King Saud UniversityKing Saud UniversityDental CollegeDental College

Oral and Maxillofacial SurgeryOral and Maxillofacial Surgery

Maxillary Sinus in Health and Maxillary Sinus in Health and DiseaseDisease

Anatomical facts and location:Anatomical facts and location:

√√ The largest para-nasal The largest para-nasal sinuses.sinuses.

√√ Situated in the maxilla.Situated in the maxilla.

√√ Has pyramidal shape.Has pyramidal shape.

√√ Lateral nasal bone forms Lateral nasal bone forms its base.its base.

√ √ Apex headed towards the Apex headed towards the zygomatic bone.zygomatic bone.√ √ Canine fossa, orbital floor Canine fossa, orbital floor and hard palate form the and hard palate form the pyramidal walls. pyramidal walls. √√ Communicates with nasal Communicates with nasal cavity through maxillary cavity through maxillary ostium, in the posterior end ostium, in the posterior end of hitus simlunaris of middle of hitus simlunaris of middle meatus.meatus.

Anatomical morphology:Anatomical morphology:

√√ Size varies from one Size varies from one person to another.person to another.

√ √ Asymmetry existed in Asymmetry existed in the same individual.the same individual.

√√ Small in children and Small in children and grows up with aging.grows up with aging.

√√ Average height is about Average height is about 3.5 cm, depth 3.2 cm 3.5 cm, depth 3.2 cm and width 2.5 cm.and width 2.5 cm.

√√ Capacity of about 15 cc.Capacity of about 15 cc.

Anatomical morphology:Anatomical morphology:

√√ Divided into several Divided into several compartments by bony septa compartments by bony septa (underwood’s septa).(underwood’s septa).

√√ Lined with pseduo-Lined with pseduo-stratified columnar ciliary stratified columnar ciliary epithelium (schneiderian epithelium (schneiderian membrane).membrane).

Relation with other structures:Relation with other structures:

√√ Alveolar bone and dentition.Alveolar bone and dentition.√√ Nasal cavity and Nasal cavity and

nasopharynex.nasopharynex.√√ Orbital cavity and its Orbital cavity and its

contents.contents.√√ Hard palate and oral cavity Hard palate and oral cavity

proper.proper.√√ Pterygomaxillary fissure and Pterygomaxillary fissure and

its contents.its contents.√√ Neurovascular structures Neurovascular structures

including infraorbital and including infraorbital and superior alveolar nerve.superior alveolar nerve.

Development:Development:

√√ Develops from invagination of the mucous Develops from invagination of the mucous membrane of middle meatus of the nasal membrane of middle meatus of the nasal cavity at about the 3cavity at about the 3rdrd month of intrauterine month of intrauterine life.life.

√√ Fully development reaches with the age of Fully development reaches with the age of 16 years.16 years.

√√ Loss of permanent teeth and alveolar bone Loss of permanent teeth and alveolar bone may make the sinus to appear huge in size.may make the sinus to appear huge in size.

Blood supply:Blood supply:

Blood supply from facial, maxillary, Blood supply from facial, maxillary, infraorbital, greater and lesser palatine infraorbital, greater and lesser palatine arteries and lateral and posterior nasal arteries and lateral and posterior nasal branches of sphenopalatine artery.branches of sphenopalatine artery.

Venous drainage to the anterior facial vein, Venous drainage to the anterior facial vein, sphenopalatine vein and pterygopaltine sphenopalatine vein and pterygopaltine plexus.plexus.

Nerve supply:Nerve supply:

√√ Infraorbital nerve.Infraorbital nerve.

√ √ Posterior, middle and Posterior, middle and anterior superior anterior superior alveolar nerves.alveolar nerves.

√ √ Greater and lesser Greater and lesser palatine nerves.palatine nerves.

Lymphatic drain:Lymphatic drain:

The lymphatic drain of the sinus is through The lymphatic drain of the sinus is through the nose or the submandibular lymph nodes.the nose or the submandibular lymph nodes.

Physiology:Physiology:

Unknown but the following functions have Unknown but the following functions have been proposed:been proposed:

√√ Speech and voice resonance.Speech and voice resonance.

√√ Reduce weight of skull.Reduce weight of skull.

√√ Warmth inspired air.Warmth inspired air.

√√ Filtration of inspired air.Filtration of inspired air.

√√ Immunologic barrier ( body defense).Immunologic barrier ( body defense).

Pathology:Pathology:

Congenital anomalies.Congenital anomalies. Inflammatory diseases.Inflammatory diseases. Cysts and odontogenic Cysts and odontogenic

infection.infection. Bone metaplasia and benign Bone metaplasia and benign

tumors.tumors. Neoplasia.Neoplasia. Trauma.Trauma.

Congenital anomalies:Congenital anomalies:

√√ Cleft palate.Cleft palate.

√√ Facial fistula and cleft.Facial fistula and cleft.

√√ Cystic formation.Cystic formation.

√√ Atresia.Atresia.

Inflammatory diseases:Inflammatory diseases:

√√ Bacterial infection.Bacterial infection.

√√ Bacterial infection secondary to viral Bacterial infection secondary to viral infection.infection.

√√ Fungal infection.Fungal infection.

SinusitisSinusitisAcute sinusitis:Acute sinusitis:

Suppurative or non suppurative inflammation Suppurative or non suppurative inflammation of the mucosal lining of the sinus. It of the mucosal lining of the sinus. It

involves one or both sinuses.involves one or both sinuses.

Causes:Causes:

√ √ Secondary to hay fever and allergic rhinitis.Secondary to hay fever and allergic rhinitis.

√ √ Secondary to acute rhinitis (common cold) Secondary to acute rhinitis (common cold) and URT infection.and URT infection.

√ √ Bacterial infection due to: dental sepsis, Bacterial infection due to: dental sepsis, swimming and diving, trauma and foreign swimming and diving, trauma and foreign body dislodgment.body dislodgment.

SingsSings and symptoms:and symptoms:

√√ Headache.Headache.√√ Pain and tenderness.Pain and tenderness.√√ Nasal obstruction.Nasal obstruction.√√ Nasal discharge.Nasal discharge.√√ Toxic manifestations.Toxic manifestations.√√ Heavy filling with bending.Heavy filling with bending.√√ Nasal congestion.Nasal congestion.√√ X-ray and transillumination findings.X-ray and transillumination findings.

TreatmentTreatment::

√√ Rest and fluid and mouth hygiene.Rest and fluid and mouth hygiene.

√√ Antibiotics (C&S); pneumococci and Antibiotics (C&S); pneumococci and streptococci are the most causative streptococci are the most causative organisms.organisms.

√√ Analgesics and antihistamines.Analgesics and antihistamines.

√√ Local treatment (decongestant and steam Local treatment (decongestant and steam inhalation).inhalation).

SinusitisSinusitis Chronic sinusitis:Chronic sinusitis:

It is a chronic type of infection affected the It is a chronic type of infection affected the mucosal lining of one or both sinuses, mucosal lining of one or both sinuses,

resulted in mucopus or pus collection. A resulted in mucopus or pus collection. A polypoidal type of inflammation can lead to polypoidal type of inflammation can lead to

formation of multiple or single mucosal formation of multiple or single mucosal polyps. polyps.

Causes:Causes:

√√ As a consequence of non resolved acute As a consequence of non resolved acute sinusitis.sinusitis.

√√ Dental abscesses.Dental abscesses.

√√ Virulent organism with low resistance.Virulent organism with low resistance.

√√ Foreign body dislodgement or trauma.Foreign body dislodgement or trauma.

Signs and symptoms:Signs and symptoms:

√√ Headache.Headache.

√√ Nasal obstructionNasal obstruction

√√ Nasal discharge.Nasal discharge.

√√ Fatigue.Fatigue.

√√ Hyposmia/ cacosmia.Hyposmia/ cacosmia.

√√ Transllumination findings.Transllumination findings.

√√ Proof puncture.Proof puncture.

TreatmentTreatment: :

√√ Antibiotics.Antibiotics.

√√ Systemic decongestants.Systemic decongestants.

√√ Sinus wash-out.Sinus wash-out.

Mycotic infection:Mycotic infection:

Aspergillosis:Aspergillosis:

Opportunistic infection caused by maxillary Opportunistic infection caused by maxillary sinus flora fungi environment in susceptible sinus flora fungi environment in susceptible individual, leads to obliteration of the sinus individual, leads to obliteration of the sinus space and erosion of its bony components.space and erosion of its bony components.

Complications of sinusitis:Complications of sinusitis:

Orbital abscess and orbital cellulites.Orbital abscess and orbital cellulites. Intracranial abscesses.Intracranial abscesses. Meningitis.Meningitis. Cavernous sinus thrombosis.Cavernous sinus thrombosis. Spread of infection to neighboring sinuses, Spread of infection to neighboring sinuses,

structures and organs.structures and organs. Osteomyelitis.Osteomyelitis. Gastrointestinal disturbances.Gastrointestinal disturbances.

Cysts and odontogenic tumors:Cysts and odontogenic tumors:

Odontogenic Odontogenic cysts:cysts:

√ √ radicular cysts.radicular cysts.√ √ residual cysts.residual cysts.√ √ dentigerous cysts.dentigerous cysts.√ √ premordial cysts.premordial cysts.

Non-odontogenic Non-odontogenic cysts.cysts.

Mucocele and Mucocele and retention cysts.retention cysts.

Odontogenic Odontogenic tumors:tumors:

√ √ ameloblastoma.ameloblastoma.√ √ Myxoma.Myxoma.

Bone metaplasia and benign tumors:Bone metaplasia and benign tumors:

√√ Fibrous dysplasia.Fibrous dysplasia.

√√ Ossifying fibroma.Ossifying fibroma.

√√ Transitional papilloma.Transitional papilloma.

√√ Osteoma.Osteoma.

√√ Giant cell lesions.Giant cell lesions.

NeoplasiaNeoplasia::

√√ Squamous cell carcinoma.Squamous cell carcinoma.

√√ Adenocarcinoma.Adenocarcinoma.

√√ Sarcoma (osteosarcoma).Sarcoma (osteosarcoma).

√√ Ewing’s sarcoma.Ewing’s sarcoma.

TraumaTrauma::

√√ Tuberosity fracture.Tuberosity fracture.

√√ Dentoalveolar fracture.Dentoalveolar fracture.

√√ LeFort’s fractures.LeFort’s fractures.

√√ Zygomatic complex fracture.Zygomatic complex fracture.

√√ Pure and impure orbital floor fractures.Pure and impure orbital floor fractures.

√√ Establishment of oro-antral fistula.Establishment of oro-antral fistula.

Clinical examination:Clinical examination:InspectionInspection

√√ Assess asymmetry.Assess asymmetry.

√√ Color of overlaying skin.Color of overlaying skin.

Clinical examination:Clinical examination:PalpationPalpation

√ √ Tenderness. Tenderness.

√ √ Swelling and expansion.Swelling and expansion.

√ √ DepressionDepression..

Clinical examination:Clinical examination: Examination of nasal passage Examination of nasal passage

√√ Nasal patency.Nasal patency.

√√ Pus discharge.Pus discharge.

√√ Nasal polyps.Nasal polyps.

√√ Erythema, redness, change in the color of Erythema, redness, change in the color of nasal mucosa.nasal mucosa.

Clinical examination:Clinical examination: Transillumination Transillumination

Clinical examination:Clinical examination:Diagnostic sinus lavageDiagnostic sinus lavage

√ √ sinus rinsing through sinus rinsing through the canine fosaa.the canine fosaa.

√ √ Nasal antrostomy.Nasal antrostomy.

Radiographical examination:Radiographical examination:Routine radiographical examinationRoutine radiographical examination

√√ Orthopantomogram Orthopantomogram (OPG)(OPG)

√√ Occipitomental (water’s Occipitomental (water’s view), with lateral tilt.view), with lateral tilt.

Radiographical examination:Radiographical examination:Special investigation and radiographical examinationSpecial investigation and radiographical examination

SinuscopySinuscopy SinogramSinogram CT scanCT scan MRIMRI

Microbiology and histological examination:Microbiology and histological examination:

Culture and sensitivity and biopsy.Culture and sensitivity and biopsy.