C. Pipolo

G. Felisati

M. Chiapasco

P. Casentini

P. Lozza

R. Borloni

AIR Universita degli studi di Milano

47
ACTA oTorhinolAryngologiCA iTAliCA 2013;33:47-48
Letter to the Editor
Reply to: “The ENT’s role in sinus lift management 
doesn’t need misleading messages”
Replica a: “Il ruolo dello Specialista ORL nella gestione del grande rialzo sinusale 
non necessita di messaggi fuorvianti”
G. FeliSati1, r. Borloni2, M. chiaPaSco3, P. lozza1, P. caSentini3, c. PiPolo1
1 otorhinolaryngology unit, head and neck department, San Paolo hospital, university of Milan; 2 oral and 
Maxillofacial Surgery unit, istituto Stomatologico italiano, Milan; 3 oral Surgery unit, head and neck department, 
San Paolo hospital, university of Milan, italy
Acta Otorhinolaryngol Ital 2013;33:47-48
Dear Editor, 
Two years ago we published an article in Acta Otorhi-
nolaryngologica Italica entitled “Maxillary sinus eleva-
tion in conjunction with transnasal endoscopic treatment 
of rhino-sinusal pathoses: preliminary results on 10 con-
secutively treated patients” by g. Felisati et al. 1. 
Two years later, Dr. mario mantovani published a letter to 
the editor in the same journal 2 with some negative com-
ments on our publication.
Dr. mantovani widely cited a previous publication pub-
lished in 2008 3 of which we are well aware, since the first 
author of the commented paper was one of the authors of 
this last manuscript. 
in the 2008 paper, the authors stated that: “The potentially 
reversible otorhinolaryngological contraindications to si-
nus lift surgery need to be corrected by means of con-
servative medical therapy or functional endoscopic sinus 
surgery – FESS – (the current gold standard for many 
naso-sinusal conditions amenable to surgery) to restore 
physiological maxillary sinus clearance and ventilation, 
after which it is possible to perform the sinus lift proce-
dure to begin oral rehabilitation.” 
our proposal, published for the first time in 2010 and now 
opposed by mantovani, was exactly the same as that pro-
posed by Pignataro, mantovani et al. in 2008, and also in 
previous publications by mantovani. 
The only difference is that, according to our approach 
and in selected cases, reversible contraindications to 
sinus lift requiring FESS for resolution can be treated 
in a single surgical session (FESS+sinus floor elevation 
(SFE)). it must be stressed, as we already have, that the 
combination of two different operations must be care-
fully planned and applied only in specific cases, by ex-
perienced surgeons.
in the first part of the letter, Dr. mantovani, in the absence 
of any significant data, states that with our publication we 
may promote “diffusion of misleading messages”. We be-
lieve that this phrase does not merit specific comments 
except for a fundamental one, namely that research brings 
new contributions over time, and that today we have the 
data to support our approach. 
in the same letter to the editor, Dr. mantovani stated that: 
“any surgical manoeuver apt to compromise the delicate 
homeostasis of the nose and the maxillary sinus must be 
formally contraindicated in conjunction with the sinus lift 
procedure”. 
The results reported in our publication showed that our 
surgical approach, performed on 10 consecutive patients, 
was not associated with any complications following si-
nus floor elevation in conjunction with FESS, similar to 
another 15 cases treated by us since then. 
Thus, our comments to Dr. mantovani’s criticism consist 
in the following: 
1. The clinical results appear to demonstrate that our 
combined and simultaneous approach (FESS+sinus 
lift) indeed does not compromise homeostasis of the 
maxillary sinus, provided that the sinus is well ven-
tilated thanks to the FESS, which creates an efficient 
middle antrostomy.
2. in the second part of the letter, Dr. mantovani’s com-
ments are directed towards the necessity or not of 
FESS in association with sinus floor elevation. he 
clearly defines two points that, in his opinion, dem-
onstrate a structural weakness in our paper. Firstly, 
he underlined that “only three of the 10 patients treat-
ed according this combined protocol reported recur-
rent minor rhinosinusitis. We can then argue that the 
other seven were free of rhino-sinusitis: why then 
were they operated on?“. Secondly, he reported that: 
“Four patients presented with a large maxillary sinus 
cyst: why did they undergo an endoscopic transnasal 
approach … when it was possible to empty the cyst 
by a simple and well known trans-oral non-invasive 
manoeuver?”
48
g. Felisati et al.
The two points are very important not only per se, but in 
more general terms, to understand what is really needed in 
patients who must undergo SFE.
Considering the first point of the letter, Dr. mantovani stat-
ed that anatomical alterations need a history of sinusitis to 
constitute a true contraindication for SFE (which requires 
FESS prior to SFE). This statement is reminiscent of the 
data reported by Timmenga e al (1997) 4 which is the only 
clinical report presently available in the literature (to our 
knowledge) on the risk of SFE failure. on the other hand, 
in other reports 5, mantovani appears to sustain that all the 
reversible contraindications to SFE (such as septal devia-
tion or concha bullosa) need to be corrected prior to SFE 
without taking into account a history of sinusitis. 
We would like to present our point of view. 
First of all, it would be strange to base surgical indica-
tions on the basis of anamnesis when it is well known that 
diagnosis of sinusitis made by patients or by a general 
practitioner is highly unreliable 6. in trying to answer to 
the question “what is right” we can say that our combined 
approach makes SFE safer, especially when a large SFE 
is programmed to allow the insertion of multiple dental 
implants. Secondly, the combined approach that we pro-
pose solves, at the same time, rhino-sinusal problems that 
were only minor in the 10 cases reported in the article 
published in 20101, but which were also relevant in the 
consecutive 15 new cases carried out to date. For these 
reasons, we continue to perform, in selected cases, a com-
bined approach.
Considering the second point, Dr. mantovani states that 
maxillary cysts do not require FESS. in the 2008 paper 3, 
therefore, only small cysts were not considered as a con-
traindication to SFE, while large ones should be treated 
prior to SFE (or in our hands simultaneously). 
We agree with the proposal to puncture the cyst during SFE 
for cysts of small or medium size, but we are not sure that 
this technique is “well known”, and we think that it cannot 
be considered validated for large cysts that can still create 
an occlusion of the ostium (immediate or delayed).
in conclusion, we believe scientific debate to be beneficial, 
but all should be open to new developments and be confi-
dent in their statements only when relying on reliable data.
References
1 Felisati g, Borloni r, Chiapasco m, et al. Maxillary sinus 
elevation in conjunction with transnasal endoscopic treat-
ment of rhino-sinusal pathoses: preliminary results on 10 
consecutively treated patients. Acta otorhinolaryngol ital 
2010;30:289-93.
2 mantovani m. The ENT’s role in sinus lift management 
doesn’t need misleading messages. Acta otorhinolaryngol 
ital. 2012;32:404.
3 Pignataro l, mantovani m, Torretta S, et al. ENT assessment 
in the integrated management of candidate for (maxillary) 
sinus lift. Acta otorhinolaryngol ital 2008;28:110-9.
4 Timmenga nm, raghoebar gm, Boering g, et al. Maxil-
lary sinus function after sinus lifts for the insertion of dental 
implants. J oral maxillofac Surg 1997;55:936-9, discussion 
940.
5 mantovani m. Otorhinolaryngological contraindications in 
augmentation of the maxillary sinus. in: Testori T, et al., edi-
tors. Maxillary Sinus Surgery and alternatives in treatment. 
london: Quintessence Publishing Co. ltd.: 2009. p. 23-33.
6 Jones nS. Sinus headaches: avoiding over- and mis-diagno-
sis. Expert rev neurother 2009;9:439-44.
Address for correspondence: giovanni Felisati, Dipartimento Testa 
e Collo, ospedale San Paolo, università di milano, via di rudinì 8, 
20142 milano. Fax +39 02 50323166. E-mail: giovanni.felisati@
gmail.com
received: January 7, 2013 - Accepted: January 22, 2013


Reply to: &quot;The ENT&apos;s role in sinus lift management doesn&apos;t need misleading messages&quot; = Replica a: &#8220;Il ruolo dello Specialista ORL nella gestione del grande rialzo sinusale non necessita di messaggi fuorvianti&#8221;

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Reply to: "The ENT's role in sinus lift management doesn't need misleading messages" = Replica a: “Il ruolo dello Specialista ORL nella gestione del grande rialzo sinusale non necessita di messaggi fuorvianti”

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Reply to: &quot;The ENT&apos;s role in sinus lift management doesn&apos;t need misleading messages&quot; = Replica a: &#8220;Il ruolo dello Specialista ORL nella gestione del grande rialzo sinusale non necessita di messaggi fuorvianti&#8221;

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AIR Universita degli studi di Milano

Reply to: "The ENT's role in sinus lift management doesn't need misleading messages" = Replica a: “Il ruolo dello Specialista ORL nella gestione del grande rialzo sinusale non necessita di messaggi fuorvianti”