MAXILLARY SINUS

IMAGING

BY HASMAT ALI
FINAL YEAR
contents
 DEFINITION
 DEVELOPMENT
 ANATOMY
 RADIOGRAPHS
 PATHOLOGY OF MAXILLARY SINUS
Definition
Maxillary sinus is the
pneumatic space that is
lodged inside the body of
maxilla and that
communicates with the
environment by way of the
middle meatus and nasal
vestibule.”
Development
 Maxillary sinus is first of the PNS to develop.
 It develops by the invagination of mucous membrane from
nasal cavity.
 It starts as a shallow groove on the medial surface of maxilla
during the 4th month of intrauterine life.
 Expansion occurs more rapidly until all the permanent teeth
have erupted.
 It reaches to maximum size around 18years of age.
Anatomy
 The sinus may be considered as a three
sided pyramid
 The base of the pyramid forming the
lateral nasal wall and apex extending
laterally into the zygomatic process of
maxilla and 3 wall.
 Superior wall
 Anterior wall
 Posterior wall
Medial wall
Formed by lateral nasal wall
 Below -inf. nasal conchae
 Behind -palatine bone
 Above -uncinate process of ethmoid, lacrimal bone
 Contains double layer of mucous
membrane(parsmembranacea)
 Imp structures
 Sinus ostium
 Hiatus semilunaris
 Ethmoidal bulla
 Uncinate process
 Infundibulum
 Superior wall

 It Forms roof of sinus and form by floor of orbit

 Imp structures

• Infraorbital canal
• Infraorbital foramen
• Infraorbital nerve and vessels.
Anterior Wall
 Extends from pyriform aperture anteriorly
to ZM suture & Inferior orbital rim
superiorly to alveolar process inferiorly.
 Convexity towards sinus
 Thinnest in canine fossa

 Imp structures
 Infraorbital foramen
 ASA, MSA nerves
Posterolateral Wall
 It is Made of zygomatic and greater wing of sphenoid bone.
 It is thick laterally, thin medially

 Imp structures
• PSA nerve
• Maxillary artery
• Pterygopalatine ganglion
• Nerve of pterygoid canal
Ostium
 Opening of the maxillary sinus is called ostium.
 It opens in middle meatus at the lower part of the hiatus semilunaris.
 Lies above the level of nasal floor.
 The ostium lies 3 to 6 mm in diameter positioned and under the posterior
aspect of the middle concha of the ethmoid bone.
Radiographs
 Radiography is the most important supplementary investigation to clinical examination of the
sinuses

 Intra-Oral : Extra-Oral:
* Intraoral Periapical * OPG View
* Occlusal * Waters view
(Occipitomental view)
* Lateral Occlusal view * Sub-mento vertex view
* PA view
*Lateral view
*Caldwell’s view (occipito frontal)

 Others:
* MRI & CT scan
Intraoral Periapical Radiograph
 The borders of the maxillary sinus
appear on periapical radio-graphs as a
thin, delicate, tenuous radiopaque line
(actually a thin layer of cortical bone).
 In adults the sinuses are usually seen to
extend from the distal aspect of the
canine to the posterior wall of the
maxilla above the tuberosity.

The inferior border of the maxillary

sinus (arrows) appears as a thin
radiopaque line near the apices of
the maxillary premolars and molars.
Y- line of ennis
 on periapical radiographs of the
canine, the floors of the sinus and
nasal cavity are often super-imposed
and may be seen crossing one
another, forming an inverted Y in the
area.

The anterior border of the maxillary

sinus (white arrows) crosses the floor
of the nasal fossa (black arrow) .
 In the absence of disease, sinus floor appears
continuous, but on close examination it has small
interruptions in its smoothness or density.
 The roots of maxillary molars usually lie in close
apposition to the maxillary sinus and may project
into the floor of the sinus, causing small elevations
or prominences.
 The thin layer of bone covering the root is seen as a
fusion of the lamina dura and the floor of the sinus.
 The degree of extension of the maxillary
sinus into the alveolar process is extremely
variable.

 In response to a loss of function (associated

with the loss of posterior teeth) the sinus
may expand farther into the alveolar bone,
occasionally extending to the alveolar ridge

The floor of the maxillary sinus

(arrows) extends toward the crest of the
alveolar ridge in response to missing
teeth.
 Frequently, thin radiolucent lines of uniform
width are found within the image of the
maxillary sinus, These are the shadows of
neurovascular canals or grooves in the lateral
sinus walls that accommodate the posterior
superior alveolar vessels, their branches, and
the accompanying superior alveolar nerves.
 they are usually seen running a curved
posteroanterior course that is convex toward
the alveolar process.

Neurovascular canals
(arrows) in the lateral wall
of the maxillary sinus.
Septa

 one or several radiopaque lines traverse the image of the

maxillary sinus ,These opaque lines are called septa .
 . They are thin folds of cortical bone that projecting a few
millimeters away from the floor and wall of the antrum or
they may extend across the sinus.
 They appear on many periapical intraoral radiographs and
frequently on cone-beam images.
 Septa deserve attention because they sometimes mimic
periapical disease, and the chambers they create in the
alveolar recess may complicate the search for a root
fragment dis-placed into the sinus. Maxillary Sinus Septa.- Septum
(arrow) in the maxillary sinus formed
by a low ridge of bone on the sinus
wall.
 The floor of the maxillary sinus occasionally shows
small radiopaque projections, which are nodules of
bone.
 These must be differentiated from root tips, which
they resemble in shape.
 the bony nodules often show trabeculation; and
although they may be quite well defined, at certain
points on their surface they blend with the
trabecular pattern of adjacent bone.
 A root fragment, which is quite homogeneous in
appearance, may also be recognized by the This bony nodule (arrow) is a
presence of a root canal. normal variant of the floor of the
maxillary sinus.
Occlusal radiograph
 the anterior maxillary occlusal
projection, the cross sectional
maxillary anterior projection
and the lateral maxillary
occlusal projection are
excellent techniques to
visualize maxilla from the
palatal aspect .

 To demonstrate and evaluate

the integrity of the anterior,
medial,
and lateral outlines of the
maxillary sinus
 TECHNIQUE AND POSITIONING
 The patient is seated with the head supported and with
the occlusal plane horizontal and parallel to the floor
 The film packet, with the white (pebbly) surface facing
uppermost, is placed flat into the mouth on to the
occlusal surfaces of the lower teeth. The patient is asked
to bite together gently. The film packet is placed centrally
in the mouth with its long axis crossways in adults and
antero-posteriorly in children.
 The X-ray tube head is positioned above the patient in
the midline, aiming downwards through the bridge of the
nose at an angle of 65°-70° to the film packet
Lateral Occlusal radiograph
o A maxillary lateral occlusal
projection may be used for a
more extensive view of the
sinus.
 TECHNIQUE AND POSITIONING
 The patient is seated with the head supported and
with the occlusal plane horizontal and parallel to the
floor.
 The film packet, with the white (pebbly) surface
facing uppermost, is inserted into the mouth on to
the occlusal surfaces of the lower teeth, with its long
axis antero-posteriorly. It is placed to the side of the
mouth under investigation, and the patient is asked
to bite together gently.
 The X-ray tube-head is positioned to the side of
the patient's face, aiming downwards through the
cheek at an angle of 65°-70° to the film, centring on
the region of interest
 OPG (Orthopantomogram)

 A technique for producing a single tomographic image of the facial structures that
includes both the maxillary and mandibular dental arches and their supporting
structures.
 pantomography is derived from two words – panorama and tomography
 Ortho - straight
 Panoramic - An unobstructed or a complete view of the object in every direction
 Tomography – An x ray technique for making radiographs of layers of tissue in depth,
without the interference of tissue above and below that level.
 The radiograph depicts both maxillary sinuses, revealing greater internal structure and
parts of the inferior, posterior, and anteromedial walls.
 As the tube head rotates around the patient, the x-ray beam passes through different
parts of the jaws, producing multiple images that appear as one continuous image on
the film (“panoramic view”).
 It gives a good display of the lower aspects of sinus On the panoramic radiograph maxillary
sinus appear as paired radiolucent areas located above the apices of maxillary premolars
and molars .the floor of the maxillary sinus is composed if dense cortical bone and appear as
a radiopaque line
 It is difficult to compare the internal radiopacities of the right and left sinus in the panoramic
image because of variations that result from overlapping phantom images of other structures.
Waters view (Occipitomental view)
 The most important view for sinus
problems or injury involving the
maxilla or orbits.

 By taking the view erect, fluid levels

within the maxillary sinuses can be
seen.

 The Waters projection is optimal for

visualization of the maxillary sinuses,
especially to compare internal
radiopacities, and the frontal sinuses
and ethmoid sinus.
 Image Receptor and Patient Placement
 The image receptor is placed in front of the patient and
perpendicular to the midsagittal plane.
 The patient ’ s head is tilted upward so that the
canthomeatal line forms a 37-degree angle with the
image receptor.
 Position of the Central X-Ray Beam
 The central beam is perpendicular to the image
receptor and centered in the area of the maxillary
sinuses.
 Submento-vertex view
 The submento-vertex view may be useful in evaluating the lateral and
posterior borders of the maxillary sinuses and the ethmoid air cells.
 Image Receptor and Patient Placement
 The image receptor is positioned parallel to patient ’ s transverse
plane and perpendicular to the midsagittal and coronal planes.
 The patient ’ s neck is extended as far backward as possible, with the
canthomeatal line forming a 10-degree angle with the image receptor.
 Position of the Central X-Ray Beam
Maxillary sinus
 The central beam is perpendicular to the image receptor, directed
from below the mandible toward the vertex of the skull (hence the
name submentovertex, or SMV ), and centered about 2 cm anterior to
a line connecting the right and left condyles.
Posteroanterior Skull (PA) View
 This projection shows the skull vault, primarily the
frontal bones and the jaws.
 TECHNIQUE AND POSITIONING
 The patient is positioned facing the film with the
head tipped forwards so that the forehead and tip of
the nose touch the film — the so-called fore head
nose position. The radiographic baseline is
horizontal and at right angles to the film.
 The X-ray tube head is positioned with the central
ray horizontal (0°) centered through the occiput and
aimed to exit at nasion .
PA view
 The lateral Radiograph
 The lateral skull view allows examination
of all four pairs of the paranasal sinuses, but
with each member of a pair superimposed
on the other.

 this is an ideal view when opaque foreign

bodies are being looked for in the maxillary
sinus
 Image Receptor and Patient Placement
 The image receptor is positioned parallel to the patient ’
s midsagittal plane.
 The site of interest is placed toward the image receptorto
minimize distortion.

 Position of the Central X-Ray Beam

 The central beam is perpendicular to the midsagittal
plane of the patient and the plane of the image receptor
and is centered over the external auditory meatus.
Caldwell’s View(occipitofrontal)
 The Caldwell view is a caudally angled PA radiograph
of the skull, designed to better visualize the paranasal
sinuses, especially the frontal sinuses.
 The Caldwell view is most useful in evaluating the frontal
sinuses and ethmoid sinus.
 The superior orbital rims can be evaluated.
 TECHNIQUE AND POSITIONING
 The patient is positioned facing the film with
the head tipped forwards so that the
forehead and tip of the nose touch the film
— the so-called forehead nose position.
The radiographic baseline is horizontal and
at right angles to the film.
 The X-ray tube head is positioned with the
central ray horizontal (15-20°) centered
through the occiput and aimed to exit at
nasion .
 CT AND MRI
o High-resolution axial and coronal CT and MRI examinations
are the most revealing imaging techniques for the paranasal
sinuses and the adjacent structures and areas.
o CT examination is appropriate to determine the extent of
disease in patients who have chronic or recurrent sinusitis
o MRI provides superior visualization of the soft tissues,
especially the extension of infiltrating neoplasms into the
sinuses or surrounding soft tissues, or the differentiation of
retained fluid secretions from soft tissue masses in the
sinuses.
CT (Computed Tomography)
  CT scanning is painless, noninvasive and accurate. It's also the most
reliable imaging technique for determining if the sinuses are
obstructed and the best imaging modality for sinusitis.
 CT has several advantages over conventional film radiography and
tomography.
 First, CT eliminates the superimposition of images of structures outside the
area of interest.
 Second, because of the inherent high-contrast resolution of CT, differences
between tissues that differ in physical density by less than 1% can be
distinguished; conventional radiography requires a 10% difference in physical
density to distinguish between tissues.
 Third, data from a single CT imaging procedure,
consisting of either multiple contiguous or one helical
scan, can be viewed as images in the axial, coronal, or
sagittal planes, or in any arbitrary plane, depending on
the diagnostic task. This is referred to as multiplanar
reformatted imaging. Having the capability of viewing
normal anatomy or pathologic processes simultaneously
in three orthogonal planes greatly facilitates radiographic A
interpretation.

A, CT images demonstrating sagittal plane

ethmoid, and sphenoid sinuses.
B, Coronal view through ethmoid and
maxillary sinuses .
C, Axial view through level of maxillary
sinuses

B
C
MRI (Magnetic Resonance Imaging)
 A magnetic resonance imaging (MRI) scan of the sinuses creates
detailed pictures of the air-filled spaces inside the skull.
 It is noninvasive process.
 MRI uses powerful magnets and radio waves instead of
radiation. Signals from the magnetic field bounce off your body
and are sent to a computer. There, they are turned into images.
 MRI has several advantages over other diagnostic imaging
procedures.
 First, it offers the best contrast resolution of soft tissues.
Although x ray attenuation coefficients of soft tissues.
 Second, no ionizing radiation is involved with MRI.
 Third, because the region of the body imaged in MRI is
controlled with the gradient coils, direct multiplanar imaging is
possible without reorienting the patient.
Pathology Of Maxillary Sinus
 Inflammatory - Maxillary sinusitis
 Traumatic - Fractured root
-Blow out fracture
- Zygomatic complex fracture
 Calcification -Antrolith
 Cyst -Radicular cyst
-Dentigerous cyst
-Mucous retention cyst
 Tumour -Antral Polyps
-Squamous cell carcinoma
Maxillary Sinusitis
 Sinusitis is a condition involving generalized inflammation of the maxillary sinus
mucosa caused by an allergen, bacteria, or a virus.
 Inflammatory changes may lead to ciliary dysfunction and retention of sinus secretions.
 Clinical Features
- Acute maxillary sinusitis is often a complication of the common cold, which is
accompanied by a clear nasal discharge or pharyngeal drainage.
-patient may complain of pain and tenderness to pressure or swelling over the
involved sinus.
- the key signs and symptoms are those of sepsis: fever, chills, malaise, and an
elevated leukocyte count.
-Acute sinusitis is the most common of the sinus conditions that cause pain.
 - Chronic maxillary sinusitis is typically a sequela of an acute infection
that fails to resolve by 3 months.
-Chronic sinusitis is often associated with anatomic derangements including
deviation of the nasal septum and the presence of concha bullosa (pneumatization
of the middle concha) that inhibit the outflow of mucus.
 Radiographic Features
-The most common radiopaque patterns that occur in the Waters view
are localized mucosal thickening along the sinus floor, generalized thickening of
the mucosal lining around the entire wall of the sinus, and near-complete or
complete radiopacification of the sinus
-It may cause blockage of the ostium.
-The image of thickened sinus mucosa on the radiograph may be
uniform or polypoid.

A
 -Chronic sinusitis may result in persistent
radiopacification of the sinus with sclerosis and thickening of the
sinus wall .
 Management
-The goals of treatment of sinusitis are to control the
infection, promote drainage, and relieve pain
- treated medically with decongestants to reduce
mucosal swelling and with antibiotics in the case of a bacterial
sinusitis.

Axial cone-beam CT images show

peripheral bony thickening of the left
maxillary sinus from chronic sinusitis.
Fractured Root
 A root tip of the maxillary first molar accidentally
pushed into the sinus at the time of tooth extraction.
 Removal of root tip can be done through the tooth
socket or through the canine fossa by Caldwell luc
approach.
Antrolith
 Antroliths are the calcified masses found in the maxillary sinus.
 The smaller antroliths are usually asymptomatic and usually are discovered as
incidental findings on radiographic examination.
 If continues to grow the patient may have associated sinusitis, bloodstained nasal
discharge, nasal obstruction, or facial pain.
Radicular Cyst
 Synonyms
-Periapical cyst, apical periodontal cyst, and dental cyst
 A radicular cyst is a cyst that most likely results when rests of epithelial cells
(Malassez) in the periodontal ligament are stimulated to proliferate and undergo cystic
degeneration by inflammatory products from a nonvital tooth.
 Clinical Features
-Radicular cysts are the most common type of cyst in the jaws.
-Incidence of radicular cysts is greater in the third to sixth decades and shows a
slight male predominance.
-Radicular cysts produce no symptoms unless secondary infection occurs.
-On palpation the swelling may feel bony and hard if the cortex is intact, crepitant
as the bone thins, and rubbery and fluctuant if the outer cortex is lost.
 Radiographic Features
- In most cases the epicenter of a radicular cyst is
located approximately at the apex of a nonvital tooth
-Most radicular cysts (60%) are found in the
maxilla, especially around incisors and canines.
Because of the distal inclination of the root, cysts that
arise from the maxillary lateral incisor may invaginate
the antrum.
-the internal structure of radicular cysts is radiolucent.
 The cyst may invaginate the antrum, but there the epicenter is apical to the lateral
should be evidence of a cortical boundary between incisor and the presence of a
the contents of the cyst and the internal structure peripheral cortex (arrows)
of the antrum .
A coronal cone beam CT image of a radicular
cyst related to the buccal root of a maxillary
molar.
Note the circular shape of the cyst as it
invaginates the maxillary sinus
Dentigerous Cyst
 Synonym
Follicular cyst
 A dentigerous cyst is a cyst that forms around the crown of an unerupted tooth. It begins
when fluid accumulates in the layers of reduced enamel epithelium or between the
epithelium and the crown of the unerupted tooth
 Clinical Features
- Dentigerous cysts are the second most common type of cyst in the jaws.
- They develop around the crown of an unerupted or supernumerary tooth.
-The patient typically has no pain or discomfort.
- The clinical examination reveals a missing tooth or teeth and possibly a hard swelling,
occasionally resulting in facial asymmetry
 Radiographic Features
 The epicenter of a dentigerous cyst is found just above the crown of
the involved tooth, most commonly the mandibular or maxillary
third molar or the maxillary canine
 An important diagnostic point is that this cyst attaches at the
cementoenamel junction
 Cysts related to maxillary third molars often grow into the maxillary
antrum and may become quite large before they are discovered.
 Dentigerous cysts typically have a well defined cortex with a curved
or circular outline.
 The internal aspect is completely radiolucent except for the crown of
the involved tooth
 The floor of the maxillary antrum may be displaced as the cyst
invaginates the antrum

Axial (1) and coronal (2)CT images with bone algorithm reveal
a maxillary third molar displaced into the space occupied by the
maxillary antrum; note the presence of a cortex
between the cyst and the antrum.
 Management
-Dentigerous cysts are treated by surgical removal, which
may include the tooth as well.
-Large cysts may be treated by marsupialization before
removal.
Mucous Retention Cyst
 Synonyms
Antral pseudocyst, benign mucous cyst, mucous retention pseudocyst, mesothelial cyst, pseudocyst,
interstitial cyst, lymphangiectatic cyst, false cyst, retention cyst of the maxillary sinus,mucosal antral cyst.
 The term Mucous retention cyst is used to describe several related conditions.
 One etiology suggests that blockage of the secretory ducts of seromucous glands in the sinus mucosa
may result in a pathologic submucosal accumulation of secretions, resulting in swelling of the tissue.
 Clinical Features
* Retention pseudocysts may be found in any of the sinuses at any time of the year but
occur more often in the early spring or fall.
* more common in males
*The maxillary sinus is the most common site of Mucous retention cysts,
*The retention pseudocyst rarely causes any signs or symptoms, and thus the patient is
usually unaware of the lesion
 when the pseudocyst completely fills the maxillary sinus
cavity, it may prolapse (extrude) through the ostium and cause nasal
obstruction and postnasal discharge.
 Radiographic Features
* Partial images of retention pseudocysts of the maxillary
antrum may appear on maxillary posterior periapical radiographs,
but they are best demonstrated in extraoral radiographs
* pseudocysts may occur bilaterally, usually only a single
pseudocyst develops. Occasionally more than one pseudocyst may
form in a single sinus
*Cyst usually form on the floor of the sinus , although some
may form on the lateral walls or the roof
* pseudocysts may vary in size from that of a fingertip to
completely filling the sinus and making it radiopaque.

The non-corticated, dome-shaped

retention pseudocyst imaged on
periapical (1) , panoramic (2)
 Periphery and Shape Retention pseudocysts usually
appear as well-defined, non-corticated, smooth, dome-
shaped radiopaque masses.
 Because the lesion originates within the sinus, no osseous
border surrounds
 Internal Structure internal aspect is homogeneous and
more radiopaque than the surrounding air of the sinus
cavity
 Effects on Surrounding Structures. There are no effects
on the surrounding structures, and thus it is of note that the
sinus floor isintact
 Management Retention pseudocysts in the maxillary
sinus usually require no treatment because they
customarily resolve spontaneously without any residual
effect on the antral mucosa.
reconstructed panoramic (1), and coronal (2) cone-beam CT images. Retention
pseudocysts have non-corticated borders, indicating that they arise from within
the sinus.
Antral Polyps
 The thickened mucous membrane of a chronically
inflamed sinus frequently forms into irregular folds called
polyps.
 The thickened mucous membrane of a chronically
inflamed sinus frequently forms into irregular folds called
polyps.
 Clinical Features
 Polyps may cause displacement or destruction of bone.
 Radiographic Features
 on a radiograph by noting that a polyp usually occurs with
a thickened mucous membrane lining because the
polypoid mass is no more than an accentuation of the Red arrow show antral polyp on
mucosal thickening. roof of sinus
 The radiographic image of the bone displacement or
destruction associated with polyps may mimic a benign or
malignant neoplasm
Squamous Cell Carcinoma
 Squamous cell carcinoma likely originates from metaplastic epithelium of the sinus
mucosal lining.
 The most common symptoms of cancer in the maxillary sinus are facial pain or
swelling, nasal obstruction, and a lesion in the oral cavity.
 mean age of the patient is 60 years (range, 25 to 89 years).
 The symptoms produced by malignant neoplasms in the maxillary sinus depend on
which wall(s) of the sinus is/are involved.
 Medial wall is usually the first to become eroded, leading to such nasal signs and
symptoms as obstruction, discharge, bleeding, and pain.
 Lesions that arise on the floor of the sinus may first produce dental signs and
symptoms, including expansion of the alveolar process, unexplained pain and altered
sensation of the teeth, loose teeth, swelling of the palate or alveolar ridge, and ill-fitting
dentures.
 When the lesion penetrates the lateral wall, facial and
vestibular swelling becomes apparent and the patient may
complain of pain and hyperesthesia of the maxillary teeth.
 If Involvement of the sinus roof and the floor of the orbit
cause signs and symptoms related to the eye: diplopia,
proptosis, pain, and hyperesthesia or anesthesia and pain
over the cheek and upper teeth.
 Invasion and penetration of the posterior wall lead to
invasion of the muscles of mastication, causing painful
trismus, obstruction of the eustachian tube causing a stuffy
ear, and referred pain and hyperesthesia over the
distribution of the second and third divisions of the fifth
nerve.
 Radiographic Features
*Sometimes the radiographic findings, especially in early malignant
disease of the paranasal sinuses, are nonspecific.
 Internal Structure.
* The internal aspect of the maxillary sinus has a soft tissue radiopaque
appearance.
 Effects on Surrounding Structures.
* As the lesion enlarges, it may destroy sinus walls and in general, cause
irregular radiolucent areas in the surrounding bone.
* Frequently the medial wall of the maxillary sinus is thinned or destroyed
 Management :
Treatment of squamous cell carcinoma in the paranasal sinuses generally
combines surgery and radiation therapy.
It have a poor prognosis
1, This panoramic image of a squamous
cell carcinoma shows a loss of definition of
the cortex of the left maxillary sinus, nasal
floor, and alveolar crest.

2, The Waters view of the same

patient shows a similar loss of cortical
integrity to the lateral wall of the left maxilla
and radiopacification
of the left maxillary sinus.
1 This axial bone algorithm CT image of a
squamous
cell carcinoma of the left maxillary sinus
shows destruction of the posterolateral
wall and the medial wall of the sinus.

2 The same axial

image slice with soft tissue algorithm
demonstrates extension of the
malignant tumor into the surrounding soft
tissues (arrows).
REFERENCES
 STUART C. WHITE AND MICHAEL J. PHAROAH 6TH EDITION
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