MAXILLARY SINUS

INTROUDCTION
Growth of max. sinus
Mucosa lining
CLINICAL EXAMINATION OF THE MAXILLARY
SINUS
Inspection:
Inspection of adjacent and overlying tissues should include
evaluation of the cheek, vestibule, palate and abnormalities in the
neighboring structures in the orbit.
Palpation and Percussion:
Both the left and the right side should be examined simultaneously
to compare the findings
Investigations
Rhinoscopy:

Vestibule of the nose, nasal septum, lateral

wall of nose is examined

Posterior rhinoscopy is also accomplished with a post nasal mirror.

Nasal Endoscopy:

rigid fibro optic instruments provide information about

areas not well visualized by rhinoscopy.
advantage :improved visualization of the intra nasal
structures

Sinus Endoscopy:
indicated suspicion of intra sinus
pathologic condition.
 Aspiration:

Indications:-

• sinusitis that are

unresponsive to multiple
course of antibiotic

• severe unremitting pain or

an orbital or intra-cranial
complication of sinusitis.
Transillumination:

The involved sinus shows

decreased transmission of
light secondary to the
accumulation of fluid,
debris, and pus and the
thickening of the sinus
mucosa.

Most commonly used as a

screening tool
 RADIOGRAPHIC EXAMINATION OF THE
MAXILLARY SINUS
Extraoral views
Occipito mental
Lateral skull
Submento vertex
Linear tomography
OPG
CAT
Intra oral views
Occlusal
Peri apical
CALDWELL VIEW OF SINUS

WATERS VIEW
LATERAL SINUS & SKULL

AXIAL VIEW OF 3D CT SCAN.

FINDINGS

Normal antrum
Radiolucent
Outlined by cortical bone

Waters' view of the sinuses showing

partial opacification of the right
maxillary sinus, with an air-fluid level
Sinusitis can be diagnosed regardless of symptomatic criteria if pus is noted
in the middle meatus
Nasal endoscopy can detect mucosal inflammation, edema, polyposis, fungal
ball.
 Maxillary Sinusitis
• Sinusitis is a condition involving inflammation of
paranasal sinus mucosa, the term is usually restricted to
conditions that are primarily inflammatory,

• ROBERT S.JULIAN, D.D.S,M.D (ORAL &

MAXILLOFACIAL SURGERY CLINICS OF
NORTH AMERICA FEB 1999 ,VOLUME 11,
NUMBER 1)
ODONTOGENIC INFECTIONS OF THE MAXILLARY
SINUS
• Pathophysiology
Viral infection, Allergy

Mucosal Swelling

Blockage of drainage in Ostomeatal complex

Mucotasis

Bacterial Invasion & Over growth

Inflammation of sinus mucosa due to infection.

 CLASSIFICATION OF SINUSITIS
1. Clinical
• Acute Sinusitis
• Chronic Sinusitis
• Nosocomial Sinusitis
• Odontogenic Sinusitis
• Immunocompromise Sinusitis
• Cystic fibrosis Sinusitis

2. Based on duration (American association of otolaryngology & Head & neck

Surgery)
• Acute sinusitis < 4wks
• Subacute sinusitis 4 – 12wks
• Chronic sinusitis > 12wks
Etiology

• Infection
• Trauma
• Allergy
• Neoplasm
• infected cysts
• Oro – antral communication and fistula
• Displaced tooth or root
• Blockage of the ostium of the maxillary sinus
 SIGN & SYMPTOMS OF ACUTE SINUSITIS
Symptoms-
•Heavy feeling in the head.
•Constant throbbing pain in the
upper part of cheek.
•Maxillary teeth in relationpainful.
•Unilateral foul nasal discharge.
•Unilateral nasal obstruction.
Signs-
Extraoral examination:
•Tenderness over the cheeks.
•Anesthesia of the cheek.
•Severe infection
•swelling of the cheek.
Intraoral examination:
• Existence of oroantral fistula.
• Fetor oris.
• Discharge of pus into mouth.
• Sensitivity of maxillary teeth on
percussion.
MANAGEMENT
• Classic antral regimen (for 5 to 7 days)
– Bed rest
– Plenty of fluids
– Maintenance of oral hygiene

• Antimicrobials
– Macrolides- erythromycin 250-500 mg Q6h X 5 days
– Broad spectrum-amoxycillin 250-500 mg Q8h X 5 days.

• Decongestants : nasal drops or spray

– Ephedrine sulphate 0.5% - 1% in NS Q6h
– Xylometazoline hydrochloride o.1%

• Mucolytic agents
– Volatile oil preparations – Tinc of benzoin, camphor, menthol
etc or simple steam inhalation Q4h
• NSAID – aspirin, paracetamol, ibuprofen
 MICROBIOLOGY
The bacteria most commonly involved in acute sinusitis are part
of the normal nasal flora.
1. Streptococcus pneumoniae (30-40%),
2. Haemophilus influenzae (20-30 %),
3. and Moraxella catarrhalis (12-20%)

4. Viruses are the most common triggers of acute sinusitis.

Rhinovirus,
influenza viruses,
and parainfluenza viruses are the primary pathogens in 3-15% of
cases of acute sinusitis.
 SURGICAL MANAGEMENT
• Sinus puncture and irrigation techniques --means of removal of
thick purulent sinus secretions.(obtain culture guide antibiotic
selection if empiric therapy has failed or antibiotic choice is limited)

• sinus drainage used when medical therapy has failed in

infection control
 SURGICAL MANAGEMENT
CANINE FOSSA PUNCTURE
•Placement of a straight
trocar through the mucosa
and bone.

•Advance the trocar until the

sinus mucosa is penetrated.
 SUB-ACUTE MAXILLARY SINUSITIS

 asymptomatic with acute congestion such as pain and

generalized toxaemia.
 Discharge is persistent and is associated with the
nasal voice and stiffness.
 Throat soreness
 The patient can not sleep well (irritating cough often keep
him awake)
 TREAMENT
 control of infection and removal of the causative factor.
 maintain a good oral hygiene
 antibiotics, (according to the culture and sensitivity)
analgesics, antihistamines ,nasal decongestant epthidrine
spray.
 Steam inhalation
 Exploration and lavage of the antrum (with the help of
trocar and cannula)
 Extraction of the offending tooth
 Any exploratory procedures such as removal of the tooth,
root, polyp, cysts, tumour
 CHRONIC MAXILLARY SINUSITIS:

ETIOLOGY:
(1) Repeated attacks of acute antritis or a single attack
that has a persisted to a chronic state.
(2) Neglected or over looked dental focus.
(3) Chronic infection in the frontal and ethmoidal sinus
(4) Altered metabolism
(5) Allergies
(6) Endocrine imbalances
 Symptoms

• Discolored nasal drainage from the nasal passages,

• nasal polyps, or polypoid swelling (examined
using: anterior rhinoscopy or nasal endoscopy)
• Edema or erythema of the middle meatus

• Transillumination-
Reveals radiopacity on the affected side
Imaging modalities:-

To confirm the diagnosis :

•CT scanning (demonstrates isolated or diffuse mucosal

thickening, bone changes, or air-fluid levels) OR
•Plain sinus radiography (revealing air-fluid levels or
greater than 5 mm of opacification of one or more
sinuses)
Management-
•Medical therapy-- first-line  3-6 week course of
--oral antibiotics (eg, fluoroquinolone or macrolide, a broad-
spectrum penicillin class drug with beta lactamase inhibitor),
--steroids, and
--nasal saline irrigations

•Antral polypsremoved.
•Antral air space  irrigated.
•post-operative instructions.
•If chronic sinusitis non responsive to other treatment surgical
drain
SURGICAL MANAGEMENT
• Surgical therapy decisions:-
- History
- physical examination findings
- CT

Three main surgical options are available:-

(1) endoscopic uncinectomy with or without maxillary
antrostomy,
(2) Caldwell-Luc procedure, and
(3) inferior antrostomy (naso-antral window).
 SURGICAL MANAGEMENT
• Caldwell-Luc procedure Caldwell in 1893
Def:-- Henri luc in1897
The direct visual examination of the maxillary antrum is best
made by cutting a window in the antero lateral wall of the
maxillary antrum and this approach is called Cald–Well Luc.
INDICATIONS:

(1) Removal of tooth or root from the antrum that has been
pushed up during course of extraction.
(2) Removal of foreign bodies like antrolith from the sinus.
(3) Chronic maxillary sinusitis where the removal of the lining
of the antrum is desired.
(4) For removal of any benign growth from the maxillary
sinus.
(5) For control of any active haemorrhage
SURGICAL MANAGEMENT
• Caldwell-Luc procedure
Caldwell-Luc procedure Complications

•Oro-antral fistula
•infraorbital nerve injury with associated hypesthesia
• injury to the tooth roots
 PREDISPOSING FACTORS

1) Proximity of the tooth t0 the antrum during to Extraction of teeth

2) Tooth with hypercementosis
3) Root anomaly
4) Destruction of the floor of the sinus by periapical lesions.
5) Perforation of the floor of the sinus and membrane with injudious use of
instruments
6) Antral extention to the alveolus; sometimes in to the tuberosity area.
5) Any cyst and tumours associated with the tooth with periapical bone
loss
6) Extensive trauma to the face
7) Surgery of the maxillary sinus
8) Infected implant denture
9) Malignant diseases
 SYMPTOMS
• Established oro-antral
• Fresh oro-antral fistula
communication – Pain
– Escape of fluids from – Persistent purulent nasal
mouth to nose discharge
– Epistaxis unilaterally – Post nasal drip
– Escape of air from – Popping out of antral
polyp
mouth into nose
– Possible sequelae of
– Enhanced column of general systemmic
air symptoms
– Excruciating pain • 5P
• 5E
• Diagnosis :-
– appearance of the thin,
smooth, curved plate of
bone attached to the roots
of the extracted tooth.
– Large fistula (inspection )
– Nose blowing test
– Escaping air bubbles, blood,
pus at the oral orifice
– Cotton-wisp test
• Need for closure
– To protect from
oral microbial flora
– To prevent escape
of fluid across
– To eliminate
existing antral
pathology
SIGNS OBSERVED WHEN FISTULA HAS BEEN
PRESENT FOR CONSIDERABLE PERIOD OF TIME:

• Sinusitis
• Foul smell
• Tenderness to pressure over maxilla
• Percussion of premolar and molar on infected site elicit
pain
• Flushing of the cheek with edema of infraorbital soft
tissue
• presence of pus in middle meatus
 TREATMENT OF OROANTRAL FISTULA

 immediately (when the opening is created)

later (long-standing fistula or failure of an
attempted primary closure)
 IMMEDIATE TREATMENT

This includes:-
Pack
denture plate

The ideal treatment -- is to perform an immediate

surgical repair so that primary closure can be
combined with antibiotic prophylaxis to prevent
sinus infection.
 DELAYED TREATMENT

• If an OAF seen after a period of 24 hrs-- the soft tissue

margins often get infected (preferable to defer the treatment
till the gingival edges shows sound healing).

• If purulent discharge -- sinus irrigated with NS

• Prophylactic/supportive treatment : antibiotic & local

decongestants & analgesics
 PRECAUTIONS

These include
-opening the mouth while sneezing,
- not sucking on a straw or cigarettes,
- avoiding nose-blowing.
use nasal precautions for 10 to 14 days.
Surgical closure of oroantral fistula
• Local flaps
– Buccal flap
• Straight advancement
• Sliding
• Transverse flap
– Palatal flap
• Straight advancement
• Rotational flap
• Hinged
• Island flap
– Combined local flap
 LOCAL FLAPS
Von Rehrmann Buccal advancement flap
Moczair Buccal sliding flap
 Palatal pedicle flap method
This is one of the major treatment modality in
closing the oroantral fistula
A– Hard and soft tissues surrounding the fistula are freshened
B – A Mucoperiosteal flap is raised with the artery.
C – The flap is swung over the defect
 COMBINED FLAPS

Hinged flap Hinged & palatal rotational

advancement flap
DISTANT FLAP-TONGUE FLAP
TEMPORALIS FLAP
Buccal pad of Fat
 Another Methods

 Another method of closure is disoribed by Proctor.

cone shaped cartilage in to the defect.

Autogenous bone disks have been advocated like Gold

foil, gold disks 24 – Karat ,Gold plate have been used
most successfully.
• Hydroxyapatite blocks
• Fibrin glues
Supportive measures
• Avoid movements which stretch the cheek or blowing
activities or forceful mouth rinsing

•Antibiotics

• Steal inhalation – benzoin/ menthol 6 th hrly

 Causes of failure

(1)Incomplete elimination of all infection from the antral

cavity prior to closure

(2) Systemic condition- . Eg: diabetes, syphillis, TB – adversely

affect the healing

(3) too much tension while closure.

 Intranasal Antrostomy
Procedure:
The window is enlarged in all directions until a diameter of at least 2 cm is
obtained at the narrow point.
 FESS
• intra nasal endoscopic technique -
Indications
1)Recurrent sinusitis with
2)Chronic hyperplastic sinusitis with obstructive nasal polyps
3)Fungal sinusitis
4)neoplasm
DISPLACEMENT OF TOOTH OR ROOT
• common complication.
Commonly – 1st molar ( almost 80%)
2nd molar (20%) and sometimes 3rd
molar, premolar and rarely canines.

Palatal Roots-
First maneuver- place pt upright
position.
-Location must be determined.
1. The first consideration whether buccal displacement,(determined by
manual palpation).

2. Next -determine antral perforation, (by nose blow test, water test).

3. radiograph locate the position of root tip.

4. Once it is determined in the sinus

-Gently place the suction tip in the socket.
- Sinus can be irrigated with a sterile saline solution and suction applied.

5. Another tech.- packing a long strip of 0.5 inch iodoform gauze into the
antrum through the socket and then pulling it out in one stroke.

6. If the root tip cannot be removed by suction and irrigation Caldwell- luc
procedure
 INVOLVEMENT IN TRAUMA
• Zygomatic complex fracture
• Lefort I, II and III

•Orbital floor fracture – blow

out type.
• Periorbital fat herniates
into the sinus.
• “Hanging drop sign” in
PNS or Water’s view
 MAXILLARY ANTROLITHIASIS
• Exogenous – snuff, paper
• Endogenous – root tip, fragment of bone, soft tissue, blood,
mucus.

• Asymptomatic or pain, nasal obstruction,

epistaxis, sinusitis.

• Investigation:
• Radiographs – opaque mass
• Treatment – surgical removal
 MUCOCELE OF MAX. SINUS
• Involvement of mucous glands in
the lining of the max. sinus

• Asymptomatic ,occasional
discomfort in the cheek, toothache
 BENIGN LESIONS
CYSTS TUMORS
Intrinsic origin Intrinsic origin
Mucus retention cyst Squamous papilloma
Mucocele Inverted papilloma
Cholesteatoma Juvenile angiofibroma
Pseudocyst Vascular lesions
Giant cell tumor
Extrinsic Origin
Odontogenic keratocyst Extrinsic origin
Dentigerous cyst Ameloblastoma
Radicular cyst OAT
Calcifying odontogenic Odontoma
cyst Odontogenic myxoma
 MALIGNANT LESIONS
Risk factors:
- Upper respiratory cancer - exposure to nickel (approx 250
times)
-furniture& shoe-making industries - adenocarcinomas
First clinical sign swelling
of the maxillary alveolar ridge.
Medial spread into nose –
epistaxis
Superior spread into orbit –
diplopia, proptosis
Posterior spread via the
pterygoid region into the
infra temporal fossa –
trismus
Anterior spread into the
cheek – swelling, and
anesthesia of the infra
orbital nerve
 TUMOURS INVADING THE SINUS
Ohngren’s line
Infrastructure – Anterior and Inferior

Supra Structure – Posterior and Superior

SURGICAL APPROACHES :-

Caldwell- luc
FESS
Lateral rhinotomy and medial maxillectomy
Weber- fergussion approach for maxillectomy
Radiation therapy
Chemotherapy
combined therapy
Weber –Fergusson approach for maxillectomy
Indication:
Aggressive odontogenic cysts and tumors as well as a variety
of malignant conditions
 Sinus lift procedure

Posterior Maxillary Height

Deficiencies while placing
implants
Direct or indirect method
Osteotomes used to
infracture of the antral floor
Bone Grafts