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THE DISEASES OF MAXILLARY SINUS

INTRODUCTION:

• Largest of the PNS

• Also known as the antrum “cave” of Highmore – English

physician described an infection of sinus in 1651.

• First sinus to develop.

• In addition to maxillary sinus, the other sinuses we haves

are: o the ethmoids

o the sphenoids

o the frontals The adult maxillary sinus is a pyramid which has a volume of approximately 15 ml

(34x33x23mm). The base of the pyramid is the nasal wall with the peak pointing toward the

zygomatic process. The anterior wall has the infraorbital foramen located at the midsuperior

portion with the infraorbital nerve running over the roof of the sinus and exiting through the

foramen. This nerve can be dehiscent (14%). The thinnest portion of the anterior wall is just

above the canine tooth--the canine fossa. The roof is formed by the orbital floor and transected

by the course of the infraorbital nerve. The posterior wall is unremarkable. Behind this wall is

the pterygomaxillary fossa with the internal maxillary artery, sphenopalatine ganglion and the

Vidian canal, the greater palatine nerve and the foramen rotundum. The floor, as discussed

above, varies in it's level. From birth to age nine the floor of the sinus is above that of the nasal

cavity. At age nine the floor is generally at the level of the nasal floor. The floor continues to

sink as the maxillary sinus pneumatizes. Because of the close relationship with the dentition

dental disease can cause maxillary infection, and tooth extraction can result in oral-antral

fistulae.

The max. sinus is usually present at birth, it starts effectively around the age of 8.

Embryology

3rd IU month - mucosal outpouching of the ethmoidal infundibulum (1° pneumatization

– confined to mucosa of nasal capsule)

2° pneumatization - 5th IU month – growth into adjacent maxilla

a. 7mm in AP length

b. 4mm in height and width

c. Volume – 6-8ml.

Post natally- Sinus grows at yearly rate of 2mm vertically and 2mm AP. a. By 4th or 5th month radiographically it appears.

Postnatal growth continues rapidly in all the three dimension

with 3 recognized growth spurts.

a. Birth-2.5yrs

b. - 7.5-10yrs

c. - 12-14yrs

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By third year sinus extend laterally to underneath the infraorbital foramen where the

sinus floor is still above the nasal floor.

By 7yrs of age growth corresponds to the eruption of the permanent tooth. Final growth

spurt corresponds to the eruption of posterior teeth

With completion of all the maxillary permanent teeth expansion of maxillary sinus fill the

growing maxillary bone to produce the adult pyramidal shape of the sinus.

Floor of the sinus approximately 5-12mm below the nasal floor.

Between15-18yrs minimal changes takes place

Anatomy of maxillary sinus Vascular supply

Branches of the internal maxillary artery supply this sinus. These include the infraorbital

(as it runs with the infraorbital nerve), lateral branches of the sphenopalatine, greater palatine,

and the alveolar arteries. Venous drainage runs anteriorly into the facial vein and posteriorly into

the maxillary vein and jugular vs. dural sinus systems.

Innervation

The maxillary sinus is innervated by branches of V2. Specifically, the greater palatine

nerve and the branches of the infraorbital nerve.

The maxillary sinus as a pyramid Horizontal pyramidal shape consists of a base an apex and four sides.

Base – Vertical Lateral wall of the nasal cavity. Apex- Junction of the maxillary and zygomatic

bone

Medial wall

Also refer to the base of the sinus formed by- lateral wall of the nose, namely

Inferior nasal concha , Perpendicular plate of palatine bone, Uncinate process of the ethmoid

Descending part of the lacrimal bone

Wall is slightly convex towards the sinus

Pars membranacea

Clinical significance

Maxillary ostium

SUPERIOR/ ORBITAL WALL

Roof of the sinus and floor of the orbit

Superior wall most vulnerable among all sinus walls to trauma

Tumors of the sinus erodes this wall can cause proptosis, alteration of pupillary level, neurologic

symptoms associated with the infraorbital nerves

ANTERIOR/ FACIAL WALL

Anterior aspect of the maxilla – piriform aperture medially to the zygomaticomaxillary suture

laterally, infraorbital rim superiorly to alveolar process and maxillary teeth inferiorly.

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Convex towards sinus. Thinnest portion over canine fossa - approach to the sinus via Caldwell-

Luc procedure

POSTEROLATERAL WALL

Made up of zygomatic bone and greater wing of sphenoid

Posterior superior alveolar nerves and vessels sometimes in close contact with the sinus mucosa.

Acute sinusitis – pain in posterior upper posterior teeth

This wall is convex, bulging posteriorly

Access to the pterygopalatine fossa is accomplished by careful removal of this wall

FLOOR / BUCCOALVEOLAR WALL

Formed by the junction ant sinus wall and lateral nasal wall

Septa may be present in the alveolar recess of the sinus -. Of significance in root retrieval and

sinus drainage

Floor is 1-1.5 cm below to the nasal floor

Risk of creating oroantral fistula increases with age

Descending order of proximity to sinus: palatal root of 1st molar, 2nd molar, 1st molar, 3rd

molar, 2nd PM, 1st PM, canine

FUNCTION

1. They humidify and warm the area .

2. They regulate the intranasal pressure increasing the surface area of the olfaction, so the

smell sense becomes better.

3. They lighten the skull; that's why ppl with sinusitis say " rase thaglan".

4. People notice their voice changes with upper respiratory tract infection which is the most

to cause cervical lymphadenopathy and it's viral most of the time ,, so their voice changes

because the resonance becomes different when the person has the flue .

5. They absorbing shock .

6. They contributes to the facial growth , cuz the facial growth is a cartillagenous growth

through the nasal septum and sphenooccipital synchondrosis which is elongation of the

base of the skull .

Physical Examination Both the left and the right side should be examined simultaneously to compare the findings. Crepitations, sensitivity to pressure, painful trigger points and change in texture of the

overlying skin and mucosa as well as deformations of neighboring structures

Rhinoscopy: • Anterior rhinoscopy should be performed with a normal speculum. The nasal speculum

should be held in the examiners left hand with the left index finger pressed firmly on the

ala of the nose to stabilize the position of the upper blade.

• The examiners right hand should be used to position the patient’s head.

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Nasal Endoscopy: These are rigid fibro optic instruments which provide information about areas not well

visualized by rhinoscopy. The advantage over rhinoscopy is the improved visualization and

illumination of the intra nasal structures.

Sinus Endoscopy:

Is indicated when there is high index of suspicion of an intra sinus pathologic

condition or if any therapeutic procedure is anticipated.

Aspiration:

• Sinus aspiration is usually not necessary to establish a diagnosis of either a/c chronic

sinusitis because non-invasion means are usually adequate.

• This is indicated in case of sinusitis that are unresponsive to multiple course of antibiotic

as well as when there is severe unremitting pain or an orbital or intra-cranial complication

of sinusitis.

Trasnillumination

• Is performed in a darkened place by a lightened instrument into the with the pt lip close

tightly oral cavity

• Observation then can be made as to how well the ant wall of the sinus transilluminates

• When findings in the both antra are markedly different,the dull side suggest that the

sinus mucosa may be thickened or sinus contain fluid or mass

• Most commonly used as a screening tool

DIAGNOSTIC IMAGING Standard radiograph

Plain film evaluation of the max sinus should include at least 3 standard views:

Caldwel,

Waters

lateral view.

CT:

THREE – DIMENSIONAL CT

MRI

CLASSIFICATION OF MAXILLARY SINUS PATHOLOGY

INFLAMMATORY CONDITIONS

MAXILLA RY SINUSITIS

-ACUTE

-CHRONIC

CYSTICCONDITIONS

*INTRINSIC

-MUCOCELE

*EXTRINSIC

-OKC

-RC

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BENIGN TUMOURS

*PAPILLOMAS

*JUVENILE ANGIOFIBROMA

*AMELOBLASTOMA

*ODONTOGENIC MYXOMA

*PLEOMORPHIC ADENOMA

*OSSIFYING FIBROMA

MALIGNANT TUMOUR

*SCC

*ADENOCYSTIC

CARCINOMA

*OSTEOSARCOMA

*FIBROSARCOMA

*LYMPHOMA

ORO ANTRAL FISTULA

*OAC

*DISPLACED ROOT TIPS

*# TUBEROSITY

*FOREIGN BODY IN SINUS

*RESORPTION DUE TO EXPANSILE LESIONS

RARE CONDITIONS

*PHYCOMYCOSIS

*LYTIC OSTEITIS

*WEGNERS GRANULOMATOSA

*ANTROLITH

Maxillary Sinusitis Sinusitis is a condition involving inflammation of paranasal sinus mucosa, the term is usually

restricted to conditions that are primarily inflammatory, cause subjective symptoms and persist

longer than 7 days.

CLASSIFICATION OF SINUSITIS

1. Clinical

• Acute Sinusitis

• Chronic Sinusitis

• Nosocomial Sinusitis

• Odontogenic Sinusitis

• Immunocompromise Sinusitis

• Cystic fibrosis Sinusitis

2. Based on duration (American association of otolaryngology & Head & neck Surgery)

• Acute sinusitis < 4wks

• Subacute sinusitis 4 – 12wks

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• Chronic sinusitis > 12wks

Causes Of mucostasis

1. Cilliary dismotility

2. Thickened mucous secretion

3. Anatomical abnormalities

• Concha bullosa

• DNS

• Malformed uncinate process

4. Space occupying lesions

• Tumours

• Cysts

• Polyps

• Mucoceles

Parasitic sinusitis

Reported only in AIDS patients

• Microsporadium

• Cryptosporadium

• Acanthamoeba

SIGNS & SYMPTOMS

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• Heavy feeling in the head

• Constant pain in upper part of the cheek

• Maxillary teeth on affected side may be painful

• Unilateral foul nasal discharge

• Unilateral nasal obstruction on affected side

• Tenderness to pressure or swelling over the involved sinus

• Sensitivity of tooth on percussion

• Fever, chills, malaise

• Extension in orbit or intracranial cause enopthalmous and meningitis

MANAGEMENT

Medical management

Surgical Management

The medical or conservative management is preferred over the surgical one

MEDICAL MANAGEMENT

• ANTIBIOTICS

•

• ANALGESICS

• SYSTEMIC DECONGESTANTS

• TOPICAL DECONGESTANTS

• ANALGESICS

• TOPICAL STEROIDS

• ANTIHISTAMINES

• SALINE LAVAGE

• MUCOLYTICS

ANTIBIOTICS

• Acute sinusitis

Amoxicillin is the drug of choice (3to 10 days course is indicated)

Pencilin allergic patient- TMP-SMX is the first line drug

Amoxycillin fails to improve clinical situation- augmentin should be

considered

Azithromycin, erythromycin,doxycycline can also be given

• Chronic sinusitis

Antibiotic coverage is shifted towards covering oral anaerobes

Pencillin with metranidazole

Clindamycin

• Nosocomial –

ampicillin/ sulbactum,

Should be culture specific if possible

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Surgical Management

• Sinus Aspiration & Lavage

• Caldwell-luc approch

• FESS

Trauma

The fractures involving max sinus can be classified as a single wall fracture (isolated), as a part

of complex fractures, or as a component of a transfacial fractures

Isolated fractures

Isolated wall fractures are uncommon but can result from a direct blow, that involve the

max roof

• Blow out fractures

• On plain film trap door

effect

There may be one or more free bone fragments, or one end of a single fragment may be in

contact with the remaining wall

Hanging drop effect

TRANSFACIAL FRACTURES

• LeFort I involves medial and lateral walls of the sinus

• LeFort II involves the roof, anterior, and posterolateral walls

• COMPLEX FACIAL FRACTURES

• Tripod (trimalar) fracture involves sinus. Involves orbital floor, anterior and posterior

walls, zygomatic arch, and zygomaticofrontal suture

• ZMfracture is Similar to trimalar fracture but is more extensive along with involvement

of pterygoid

Displacement of tooth or root

• Displacement of a root tip in the maxillary sinus during extraction is a common

complication.

Commonly – 1st molar ( almost 80%)

2nd molar (20%) and sometimes 3rd molar premolar and rarely canines.

Palatal Roots

• When occurs

First maneuver is to place the patient in upright position.

-Location must be determined.

• Some instances:

• -Root tip slipped between the outer wall of the maxilla and the periostium.

• -May penetrate the periostium and become located sub periosteally.

• -Also possible that the root tip is located in the antrum but is beneath the intact sinus

membrane.

• The first consideration is whether there is buccal displacement,( often determined by

manual palpation.)

• Next is to determine the antral perforation,( determined by patient blow air through the

nose with nostrils closed).

• The socket should never probe in an attempt to determine a perforation because this could

cause a perforation when one dose not exist or further movement of the root tip.

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• Panoramic and periapical radiograph can be used to locate the position of the displaced

root tip.

• Once it is determined that the root tip is in the sinus

-Gently place the suction tip in the socket.

- Sinus can be irrigated with a sterile saline solution and suction applied.

If the root is still inside the sinus, surgical management can be planned.

Benign lesions CYSTS

Intrinsic origin Mucus retention cyst

Mucocele

Cholesteatoma

Pseudocyst

Extrinsic Origin Odontogenic keratocyst

Dentigerous cyst

Radicular cyst

Calcifying odontogenic cyst

TUMORS

Intrinsic origin Squamous papilloma

Inverted papilloma

Juvenile angiofibroma

Vascular lesions

Myxoma

Giant cell tumor

Extrinsic origin Ameloblastoma

OAT

Odontoma

Odontogenic myxoma

Surgical approaches

• FESS

• CALDWELL- LUC

• LATERAL RHINOTOMY AND MEDIAL MAXILLECTOMY

• WEBER- FERGUSSION APPROACH FOR MAXILLECTOMY

Malignant lesions In the PNS malignant tumors comprises less than 1% of all malignancies

Neoplasm arises fundamentally from the epithelial origin

Metaplastic type of epithelium- squamous cell lesion

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Glandular type- adenocarcinoma group

`mean age-50-65yrs

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Treatment

-Surgery

Maxillectomy

medial

segmental

midfacial deglowing

with orbital exenteration

Radiation therapy

Chemotherapy

combined therapy

Surgical approaches

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OROANTRAL FISTULA An oro antral perforation is an unnatural communication between the oral cavity and maxillary

sinus.

An oro antral fistula is an epithelized unnatural communication between these two cavities.

ETIOLOGY

Extraction of teeth

Destruction of the floor of the sinus by periapical lesions.

Perforation of the floor of the sinus and sinus membrane with injudious use of instruments

SYMPTOMS OF A FRESH ORO-ANTRAL COMMUNICATION

– regurgitation of the liquids from the mouth into the nose in the extracted side

– unilateral epistaxis

– escape of air from mouth into the nose and alteration in vocal resonance

– inability to blow out the cheek

– excruciating pain

SYMPTOMS OF AN ESTABLISHED ORO-ANTRAL FISTULA

• Once a fistula is created superimposed infection of the sinus ensues due to oral organism.

• Post nasal mucus drip accompanied by a nocturnal cough, hoarseness, ear ache or

catarrhal deafness.

• Pain may be severe, throbbing or dull ache

• Malaise, fever, anorexia

PHYSICAL SIGNS

• those presenting immediately after the formation of the fistula

• those relevant to an established oro-antral fistula

RECENTLY CREATED COMMUNICATION

• Surgery in the vicinity of the maxillary sinus such as extraction of the maxillary

posterior teeth

• Attempted extraction of maxillary molar root which disappears as soon as force is

applied

• Attempted extraction of a partially erupted third molar

TEST TO ESTABLISH THE PRESENCE OF ORO-ANTRAL FISTULA -Nose blowing test

-Escaping air bubbles, blood, mucopus at the oral orifice

-A wisp of cotton held just below the alveolar opening will usually be deflected by the air stream

MANAGEMENT

IMMEDIATE TREATMENT FOLLOWING THE CREATION OF AN ORO-ANTRAL

COMMUNICATION

-The closure of the oro-antral fistula should be performed

-To protect the sinus from oral microbial flora

-To prevent escape of fluids and other contents across the communications

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-To eliminate existing pathology

-The ideal treatment following the creation of oro-antral communication is to perform an

immediate surgical repair so that primary closure can be combined with antibiotic prophylaxis to

prevent sinus infection.

• If the oro-antral communication is complicated by the deflexion of the tooth or root in

the maxillary sinus and is in convenient position, it should be recovered

• In all cases in which there has been an immediate closure following penetration of the

antrum. Action supporting measures should be instituted

.this includes

Antibiotics

Analgesics

Nasal decongestants

• TEMPORARY THERAPEUTIC MEASURES BEFORE SURGICAL CLOSURE

• This includes

Pack

the ribbon gauge pack is positioned at the socket and held securely by a suture frame work

denture plate

this is indicated if the surgical repair of the fistula is to be deferred

TREATMENT OF DELAYED CASES

• If an OAF is referred after a period of 24 hrs of its occurrence

• When a period of 24 hrs has elapsed the soft tissue margins often get infected .

it is preferably to defer the treatment till the gingival edges shows sound healing

• Prophylactic treatment consist of antibiotic along with local de

congestants and analgesics should be prescribed

• If the pt produces a purulent discharge from the fistula or develop signs

of a/c or chronic sinusitis the sinus should be gently irrigated with warm normal saline

TREATMENT OF OAF PRESENT MORE THAN ONE WEEK

• IN these cases fistulous tract is well epithelised. At this stage surgical

closure is necessary. Pt presents with symptoms 2-3 wks after extraction complains of

foul taste in the mouth. Pus discharge from fistula into the mouth. Drainage of the sinus

should be re established through the fistula by enlarging it surgically and the sinus

should be gently irrigated daily until it is clear.

SURGICAL APPROACHES

LOCAL FLAPS

BUCCAL FLAP

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Rehrmann Buccal Advancement Flap Moczair Buccal Sliding Flap

Schchard Transversal Flap & Egyedi Bipedicle Flap

Palatal Flaps

Straight advancement flap Ito & Hara submucosal conective tissue flap

& ashley Rotational falp. & Hendersen pedicle flap

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Combined flaps

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TEMPORALIS FLAP

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NOTES: