Odontogenic Sinusitis: Clinical, Radiologic, and Quality-of-Life Characterization in a Prospective Study

Odontogenic Sinusitis: Clinical, Radiologic, and Quality-of-Life Characterization in a Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Odontogenic Sinusitis: Clinical, Radiologic, and Quality-of-Life Characterization in a Prospective Study Narjesse Kemcha, Helena Rey-Martínez, Pedro Luis Ruiz-Sáenz, Natalia Martínez-Rodríguez, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7077259/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background Rhinosinusitis is an increasingly diagnosed condition which compromise the daily quality of life of the population and exerting a serious strain on public healthcare systems. Under the rhinosinusitis spectrum falls the odontogenic sinusitis, a predominantly unilateral rhinosinusitis, implicated in up to 75% of unilateral maxillary sinusitis cases. This study aimed to analyze the clinical and radiological characteristics of patients with odontogenic sinusitis and to determine how these findings relate to their quality of life. Methods Thirty-eight patients with unilateral sinusitis caused by dental pathology/treatment were recruited. OS diagnosis criteria were established according to EPOS-2020 guidelines. The 22-item SNOT-22 questionnaire was used to gauge symptom severity and social/emotional impact. In addition, all patients underwent CT imaging and were staged with the Lund-Mackay scale for involvement of the maxillary, anterior and posterior ethmoid, sphenoid and frontal sinuses. Results Smoking was associated with higher SNOT-22 scores (active smokers: 59.44 ± 18.29; non-smokers: 38.22 ± 22.29; p = 0.026). Younger patients reported a slightly lower symptom burden than older ones but had significantly more nasal obstruction (rho=–0.525; p < 0.001) and facial/otologic symptoms (rho=–0.328; p = 0.045). Patients with frontal and posterior ethmoid total opacification averaged 60.2 ± 11.1 (p = 0.039) and 68.5 ± 14.85 years (p = 0.018) respectively. Patients treated with ATB/Nasal-GCC showed a prolonged symptom duration (26.61 ± 16.79 and 30.67 ± 26,63 months respectively). Extra-maxillary involvement was observed in 71.1% of the patients. Purulence correlated with higher LM scores (7.77 ± 2.27 vs. 2.83 ± 1.75 without purulence, p < 0.001), longer symptom duration and a greater likelihood of extra-maxillary spread (92.3%, p < 0.001). Conclusions In this study, smokers and patients exhibiting purulent discharge experienced greater quality-of-life impairment and a more extensive extra-sinus spread. Clinical Trial Number: Not applicable. Odontogenic sinusitis SNOT-22 Nasal domain Lund-Mackay scoring smoking purulence extra-maxillary extension Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Rhinosinusitis is an increasingly diagnosed condition impacting 10–20% of the population in industrialized countries, significantly compromising their daily quality of life (QoL) and exerting a serious strain on public healthcare systems [ 1 , 2 ]. In the latest European position paper on rhinosinusitis and nasal polyps (EPOS 2020), rhinosinusitis was defined as nasal and paranasal sinus inflammation, characterized by two or more symptoms, one being nasal obstruction/congestion/discharge, associated with facial pain/pressure and/or hyposmia/anosmia. Supporting evidence is provided by nasal endoscopy or imaging findings via computed tomography (CT). Rhinosinusitis is considered chronic when symptoms persist for more than 12 weeks [ 3 ]. Under the rhinosinusitis spectrum falls the odontogenic sinusitis (OS), a predominantly unilateral rhinosinusitis, implicated in up to 75% of unilateral maxillary sinusitis cases. Its identification may prove convolute due to its heterogeneous etiology and the non-specificity of the elicited symptomatology [ 4 , 5 ]. OS stems from dental/oral pathoses or iatrogenic processes undertaken in the vicinity of the maxillary sinus, triggering mucosal inflammation and hyperplasia, barrier dysfunction, impaired mucociliary clearance, and mucus hypersecretion [ 6 – 8 ]. These processes contribute to tissue fibrosis potentially compromising the patency of the ostio-meatal complex (OMC) causing sinus drainage impairment, and potential spread to other paranasal sinuses [ 6 , 9 – 12 ]. Despite its prevalence (10–40% of maxillary rhinosinusitis cases), OS origin is often overlooked in otolaryngology consultations, and its complications insufficiently managed in primary dental care [ 5 , 13 ]. While chronic rhinosinusitis (CRS) is widely studied, the clinicopathological, radiological and psychosocial aspects of OS and its impact on QoL remain underexplored. This study aims to evaluate those parameters using the Sino-Nasal-Outcome-Test questionnaire (SNOT-22) [ 14 ] to assess symptom burden and QoL, alongside Lund-Mackay (LM) staging system [ 15 ] to quantify sinus opacification and extra-maxillary spread. By utilizing these metrics, we sought to identify patterns linking symptom severity to radiological findings, and by stratifying outcomes by demographics, smoking status, and purulence, we aimed to identify high-risk subgroups and disease spread patterns that may require targeted interventions. METHODS Study design A group of 38 consecutive patients with a diagnosis of sinusitis originated by dental pathology/treatment, was included in this observational prospective study approved by the Ethic board of San Carlos Hospital-Madrid (22/190-E;13/07/2023), and conforming to Helsinki Declaration’s ethical provisions. The patients presented to oral surgery and implantology department clinic at the Madrid Complutense University’s Faculty of Dentistry, from July 2023 to June 2024 and provided an informed consent. Size collection The sample size was determined with reference to prior prospective studies conducted in a similar clinical context. Yoo et al. [ 16 ] and Craig et al. [ 17 ] included cohorts of 33 and 37 patients, respectively, and successfully derived meaningful insights into the clinical features and treatment outcomes of odontogenic sinusitis. Their findings support the adequacy of our sample for the purposes of exploratory analysis. Patient selection was conducted by a multidisciplinary team (a dentist, an oral surgeon, and ENT specialist) with sinusitis diagnosis based on EPOS-2020 criteria [ 3 ]. Patients legal-aged with unilateral sinusitis linked to a dental factor were included. Were excluded those with prior CRS history, fungal/allergic rhinosinusitis, previous endoscopic sinus surgery (ESS), sinonasal tumors, systemic diseases affecting the sinuses (e.g., radiotherapy, primary ciliary dyskinesia, cystic fibrosis, vasculitis, asthma), and pregnancy. The SNOT-22 questionnaire[ 14 ] (2006, Washington University, St. Louis) was completed by healthcare professionals using a standardized data sheet comprising 22 items, assessing symptom severity and social/emotional impact over the past two weeks, ranging in a Lickert-like scale from 0 (“No problem”) to 5 (“As bad as it can be”) (Appendix). The questionnaire was divided into five domains to identify the most affected areas: The nasal domain (items 1–7), ear/facial (8–12), Sleep (13–16), concentration/productivity/function (17–19) and psycho-social (20–22). The SNOT-22 score threshold for pathologic values was 9 points [ 14 ]. The standard LM staging system [ 15 ] widely used in otorhinolaryngology, was applied to quantify rhinosinusitis severity via CT scans. Each sinus group (maxillary (Mx), anterior ethmoid (AE), posterior ethmoid (PE), frontal (Frt), and sphenoid (Sph)) is scored from 0 (normal) to 2 (complete opacification), while the OMC is scored 0 (patent) or 2 (obstructed). The total score ranges between 0–12 per side (Appendix). To minimize interpretive variability, CT scans were evaluated repeatedly and inter/intra-examiner discrepancies were assessed via the Kappa coefficient. Purulence and mucosal oedema were evidenced subsequently to endoscopic examination. Independent variables were gender, age, smoking habits, duration of the symptoms before OS diagnosis and prior treatments. The outcome variables comprise the SNOT-22 scores to assess the degree of impairment caused by OS, and the LM scoring to assess the degree of paranasal sinuses occupancy and the OMC patency. The data obtained was reported in compliance with the STROBE guidelines. Statistical analysis The software IBM-SPSS 24 (IBM, Armonk, United States) was used for statistical processing. Chi-square test and Yates' correction were employed for categorical variables, while Kruskal-Wallis test was used to assess the correlation of the means between dependent and independent variables. A correlation analysis had been conducted using Pearson test and Spearman’s Rho correlation. The threshold of statistical significance was set at p ≤ 0.05. RESULTS Study Population Characteristics The study included 38 participants, with a slight male predominance (20 men, 18 women) and a mean age of 49.26 ± 9.94 years (25–79 years). Patients over 45 represented 71.1% of the sample (≤ 45 years 28.9%). Active smokers represented 44.7% of the participants, 7.9% were former smokers and 47.4% were non-smokers. The affected side was nearly balanced (54% left, 46% right). The symptom duration averaged 23.47 months. Regarding prior treatments, 45.5% received antibiotics (ATB), 39.4% intranasal glucocorticoids (GCC), 9.1% dental treatment (DT), and 6% had no prior treatment (NoT). Purulence was observed in 68.4% of cases, while oedema was present in 13.1%. The mean SNOT-22 score was 48.71 ± 22.84, and the LM score averaged 6.21 ± 3.13 (Table-1). Table 1 Characteristics of the study population . Gender M:52.6% (n = 20) F:47.4% (n = 18) Age 49.26 ± 9.94; [25–79 years] Smoking Habits NS: 47.4% FS: 7.9% CS: 44.7% Affected Side L:54% R:46% Symptoms Duration 23.47 ± 18.73 months Previous Treatments ATB:45.5% DT:39.4% GCC: 9.1% NoT: 6% Purulence Yes:68.4% (26) No:31.6% (12) Oedema Yes:13.1% (5) No:86.9% (33) Mean SNOT-22 48.71 ± 22.84 Mean Lund-Mackay 6.21 ± 3.13 M: Male, F: Female, NS: non-smoker, FS: former smoker, CS: current smoker, L: left, R: right, ATB: antibiotics, DT: dental treatment, GCC: glucocorticoids, NoT: no treatment. The most frequent etiological factors associated with the OS in the sample were periapical cysts, (26.3%, 10 patients) of all cases. Periodontal diseases followed with 23.7% (9 patients), and endo-periodontal lesions were incriminated in 18.4% of cases (7 patients). Post-extraction oroantral communications represented also 18.4% (7 patients) of the etiologies involved, whereas foreign body retention (7.9%; 3 patients) and sinus augmentation procedure (5.3%; 2 patients), were the less implicated in this sample. SNOT-22 scores The mean SNOT-22 of the study population was 48,71 ± 22,84, with no significant gender differences (men:47.1 ± 25.16, women:50.5 ± 20.5), though women reported higher, yet non-significant trends in sleep (8.90 against 6.44 in men) and functional domains (7.15 against 5.22 in men) (Table-2). Table-2: SNOT-22 domains mean scores yielded,and standard deviations stratified by gender and purulence at endoscopic examination. SNOT-22 Domains Gender N Mean SD p Purulence N Mean SD p NASAL M 20 20.95 9.84 0.303 NO 12 18.08 9.03 0.071 F 18 23.72 7.92 YES 26 24.19 8.80 Total 38 22.26 8.92 Total 38 22.26 8.92 FACIAL-EAR M 20 7.25 5.99 0.119 NO 12 8.08 3.82 0.327 F 18 9.78 4.15 YES 26 8.62 5.36 Total 38 8.45 4.73 Total 38 8.45 4.73 SLEEP M 20 8.90 6.12 0.361 NO 12 5.33 7.38 0.106 F 18 6.44 6.64 YES 26 8.85 5.55 Total 38 7.74 6.61 Total 38 7.74 6.61 FUNCTION M 20 7.15 4.78 0.264 NO 12 4.08 5.58 0.066 F 18 5.22 5.06 YES 26 7.23 4.52 Total 38 6.24 5.13 Total 38 6.24 5.13 PSYCHOLOGICAL M 20 5.95 5.33 0.806 NO 12 4.33 5.03 0.164 F 18 5.61 4.69 YES 26 6.46 4.96 Total 38 5.79 4.93 Total 38 5.79 4.93 FUNCTION-PSYCHOLOGICAL M 20 13.10 9.79 0.478 NO 12 8.42 10.46 0.076 F 18 10.83 9.18 YES 26 13.69 8.62 Total 38 12.03 9.57 Total 38 12.03 9.57 TOTAL SNOT-22 M 20 47.10 23.89 0.718 NO 12 39.75 25.16 0.121 F 18 50.50 21.5 YES 26 52.85 20.51 Total 38 48.71 22.84 Total 38 48.71 22.84 SD: standard deviations. M: male, F: female, N: number of patients. No correlation was established between SNOT-22 scores and age (rho=–0.206, p = 0.215). However, younger patients (< 45 years) showed a slightly lower overall symptom burden (44.00 ± 22.79) than those above 45 (51.00 ± 22.84) but significantly more nasal obstruction (rho=–0.525; p < 0.001) and facial/otologic symptoms (rho=–0.328; p = 0.045). Symptom distribution analysis revealed the nasal domain as the most affected (22.26 ± 8.92), comprising 45.7% of the total burden, followed by facial/otologic (8.45 ± 4.73) and sleep disturbances (7.74 ± 6.61). Functional (6.24 ± 5.13) and psychological domains (5.79 ± 4.93) showed lower yet notable impact, but when combined, they yielded a mean score of 12.03 ± 9.57, indicating a substantial effect on QoL (Appendix-Table 1). Gender-based stratification showed higher nasal and facial/ear scores in women than in men (23.72 ± 8.80 vs. 20.95 ± 9.03 and 9.78 ± 5.36 vs. 7.25 ± 3.82 respectively), while men reported higher sleep-related and functional impairment (8.90 ± 7.38 vs. 6.44 ± 5.55 and 7.15 ± 5.58 vs. 5.22 ± 4.52 respectively). Psychological scores were comparable (men:5.95 ± 5.03; women:5.61 ± 4.96), though the combined function-psychological domain showed slightly higher impact in men (13.10 ± 10.46 vs. 10.83 ± 8.62). Total SNOT-22 scores were marginally higher in women, though without clear statistical significance ( Table-2, Fig-1: SNOT-22 and Purulence Endoscopic examination revealed purulent secretions in 26 patients (68.4%). Symptom severity measured by SNOT-22, was consistently higher in purulent cases across all domains. The mean total SNOT-22 score in purulent cases was 52.85 ± 21.55 compared to 39.75 ± 23.89 in non-purulent cases, representing a substantial mean difference of 13.1 points, despite the absence of statistical significance​. The nasal domain showed the largest score in patients with purulent secretions (24.19 ± 7.92 against 18.08 ± 9.84 without purulence), followed by the sleep domain (8.85 ± 6.64 against 5.33 ± 6.12 without purulence). Functional impairment in purulent cases scored higher (7.23 ± 4.52) than in non-purulent cases (4.08 ± 5.58) without reaching statistical significance. However, within this domain, items like concentration or nasal congestion/obstruction registered significantly higher scores in presence of purulence (2.27 ± 1.66 and 26 ± 4.42) than in its absence (1 ± 1.54 and 12 ± 3.08) (p = 0.023 and p = 0.008 respectively). The psychological domain demonstrated a similar trend, with higher values in purulent cases (6.46 ± 4.69 vs. 4.33 ± 5.33, p = 0.164). This pattern persisted when combining functional and psychological domains (13.69 ± 9.18 vs. 8.42 ± 9.79). The facial-ear domain showed the smallest difference between groups (8.62 ± 4.15 vs. 8.08 ± 5.99), suggesting minimal influence of purulence on this symptom cluster (Table-2, Appendix-Figure1: Radar Plot comparing SNOT-22 domains’ scores between patients presenting purulence and patients without purulence. ). LM scores In our cohort of 38 patients, the mean total LM score was balanced through genders (6.25 ± 3.06 in men 6.17 ± 3.29 in women) (Fig-2: ) despite minor variations in subregions (LM right-Mx, LM right-AE, LM right/left-OMC). While total LM scores did not correlate with age (≤ 45 years: 6.64 ± 2.77; >45 years: 6.33 ± 3.13), older patients exhibited greater opacification in specific regions. Those with total opacification of right-Frt had a mean age of 60.2 ± 11.1 years (47.53 ± 8.93 without opacification, p = 0.039), while patients with right-PE opacification averaged 68.5 ± 14.85 years (48.57 ± 8.06 without opacification, p = 0.018). Similarly, age distribution differed between maxillary and extra-maxillary involvement. Patients with extra-maxillary involvement at the right nasal fossa were older than those who showed only maxillary involvement (p = 0.011). Laterality analysis concluded to a slightly higher mean age in extra-maxillary cases on the right side (n = 13; 51.08 ± 12.68 years) than maxillary cases (n = 25; 48.32 ± 8.33 years,), though these means are close to the mean age of the sample. LM scores, purulence and extra-maxillary extension Purulent cases had significantly higher total LM scores (7.77 ± 2.27 against 2.83 ± 1.75 in non-purulent cases, p < 0.001), indicating greater sinus opacification (Table-3, Fig-2). On the left side, opacification was notably higher in purulent cases (4.19 ± 4.35 vs. 0.75 ± 1.42), reflecting its radiologic impact. Paranasal sinus involvement extended beyond the maxillary sinus in 71.1% of cases. The AE was most affected after the Mx sinus, with 79.5% showing partial or total opacification (Table-3). Purulence was strongly associated with extra-maxillary extension, present in 92.3% of purulent cases vs. 25% of non-purulent cases (Chi-square = 18.085, p < 0.001). Table-3: LM scores distribution by genders and purulence, and rates of cases presenting other paranasal sinuses involvement. Gender N Mean SD p Purulence N Mean SD p Ex-Mx Ext Rate (%) LM RNF M 20 4,10 3,70 0.126 No 12 2,08 2,11 0.429 AE 79.5 F 18 2,00 3,03 Yes 26 3,58 3,95 Total 38 3,11 3,52 Total 38 3,11 3,52 PE 46.15 LM LNF M 20 2,15 3,70 0.2 No 12 0,75 1,42 0.114 F 18 4,17 4,16 Yes 26 4,19 4,35 Frt Total 38 3,11 4,01 Total 38 3,11 4,01 41.03 LM TOTAL M 20 6,25 3,06 0.96 No 12 2,83 1,75 < 0.001 F 18 6,17 3,29 Yes 26 7,77 2,27 Sph 10.25 Total 38 6,21 3,13 Total 38 6,21 3,13 RNF: right nasal fossa, LNF: left nasal fossa, M: male, F: female, N: number of patients, SD: standard deviation, Ex-Mx-Ext: extra-maxillary extension, AE: anterior ethmoid sinus, PE: posterior ethmoid, Frt: frontal sinus, Sph: sphenoid. OMC obstruction was present in 84.6% of cases, with 46.1% on the right, 38.5% on the left, and 15.4% unaffected. Among purulent cases, 96.3% had OMC obstruction against 58.3% in non-purulent cases. Unexpectedly, patients with oedema had lower LM scores (3.20 ± 2.05) than patients clear of oedema (6.67 ± 3.03, p = 0.019), suggesting oedema correlates with symptoms but not increased sinus opacification. Smoking Status : The current smokers reported the highest average SNOT-22 scores (59.44 ± 18.29), while non-smokers displayed the lowest scores (38.22 ± 22.29), with former smokers falling in between (43 ± 19.16) (p = 0.0026) ( Fig-3 ). Furthermore, pairwise comparison indicated an important statistically significant difference between current and never smokers (p = 0.009). Smokers registered higher scores particularly in the nasal domains of SNOT-22 with a mean of 21.88 ± 7.13 and 11.29 ± 3.98 in facial/ear domain, compared to non-smokers (16.83 ± 8.63 in nasal domain, and 6.94 ± 4.23 in facial/ear domain), without these values reaching statistical significance. Smokers showed higher mean total LM - score (7 ± 3.14; non-smokers: 5.61 ± 3.09) and opacification in specific regions, particularly the Mx and AE/PE sinuses. However, no specificities were reported for smokers in terms of purulence, oedema or symptoms’ duration (Table 4 ). Table 4 Total SNOT-22 and LM scores in patients according to their smoking status. Smoking Status Patients (N = 38) LM p SNOT-22 p Non-smokers n = 18 (47.4%) 5.61 ± 3.09 0.363 38.22 ± 22.29 0.026 Former smokers n = 3 (7.9%) 5.33 ± 4.04 43 ± 19.16 Active smokers n = 17 (44.7%) 7 ± 3.14 59.44 ± 18.29 Previous treatments and symptoms duration : The mean symptom duration reported in this study (23.47 months) reflects a chronic disease course. 94% of the patients received previous treatments including ATB, nasal GCC or DT. Patients treated with nasal GCC experienced longer symptom durations (30.67 ± 26,63 months) compared to NoT patients (7 ± 7.07 months). The ATB group showed a high mean symptom duration (26.61 ± 16.79) but lower than the GCC group, whereas the DT group showed shorter symptom duration (19.56 ± 19.80) than both. Patients with purulence had prolonged symptoms (26.88 ± 9.66 months) compared to those with normal endoscopic findings (16.08 ± 14.6 months) ( Fig-4 ). Symptom duration was generally longer in patients with partial or total sinus opacification than in those without sinus opacification, though the overall differences regarding symptoms’ duration were not statistically significant. DISCUSSION OS remains underdiagnosed and often mismanaged leading to prolonged disease course and ineffective treatment pathways, entailing profound implications for patients' QoL. The SNOT-22 questionnaire is widely employed to assess CRS symptom burden but scarcely used for sinusitis of various dental origins. In this study it was clustered into five domains, and LM scoring was segmented to assess extra-maxillary extension, enabling a precise radiographic evaluation of paranasal sinus involvement, and a thorough assessment of the condition's clinical implications within the study population. The analysis of etiological factors of the OS within the study sample identified a clear predominance of infectious etiologies (68.4%), primarily represented by periapical cysts (26.3%), periodontal disease (23.7%), and endo-periodontal lesions (18.4%), underscoring the critical role of odontogenic infections in sinus-related dental complications. In contrast, iatrogenic causes represented 31.6% of OS triggers, largely attributed to post-extraction oroantral communications (18.4%), foreign bodies (7.9%), and sinus lift procedures (5.3%). SNOT-22 domains and LM scores The highest SNOT-22 scores retrieved are in the nasal domain, the lowest in the psychological (emotional)domain, aligning with Kwiatkowska et al. 18 where the highest and lowest SNOT-22 scores correspond to the same domains of the present study, although their research focused only on OS caused by periapical lesions. QoL-related domains (sleep, function and psychological) when combined, yielded a score of 19.45 ± 14.87, underscoring a serious disease burden as concluded in Gaudin et al.[ 19 ] and Kwiatkowska et al.[ 18 ] studies. Simuntis et al.[ 20 ] reported even higher emotional distress in OS than in rhinogenic sinusitis. In the present study, the extra-maxillary extension registered was substantial, with AE involvement reaching 79.5% and Frt sinusitis in almost 41%, likely due to the prolonged symptom duration in the study cohort (23.47 months), promoting disease progression. Fadda et al.[ 21 ] reported lower AE involvement (51.6%, and 12.9% of the Frt sinus) while Saibene et al.[ 22 ] found 41% of unilateral extra-maxillary extension. Goyal et al.[ 23 ] identified Frt sinus involvement as a diagnostic indicator of OS over CRS. While LM scoring objectively complemented SNOT-22 assessment, the correlation between both metrics was inconclusive within this sample. Purulence Multiple studies have identified purulence in the middle meatus as a hallmark of OS, particularly in acute cases, where it appears in up to 58% of patients [ 24 – 26 ]. In the present study 68.4% of the patients presented purulence at the endoscopic observation, a very similar rate to that found by of Costa et al. [ 27 ] (two thirds of the study population had purulence) and Aljeraisi [ 28 ] (70%). Total SNOT-22 scores were 13.1 points higher in patients with purulence, reflecting a severe impact on nasal function and QoL (sleep quality, performance status). This finding may inform clinical evaluation and therapeutic strategy development for OS patients. Robinson et al.[ 29 ] in their study concluded to the absence of correlation between purulence and LM scores contrasting with our findings where elevated LM scores were registered in presence of purulence. Purulence also correlated with extensive sinus involvement patterns present in 92.3% of purulent cases (p < 0.001). Similarly, longer symptom duration was observed in patients presenting purulence, likely due to a pathophysiological cascade of persistent inflammation leading to suppuration, which in turn impairs sinus outflow and promotes both persistence and trans-sinusal progression of the disease, reinforcing purulence as a marker of advanced OS and more extensive sinus involvement. OMC Obstruction is a key criterion in endoscopic sinus surgery decision-making [ 30 ]. Sabatino et al.[ 31 ] reported it in 42% of cases, while in our study, 84.6% of the study participants had OMC obstruction, that was also observed in 96.3% of the patient with evidenced purulence. These findings highlight the need to assess OMC patency when considering surgical intervention in OS cases. Smoking status : Up to date, various studies addressed smoking status as a covariate contrastingly impacting surgical outcomes in CRS [ 32 , 33 ]. Gill et al. [ 34 ] observed that tobacco increases the CRS risk 1.42 to 3.60-fold while Tan et al. [ 35 ] in a meta-analysis including 45 studies, found that smokers and former smokers had poorer baseline QoL compared to never-smokers. This is the first study that explores the contribution of smoking in symptom burden in OS, and its role in the deterioration of QoL and interestingly, we found that current smokers were significantly impacted by the condition compared to never smokers. Regarding radiological severity, smokers had higher mean LM scores and despite similar disease duration across groups, smokers consistently showed more opacification. Previous treatments and Symptom duration : Despite 94% of the patients receiving previous treatments (ATB, DT or GCC), symptoms persisted, highlighting limited effectiveness when underlying dental causes remain unaddressed. The patients subjected either to nasal GCC or ATB showed the longest symptom duration. In OS, This aligns with expert consensus that ATB alone are inadequate to reach a conclusive recovery in OS, and that non-surgical treatments should be reserved for the acute phase management while dental treatments are conducted [ 10 , 36 ]. In contrast, patients who received DT reported shorter symptom durations, likely due to the immediate referral to ENT (Ear, throat, nose) specialist in instances of symptoms persistence after dental cause elimination. Intriguingly, patients without prior treatment exhibited the shortest symptom duration, possibly due to a milder disease form or timely diagnosis. While delivering an estimation of pathological metrics in a heterogeneous OS population, this study should be considered alongside its limitations. The investigation focused on a cohort with a long symptom duration, representing predominantly chronic cases, offering valuable insights into long-term disease but may not fully capture the spectrum of early-stage presentations. While the sample size was adequate for primary analyses, it created certain constraints in subgroup comparisons. A structured disease severity assessment in dental consultation may enhance OS management by preventing both undertreatment of the advanced forms of the disease, and overtreatment of mild cases, facilitating timely referrals for advanced forms and high-risk groups (smokers, older patients). The study’s broad approach to dental pathologies underscores that future research could benefit from stratification based on specific dental conditions and procedures, potentially revealing more nuanced patterns in disease presentation and severity. Prospective studies evaluating treatment outcomes based on these identified patterns could provide valuable insights. Conclusions Odontogenic sinusitis necessitates close coordinated interdisciplinary dental-ENT management. A thorough clinical and tomographic evaluation can help identify key nasal, facial, and otologic symptoms, and track anatomical spread. In this study, smokers and patients exhibiting purulent discharge experienced greater quality-of-life impairment and a more extensive extra-sinus spread. Declarations Ethics approval and consent to participate: This study was approved by the Ethic board of San Carlos Hospital-Madrid (22/190-E;13/07/2023). Informed consent was obtained from all participants at the beginning of the study. This study adhered to the Declaration of Helsinki. Consent publication: Not applicable. Availability of data and materials: All data analysed during this study are included in this published article and its supplementary information files. Competing interests : The authors declare that they have no competing interests. Funding : No funding has been provided for the present work. Author Contributions: NK: writing-original draft preparation and investigation, . HR-M: methodology, investigation. PL R-S: formal analysis. N M-R : conceptualization, review and editing. C B-D: data curation, investigation. JM M-G: conceptualization, supervision and project administration. All the authors read and approved the final manuscript. Acknowledgements: Not applicable. References Michalik M, Krawczyk B. Chronic Rhinosinusitis-Microbiological Etiology, Potential Genetic Markers, and Diagnosis. Int J Mol Sci. 2024;25(6):3201. 10.3390/ijms25063201 . Rathi VK, Soler ZM, Schlosser RJ, Workman AD, Chapurin N, Rowan NR, et al. The Inflation Reduction Act: Implications for Medicare spending and access to biologic therapies for chronic rhinosinusitis with nasal polyposis and asthma. Int Forum Allergy Rhinol. 2024;4(7):1261–5. 10.1002/alr.23344 . Fokkens WJ, Lund VJ, Hopkins C, Hellings PW, Kern R, Reitsma S, et al. Executive summary of EPOS 2020 including integrated care pathways. Rhinology. 2020;58(2):82–111. 10.4193/Rhin20.601 . Wuokko-Landén A, Blomgren K, Suomalainen A, Välimaa H. Odontogenic causes complicating the chronic rhinosinusitis diagnosis. Clin Oral Investig. 2021;25(3):947–55. 10.1007/s00784-020-03384-4 . Grayson JW, Hopkins C, Mori E, Senior B, Harvey RJ. Contemporary Classification of Chronic Rhinosinusitis Beyond Polyps vs No Polyps: A Review. JAMA Otolaryngol Head Neck Surg 20200; 146(9):831–8. 10.1001/jamaoto.2020.1453 Martu C, Martu MA, Maftei GA, Diaconu-Popa DA, Radulescu L. Odontogenic Sinusitis: From Diagnosis to Treatment Possibilities-A Narrative Review of Recent Data. Diagnostics (Basel). 2022;12(7):1600. 10.3390/diagnostics12071600 . Lechien JR, Filleul O, Costa de Araujo P, Hsieh JW, Chantrain G, Saussez S. Chronic maxillary rhinosinusitis of dental origin: a systematic review of 674 patient cases. Int J Otolaryngol. 2014;465173. 10.1155/2014/465173 . Allevi F, Fadda GL, Rosso C, Martino F, Pipolo C, Cavallo G, Felisati G, Saibene AM. Treatment of Sinusitis Following Dental Implantation: A Systematic Review and Meta-Analysis. Am J Rhinol Allergy. 2022;36(4):539–49. 10.1177/19458924221084484 . Turfe Z, Ahmad A, Peterson EI, Craig JR. Odontogenic sinusitis is a common cause of unilateral sinus disease with maxillary sinus opacification. Int Forum Allergy Rhinol. 2019;9(12):1515–20. 10.1002/alr.22434 . Craig JR, Tataryn RW, Aghaloo TL, Pokorny AT, Gray ST, Mattos JL, Poetker DM. Management of odontogenic sinusitis: multidisciplinary consensus statement. Int Forum Allergy Rhinol. 2020;10(7):901–12. 10.1002/alr.22598 . Kaliniak S, Fiedoruk K, Spałek J, Piktel E, Durnaś B, Góźdź S, et al. Remodelling of Paranasal Sinuses Mucosa Functions in Response to Biofilm-Induced Inflammation. J Inflamm Res. 2024;17:1295–323. 10.2147/JIR.S443420 . De Corso E, Rigante M, Mele DA, Settimi S, Penazzi D, Lajolo C, Cordaro M et al. Real-Life Experience in the Management of Sinonasal Complications of Dental Disease or Treatments. J Pers Med. 2022; 12(12):2078. 10.3390/jpm12122078 Tröltzsch M. Epidemiology of Odontogenic Sinusitis. Otolaryngol Clin North Am. 2024;57(6):919–26. 10.1016/j.otc.2024.07.001 . Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP. Psychometric validity of the 22-item Sinonasal Outcome Test. Clin Otolaryngol. 2009;34(5):447–54. 10.1111/j.1749-4486.2009.01995.x . Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology. 1993;31(4):183–4. Yoo BJ, Jung SM, Lee HN, Kim HG, Chung JH, Jeong JH. Treatment Strategy for Odontogenic Sinusitis. Am J Rhinol Allergy. 2021;35(2):206–12. https://doi.org/10.1177/1945892420946969 . Craig JR, McHugh CI, Griggs ZH, Peterson EI. Optimal timing of endoscopic sinus surgery for odontogenic sinusitis. Laryngoscope. 2019;129(9):1976–83. https://doi.org/10.1002/lary.28001 . Kwiatkowska M, Szczygielski K, Chloupek A, Panasiewicz P, Jurkiewicz D. The effect of odontogenic sinusitis with periapical lesions on quality of life. Otolaryngol Pol. 2021;76(1):13–20. 10.5604/01.3001.0015.4539 . Gaudin RA, Hoehle LP, Smeets R, Heiland M, Caradonna DS, Gray ST, et al. Impact of odontogenic chronic rhinosinusitis on general health-related quality of life. Eur Arch Otorhinolaryngol. 2018;275(6):1477–82. 10.1007/s00405-018-4977-5 . Simuntis R, Vaitkus J, Kubilius R, Padervinskis E, Tušas P, Leketas M, et al. Comparison of Sino-Nasal Outcome Test 22 Symptom Scores in Rhinogenic and Odontogenic Sinusitis. Am J Rhinol Allergy. 2019;33(1):44–50. 10.1177/1945892418804975 . Fadda GL, Berrone M, Crosetti E, Succo G. Mono-lateral sinonasal complications of dental disease or treatment: when does endoscopic endonasal surgery require an intraoral approach. Acta Otorhinolaryngol Ital. 2016;36(4):300–9. 10.14639/0392-100X-904 . Saibene AM, Pipolo GC, Lozza P, Maccari A, Portaleone SM, Scotti A et al. (2014) Redefining boundaries in odontogenic sinusitis: a retrospective evaluation of extra-maxillary involvement in 315 patients. Int Forum Allergy Rhinol. 2014; 4(12):1020-3. 10.1002/alr.21400 Goyal VK, Ahmad A, Turfe Z, Peterson EI, Craig JR. Predicting Odontogenic Sinusitis in Unilateral Sinus Disease: A Prospective, Multivariate Analysis. Am J Rhinol Allergy. 2021;35(2):164–71. 10.1177/1945892420941702 . Craig JR. Odontogenic sinusitis: A state-of-the-art review. World J Otorhinolaryngol Head Neck Surg. 2022;8(1):8–15. 10.1002/wjo2.9 . Craig JR, Tataryn RW, Cha BY, Bhargava P, Pokorny A, Gray ST, et al. Diagnosing odontogenic sinusitis of endodontic origin: A multidisciplinary literature review. Am J Otolaryngol. 2021;42(3):102925. 10.1016/j.amjoto.2021.102925 . Kwon KW, Gwak JW, Chung YS. Retrospective comparison of first-line treatments for odontogenic sinusitis based on duration of symptoms. Acta Otorhinolaryngol Ital. 2024;44(2):91–9. 10.14639/0392-100X-N2648 . Costa F, Emanuelli E, Franz L, Tel A, Robiony M. Single-step surgical treatment of odontogenic maxillary sinusitis: A retrospective study of 98 cases. J Craniomaxillofac Surg. 2019;47(8):1249–54. 10.1016/j.jcms.2019.04.012 . Aljeraisi T. Efficacy of endoscopic sinus surgery in management of odontogenic maxillary sinusitis after control of dental pathology. Egypt J Otolaryngol. 2024;40(1):42. 10.1186/s43163-024-00602-8 . Robinson S, Der-Haroutian V, Grove D, Rees G, Wormald PJ. Prevalence of pus in radiologically diseased sinuses in patients undergoing surgery for chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2005;133(2):181–4. 10.1016/j.otohns.2005.04.019 . Tomomatsu N, Uzawa N, Aragaki T, Harada K. Aperture width of the osteomeatal complex as a predictor of successful treatment of odontogenic maxillary sinusitis. Int J Oral Maxillofac Surg. 2014;43(11):1386–90. 10.1016/j.ijom.2014.06.007 . Sabatino L, Pierri M, Iafrati F, Di Giovanni S, Moffa A, De Benedetto L, et al. Odontogenic Sinusitis from Classical Complications and Its Treatment: Our Experience. Antibiot (Basel). 2023;12(2):390. 10.3390/antibiotics12020390 . Kennedy JL, Hubbard MA, Huyett P, Patrie JT, Borish L, Payne SC. Sino-nasal outcome test (SNOT-22): a predictor of postsurgical improvement in patients with chronic sinusitis. Ann Allergy Asthma Immunol. 2013;111(4):246–e512. 10.1016/j.anai.2013.06.033 . Sella A, Ben-Zvi Y, Gillman L, Avishai G, Chaushu G, Rosenfeld E. Evaluation of Surgical Treatment of Oroantral Fistulae in Smokers Versus Non-Smokers. Med (Kaunas). 2020;56(6):310. 10.3390/medicina56060310 . Gill AS, Meeks H, Curtin K, Kelly K, Alt JA. Tobacco use increases the risk of chronic rhinosinusitis among patients undergoing endoscopic sinus surgery. Clin Otolaryngol. 2023;48(3):414–22. 10.1111/coa.14013 . Tan CJ, Leow BHW, Tan BKJ, Tan SF, Teo NWY, Charn TC. Association Between Smoking and Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis. Laryngoscope. 2024;134(6):2513–24. 10.1002/lary.31223 . Lin J, Wang C, Wang X, Chen F, Zhang W, Sun H, et al. Expert consensus on odontogenic maxillary sinusitis multi-disciplinary treatment. Int J Oral Sci. 2024;16(1):11. 10.1038/s41368-024-00278-z . Additional Declarations No competing interests reported. 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Madrid","correspondingAuthor":false,"prefix":"","firstName":"Helena","middleName":"","lastName":"Rey-Martínez","suffix":""},{"id":497349259,"identity":"5b820dc3-9d72-49c2-8d2e-7b24d47c0746","order_by":2,"name":"Pedro Luis Ruiz-Sáenz","email":"","orcid":"","institution":"Central Hospital of the Red Cross of Madrid","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"Luis","lastName":"Ruiz-Sáenz","suffix":""},{"id":497349260,"identity":"d353d065-27d4-4cab-8bb0-d2ffc22fc80a","order_by":3,"name":"Natalia Martínez-Rodríguez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYLCCBwYQ+gAQyxGhnpmBIcEAwgBpMSZSC4wBBIkNhDSYs58/+CGhwC6af/b5g4cLKurSNxw/ncDw4Q9uLZY9ycwSCQbJuTPOJTMcnnGGLXfDmdwNjDPbcGsxOJDMANTCnNtwhpnhMG8bT+6GG7wbmHnxOM/g/GPmHwkG9bnzwVr+SaQbgLT8weMwgxvJbEBbDgPdA9LSYJAA1sLAhk/LYzOLBIPjuRvPMBsc5jmWYDgT6JeDvfj8cj7x8Y0Pf6pz551hfPyZp6ZOnu/42Y0PfuBxGHZwgFQNo2AUjIJRMApQAQDXBFYqlFuvsAAAAABJRU5ErkJggg==","orcid":"","institution":"Complutense University of Madrid","correspondingAuthor":true,"prefix":"","firstName":"Natalia","middleName":"","lastName":"Martínez-Rodríguez","suffix":""},{"id":497349261,"identity":"cbdac879-774b-4378-bc27-272f2722dead","order_by":4,"name":"Cristina Barona-Dorado","email":"","orcid":"","institution":"Complutense University of Madrid","correspondingAuthor":false,"prefix":"","firstName":"Cristina","middleName":"","lastName":"Barona-Dorado","suffix":""},{"id":497349264,"identity":"5452b6ca-15f6-43da-8487-58d3132719a2","order_by":5,"name":"José María Martínez-González","email":"","orcid":"","institution":"Complutense University of Madrid","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"María","lastName":"Martínez-González","suffix":""}],"badges":[],"createdAt":"2025-07-08 17:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7077259/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7077259/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88775949,"identity":"d43984f5-44a8-4d37-a858-01d098bcec78","added_by":"auto","created_at":"2025-08-11 10:08:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119493,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadar Plot representing the distribution of SNOT-22 domains’ scores across genders\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIGURE1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7077259/v1/fb0bf1077ce376346b48c2b2.jpg"},{"id":88774117,"identity":"44eebc41-3cab-425e-ba5a-296c95a865c4","added_by":"auto","created_at":"2025-08-11 10:00:15","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":95804,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLM scores distribution in function of genders and presence of purulence\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIGURE2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7077259/v1/9fe84597f4c8415d7526a880.jpg"},{"id":88774096,"identity":"d6747923-7a92-4eed-b2f5-5bc414d3e513","added_by":"auto","created_at":"2025-08-11 10:00:14","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":134879,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBar chart of mean LM and SNOT-22 Scores with Standard Deviations Across Smoking Status Groups.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIGURE3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7077259/v1/142176918f35011546e19c80.jpg"},{"id":88774113,"identity":"16caa4ff-9e40-414b-9ece-c343b2caaddb","added_by":"auto","created_at":"2025-08-11 10:00:14","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":135491,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBoxplot representing the duration of symptoms in groups of patients according to the previous treatments they were subjected to. SD: standard deviation, Nasal GCC: nasal glucocorticoids, Oral ATB: oral antibiotics, DT: dental treatment, NoT: no treatment.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIGURE4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7077259/v1/e076c74f22391eb8f7651441.jpg"},{"id":88778899,"identity":"fa483d57-be46-47b3-a87c-33f01bcc3318","added_by":"auto","created_at":"2025-08-11 10:24:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1875309,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7077259/v1/9b0defd6-a706-4b5b-89e0-d20aa1309d78.pdf"},{"id":88774105,"identity":"5fa77265-7b57-4b79-9474-2fa23a8aca1d","added_by":"auto","created_at":"2025-08-11 10:00:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":129132,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7077259/v1/6711700a9cff90edc6fc9e5e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Odontogenic Sinusitis: Clinical, Radiologic, and Quality-of-Life Characterization in a Prospective Study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eRhinosinusitis is an increasingly diagnosed condition impacting 10\u0026ndash;20% of the population in industrialized countries, significantly compromising their daily quality of life (QoL) and exerting a serious strain on public healthcare systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the latest European position paper on rhinosinusitis and nasal polyps (EPOS 2020), rhinosinusitis was defined as nasal and paranasal sinus inflammation, characterized by two or more symptoms, one being nasal obstruction/congestion/discharge, associated with facial pain/pressure and/or hyposmia/anosmia. Supporting evidence is provided by nasal endoscopy or imaging findings via computed tomography (CT). Rhinosinusitis is considered chronic when symptoms persist for more than 12 weeks [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUnder the rhinosinusitis spectrum falls the odontogenic sinusitis (OS), a predominantly unilateral rhinosinusitis, implicated in up to 75% of unilateral maxillary sinusitis cases. Its identification may prove convolute due to its heterogeneous etiology and the non-specificity of the elicited symptomatology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. OS stems from dental/oral pathoses or iatrogenic processes undertaken in the vicinity of the maxillary sinus, triggering mucosal inflammation and hyperplasia, barrier dysfunction, impaired mucociliary clearance, and mucus hypersecretion [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These processes contribute to tissue fibrosis potentially compromising the patency of the ostio-meatal complex (OMC) causing sinus drainage impairment, and potential spread to other paranasal sinuses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite its prevalence (10\u0026ndash;40% of maxillary rhinosinusitis cases), OS origin is often overlooked in otolaryngology consultations, and its complications insufficiently managed in primary dental care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While chronic rhinosinusitis (CRS) is widely studied, the clinicopathological, radiological and psychosocial aspects of OS and its impact on QoL remain underexplored.\u003c/p\u003e\u003cp\u003eThis study aims to evaluate those parameters using the Sino-Nasal-Outcome-Test questionnaire (SNOT-22) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] to assess symptom burden and QoL, alongside Lund-Mackay (LM) staging system [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] to quantify sinus opacification and extra-maxillary spread. By utilizing these metrics, we sought to identify patterns linking symptom severity to radiological findings, and by stratifying outcomes by demographics, smoking status, and purulence, we aimed to identify high-risk subgroups and disease spread patterns that may require targeted interventions.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA group of 38 consecutive patients with a diagnosis of sinusitis originated by dental pathology/treatment, was included in this observational prospective study approved by the Ethic board of San Carlos Hospital-Madrid (22/190-E;13/07/2023), and conforming to Helsinki Declaration\u0026rsquo;s ethical provisions. The patients presented to oral surgery and implantology department clinic at the Madrid Complutense University\u0026rsquo;s Faculty of Dentistry, from July 2023 to June 2024 and provided an informed consent.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSize collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe sample size was determined with reference to prior prospective studies conducted in a similar clinical context. Yoo et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and Craig et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] included cohorts of 33 and 37 patients, respectively, and successfully derived meaningful insights into the clinical features and treatment outcomes of odontogenic sinusitis. Their findings support the adequacy of our sample for the purposes of exploratory analysis.\u003c/p\u003e\u003cp\u003ePatient selection was conducted by a multidisciplinary team (a dentist, an oral surgeon, and ENT specialist) with sinusitis diagnosis based on EPOS-2020 criteria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Patients legal-aged with unilateral sinusitis linked to a dental factor were included. Were excluded those with prior CRS history, fungal/allergic rhinosinusitis, previous endoscopic sinus surgery (ESS), sinonasal tumors, systemic diseases affecting the sinuses (e.g., radiotherapy, primary ciliary dyskinesia, cystic fibrosis, vasculitis, asthma), and pregnancy.\u003c/p\u003e\u003cp\u003eThe SNOT-22 questionnaire[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] (2006, Washington University, St. Louis) was completed by healthcare professionals using a standardized data sheet comprising 22 items, assessing symptom severity and social/emotional impact over the past two weeks, ranging in a Lickert-like scale from 0 (\u0026ldquo;No problem\u0026rdquo;) to 5 (\u0026ldquo;As bad as it can be\u0026rdquo;) (Appendix). The questionnaire was divided into five domains to identify the most affected areas: The nasal domain (items 1\u0026ndash;7), ear/facial (8\u0026ndash;12), Sleep (13\u0026ndash;16), concentration/productivity/function (17\u0026ndash;19) and psycho-social (20\u0026ndash;22). The SNOT-22 score threshold for pathologic values was 9 points [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe standard LM staging system [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] widely used in otorhinolaryngology, was applied to quantify rhinosinusitis severity via CT scans. Each sinus group (maxillary (Mx), anterior ethmoid (AE), posterior ethmoid (PE), frontal (Frt), and sphenoid (Sph)) is scored from 0 (normal) to 2 (complete opacification), while the OMC is scored 0 (patent) or 2 (obstructed). The total score ranges between 0\u0026ndash;12 per side (Appendix). To minimize interpretive variability, CT scans were evaluated repeatedly and inter/intra-examiner discrepancies were assessed via the Kappa coefficient. Purulence and mucosal oedema were evidenced subsequently to endoscopic examination.\u003c/p\u003e\u003cp\u003eIndependent variables were gender, age, smoking habits, duration of the symptoms before OS diagnosis and prior treatments. The outcome variables comprise the SNOT-22 scores to assess the degree of impairment caused by OS, and the LM scoring to assess the degree of paranasal sinuses occupancy and the OMC patency. The data obtained was reported in compliance with the STROBE guidelines.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe software IBM-SPSS 24 (IBM, Armonk, United States) was used for statistical processing. Chi-square test and Yates' correction were employed for categorical variables, while Kruskal-Wallis test was used to assess the correlation of the means between dependent and independent variables. A correlation analysis had been conducted using Pearson test and Spearman\u0026rsquo;s Rho correlation. The threshold of statistical significance was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eStudy Population Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study included 38 participants, with a slight male predominance (20 men, 18 women) and a mean age of 49.26\u0026thinsp;\u0026plusmn;\u0026thinsp;9.94 years (25\u0026ndash;79 years). Patients over 45 represented 71.1% of the sample (\u0026le;\u0026thinsp;45 years 28.9%). Active smokers represented 44.7% of the participants, 7.9% were former smokers and 47.4% were non-smokers. The affected side was nearly balanced (54% left, 46% right). The symptom duration averaged 23.47 months.\u003c/p\u003e\u003cp\u003eRegarding prior treatments, 45.5% received antibiotics (ATB), 39.4% intranasal glucocorticoids (GCC), 9.1% dental treatment (DT), and 6% had no prior treatment (NoT). Purulence was observed in 68.4% of cases, while oedema was present in 13.1%. The mean SNOT-22 score was 48.71\u0026thinsp;\u0026plusmn;\u0026thinsp;22.84, and the LM score averaged 6.21\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13 (Table-1).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eCharacteristics of the study population\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM:52.6% (n\u0026thinsp;=\u0026thinsp;20) F:47.4% (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49.26\u0026thinsp;\u0026plusmn;\u0026thinsp;9.94; [25\u0026ndash;79 years]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSmoking Habits\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNS: 47.4% FS: 7.9% CS: 44.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAffected Side\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eL:54% R:46%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSymptoms Duration\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.47\u0026thinsp;\u0026plusmn;\u0026thinsp;18.73 months\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrevious Treatments\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eATB:45.5% DT:39.4%\u003c/p\u003e\u003cp\u003eGCC: 9.1% NoT: 6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePurulence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes:68.4% (26) No:31.6% (12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOedema\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes:13.1% (5) No:86.9% (33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean SNOT-22\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48.71\u0026thinsp;\u0026plusmn;\u0026thinsp;22.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean Lund-Mackay\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.21\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eM: Male, F: Female, NS: non-smoker, FS: former smoker, CS: current smoker, L: left, R: right, ATB: antibiotics, DT: dental treatment, GCC: glucocorticoids, NoT: no treatment.\u003c/p\u003e\u003cp\u003eThe most frequent etiological factors associated with the OS in the sample were periapical cysts, (26.3%, 10 patients) of all cases. Periodontal diseases followed with 23.7% (9 patients), and endo-periodontal lesions were incriminated in 18.4% of cases (7 patients). Post-extraction oroantral communications represented also 18.4% (7 patients) of the etiologies involved, whereas foreign body retention (7.9%; 3 patients) and sinus augmentation procedure (5.3%; 2 patients), were the less implicated in this sample.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSNOT-22 scores\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe mean SNOT-22 of the study population was 48,71\u0026thinsp;\u0026plusmn;\u0026thinsp;22,84, with no significant gender differences (men:47.1\u0026thinsp;\u0026plusmn;\u0026thinsp;25.16, women:50.5\u0026thinsp;\u0026plusmn;\u0026thinsp;20.5), though women reported higher, yet non-significant trends in sleep (8.90 against 6.44 in men) and functional domains (7.15 against 5.22 in men) (Table-2).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable-2: SNOT-22 domains mean scores yielded,and standard deviations stratified by gender and purulence at endoscopic examination.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSNOT-22 Domains\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePurulence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eNASAL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.303\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e18.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e9.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e24.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e8.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e22.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e8.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eFACIAL-EAR\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e8.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e3.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.327\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e8.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e8.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSLEEP\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.361\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e5.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e7.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.106\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e8.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e7.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e6.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eFUNCTION\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.264\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e4.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.066\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e7.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e6.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003ePSYCHOLOGICAL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.806\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e4.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.164\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e6.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e5.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eFUNCTION-PSYCHOLOGICAL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e8.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e10.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.076\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e8.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e12.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e9.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eTOTAL SNOT-22\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e47.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e23.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.718\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eNO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e39.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e25.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eYES\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e52.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e20.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e48.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e22.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e48.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e22.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSD: standard deviations. M: male, F: female, N: number of patients.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNo correlation was established between SNOT-22 scores and age (rho=\u0026ndash;0.206, p\u0026thinsp;=\u0026thinsp;0.215). However, younger patients (\u0026lt;\u0026thinsp;45 years) showed a slightly lower overall symptom burden (44.00\u0026thinsp;\u0026plusmn;\u0026thinsp;22.79) than those above 45 (51.00\u0026thinsp;\u0026plusmn;\u0026thinsp;22.84) but significantly more nasal obstruction (rho=\u0026ndash;0.525; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and facial/otologic symptoms (rho=\u0026ndash;0.328; p\u0026thinsp;=\u0026thinsp;0.045).\u003c/p\u003e\u003cp\u003eSymptom distribution analysis revealed the nasal domain as the most affected (22.26\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92), comprising 45.7% of the total burden, followed by facial/otologic (8.45\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73) and sleep disturbances (7.74\u0026thinsp;\u0026plusmn;\u0026thinsp;6.61). Functional (6.24\u0026thinsp;\u0026plusmn;\u0026thinsp;5.13) and psychological domains (5.79\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93) showed lower yet notable impact, but when combined, they yielded a mean score of 12.03\u0026thinsp;\u0026plusmn;\u0026thinsp;9.57, indicating a substantial effect on QoL (Appendix-Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eGender-based stratification showed higher nasal and facial/ear scores in women than in men (23.72\u0026thinsp;\u0026plusmn;\u0026thinsp;8.80 vs. 20.95\u0026thinsp;\u0026plusmn;\u0026thinsp;9.03 and 9.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36 vs. 7.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.82 respectively), while men reported higher sleep-related and functional impairment (8.90\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38 vs. 6.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55 and 7.15\u0026thinsp;\u0026plusmn;\u0026thinsp;5.58 vs. 5.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52 respectively). Psychological scores were comparable (men:5.95\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03; women:5.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.96), though the combined function-psychological domain showed slightly higher impact in men (13.10\u0026thinsp;\u0026plusmn;\u0026thinsp;10.46 vs. 10.83\u0026thinsp;\u0026plusmn;\u0026thinsp;8.62). Total SNOT-22 scores were marginally higher in women, though without clear statistical significance (\u003cb\u003eTable-2, Fig-1:\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSNOT-22 and Purulence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEndoscopic examination revealed purulent secretions in 26 patients (68.4%). Symptom severity measured by SNOT-22, was consistently higher in purulent cases across all domains. The mean total SNOT-22 score in purulent cases was 52.85\u0026thinsp;\u0026plusmn;\u0026thinsp;21.55 compared to 39.75\u0026thinsp;\u0026plusmn;\u0026thinsp;23.89 in non-purulent cases, representing a substantial mean difference of 13.1 points, despite the absence of statistical significance​.\u003c/p\u003e\u003cp\u003e The nasal domain showed the largest score in patients with purulent secretions (24.19\u0026thinsp;\u0026plusmn;\u0026thinsp;7.92 against 18.08\u0026thinsp;\u0026plusmn;\u0026thinsp;9.84 without purulence), followed by the sleep domain (8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.64 against 5.33\u0026thinsp;\u0026plusmn;\u0026thinsp;6.12 without purulence).\u003c/p\u003e\u003cp\u003eFunctional impairment in purulent cases scored higher (7.23\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52) than in non-purulent cases (4.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.58) without reaching statistical significance. However, within this domain, items like concentration or nasal congestion/obstruction registered significantly higher scores in presence of purulence (2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66 and 26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42) than in its absence (1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54 and 12\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08) (p\u0026thinsp;=\u0026thinsp;0.023 and p\u0026thinsp;=\u0026thinsp;0.008 respectively).\u003c/p\u003e\u003cp\u003eThe psychological domain demonstrated a similar trend, with higher values in purulent cases (6.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.69 vs. 4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.33, p\u0026thinsp;=\u0026thinsp;0.164). This pattern persisted when combining functional and psychological domains (13.69\u0026thinsp;\u0026plusmn;\u0026thinsp;9.18 vs. 8.42\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79). The facial-ear domain showed the smallest difference between groups (8.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15 vs. 8.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.99), suggesting minimal influence of purulence on this symptom cluster (Table-2, Appendix-Figure1: \u003cb\u003eRadar Plot comparing SNOT-22 domains\u0026rsquo; scores between patients presenting purulence and patients without purulence.\u003c/b\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLM scores\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn our cohort of 38 patients, the mean total LM score was balanced through genders (6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06 in men 6.17\u0026thinsp;\u0026plusmn;\u0026thinsp;3.29 in women) \u003cb\u003e(Fig-2: )\u003c/b\u003e despite minor variations in subregions (LM right-Mx, LM right-AE, LM right/left-OMC). While total LM scores did not correlate with age (\u0026le;\u0026thinsp;45 years: 6.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77; \u0026gt;45 years: 6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13), older patients exhibited greater opacification in specific regions. Those with total opacification of right-Frt had a mean age of 60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1 years (47.53\u0026thinsp;\u0026plusmn;\u0026thinsp;8.93 without opacification, p\u0026thinsp;=\u0026thinsp;0.039), while patients with right-PE opacification averaged 68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.85 years (48.57\u0026thinsp;\u0026plusmn;\u0026thinsp;8.06 without opacification, p\u0026thinsp;=\u0026thinsp;0.018). Similarly, age distribution differed between maxillary and extra-maxillary involvement. Patients with extra-maxillary involvement at the right nasal fossa were older than those who showed only maxillary involvement (p\u0026thinsp;=\u0026thinsp;0.011). Laterality analysis concluded to a slightly higher mean age in extra-maxillary cases on the right side (n\u0026thinsp;=\u0026thinsp;13; 51.08\u0026thinsp;\u0026plusmn;\u0026thinsp;12.68 years) than maxillary cases (n\u0026thinsp;=\u0026thinsp;25; 48.32\u0026thinsp;\u0026plusmn;\u0026thinsp;8.33 years,), though these means are close to the mean age of the sample.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLM scores, purulence and extra-maxillary extension\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePurulent cases had significantly higher total LM scores (7.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27 against 2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75 in non-purulent cases, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating greater sinus opacification (Table-3, Fig-2). On the left side, opacification was notably higher in purulent cases (4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;4.35 vs. 0.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42), reflecting its radiologic impact. Paranasal sinus involvement extended beyond the maxillary sinus in 71.1% of cases. The AE was most affected after the Mx sinus, with 79.5% showing partial or total opacification (Table-3). Purulence was strongly associated with extra-maxillary extension, present in 92.3% of purulent cases vs. 25% of non-purulent cases (Chi-square\u0026thinsp;=\u0026thinsp;18.085, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable-3: LM scores distribution by genders and purulence, and rates of cases presenting other paranasal sinuses involvement.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"15\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePurulence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eEx-Mx Ext\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u003cp\u003eRate (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eLM RNF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4,10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2,08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e2,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.429\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eAE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e79.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2,00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3,58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e3,95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e3,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e3,52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e46.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eLM LNF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2,15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0,75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1,42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4,17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4,16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e4,19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e4,35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eFrt\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e3,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4,01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e4,01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e41.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eLM TOTAL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e6,25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2,83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1,75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e6,17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7,77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e2,27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e\u003cb\u003eSph\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e10.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e6,21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6,21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e3,13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRNF: right nasal fossa, LNF: left nasal fossa, M: male, F: female, N: number of patients, SD: standard deviation, Ex-Mx-Ext: extra-maxillary extension, AE: anterior ethmoid sinus, PE: posterior ethmoid, Frt: frontal sinus, Sph: sphenoid.\u003c/p\u003e\u003cp\u003eOMC obstruction was present in 84.6% of cases, with 46.1% on the right, 38.5% on the left, and 15.4% unaffected. Among purulent cases, 96.3% had OMC obstruction against 58.3% in non-purulent cases.\u003c/p\u003e\u003cp\u003eUnexpectedly, patients with oedema had lower LM scores (3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05) than patients clear of oedema (6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03, p\u0026thinsp;=\u0026thinsp;0.019), suggesting oedema correlates with symptoms but not increased sinus opacification.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSmoking Status\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe current smokers reported the highest average SNOT-22 scores (59.44\u0026thinsp;\u0026plusmn;\u0026thinsp;18.29), while non-smokers displayed the lowest scores (38.22\u0026thinsp;\u0026plusmn;\u0026thinsp;22.29), with former smokers falling in between (43\u0026thinsp;\u0026plusmn;\u0026thinsp;19.16) (p\u0026thinsp;=\u0026thinsp;0.0026) (\u003cb\u003eFig-3\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, pairwise comparison indicated an important statistically significant difference between current and never smokers (p\u0026thinsp;=\u0026thinsp;0.009). Smokers registered higher scores particularly in the nasal domains of SNOT-22 with a mean of 21.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.13 and 11.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98 in facial/ear domain, compared to non-smokers (16.83\u0026thinsp;\u0026plusmn;\u0026thinsp;8.63 in nasal domain, and 6.94\u0026thinsp;\u0026plusmn;\u0026thinsp;4.23 in facial/ear domain), without these values reaching statistical significance.\u003c/p\u003e\u003cp\u003eSmokers showed higher mean total LM\u003cb\u003e-\u003c/b\u003escore (7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14; non-smokers: 5.61\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09) and opacification in specific regions, particularly the Mx and AE/PE sinuses. However, no specificities were reported for smokers in terms of purulence, oedema or symptoms\u0026rsquo; duration (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTotal SNOT-22 and LM scores in patients according to their smoking status.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking Status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSNOT-22\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNon-smokers\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;18 (47.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.61\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.363\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.22\u0026thinsp;\u0026plusmn;\u0026thinsp;22.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFormer smokers\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;3 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;19.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eActive smokers\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;17 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59.44\u0026thinsp;\u0026plusmn;\u0026thinsp;18.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevious treatments and symptoms duration\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe mean symptom duration reported in this study (23.47 months) reflects a chronic disease course. 94% of the patients received previous treatments including ATB, nasal GCC or DT. Patients treated with nasal GCC experienced longer symptom durations (30.67\u0026thinsp;\u0026plusmn;\u0026thinsp;26,63 months) compared to NoT patients (7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.07 months). The ATB group showed a high mean symptom duration (26.61\u0026thinsp;\u0026plusmn;\u0026thinsp;16.79) but lower than the GCC group, whereas the DT group showed shorter symptom duration (19.56\u0026thinsp;\u0026plusmn;\u0026thinsp;19.80) than both. Patients with purulence had prolonged symptoms (26.88\u0026thinsp;\u0026plusmn;\u0026thinsp;9.66 months) compared to those with normal endoscopic findings (16.08\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6 months) (\u003cb\u003eFig-4\u003c/b\u003e). Symptom duration was generally longer in patients with partial or total sinus opacification than in those without sinus opacification, though the overall differences regarding symptoms\u0026rsquo; duration were not statistically significant.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOS remains underdiagnosed and often mismanaged leading to prolonged disease course and ineffective treatment pathways, entailing profound implications for patients' QoL. The SNOT-22 questionnaire is widely employed to assess CRS symptom burden but scarcely used for sinusitis of various dental origins. In this study it was clustered into five domains, and LM scoring was segmented to assess extra-maxillary extension, enabling a precise radiographic evaluation of paranasal sinus involvement, and a thorough assessment of the condition's clinical implications within the study population.\u003c/p\u003e\u003cp\u003eThe analysis of etiological factors of the OS within the study sample identified a clear predominance of infectious etiologies (68.4%), primarily represented by periapical cysts (26.3%), periodontal disease (23.7%), and endo-periodontal lesions (18.4%), underscoring the critical role of odontogenic infections in sinus-related dental complications. In contrast, iatrogenic causes represented 31.6% of OS triggers, largely attributed to post-extraction oroantral communications (18.4%), foreign bodies (7.9%), and sinus lift procedures (5.3%).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSNOT-22 domains and LM scores\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe highest SNOT-22 scores retrieved are in the nasal domain, the lowest in the psychological (emotional)domain, aligning with Kwiatkowska et al.\u003csup\u003e18\u003c/sup\u003e where the highest and lowest SNOT-22 scores correspond to the same domains of the present study, although their research focused only on OS caused by periapical lesions. QoL-related domains (sleep, function and psychological) when combined, yielded a score of 19.45\u0026thinsp;\u0026plusmn;\u0026thinsp;14.87, underscoring a serious disease burden as concluded in Gaudin et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Kwiatkowska et al.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] studies. Simuntis et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported even higher emotional distress in OS than in rhinogenic sinusitis.\u003c/p\u003e\u003cp\u003eIn the present study, the extra-maxillary extension registered was substantial, with AE involvement reaching 79.5% and Frt sinusitis in almost 41%, likely due to the prolonged symptom duration in the study cohort (23.47 months), promoting disease progression. Fadda et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported lower AE involvement (51.6%, and 12.9% of the Frt sinus) while Saibene et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] found 41% of unilateral extra-maxillary extension. Goyal et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] identified Frt sinus involvement as a diagnostic indicator of OS over CRS.\u003c/p\u003e\u003cp\u003eWhile LM scoring objectively complemented SNOT-22 assessment, the correlation between both metrics was inconclusive within this sample.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePurulence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMultiple studies have identified purulence in the middle meatus as a hallmark of OS, particularly in acute cases, where it appears in up to 58% of patients [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the present study 68.4% of the patients presented purulence at the endoscopic observation, a very similar rate to that found by of Costa et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] (two thirds of the study population had purulence) and Aljeraisi [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] (70%).\u003c/p\u003e\u003cp\u003eTotal SNOT-22 scores were 13.1 points higher in patients with purulence, reflecting a severe impact on nasal function and QoL (sleep quality, performance status). This finding may inform clinical evaluation and therapeutic strategy development for OS patients.\u003c/p\u003e\u003cp\u003eRobinson et al.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] in their study concluded to the absence of correlation between purulence and LM scores contrasting with our findings where elevated LM scores were registered in presence of purulence.\u003c/p\u003e\u003cp\u003ePurulence also correlated with extensive sinus involvement patterns present in 92.3% of purulent cases (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, longer symptom duration was observed in patients presenting purulence, likely due to a pathophysiological cascade of persistent inflammation leading to suppuration, which in turn impairs sinus outflow and promotes both persistence and trans-sinusal progression of the disease, reinforcing purulence as a marker of advanced OS and more extensive sinus involvement.\u003c/p\u003e\u003cp\u003eOMC Obstruction is a key criterion in endoscopic sinus surgery decision-making [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Sabatino et al.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] reported it in 42% of cases, while in our study, 84.6% of the study participants had OMC obstruction, that was also observed in 96.3% of the patient with evidenced purulence. These findings highlight the need to assess OMC patency when considering surgical intervention in OS cases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSmoking status\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eUp to date, various studies addressed smoking status as a covariate contrastingly impacting surgical outcomes in CRS [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Gill et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] observed that tobacco increases the CRS risk 1.42 to 3.60-fold while Tan et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] in a meta-analysis including 45 studies, found that smokers and former smokers had poorer baseline QoL compared to never-smokers.\u003c/p\u003e\u003cp\u003eThis is the first study that explores the contribution of smoking in symptom burden in OS, and its role in the deterioration of QoL and interestingly, we found that current smokers were significantly impacted by the condition compared to never smokers. Regarding radiological severity, smokers had higher mean LM scores and despite similar disease duration across groups, smokers consistently showed more opacification.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevious treatments and Symptom duration\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eDespite 94% of the patients receiving previous treatments (ATB, DT or GCC), symptoms persisted, highlighting limited effectiveness when underlying dental causes remain unaddressed. The patients subjected either to nasal GCC or ATB showed the longest symptom duration. In OS, This aligns with expert consensus that ATB alone are inadequate to reach a conclusive recovery in OS, and that non-surgical treatments should be reserved for the acute phase management while dental treatments are conducted [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn contrast, patients who received DT reported shorter symptom durations, likely due to the immediate referral to ENT (Ear, throat, nose) specialist in instances of symptoms persistence after dental cause elimination. Intriguingly, patients without prior treatment exhibited the shortest symptom duration, possibly due to a milder disease form or timely diagnosis.\u003c/p\u003e\u003cp\u003eWhile delivering an estimation of pathological metrics in a heterogeneous OS population, this study should be considered alongside its limitations. The investigation focused on a cohort with a long symptom duration, representing predominantly chronic cases, offering valuable insights into long-term disease but may not fully capture the spectrum of early-stage presentations. While the sample size was adequate for primary analyses, it created certain constraints in subgroup comparisons.\u003c/p\u003e\u003cp\u003eA structured disease severity assessment in dental consultation may enhance OS management by preventing both undertreatment of the advanced forms of the disease, and overtreatment of mild cases, facilitating timely referrals for advanced forms and high-risk groups (smokers, older patients).\u003c/p\u003e\u003cp\u003eThe study\u0026rsquo;s broad approach to dental pathologies underscores that future research could benefit from stratification based on specific dental conditions and procedures, potentially revealing more nuanced patterns in disease presentation and severity. Prospective studies evaluating treatment outcomes based on these identified patterns could provide valuable insights.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOdontogenic sinusitis necessitates close coordinated interdisciplinary dental-ENT management. A thorough clinical and tomographic evaluation can help identify key nasal, facial, and otologic symptoms, and track anatomical spread. In this study, smokers and patients exhibiting purulent discharge experienced greater quality-of-life impairment and a more extensive extra-sinus spread.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewas approved by the Ethic board of San Carlos Hospital-Madrid (22/190-E;13/07/2023). Informed consent was obtained from all participants at the beginning of the study. This study adhered to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data analysed during this study are included in this published article and its supplementary information files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e : The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding :\u0026nbsp;\u003c/strong\u003eNo funding has been provided for the present work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNK: writing-original draft preparation and investigation, .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHR-M: methodology, \u0026nbsp;investigation.\u003c/p\u003e\n\u003cp\u003ePL R-S: formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN M-R : conceptualization, review and editing.\u003c/p\u003e\n\u003cp\u003eC B-D: data curation, investigation.\u003c/p\u003e\n\u003cp\u003eJM M-G: conceptualization, supervision and project administration.\u003c/p\u003e\n\u003cp\u003eAll the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMichalik M, Krawczyk B. 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Int J Oral Sci. 2024;16(1):11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41368-024-00278-z\u003c/span\u003e\u003cspan address=\"10.1038/s41368-024-00278-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Odontogenic sinusitis, SNOT-22, Nasal domain, Lund-Mackay scoring, smoking, purulence, extra-maxillary extension","lastPublishedDoi":"10.21203/rs.3.rs-7077259/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7077259/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRhinosinusitis is an increasingly diagnosed condition which compromise the daily quality of life of the population and exerting a serious strain on public healthcare systems. Under the rhinosinusitis spectrum falls the odontogenic sinusitis, a predominantly unilateral rhinosinusitis, implicated in up to 75% of unilateral maxillary sinusitis cases. This study aimed to analyze the clinical and radiological characteristics of patients with odontogenic sinusitis and to determine how these findings relate to their quality of life.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThirty-eight patients with unilateral sinusitis caused by dental pathology/treatment were recruited. OS diagnosis criteria were established according to EPOS-2020 guidelines. The 22-item SNOT-22 questionnaire was used to gauge symptom severity and social/emotional impact. In addition, all patients underwent CT imaging and were staged with the Lund-Mackay scale for involvement of the maxillary, anterior and posterior ethmoid, sphenoid and frontal sinuses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSmoking was associated with higher SNOT-22 scores (active smokers: 59.44\u0026thinsp;\u0026plusmn;\u0026thinsp;18.29; non-smokers: 38.22\u0026thinsp;\u0026plusmn;\u0026thinsp;22.29; p\u0026thinsp;=\u0026thinsp;0.026). Younger patients reported a slightly lower symptom burden than older ones but had significantly more nasal obstruction (rho=\u0026ndash;0.525; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and facial/otologic symptoms (rho=\u0026ndash;0.328; p\u0026thinsp;=\u0026thinsp;0.045). Patients with frontal and posterior ethmoid total opacification averaged 60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1 (p\u0026thinsp;=\u0026thinsp;0.039) and 68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.85 years (p\u0026thinsp;=\u0026thinsp;0.018) respectively. Patients treated with ATB/Nasal-GCC showed a prolonged symptom duration (26.61\u0026thinsp;\u0026plusmn;\u0026thinsp;16.79 and 30.67\u0026thinsp;\u0026plusmn;\u0026thinsp;26,63 months respectively). Extra-maxillary involvement was observed in 71.1% of the patients. Purulence correlated with higher LM scores (7.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27 vs. 2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75 without purulence, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), longer symptom duration and a greater likelihood of extra-maxillary spread (92.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eIn this study, smokers and patients exhibiting purulent discharge experienced greater quality-of-life impairment and a more extensive extra-sinus spread.\u003c/p\u003e\u003ch2\u003eClinical Trial Number:\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Odontogenic Sinusitis: Clinical, Radiologic, and Quality-of-Life Characterization in a Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 10:00:08","doi":"10.21203/rs.3.rs-7077259/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-17T12:23:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-13T08:00:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336874210441197501490518564078563409489","date":"2025-09-06T14:41:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237985643159830298262612562416556422762","date":"2025-09-03T18:57:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T00:31:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"340177143959894052603601880479613656882","date":"2025-08-10T21:57:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T11:54:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144062090410676614044983361698166289398","date":"2025-08-08T11:32:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326397894247098476263165004126897626381","date":"2025-08-05T19:09:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T17:38:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-16T18:06:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-12T04:09:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-12T04:08:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-07-08T17:42:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"babfce93-6a58-4b44-941b-9b01b6b4669e","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T14:55:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 10:00:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7077259","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7077259","identity":"rs-7077259","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}