal jugular vein to measure venous pressure on the head side of the obstruction, and transesophageal echocardiography is recommended for patients with significant cardiac disease. Vascular access is equally deliberate: the femoral vein and the left radial artery are catheterized, and the right internal jugular vein is cannulated in reverse, toward the head.

The physiological logic that ties the whole anesthetic plan together is captured in a single number. Intracranial perfusion pressure, the pressure driving blood through the brain, is approximately equal to the difference between the mean arterial pressure and the right internal jugular venous pressure. The team therefore watches both values continuously throughout the operation and afterward, and maintains that difference at greater than sixty millimeters of mercury during the entire perioperative period. When the superior vena cava is clamped, venous pressure on the head side can climb steeply, so the team keeps it below thirty millimeters of mercury based on their accumulated experience, elevates the head of the operating table by fifteen to thirty degrees to encourage venous return, and administers intravenous mannitol when appropriate to reduce cerebral swelling. If the bispectral index shows burst suppression appearing or rising, a signal the authors interpret as cerebral hypoperfusion with ischemia, the response is immediate: raise the perfusion pressure, and if necessary change the mode of superior vena cava reconstruction altogether.

Ventilation during the operation follows the principles of lung-protective mechanical ventilation, adapted to the peculiar hemodynamics of venous clamping. The team uses low tidal volumes of four to six milliliters per kilogram of body weight, compensates with an increased respiratory frequency to keep the end-tidal carbon dioxide partial pressure in the normal range, and applies zero positive end-expiratory pressure. That last choice matters: positive pressure in the chest would impede venous return at precisely the moment when the surgical team is rerouting it. Other details reveal how finely tuned the procedure is. During manipulation of the pericardium, the anesthesiologist watches cardiac function, blood pressure, and arrhythmias closely. After the subclavian vein is blocked, any available upper extremity intravenous route is clamped to prevent infusions from being delivered into a territory with no venous outflow. And before the tumor-invaded superior vena cava is clamped, the team confirms that the patient has no peripherally inserted central catheter or subcutaneous port catheter that could be damaged or dislodge.

The moment the bypass graft is opened is one of quiet confirmation. The team observes whether the pressure in the right internal jugular vein drops significantly, which would indicate that the new conduit is successfully draining blood from the head. Heparin is then partially antagonized with protamine, but not fully reversed: the activated clotting time is maintained at an appropriate prolongation, below two hundred seconds, striking a balance between preventing graft thrombosis and avoiding catastrophic bleeding. Throughout the operation the team monitors bleeding, cardiac function, and central venous pressure measured through the femoral venous line, giving blood transfusion, cardiotonic drugs, or diuretics as the situation demands. Cutaneous congestion over the head, neck, and upper chest is treated as a serious warning sign that venous drainage is failing, and the operating surgeon is notified immediately if it appears.

Even the awakening and handover phases carry their own safeguards. As patients emerge from anesthesia, the team watches brain function, including consciousness and movement, and pays attention to respiration, because the right phrenic nerve, which drives one half of the diaphragm, is often transected during the operation, a loss that generally causes little harm but can affect breathing. One instruction the authors say must never be forgotten at the intensive care unit handover is that the right internal jugular vein catheter is for continuous pressure measurement only, never for infusion, since injecting fluid into that vessel would raise intracranial venous pressure. Finally, every patient receives long-term anticoagulation after surgery to keep the artificial graft open, a commitment that begins in the operating room and continues for life.

The larger message of the commentary extends beyond any single operation. Extended resection of thymic tumors with artificial bypass, the authors conclude, requires not only excellent surgical skill but also appropriate intraoperative anesthesia control and intensive critical care, and multidisciplinary teamwork is mandatory. In an era when tumors once deemed inoperable are increasingly being resected with vascular reconstruction, the Shanghai experience offers a template: a standardized anesthetic protocol built around perfusion pressure mathematics, real-time neuromonitoring, meticulous vascular access planning, and disciplined communication between surgeon and anesthesiologist. For patients facing a tumor that has claimed the body’s largest vein, that template may be the difference between palliative care and a genuine chance at extended survival.

Subject of Research: Anesthesia management for extended resection of thymic tumors invading the superior vena cava with artificial innominate vein to right atrial appendage bypass

Article Title: Anesthesia management for extended resection of thymic tumor combined with artificial bypass between the innominate vein and the right atrial appendage

Article References: Ma, Y., Ding, J., & Ge, S. (2024). Anesthesia management for extended resection of thymic tumor combined with artificial bypass between the innominate vein and the right atrial appendage. Clinical Cancer Bulletin, 3(1), Article 14. https://doi.org/10.1007/s44272-024-00020-0

Image Credits: AI Generated

DOI: 10.1007/s44272-024-00020-0

Keywords: thymic tumor, superior vena cava syndrome, anesthesia management, innominate vein bypass, right atrial appendage, vascular reconstruction, thoracic surgery, activated clotting time, bispectral index, cerebral perfusion pressure, anticoagulation, multidisciplinary surgery