Diseases of paranasal

sinuses

By – Mayur Pawar
Normal Development & Variations
They are 4 in number:
 1- Frontal
 2-Ethmoid
 3- Sphenoid
 4- Maxillary Sinus
1- Frontal Sinus
 Development – Frontal bone at birth
– Age 5 or 6y.
 Structure – Two cavities develop separately and meet at
midline with a septum.
– They drain into nasal fossa via frontonasal duct.
– Walls • Anterior vs. posterior
 Related Structures – Frontal recess
2- Sphenoid Sinus
 Development Arise within the nasal capsule
(no pouch) Age 3 begins to pneumatize
 Structure – Volume/variable pneumatization –
Wall thickness
– Position within the sphenoid
• Relation to sella turcica
• Sellar and postsellar relationships
3-Ethmoid Sinus (Ethmoid air cells)

 Development – Present at birth – Multiple

connected or separated chambers. –
Variability

 Structure – Volume/shape – Roof –

Lateral wall
 Maxillary Sinus
 Development – Present at birth as slit like.
– It grows laterally as it reach infraorbital canal by 2nd year.
– It may extend to zygomatic , alveolar or frontal – Biphasic growth
– Level of the floor

 Structure – Volume & shape

– Walls, floor, roof
Function of Paranasal Sinuses:

 Humidifying and warming inspired air

 Regulation of intranasal pressure
 Increasing surface area for olfaction
 Lightening the skull
 Resonance
 Absorbing shock
 Contribute to facial growth
Diseases associated with maxillary
sinuses

 1- Intrinsic diseases ; from within maxillary sinus.

2- Extrinsic diseases

 Clinical features:
• Feeling of pressure.
• Pain on head movements.
• Altered voice characteristics.
• Regional paresthesia.
• Swelling of facial structures.
Diagnostic imaging

1- intraoral periapical
2- Panoramic view
3- Occipitomental (Water’s view)
4- Lateral
5- Submentovertex
6-Caldwell (15ºPA)
7- computed tomography (CT)
8- Magnetic resonance image (MRI)
 I-Intrinsic diseases
 Inflammatory diseases
1- Mucositis: • Normal sinus mucosa (1mm) Is
not visualized on radiographs. During
inflammation it becomes thick 10-15 times
and seen in radiographs. Mucosal thickening >
3mm is pathologic.
• Clinically asymptomatic.
• Radiographic feature→ slight radiopaque
band parallel to sinus walls.
2- Sinusitis

 Generalized inflammation of paranasal

sinus mucosa.
 • Etiology :allergic, viral, bacterial
 Classification:
• Acute sinusitis→< 2 weeks.
• Subacute sinusitis→ 2 weeks -3 months.
• Chronic sinusitis→ > 3 months.
• Pansinusitis→ sinusitis in all paranasal
sinuses.
 Clinical features

 Acute sinusitis:→ nasal discharge , pain ,

tenderness to pressure or swelling. Sepsis, fever,
malaise & elevated leukocyte count.

 Chronic sinusitis → a sequel of acute infection.

There is inhibition of mucous outflow & there may
be deviation of nasal septum & concha bullosa.
It may be associated with allergic rhinitis,
asthma, cystic fibrosis and dental infection.
Radiographic features

 Uniform or polypoid Thickening of sinus mucosa

with accumulation of secretions inside sinus
turning it‘s air radiolucency to radiopaque .

 Water’s view showing the level of fluid and

tilting of the head taking another view it shows
changing in fluid level.

 Management: • Decongestants , antibiotics or

surgery.
3- retention pseudocysts

 They may be due to:

1- blockage of secretory ducts leading to submucous
secretion accumulation.
2- cystic degeneration due to inflammation .

 Clinical features: Asymptomatic.

It may fill the sinus causing nasal obstruction.
It may be ruptured due to change in pressure.
 Radiographic features
 Location: Single side or bilaterally.
• Best seen in panoramic view.
• It may arise from floor of sinus or lateral walls.
• More than one pseudocysts may develop.
• They may fill the sinus space and becomes radiopaque.

 Periphery and shapes: non- corticated smooth, dome-

shaped radiopaque masses.

 Effect on surrounding structures: no effect. No

treatment is required.
 4- polyps

 It is thickened mucous membrane of chronically inflamed

sinus with irregular folds called polyps.
 Clinical features: it may destroy bone.
 Radiographic features:
• Polyp usually occurs with thickened mucous membrane
lining.
• It may cause bone displacement or lining that mimic benign
or malignant neoplasm
 5- Antrolith

 It is deposition of mineral salts such as calcium phosphate ,

carbonate & magnesium a round a nidus which may be extrinsic or
intrinsic.

 Clinical features:
• small→ asymptomatic.
• Large → sinusitis , nasal obstruction or facial pain.
Radiographic Features

 Location: within maxillary sinus.

 Periphery and shape: well defined

radiopaque mass smoother irregular.

 Internal structure: Radiopaque mass

which can be distinguished from root
fragment by anatomy of root and pulp
canals.
6- Mucocele

 Definition : it is expanding destructive lesion that result

from blocked sinus ostium due to intrinsic or extrinsic
inflammation, polyp or neoplasm.
• Accumulation of mucous leads to transforming whole
max.s. to cyst like cavity which may destruct the antral
walls.

 Infected mucocele → Pyocele or mucopyocele.

Clinical features

 It exert pressure on superior alveolar nerves→ radiating

pain.
 Swelling →anteroinferior aspect of Max. s.
 Inferior expansion→ loosening of posterior teeth.
 Medial wall expansion → deformity of lat. Nasal wall →
nasal obstruction.
 Orbital expansion → diplopia, proptosis.
Radiographic features

 Location : 90% in ethmoidal & frontal sinuses and

rare in maxillary sinus.
 Periphery & shape: turns sinus into circular cyst
like shape.
 Internal structure: uniformly radiopaque.
 Effects on surrounding structures: Bony expansion
with wall destruction on the direction of lesion
extension.
 Treatment : Caldwell-Luc operation (surgical
excision.
Neoplasms

 Benign Neoplasms: • 1- Epithelial Papilloma:

 Clinically; unilateral nasal obstruction , nasal discharge,
pain and epistaxis. • 10% incidence of associated
carcinoma.
 Radiographic feature:
• Not specific .
• Diagnosis is confirmed by histopathology.
Radiographic feature

 Location: ethmoidal or maxillary sinus.

• Isolated polyp.

 Internal structure: Homogenous radiopaque mass of

soft tissue density.

 Effectson surrounding structures: Bone destruction

due to pressure erosion.
 2- Osteoma

 Most common in males than females 2:1 .

• 2nd, 3rd & 4th decade.
•Asymptomatic unless cause destruction of
surrounding tissue.
 Radiographic feature:
 Location in frontal and ethmoidal sinuses
more than maxillary sinus.
 Periphery and shape: lobulated or rounded
well defined margins.
 Internal structure: homogenous radiopaque.
Malignant neoplasms

 Squamous cell carcinoma: • It constitutes 90% of cancers

 Clinically : facial pain, swelling , nasal obstruction & a lesion

in the oral cavity.
• Medial wall destruction→ nasal signs & symptoms.
• Floor of the sinus → dental signs & symptoms.
• Lateral wall → facial & vestibular swelling.
• Sinus roof → orbital signs.
• Posterior wall → trismus.
Radiographic features

 Not specific.
Radiopacity of sinus that develop sinusitis & polyp formation.
 Location : frontal & ethmoidal sinus more common than
maxillary sinus.
 Internal structures: soft tissue radiopaque lesion.
 Effects on surrounding structures: destroying sinus walls →
irregular radiolucent areas in surrounding bone. CT and MRI
are superior for soft tissue extension.
 Treatment: Combination therapy (surgery & Radiotherapy). •
Poor prognosis.
Squamous cell carcinoma:
Extrinsic diseases involving the
paranasal sinuses
 A- inflammatory lesions:
1- Localized Mucositis:
• It is a result of inflammatory extension from dental origin
(periodontal or periapical disease) beyond the cortical floor
of the antrum .
• It resolves after treatment of the cause.

 Radiographic features:
• Homogenous radiopaque ribbon- shaped shadow that
follow the contour of sinus floor.
2- Periostitis
 Inflammatory exudate of the dental lesion
diffuse through cortical boundary of sinus so
elevate periosteum lining the sinus
stimulating new bone formation at the root
apex of involved tooth.

 Radiographic feature: • Radiopaque line

(similar to onion skin ) around apex of
infected tooth.
B- Benign odontogenic cysts and tumors
 1- Odontogenic cysts:
• Most extrinsic cysts are radicular cysts, dentigerous then
odontogenic keratocyst.
• They originate outside of sinus . The cortical border of the
cyst is distinguished from cortical border of the sinus floor .
• Cyst will displace the sinus cavity and fill the sinus space
like internal retention pseudocyst which has no radiopaque
line of that of odontogenic cyst.

 Radiographic feature: • A cystic cavity define by

corticated Border. Radiopacity of the cyst differ from that
of sinus..
2- Odontogenic tumors
 Benign odontogenic tumors (BOT) may cause facial deformity, nasal obstruction & displacement
or loosening of teeth.
 The aggressive growth pattern of some tumors as ameloblastomas require aggressive treatment
to limit invasion to the base of the skull.
Radiographic features
 Periphery & shape→ curved, oval or multilocular shape with or without thin cortical
border.
 Internal structure→ coarse or fine septa.
 Effects on surrounding structures → displacement of maxillary sinus .
• Sinus walls may be eroded or thinned with displacement of teeth.
Fibrous dysplasia
 Craniofacial fibrous dysplasia, it is a type of lesion at which
cancellous bone is transformed into fibrous tissue.

 Dysplastic bone may obliterate maxillary sinus and displace

of teeth without root resorption.

 It is more common in children & young adults.

 Radiographic features
 Location: posterior maxilla is most common site.
 Periphery: not well- defined and tend to blend into the
surrounding bone. Displacement of cortical bone but
intact.
 Internal structure: increased degrees of radiopacity
according to stage of lesion.
• Ground glass appearance in extraoral radiographs.
• Orange peel appearance on intraoral views.
 Effects on surrounding structures: • Displacement of
antral walls , elevating orbital floor, obstructing nasal
fossa.
 Traumatic injuries

 Tooth roots may be fractured due to trauma including

iatrogenic causes.
 Clinical features: Displaced roots in the sinus may cause
sinusitis.
 Radiographic features: Location → roots or fragments
located near the floor of the sinus.
 Periphery and shape: No change.
 Internal structure: radiopaque dental fragment + sinusitis.
No effect on surrounding structures.
 Treatment : surgical removal of remaining fragment.
Thank you!!!