MAXILLARY SINUS

Adama science and Technology University

By: Dr.Assefa Abera

March,2014
1
ANATOMY
 1st- described by Nathaniel high
more also known as antrum of high
more.
 They are 2 in number. 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
2
CONT.
Dimensions:
Anteroposterior 3.5 cm
Height 3.2 cm
Width 2.5 cm

Pyramidal in shape.
Base- lateral wall at the nose.
Apex- zygomatic process of maxilla. 3
CONT.
 Four walls:-
 Floor of orbit or roof of antrum
 Alveolar process of maxilla-floor
 infratemporal surface of maxilla- anterior
 lateral nasal wall.
 Blood supply
 Facial, maxillary, infraorbital and
greater palatine arteries.
 Anterior facial vein, pterigoid plexus
4
CONT.

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. 5
CONT.
Embryology:
 3/12 weeks IUL - Out pouching in
middle meatus
 Birth - Tubular 2x 1 x 1 cm
growth.
 9 years - 60% of adult size.
 12 years - Antral floor parallels
nasal floor
 18 years - Adult size 6
CONT.
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.
7
 APPLIED SURGICAL ANATOMY
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.

8
 CONT.
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.
9
CONT.
 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.

10
 CONT.

Lining of maxillary sinus

 Breach in continuity is obtained by
occipitomental radiograph- showing
radiopacity in sinus persist for 10 days to 2
weeks.

11
 CONT.
 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
12
CONT.
Periapical involvement:
 A/c or C/c Periapical abscess 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.
13
CONT.
 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.
14
CONT.
 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

15
CONT.
 Involvement of roof causes anaesthesia of
inferior orbital nerve.
 Encroachment on orbit causes alteration of
papillary level eye is lifted up proptosis.

16
CONT.
 Paraesthesia in maxillary teeth following surgical
procedures
 Mainly 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 sins is 1.5 cm below floor of nose.

17
CONT.
 Canine fossa
 Used for- Diagnostic aspiration
 Cald well-LUC operation
 Fractures of middle third of face

 Usually involve maxillary sinus

18
TRANSILLUMINATION

 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 lining, fibrosseous lesions,
tumor will not lit as in normal.

19
RADIOGRAPHS
Extra oral:
 Occipitomental
 Lateral skull
 Submento vertex
 Orthopantemography
 CT
Intra Oral:
 Occlusal
 Periapical
20
INFECTIONS OF MAXILLARY SINUSES
 Odontogenic sinusitis
 A/C maxillary sinusitis

 C/C maxillary sinusitis

21
ODONTOGENIC SINUSITIS
 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.

22
CONT.
 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
23
CONT.
 Management:
 Extraction of offending tooth
 Antibiotics
 Decongestants: Nasal inhalation or
drops

24
A/C MAXILLARY SINUSITIS
 May be suppurative or non
suppurative inflammation of antral
mucosa
 Etiology:
 Infection: common cold, Upper resp.
Tract infection
 Trauma: Fracture of antral floor and
walls
 Allergy
 Neoplasm
25
CONT.
 Oroantral communication & fistula.
 Displaced tooth or root

 Clinical features
 Signs
 Tenderness over check
 Anaesthesia of check
 Mild swelling in severe cases
 Percussion pain of maxi teeth
26
 Extrusion of oroantral fistula with or
in to socket
 Fetor oris
 Discharge of pus to mouth from
fistula.
 Symptoms:
 H/o cold
 Nasal blocking
27
CONT.
 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
28

CONT.
 Sweating
 Nausea
 Difficulty in breathing
 Anorexia
 Rhinos copy
 Edema & erythema of mucosa pus
discharge on to inferior turbinate bone.

29
CONT.
 Trans 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 30
ANTRAL REGIME
 Antimicrobials
 Macrolides: 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% 31
CONT.
 Mucolytic agents
 Tincture benzoin
 Camphor
 Menthol
 Steam inhalation
 Nsaids
 Aspirin
 Paracetamol
 Ibuprofen
32
C/C MAXILLARY SINUSITIS
 Causes
 Dental infection
 C/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 33
CONT.
 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.
34
CONT.
 Oral antral fistula may me there.
 Prolapse of polypoidal mass into mouth.
 Radiography
 Radiopacity on affected side.
Presence of fluid level
 Thickened lining membrane

35
CONT.
 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. 36
CONT.

 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 37
ORO ANTRAL COMMUNICATION & FISTULA
 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.

38
CONT.
 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 39
have high risk.
CONT.
 Periapical lesions
 Abcess, 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 40
CONT.
 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
41
CONT.
 Symptoms
 Fresh Oro antral communication 5
ES
 Escape 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.
42
CONT.
 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.
43
CONT.
 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.
44
ONT.
 Management:
 A fistulous tract persist for more than
14 days is considered as C/c fistula.
 Treatment of early cases
 Immediate surgery repair for primary
closure.
 Reduction of buccal & palatal socket
for adaptation of buccal and palatal
flap to close the defect.
Protective acrylic denture.
45

CONT.
Antibiotics

Penicillin: initially 1/V than oral

penicillin V 250-500ng 6th hrly
 Nasal decongestants
Ephedrine nasal drop

Steam inhalation.

Tincture benzoin

Menthol inhalation

46
CONT.
Analgesics.
 Aspirin 500mg 4 times/day
 Paracetamol 500mg 3 times/day

 Ibuprofen 400 mg 3 times/day

 Temporary measures
White head's varnish pack: packed

over the socket and secured with

sutures.

47
CONT.
 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.
48
CONT.
 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 49
edges show healing- 3 weeks.
CONT,
 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

50
until it is clear.
CONT.
Supportive care
When symptoms subside surgical
closures.
 Surgical closure of OAF 3 types

 Buccal flap
 Palatal flap
 Combination of both

51
CONT.
 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.
52
BUCCAL FLAP ADVANCEMENT OPERATION-
REHRMANN

 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.
53
CONT.
 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 54

CONT.
 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

55
MODIFIED REHRMANN'S BUCCAL
ADVANCEMENT FLAP

 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.

56
INTRANASAL ANTROSTOMY
 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. 57
CONT.
 Remove 1cm of medical wall of antrum, that
bulges into sinus below inferior turbinate this is
extended to floor of nose.

58
PALATAL PEDICLE FLAP: ROTATIONAL
ADVANCEMENT FLAP ASHLEY'S OPERATION.
 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.

59
CONT.
 Suturing- Interrupted suture.
 Denuded bone in palate is covered by guaze pack
soaked white head's varnish and secured with
suture.

60
COMBINATION OF BUCCAL & PALATAL
FLAP

 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.

61
CALD WELL LUC OPERATION
 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 62
CONT.
 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. 63
CONT.
 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. 64
 Incision is closed with 3-0 silk.
CONT.
 Post operative management:
 Antibiotics

 Analgesics

 Anti inflammatory drugs for 5 days

 Pack removed on 5th day

 Tincture benzoic inhalation 3 times/day

 Soft diet.

65