MAXLLARY SINUS

:Definition
air filled bony cavities within the skull that communicate with the
.nasal passages through patent Ostia
:Site
It fills the whole body of the maxilla
:Size
The largest of the all paranasal sinuses. The mean value of the
maxillary sinus length in males was (36.4 ± 4.6 mm) and in females
was (33.9 ± 4.2 mm). The mean value of the maxillary sinus width in
males was (27.4 ± 4 mm) and in females was (25.3 ± 3.9 mm) the
for mean value of the maxillary sinus height was (35.1 ± 3.9 mm) and
females was (30.8 ± 3.6 mm). The volume is about 34×31-23 mm
:Functions
diminish weight of skull ❖
resonance of voice ❖
warming & humidification of air ❖
protection of brain against temperature change ❖
Shape & relations
Pyramidal cavity
Base
lateral wall of nasal cavity
Apex
zygomatic process of maxilla
Roof
Base of the orbit
Floor
alveolar & palatine processes of maxilla
Anterior wall
anterior surface of maxilla
Posterior wall
posterior surface of maxilla
Opening of the sinus
Maxillary infundibulum
a common channel that links the*
frontal sinus , anterior ethmoid air
cells, and the maxillary sinus to the
middle meatus allowing airflow and
.mucociliary drainage
situated high up in the medial wall*
and open into hiatus semilunaris of
the middle meatus of nose under
middle turbinate (ostium maxillare).
This location is unfavourable for
drainage since floor of nasal cavity is
located above floor of maxillary sinus
.by 1cm
 Maxillary sinus septa
The prevalence of one or more septa per sinus was found
the to be 22.61% It was revealed that 25.4% were located in
anterior region & 50.8% in the middleregion & 23.7% in
the posterior region. The average measured height of the
septa was 1.63 cm
 Schneiderian Membrane
Normal membrane thickness 0.5: 3 mm
 Innervation
anterior, middle, posterior superior alveolar &
Infraorbital nerves
 Blood supply
Through Infraorbital, posterior superior, anteriorsuperior
alveolar arteries. Some collateral supply isderived from facial
and palatine arteries
Venous & Lymphatic drainage
drains via sphenopalatine and pterygoid venous plexus
.Lymphatic drainage is to submandibular lymph nodes
Pneumatisation & growth of maxillary sinus
Maxillary sinus in child 6 months is about 10 mm and is
separated from maxilla by unerupted teeth. After eruption of
deciduous the sinus continues to be rounded and elongated. In
child sinus floor is near nasal bone The adult pyramidal shape
attains its full size between 14 and 18 years and the sinus floor is
about 1cm below nasal floor. A layer of compact bone separate
these teeth from sinus mucosa. It may be very thin or absent in
some persons
Teeth related to maxillary sinus are 6, 7, 5, 8, 4
Anatomic and physiologic features that obstruct
the natural flow of drainage fromthe sinuses
inadequate higher position of the drainage✔
septal deviation ✔
hyperplasia of opening ✔
inadequate ciliary actions✔
 Diagnosis of maxillary sinus disorders
patient history*
Clinical examination*
a- inspection
b-palpation
c-percussion
Transillumination *
Radiographic examination *
intraoral ( periapical & occlusal x-ray) -
panoramic view -
Water's view -
Tomogram and radiographic dyes -
Computed tomography -
MRI-
Sinoscopy*
 Maxillary sinus pathology
Developmental anomalies ❖
Maxillary sinusitis ❖
Oroantral communication or fistula ❖
Trauma to sinus ❖
Maxillary sinus cysts ❖
Maxillary sinus tumors ❖
Antral rhinoliths ❖
Prolaps of sinus ❖
Hematoma of sinus ❖
Sino-Orbit-Cerebral mucormyosis ❖
 ’Developmental anomalies
Crouzon syndrome•
Early synostosis (fusion) of sutures produces
hypoplasia of the maxilla and maxillary sinus with the
.high arched palate
Treacher Collins syndrome
Associated with underdeveloped maxillary sinus and
.malar bones
Binders syndrome
.Midfacial hypoplasia with maxillary sinus hypoplasia
 Maxillary sinusitis
:Classification of maxillary sinusitis
according to etiologic pathogen (bacterial or viral) ❖
according to involved side ❖
according to duration and frequency (Acute, subacute ❖
(chronic, recurrent
 Acute maxillary sinusitis
Etiology
Upper respiratory tract infection ✔
Odontogenic infection (dental abscess or infected cyst) ✔
Allergy ✔
Oroantral fistula ✔
Facial fracture involves sinus ✔
Prolonged nasal intubation✔
Tooth or root displaced to sinus✔
Signs and Symptoms
cheek pain which increase on bending ✔
tenderness on percussion on maxillary teeth ✔
purulent nasal discharge ✔
hyposomia ✔
fever, malaise ✔
inability to work ✔
tenderness over cheek bone which is red and swollen ✔
✔headache
Radiographic findings of acute sinusitis
Air fluid level ✔
other nonspecific findings are diffuse opacification of sinus ✔
or mucosal thickening ( > 4 mm )
 Medical management of acute maxillary
sinusitis
Antibiotic (unasyn or augmentin) for 3-5 daysin case of ❖
sensitivity to penicillin give erythromycin
Systemic and topical decongestants for 3 days ❖
Mucolytic agents like steam inhalation or saline lavage ❖
Antihistaminic reduces osteomeatal obstruction in allergy ❖
Analgesics (NSAID) & Needle aspiration of the sinus and ❖
Antral lavage
humidification of inspired air ❖
vRemoval of cause
 Surgical treatment of maxillary
sinusitis
Antral washout -1
Caldwell Luc operation -2
FESS-3
Inferior meatal antrostomy -4
Middle meatal antrostomy -5
 Antral lavage (Antral puncture and
washout)
It is a simple operation which can be done either under L.A
or GA A large needle is passed into the nostril, and pushed
through the bone into the maxillary sinus then Salt water is
injected into the sinus until it runs out through the natural
opening back into the nose. This washes the lining of the
.sinus, so any pus or mucus in the sinus is sucked out
 Surgical removal
Caldwell-Luc operation / Sublabial antrostomy
Opening via the anterior wall in the canine fossa through ➤
.vestibular incision
Mucosal lining of the maxillary Antrum is removed ➤
A window is created through the inferior meatus ➤
This procedure can be done under L.A or G.A ➤
 Subacute & chronic sinusitis
Aetiology
repeated attacks or persistence of acute sinusitis for 3 •
months with failure to treat the underlying cause of
acute sinusitis
anatomic abnormalities clinical conditions as allergies •
or chronic infection in frontal or ethmoidal sinus
Signs and Symptoms
Dull pain headache ❖
Pain in upper teeth ❖
Rhinorrhea Nasal congestion or obstruction ❖
Cough ❖
Hyposomia ❖
 Management of subacute & chronic
maxillary sinusitis
Antibiotics ✓
corticosteroid therapy ✓
removal of underlying cause✓
decongestant and antihistaminics ✓
moisture and humidification✓
Immunotherapy ✓
surgical drainagee ✓
 Complications of maxillary sinusitis
Facial cellulitis •
Orbital complications •
inflammatory oedema ❖
orbital abscess ❖
subperiorbital abscess ❖
orbital cellulites ❖
cavernous sinus thrombosis ❖
Intracranial extension •
meningitis ❖
epidural abscess ❖
subdural abscess ❖
brain abscess ❖
Local complications •
Osteomyelitis ❖
Mucocele ❖
Displaced root or tooth in the sinus ( OAF)
Diagnosis
History *
Clinical examination *
Radiographic examination *
a- OPG
b- Water's view
c- Lateral oblique view
Most commonly displaced roots
1st molar 80% •
2nd molar approximate 20% •
3rd molar, premolars, rarely canine •

Incidence of Palatal roots 2 more than buccal roots

 Management
If asymptomatic & uninfected root tip < 3mm
.Immediate surgical intervention is unnecessary ❖
Root tip will be fibrosed, figure of -8 suture is done over ❖
. socket to hold blood clot
Standard precautions can be given to patient as ❖
antibiotic and nasal decongestant
 If tooth or large fragment or infected root is
displaced into sinus should be removed
Locate displaced root using different radiographs ❖
Good lightening & constant suction ❖

:Non surgical trials can be used

a- Irrigation of sinus and place small suction tip
b- Packing a long strip of 0.5 inch of iodoform gauze
 Surgical removal
Caldwell-Luc operation / Sublabial antrostomy
Opening via the anterior wall in the canine fossa through ➤
.vestibular incision
Mucosal lining of the maxillary Antrum is removed ➤
A window is created through the inferior meatus ➤
This procedure can be done under L.A or G.A ➤
 Acute oroantral communication
abnormal epithelised communication between oral cavity &
maxillary sinus
Diagnosis
with Through clinical examination of socket for perforation ❖
good light, irrigation, and suction
Nose blowing test / Valsalva test ❖
Air bubbles
Foggy/cloudy mirror
History of patient if sinusitis or periapical infection was ❖
present
 Management
If perforation is small less than 5 mm
healed spontaneously, then give instructions for patient include
not to blow the nose for a week -
keep mouth open when sneezing -
avoid vigorous rinsing -
eat soft diet -
avoid smoking -
antibiotic and decongestant -
it can be closed by undermining the wound margins decreasing
.the height of the buccal and palatal alveolar bone

Relaxed incision can be done on the palatal side to allow ✓

tension free closure
 if perforation more than 5 mm in size
A- Buccal advancement flap or Rehrmann flap
Advantages
it has broad base providing good blood supply •
no denuded area and require no rotation •
it allow simultaneous Caldwell-Luc procedure to be done •
Disadvantages
Reduction in the depth of buccal vestibule
 B- Buccal sliding flap or Moczair technique

Indicated in closure of buccally placed communication by distal

shifting of the flap one tooth for closure. It is recommended for
.edentulous patients
Advantages
Preserve buccal vestibular depth -
Disadvantages
.leave raw area -
Scarring of anterior releasing incision -
cause periodontal disease -
 Chronic oroantral Fistula
Extraction of maxillary molars with pneumatized sinus ❖
Application of apical force during extraction of roots ❖
Facial trauma as gun shot wounds ❖
Treatment of cyst or tumor in maxilla by excision after ❖
Caldwell-Luc operation
Osteomylitis and osteoradionecrosis ❖
Sphilitic gumma of the palate ❖
During implant placement especially subperiosteal type ❖
Signs and Symptoms
regurgitation of liquids from the mouth into the nose •
alteration of vocal resonance •
inability to blow out the cheek •
unilateral bad odour and salty tastepostnasal mucous drip •
lump appear through the extraction site •
Surgical techniques can be used for closure of Chronic OAF
pinhole fistula
undermining of wound margins with small palatal relaxing
incision
moderate size fistula
Local flaps •
Distant flaps •
Grafts •
 Local flaps
Buccal advancement flap (Rehrman buccal flap) -1
Buccal sliding flap (Moczair buccal flap) -2
Buccopalatal flap -3
palatal flaps A- Palatal transposition (pedicle) flap -4
B-Palatal rotation flap
C-Submucosal connective tissue palatal
pedicle flap
D- Island palatal flapSubscribe
: Advantages
Palatal tissue is thick and rich in blood supply
: Disadvantages
need rotation with the risk of decrease blood supply leave
.raw area that heal by secondary healing
3- palatal-based rotational flap
 Distant flaps
Nasolabial tunnel skin flap(1
Tongue flap : Anteriorly based tongue flap Posteriorly (2
based tongue flap Lateral tongue flap
Temporalis muscle flap(3
Buccal fat pad flap (4
Microvascular free-tissue transfer (5
 Bone grafts augmentation
Indications
bone defects 5mm or more .1
failure of conservative methods .2
need for recontouring of the alveolar ridge for .3
prosthesis reconstruction
Disadvantages
require 2nd surgical procedure .1
infection, loss of graft, and persistence of fistula .2
Alloplastic implants
Gold foil, titanium membrane •
Soft polymethylmethacrylate •
Lyophilized porcine collagen •
Hydroxyapatite blocks •
 Postoperative care
Instruct pt. to avoid any negative or positive pressure ❖
Antibiotics for 5-7 days to avoid infection ❖
Analgesics ❖
Nasal decongestant drops and inhalants ❖
Soft diet ❖
Warm saline mouth wash ❖
Suture removal after 10-12 days ❖
 Ohngren's line
to an imaginary line extending from medial canthus of the eye
Antrum the angle of the mandible which divides the maxillary
into the infrastructure (anteroinferior) and suprastructure
(posterosuperior), In general, tumours below this line/
anteroinferior have better prognosis