Involvement of the maxillary sinus in bisphosphonaterelated osteonecrosis of the jaw: Radiologic aspects

Background: The use of bisphosphonates is very common among patients with osteoporosis and multiple myeloma as well as those with bone metastases from various malignancies. The benefits of bisphosphonates are well recognized, but it became evident during the past decade that these medications portend the major adverse effect of osteonecrosis of the jaw, known as bisphosphonaterelated osteonecrosis of the jaw. Objectives: Our aim was to evaluate the specific manifestations of bisphosphonate use on the maxillary sinus in patients with documented bisphosphonaterelated osteonecrosis of the jaw. Methods: A retrospective review of all the patients diagnosed between October 2003 to August 2014 as having bisphosphonaterelated osteonecrosis of the jaw in a large universityaffiliated tertiary care medical center. The records of 173 patients diagnosed as having bisphosphonaterelated osteonecrosis of the jaw during the study period were retrieved. The available head and neck computed tomographic images were analyzed for cases of involvement of the maxilla. Main Outcome Measures: Manifestations of bisphosphonaterelated osteonecrosis of the jaw as observed on physical examination and on imaging studies. Results: Seventyone patients (41%) had involvement of the maxilla, 86 patients (49%) had involvement of the mandible, and 16 patients (9%) had involvement of both the maxilla and the mandible. Computerized tomography studies were available for 50 patients with involvement of the maxilla: 36 (72%) had evidence of maxillary sinus opacification (in comparison, the incidence of maxillary sinus opacification as an incidental finding in the general population is reported to be 19%, p < 0.0001). Sixteen patients (32%) had evidence of oroantral fistula, and five patients (10%) had oronasal fistula. Conclusion: In addition to its wellestablished effects on the mandible and maxilla, bisphosphonaterelated osteonecrosis of the jaw significantly affected the maxillary sinus. Its radiologic manifestations should be recognized by clinicians and especially by otolaryngologists.