Maxillary sinus

Instructor:- Dr. Jesus George

1

Anatomy2

1st - described by Nathaniel high more also known as Antrum of high more.

They are 2 in No. one on either side of maxilla.

 Largest paranasal sinus. Communicate with other sinuses through

the lateral wall of nose. Ostium opens into middle meatus Volume 15-30ml

Cont.3

Diamension: Anteroposterior 3.5 Height 3.2

Width 2.5

Pyramidal in shape. Base- lateral wall at the nose. Apex- zygomatic process of maxilla.

Cont.4

Four walls- Floor of orbit or roof of antrum, Alveolar process of maxilla-floor, infratemporal surface of maxilla anterior.

 Blood supply Facial, maxillary, infraorbital and greater palatine arteries.  

Anterior facial vein, pterigoid plexus

Cont.5

Lymphatic drainage  Submandibular and deep cervical

lymph nodes.  Nerve supply

Superior dental nerve, anterior, middle and posterior greater palatine nerve.

Branches of maxillary division of trigeminal nerve.

Cont.6

Embryology: 3/12 weeks IUL - Out pouching in

middle meatus Birth - Tubular 2x 1 x 1 cmm growth. 9 years - 60% of adult size. 12 years - Antral floor parallels nasal

floor18 years - Adult size

Cont.7

Physiology: Lined by respiratory epithelium

Functions: Impart resonance to the voice. Increase the surface area & lighten

skull Moisten and warm inspired air. Filter debris from inspired air. They provide thermal insulation to the

tissue above.

Applied surgical anatomy 8

 Relation of the root apices with floor of sinus  In adults 1-1.5cm between floor

of sinus and root apices of maxillary posterior teeth.

 Low incidence of oroantral fistula in children-under fifteen years.

Sinus reaches its normal size by the age of 18 years.

Cont.9

Circumstances with increased likelihood of oroantral fistula Large Sinuses: Floor is thinned out Risk of # when force is applied during maxillary posterior teeth extraction.

Floor is descending down between adjacent teeth and also in between roots of individual tooth.

Cont.10

Tooth lies in close proximity to sinus heading to inadvertent displacement to sinus.

Tooth has conical roots. Unerupted III molar in tuberosity

forms a line of weakness, if adjacent II molar is extracted it result in # of tuberosity.

Cont.11

Lining of maxillary sinus Breach in continuity is obtained by

occipitomental radiograph- showing radioopacity in sinus persist for 10 days to 2 weeks.

Cont.12

Unilateral epistaxis  Cracks and fractures in bony floor

of maxillary sinus. If there is tear in sinus lining it will

heal its own. If clot breaks down> oroantral

communication with in 10 days> oroantral fistula> foul smelling discharge of pus

Cont.13

Periapical involvement: A/c or C/c periapical abcess in

relation to teeth close proximity with sinus may secondarily involve sinus.

 Pus may discharge into sinus causing a fluid level extraction of such tooth cause infection of blood clot> oroantral fistula.

Cont.14

Pressure on nerves with in antrum Occurs in A/c sinusitis. Pus is not able to escape through

Ostium in to nose because of its occlusion by inflammation of adjoining mucosal lining.

 Tumours in maxillary antrum Seen as swelling in cheek, palate,

buccal sulcus.

Cont.15

Teeth maxillary get loosened due to bone destruction interference in blood supply causing pulp necrosis & A/c apical abscess.

Pressure on posterior valve causes destruction of posterior superior alveolar nerve & anaesthesia of gingival & teeth in maxillary molar area

Cont.16

Involvement of roof causes anaesthesia of inferior orbital nerve.

Encroachment on orbit causes alteration of papillary level eye is lifted up proptosis.

Cont.17

Paraesthesia in maxillary teeth following surgical proceduresMainly in the lateral wall of antrum

most cases return to normal. Antral puncture

Is done in middle meatus in children. Inferior meatus in adult.

Floor of sinus is 1.5 cm below floor of nose.

Cont.18

Canine fossa Used for- Diagnostic aspiration Cald well-LUC operation

Fractures of middle third of face Usually involve maxillary sinus

Transillumination19

 Placing a strong light in center of mouth with lips closed.

Normal sinus: Definite infraorbital crescent of light, brightly lit eye glossy pupil.

If antral cavity contains pus, mucus, polyps, blood thickened linig, fibrosseous lesions, tumour will not lit as in normal.

Radiographs 20

Extra oral: Occipitomental Lateral skull Submento vertex Orthopantemography CT

Intra Oral: Occlusal Periapical

Infections of maxillary sinuses

21

Odontogenic sinusitis A/C maxillary sinusitis C/C maxillary sinusitis

Odontogenic sinusitis22

Definition: It is the inflammation of mucosa of

any of paranasal sinuses. Inflammation of most or all

paranasal sinuses pansinusitis. Maxillary sinusitis in usually

Odontogenic in origin.

Cont.23

Clinical Features Teeth involved, IPM, IM, IIM Severe throbbing pain Slight swelling of check Mobile tooth -if involved periodontally

Diagnosis: Total radiopacity or fluid level in

radiography

Cont.24

Management: Extraction of offending tooth Antibiotics Decongestants: Nasal inhalation or

drops

A/C maxillary sinusitis 25

May be suppurative or non suppurative inflammation of antral mucosa

Etiology: Infection: common cold, Upper resp.

Tract infectionTrauma: Fracture of antral floor and

walls  Allergy Neoplasm

Cont.26

Oroantral communication & fistula. Displaced tooth or root

Clinical features Signs Tenderness over check Anesthesia of check Mild swelling in severe cases  Percussion pain of maxillary teeth

27

Extrusion of oroantral fistula with or in to socket

Fetor oris Discharge of pus to mouth from

fistula. Symptoms: H/o cold Nasal blocking

Cont.28

Thick, mucopurulant, foul smelling, discolored nasal discharge

Heavy feeling in head. Constant throbbing pain in cheek or face

more severe in morning and evening. Max. teeth of affected side painful. Generalized symptoms: Chills Fever

Cont.29

Sweating Nausea Difficulty in breathing Anorexia

Rhinoscopy Edema & erythema of mucosa pus

discharge on to inferior turbinate bone.

Cont.30

Tran illumination: Do not transmit high

Radiograph: Water's view- occipitomental 15o. Uniform opacity or fluid level.

Management: Bed rest Plenty of fluids Oral hygiene Antral regime for 5-7 days

Antral Regime31

AntimicrobialsMacrolides: erythromycin 250kg 6th hrly for

5 days. Broad spectrum: amoxicillin 250-500mg 8th

hrly for 5 days. Decongestants

Nasal drop or spay. Ephedrine sulphate 0.5-1% in Normal saline 6th hrly.

Xylomethozoline hydrochloride 0.1%

Cont.32

Mucolytic agents Tincture benzoin Camphor Menthol Steam inhalation  

Nsaids Aspirin Paracetamol Ibuprofen

C/C maxillary sinusitis 33

Causes Dental infectionC/C rhinitis C/C Infection in frontal & Ethmoid sinus. Allergy

Pathophysiology Due to C/C infection the mucous

membrane of sinus may develop hyperplasia or atrophy.

Multiple polyps Degeneration of epithelium

Cont.34

Diagnosis: H/o: Repeated attacks of A/c

mucopurulent rhinitis. Long- standing nasal or postnasal

discharge.  Anterior rhinos copy: shows nasal

congestion & mucopurulent material in middle meatus.

Oro pharynx shows descending pharyngeal exudates.

Cont.35

Oral antral fistula may me there. Prolapse of polypoidal mass into mouth.

Radiography Radiopacity on affected side. Presence of fluid level

Thickened lining membrane

Cont.36

Management: If the cause is tooth or root in sinus remove

the cause prior to any other treatment.  Antral polyp is removed Antibiotics Decongestants Analgesics C/C sinusitis due to oro antral fistula require

closure of Oro antral fistula Surgical Drainage:

Topical anaesthesia is applied to cotton wool and inserted along the nasal floor near inferior turbinate.

Cont.37

Sharp trocar and cannula is introduced inferior to inferior turbinate.

Antrum wall is punctured. Trocar with drawn Pus is drained using suction Warm saliva irrigation daily till symptoms are settled down

Oro Antral Communication & Fistula

38

Oro antral per formation: It is an unnatural communication

B/w oral cavity & maxillary sinus.  Oro antral fistula

It is an epithelized, pathological, unnatural communication b/w oral cavity and maxillary sinus.

Cont.39

Etiology: Extraction of teeth Palatal root of I molar when broken most

frequently causes oroantral communication

Conical maxillary III molar-during extraction there will be # of tuberosity oro antral communication.

Isolated posterior teeth in edentulous arch more risk of causing destruction of floor of sinus.

Surgical removal of impacted teeth also have high risk.

Cont.40

Periapical lesionsAbcess, granuloma, cyst Apicoectomy Blind instrumentation

Injudicious use of instruments. Forcing a tooth or root into sinus during

removal Trauma of face.

Trauma of middle 1/3 of face. Due to missiles or sharp objects gunshot injuries

Cont.41

Surgery of sinus Partial maxillectomy Surgical treatment of large abscess or cyst. Improper incision in Caldwell luc operation.

zygomatic complex #Osteomyelitis: Gumma involving palate Infected implants in maxilla Malignant diseases

Cont.42

Symptoms Fresh Oro antral communication 5

ESEscape of fluids- from mouth to nose

when patient rinse or gargle. Epistaxis (unilateral) - Bleeding from

nose. Escape of air - From mouth to nose on

sucking, inhaling. Enhanced column of air- Change in voice. Excruciating pain- Around the region of

involved sinus.

Cont.43

Symptoms- in late stage - OAF 5ps. Pain. Persistence purulent or mucopurulent discharge Post nasal drip. Possible Sequelae of general, systemic toxemic

condition: Fever Malaise Anonexia Frontal & parietal headache.

Cont.44

Popping out of an antral polyp.   Confirmation of presence of oro antral communication fistula

 If large; Assessed by inspection If small: nose blowing test

Compression of anterior nares & gently blow nose produces a whistling sound, escape of air bubble blood or pus. At the oral orifice.

Ont.45

Management: A fistulous tract persist for more than

14 days is considered as C/c fistula.  Treatment of early casesImmediate surgery repair for primary

closure.  Reduction of buccal & palatal socket for adaptation of buccal and palatal flap to close the defect.

Protective acrylic denture.

Cont.46

AntibioticsPenicillin: initially 1/V than oral penicillin V 250-500ng 6th hrly

Nasal decongestants Ephedrine nasal drop Steam inhalation. Tincture benzoin Menthol inhalation

Cont.47

Analgesics. Aspirin 500mg 4 times/day Paracetamol 500mg 3 times/day Ibuprofen 400 mg 3 times/day Temporary measuresWhite head's varnish pack: packed over the socket and secured with sutures.

Cont.48

White head's varnish Benzoin- 10% Storaly-7.5% Balsam of tolu- 5% Lodoform - 10% Solvent - Ether- 67.5%

Denture plate: Socket is covered with gauzes a plate is placed.

Cont.49

Treatment of delayed cases OAF with in 24 HRS If the edges of wounds are clean close

immediately. Postoperative antibiotics, decongestants

can be closed by buccal flap OAF after 24 HRS Tissue margins often get infected, so

defer surgical closure until gingival edges show healing- 3 weeks.

Cont,50

Antibiotics, analgesics, decongestants. If purulent discharge or c/c sinusitis

irrigate sinus with warm normal saliva. OAF more than 1 month Fistula is well epithelized surgical closure Surgical drainage:

Established by enlarging fistula Sinus in irrigated with normal saline

until it is clear.

Cont.51

Supportive care When symptoms subside surgical

closures. Surgical closure of OAF 3 types

Buccal flap Palatal flap Combination of both

Cont.52

Essential features of flap Free end of flap should have adequate blood

supply Base should be wider than apex for buccal flap palatal flap is designed in such a way that

greater palatine vessels are incorporated in the transposed tissue enclose the fistula.

Suture line is supported by sound bone There should not be any tension along the

suture line.

Buccal flap advancement operation-rehrmann

53

Inject LA in to mucobuccal fold Excision of fistulous tract: incision is made

around fistulous tract 3-4mm marginal to orifice. Epithelial zed tract with associated antral polyps dissected gum margins freshened with blade no: 11

Two divergent incision are done with blade No. 15 from each side of orifice into buccal sulcus (2.5cm). Till bone flap is reflected.

Reduction & smoothening of alveolar bone is done.

Cont.54

Advancement of buccal flap: If flap is not covering fistula, flap is advanced

horizontal incision is made in preventing it’s advancement.

Inspection of maxillary sinus for infection. If any polypoidal mass or other diseased tissue

removed. Irrigate with warm normal saline. If any pathology - cald well Luc procedure done. Arrest of hemorrhage Closure of wound with interrupted sutures

Cont.55

Postoperative medication: Antibiolgics Analgesics Decongestants Inhalation

Soft diet Instruction to patient: Avoid sneezing

Not to explore wound with tongue Avoid sucking of fluid and air

Removal of suture 7-10 days postoperatively

Modified rehrmann's buccal advancement flap

56

 After mobilization of buccal flap & releasing incision in free end of flap.

A step is created by removing 1-2mm mucosal layer.

The denuded margin is sutured below palatal flap by vertical mattress suture

Mucosa is sutured with palatal flap by interrupted suture, provides double layer closure.

Intranasal antrostomy 57

It is done to close an OAF & to remove tooth or root from sinus.

 Surgical procedure: A small osteotome or gouge is pushed through

the inferior meatus to max-sinus. Iodoform gauze pack is grasped into beaks of big

curved artery forceps and is passed through the opening is pulled out into nostril.

A single knot at one end of guaze will keep it in nostril other end is used to pack sinus, after achieving hemostasis.

Cont.58

Remove 1cm of medical wall of antrum, that bulges into sinus below inferior turbinate this is extended to floor of nose.

Palatal pedicle flap: Rotational Advancement flap ashley's operation. 59

 LA Excision of fistulous tract Marking of proposed palatal flap Raising palatal mucoperiosteum Inspection of sinus and irrigate with

betadine and normal saline. Trimming of buccal mucoperiosteum Rotational advancement of palatal pedicle

flap to approximate buccal margin.

Cont.60

Suturing- Interrupted suture. Denuded bone in palate is covered by

guaze pack soaked white head's varnish and secured with suture.

Combination of buccal & palatal flap

61

Used to close large defect. Used when there is H/o earlier repair with

failure. It is the combination of inversion and

rotational advancement flap We will get a double layer closure. There is mobilization of both palatal flaps.

Cald well LUC operation62

By George Cald Well Indication: For removal of root fragments, teeth foragin body

stone from maxillary sinus. To treat c/c sinusitis with hyper plastic lining &

polypoid degeneration of mucosa Removal of cyst and benign growth in sinus. Mangement of hematoma in sinus to control post

traumatic hemorrhage. Zygomatic complex # involving floor of orbit and

anterior wall of sinus. OAF with c/c sinusitis

Cont.63

Surgical procedure: Performed under LA or GA Semilunar incision in buccal vestibule from canine

to II molar above gingival attachment. Mucoperiosteal flap is elevated till the infra orbital

ridge. An opening is created in anterior wall of sinus with

gouges, drill or chisel. Opening is enlarged in an directions with roungeur

up to the size of index finger. Opening should be away from roots of maxillary

teeth.

Cont.64

Pus is sucked a ways irrigated with copious saliva wash

Inspection of sinus Removal of tooth, root, guaze, cotton, stone, bone. Thickened infected lining of sinus is elevated,

removed and sent for histopathologic examination. If profuse bleeding in sinus, it is packed with ribbon

guaze soaked in adrenaline 1:1000 for l or 2 min. Antral cavity is again irrigated and packed with l0

doforun ribbon guaze. Incision is closed with 3-0 silk.

Cont.65

Post operative management: Antibiotics Analgesics Anti inflammatory drugs for 5 days Pack removed on 5th day Tincture benzoic inhalation 3 times/day Soft diet.