Odontogenic Disease of Maxillary Sinus (Study Notes: Oral & Maxillofacial Surgery)

Odontogenic Diseases of Maxillary Sinus | Dr. Sarang S Hotchandani

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ODONTOGENIC DISEASE OF

THE MAXILLARY SINUS EMBRYOLOGY & ANATOMY

Maxillary sinus is the largest air containing space that occupy maxillary bone bilaterally.

It is 1st paranasal sinus to develop.

Its development begins in 3rd month of I.U life as mucosal invagination or pouching of ethmoid infundibula.

Penumatization; it is formation of air cavity in bone.

o Primary Penumatization (initial maxillary sinus development); in this invagination expands into the cartilaginous

nasal capsule.

o Secondary Penumatization; it occurs in 5th month of I.U life, in this, invagination of primary Penumatization expand

into developing maxillary bone.

o After birth, maxillary sinus expands by Penumatization into developing alveolar process and extend anteriorly and

inferiorly from base of skull.

o As the dentition develops, portion of alveolar process of maxillary which is vacated by eruption of teeth, become

pneumatized.

Expansion of maxillary sinus normally stops after eruption of permanent teeth.

o But sometime maxillary sinus pneumatizes further after removal of posterior tooth because of space created after

their loss.

Maxillary sinus is larger in edentulous patient than dentate patients.

Other names of Maxillary sinus; antrum, antrum of Highmore.

ANATOMY OF MAXILLARY SINUS

o It is four sided Pyramid Shaped

Base of Pyramid/medial wall; lateral wall of nose

Apex of pyramid; zygomatic process of maxilla

Roof of sinus; floor of orbit

Posterior wall; extends length of maxilla and dips into the maxillary tuberosity.

o This wall separated maxillary antrum from

infratemporal & pterygopalatine fossa.

Floor of sinus; lateral hard palate & base of alveolar process of

maxilla

Anterior Surface; facial surface of maxilla.

DIMENSIONS OF MAXILLARY SINUS

o Antero – posterior; 34 mm

o Height; 33 mm

o Width; 23 mm

o Volume; 15 – 20 ml

Opening of maxillary sinus (aka ostium) opens into middle

meatus of nasal cavity.

o This opening is present in inferior position at 2/3rd

distance up on the base of sinus.

o So that’s why mucus is drained via the help of cilia

present in sinus against the gravity.

LINING OF MAXILLARY SINUS;

o Lined by respiratory epithelium, mucus secreting,

pseudostratified, ciliated, columnar epithelium.

o Beating of cilia moves the mucus produced by lining

and any foreign material contained into nasal cavity.


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Cilia beat at rate of 1000 strokes per minute & can move mucus up to distance of 6 mm per minute.

FUNCTIONS OF MAXILLARY SINUS

Impart resonance to the voice.

Increase the surface area and lighten the skull.

Moisten and warm the inspired air.

Filter the debris from the inspired air.

Sinuses are located in front of the forebrain, olfactory region, etc. They create “air padding” to provide thermal insulation to

the important tissues.

CLINICAL EXAMINATION OF MAXILLARY SINUS

Extra oral examination:

o Pain and tenderness, swelling over the prominence of cheek bones

Intraoral examination:

o Pain and tenderness, swelling over the maxilla between the canine fossa and the zygomatic buttress.

Trans illumination:

o The affected sinus shows decreased transmission of light; due to accumulation of fluid, debris, pus, and thickening

of the sinus mucosa.

CLINICAL FEATURES ASSOCIATED WITH A HISTORY OF RHINOSINUSITIS

Major Features Minor Features

Facial pain/ pressure Headache

Facial congestion/fullness Maxillary dental pain

Nasal discharge Cough

Post nasal drip Halitosis

Nasal blockage Fatigue

Hyposmia / anosmia (decreased or absence sense of smell) Ear pain,

Fever (acute sinusitis) Fever

Purulence of nasal endoscopy (diagnostic point)

Either two major factors, or one major and two minor, are required for a diagnosis of rhinosinusitis. Purulence on nasal endoscopy is diagnostic. Fever is a major factor only in the acute stage.

RADIOLOGICAL EXAMINATION OF MAXILLARY SINUS

I. Computed tomography (CT)

II. Cone beam CT

III. Magnetic resonance (MR)

IV. Multidirectional (spiral) tomography

V. Panoramic radiography

VI. Intraoral periapical/occlusal radiography

VII. Skull radiography

a. 0° occipitomental (Standard)

i. 37-degree O.M - water’s view

b. True lateral.

Periapical radiograph shows inferior portion of pneumatized maxillary sinus. Sometimes molar roots appear to be protruding

into the sinus because the sinus has been pneumatized around the roots.

RADIOLOGICAL FINDINGS OF NORMAL MAXILLARY ANTRUM

Radiolucent cavity

Well defined, dense, corticated radiopaque margins or walls

Epithelial lining not visible

CAUSES OF COMPLETE OPACITY OF MAXILLARY SINUS


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01) Mucosal hypertrophy

02) Accumulation of fluid or blood

03) Neoplasia

CAUSES OF DISRUPTION OF CORTICAL OUTLINE OF MAXILLARY SINUS

01) Trauma

02) Tumors

03) Surgical procedures

04) Fistula formation

RADIOGRAPHIC FEATURES OF ACUTE SINUSITIS – WATER’S VIEW IS BEST (OCCIPITOMENTAL VIEW – 15

DEGREE)

Effects of Acute Sinusitis

o Thickening of antral mucosa

o Increase in secretion

o Formation of pus

Radiological Features;

o Air fluid level in sinus

o Complete or partial opacification of sinus

o Thickened mucosa

RADIOLOGICAL FEATURES OF CHRONIC SINUSITIS

Radiological Features;

o Total/partial opacity within the antral cavity

o Fluid level – usually in the base of antral cavity with a characteristic meniscus shape

o Round, domed opacity produced by a mucosal polyp

o Occasionally an increase in the bony antral walls

o Typical inflammatory changes if infected teeth are

involved – this may lead to resorption and remodeling

to produce the appearance described as antral halo.

o Evidence of a foreign body (if applicable).


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MAXILLARY SINUSITIS

Sinusitis; inflammation of sinus.

Pansinusits; inflammation of ALL para nasal sinus.

ETIOLOGY OF MAXILLARY SINUSITIS

NON – ODONTOGENIC CAUSES

o on odontogenic infections

Bacterial

Mostly Aerobic

o S. Pneumoniae

o H. Influenza

o Branhamella

catarrhalis

Few Anaerobic

o S. Viridians

o S. aureus

o Enterobacteriaceae

o Porphyromonas

o Prevotella

Fungal

Viral URTI

o Allergic reactions

o Neoplastic disease

o Obstructive nasal disease

ODONTOGENIC CAUSES – 10 – 12 % Cases

o Odontogenic Infections

Anaerobic Bacteria

Anaerobic streptococci

Bacteroids

Enterobacteriaceae

Peptococcus

Etc.

o Acute & chronic periapical disease

o Periodontal disease

o Trauma to dentition

o Surgery in posterior maxilla

Removal of teeth

Alveolectomy

Tuberosity reduction

Sinus lift grafting & implant

placement

Oro antral fistula

TYPES OF MAXILLARY SINUSITIS

01) Acute maxillary sinusitis

02) Chronic maxillary sinusitis

ACUTE MAXILLARY SINUSITIS

SIGNS OF ACUTE MAXILLARY SINUSITIS

Extra Oral Signs

o Tenderness over cheek.

o Mild swelling in severe infection.

INTRA ORAL Signs

o Presence of absence of oro – antral fistula.

o Foul smelling especially when blowing the

nose.

o Discharge of pus in mouth if fistula present.

o Tenderness on percussion of maxillary molars

SYMPTOMS OF ACUTE MAXILLARY SINUSITIS

The onset is usually described by patient as rapidly

developing sense of pressure, pain, fullness or all of

these in the affected sinus.


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Patient may give history of cold 3 – 4 days prior to acute attack.

The discomfort rapidly increases in intensity and may be accompanied by facial swelling, erythema, malaise, fever & drainage

of foul smelling pus.

Heavy feeling in head

Constant throbbing pain in upper part of cheek or entire side of face.

o Pain is exacerbated by bending down.

Pain is more sever in morning & evening.

Maxillary teeth in relation with maxillary sinus on the affected side may be painful.

o Pain in the teeth often precedes pain in the cheek,

Unilateral foul nasal discharge;

o which becomes more profuse with lowering down of head,

Unilateral nasal obstruction on affected side.

o There can be occlusion of ostium of maxillary sinus.

CHRONIC MAXILLARY SINUSITIS

Important causes

o Prolonged antral infection (10 days)

o Trauma, including roots or teeth displaced into the antrum or the formation of an oro-antral communication

o Apical infection associated with an upper posterior tooth (rare).

Diagnosis

o History of repeated attacks of acute maxillary sinusitis

o Long standing nasal discharge

TREATMENT OF MAXILLARY SINUSITIS

Humidification of inspired air to loosen & remove dried secretions from nasal passage & sinus ostium.

Decongestants

o Systemic Decongestants – pseudoephedrine

Tab. Actifed – DM (GSK)

Tab. Actifed – P (GSK)

Syp. Arinac (Abbott)

Tab. Arinac (Abbott)

Tab. Coldrex (Stand Pharma)

Syp. Combinol – DM

Syp. DayCor (Abbott)

Tab. Fexet – D (Getz)

Tab. Fexo – D (Hilton)

Panadol CF

o Topical Nasal Decongestants – 2% ephedrine OR 0.25% phenylephrine

Sudafed Spray

Analgesics for pain

ANTIBIOTICS – Initial Therapy

o Non – Odontogenic Sinusitis

Amoxicillin

Trimethoprim sulfamethoxazole

Bactrim

Septra

Augmentin

Azithromycin

Azomax

Cefuroxime

Zinacef

o Odontogenic Sinusitis

Penicillin

Clindamycin

Metronidazole

If patient fails to respond within 3 days, obtain cultural & sensitivity to choose appropriate antibiotic.

SURGICAL TREATMENT OF SINUSITIS

o Indications


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Acute sinusitis with complication

Chronic sinusitis with medical management

Fungal sinusitis

o Goal of Sinus Surgery

Remove abnormal tissue from within sinus cavity.

Restore normal drainage through ostium

o Method of Sinus Surgery

Caldwell – Luc Procedure

CALDWELL – LUC PROCEDURE

In this technique, the anterior wall of the sinus is accessed in the area of canine fossa through vestibular approach. The sinus is

opened, and abnormal tissue or foreign bodies are removed. The ostium - meatal area is evaluated & opened, or a new opening

for more dependent drainage into nose (termed antrostomy) may be created near the floor of sinus.

SINUS LIFT PROCEDURE

It is pre-prosthetic surgical procedure.

It is used for improving the maxillary alveolar base for implant placement.

In this method, careful elevation of sinus membrane (schneiderian) is performed which will create space into which graft of

bone is placed.

Complications of this Sinus Lift Procedure

o Disruption of sinus membrane

o Contamination of graft or implant by bacteria

o Foreign body rejection response

o Obstruction of sinus ostium by graft fragments or perforated sinus membrane.

Treatment of complications of Sinus Lift Procedure;

o Infection control

o Removal of contaminated or devitalized graft material.

o Antibiotic therapy

o Caldwell – Luc sinus opening.

ANTRAL PSEUDOCYSTS

Antral Pseudocyst

o Result of accumulation of serum (not sinus mucus) under sinus mucosa.

o Caused by inflammation of sinus.

o no clinical consequences.

o No Tx. required.

Sinus Mucocele

o Cystic lesion under sinus epithelium

o Causes;

Surgery on sinus – in this condition Mucocele are known as, “surgical ciliated cysts or Postoperative maxillary

cysts.

Retention Cysts

o Result from blockage of ducts

These all lesions on radiograph appear as; round, faint radio-opacity within sinus.

OROANTRAL COMMUNICATION/FISTULA

it is an epithelized, pathological unnatural communication b/w oral cavity & maxillary sinus.


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PREDISPOSING FACTORS OF OROANTRAL

COMMUNICATIONS

01) removal of maxillary posterior teeth

02) little or no bone b/w roots of teeth & maxillary sinus due to

greater Penumatization – LARGE SINUS

03) Widely divergent/ bulbous roots

04) Elongated Roots

05) Hypercementosis

06) Periodontal disease

07) Faulty extraction techniques

08) Pathology (granuloma, Cysts, Neoplasm)

ETIOLOGY OF OROANTRAL COMMUNICATIONS

Extraction of teeth.

Destruction of the portion of the floor of the sinus by

periapical lesions.

Perforation of the floor of the sinus and sinus

membrane with careless use of instruments.

Forcing a tooth or a root into the sinus during attempted

removal.

Extensive trauma to face.

Surgery of maxillary sinus; removal of large cystic lesions

encroaching on the sinus cavity.

Chronic infection of maxillary sinus, such as

osteomyelitis.

Teratomatous destruction of maxilla, such as gumma

involving palate.

Infected maxillary implant dentures.

Malignant diseases such as malignant granuloma.

SIGN & SYMPTOMS OF OROANTRAL COMMUNICATION

FRESH OROANTRAL COMMUNICATION

REMEMBER 5 “E”

Escape of fluids

o From mouth to the nose on the side of extraction.

o This happens when the patient rinses or gargles the mouth following extraction of a tooth.

Epistaxis (Unilateral)

o It is due to blood in the sinus escaping through ostium into the nostril.

Escape of air

o From mouth into the nose, on sucking, inhaling or drawing on a cigarette, or puffing the cheeks (Inability to blow

cheeks. Passage of air into mouth on sucking).

Enhanced column of air

o Causes alteration in vocal resonance and subsequently change in the voice.

Excruciating pain

o In and around the region of the affected sinus, as the local anesthesia begins to wear off.

IN LATE STAGE; ESTABLISHED OROANTRAL FISTULA

REMEMBER 5 “P”

01) Pain

a. Previously a dominant feature, is now negligible, as the fistula is established, it allows free escape of fluids.

02) Persistent, purulent or mucopurulent, foul, unilateral nasal discharge from the affected nostril

a. especially when head is lowered down.

03) Postnasal drip

a. The trickling of the nasal discharge from the posterior nares, down the pharynx.


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b. The continuous swallowing of the foul mucopurulent discharge may lead to unpleasant taste.

c. This is accompanied by nocturnal cough, hoarseness, ear ache.

04) Possible sequelae of general systemic toxemic condition

a. Fever, malaise, morning anorexia, frontal and parietal headaches and in extreme cases anosmia.

05) Popping out of an antral polyp:

a. The persistent infection in the antrum may lead to establishment of chronic long standing Oroantral fistula, which

may be occluded by an antral polyp.

b. This can be seen as a bluish red lump extruding through the fistula.

DIAGNOSIS

Examination of tooth after extraction;

o May or may not contain bone fragments attached to tooth.

Nose Blowing Test;

o Compression of anterior nares, followed by gentle blowing of nose (with mouth open), causes a rise in intranasal

pressure;

exhibited by the whistling sound as air passes down the open passage.

Escape of air bubbles, blood or pus, etc. may appear at the oral orifice.

A wisp of cotton-wool held just below the alveolar opening will usually be deflected by the air stream.

o However, if there is no communication, forceful blowing like this pose the risk of creating communication. That’s why

this test should be avoided.

Do not explore the recent extraction site with pointed instrument – it can break the clot resulting communication.

MANAGEMENT OF OROANTRAL COMMUNICATION

Treatment of Oroantral Communication depends on size of communication.

If the communication is small (2 mm or less)

o No surgical treatment necessary.

o Take measures for formation of blood clot in the socket.

o Advice Sinus/ nasal Precautions for 10 – 14 days to patient to prevent dislodgment of clot.

If the opening is moderate (2 – 6mm)

o No surgical treatment necessary.

o Take measures to establish clot.

o Figure 8 suture placed over socket to maintain the clot.

o Advice Sinus Precautions to Patient.

o Prescribe Medications

Antibiotics; Amoxicillin, cephalexin or clindamycin

Nasal decongestant spray.

If the sinus opening is large (7 mm or larger).

o Treat Surgically.

SINUS PRECAUTIONS

Avoid blowing the nose.

Avoid sneezing violently.

o Open the mouth while sneezing.

Avoid sucking on straws.

Avoid smoking.

o If cannot, advice patient to take smalls puffs, not deep drags to avoid pressure.


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SURGICAL MANAGEMENT OF OROANTRAL FISTULA

Before closing the Oroantral fistula, it is imperative to eliminate any acute of chronic infection

within sinus by irrigation of fistula & antibiotics.

There are 3 methods of surgical closing the Oroantral fistula with the help of Flap Procedure.

01) Buccal Flap Advancement

02) Palatal Flap Advancement

03) Advancement of Palatal & Facial Flaps over membrane of Alloplastic Material.

BUCCAL FLAP ADVANCEMENT PROCEDURE.

it is most common technique & involves elevating the buccal flap, releasing the periosteum, and extending the flap to cover

the extraction site with sutures.

PALATAL FLAP PROCEDURE

Advantage

o Large amount of tissue can be elevated with sufficient blood supply from palatal vessels.

o The

thickness and keratinized nature of palatal tissue more closely

resemble the crestal ridge tissue than the thinner, less keratinized tissue in the buccal vestibule.

Disadvantage

o Large area of expose bone that results from elevation of flap.

PROCEDURE OF PALATAL FLAP CLOSURE OF OROANTRAL FISTULA.

01) The flap is designed.

a. it should extend forward sufficiently on the palate to allow flap rotation to cover the defect.

b. Great attention during flap construction is required to prevent injury of palatine vessels and resultant hemorrhage.

02) The flap tissue is detached from the palate with the periosteum and it should contain blood vessels.

03) A small V-shaped excision can be made at the area of the greatest bend of the flap to prevent folding and wrinkling at the

base and also to allow easier rotation of the flap.

04) The gingiva on the buccal side of the alveolar process is undermined with a periosteal elevator to facilitate the penetration of

the entire thickness of the mucosa by the suture.

05) The flap is rotated and then advanced to attach to the gingival edge of the buccal side.

06) The flap is then sutured to the gingiva of the buccal side.

07) The donor site forms a deep wound into which a piece of iodoform gauze is tightly packed, to prevent the flap from returning

to its natural location and to relieve the tension on the suture.


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MEMBRANE ASSISTED CLOSURE OF

OROANTRAL COMMUNICATIONS.

In this method, flap from facial & palatal surface

is raised & then defect is covered with alloplastic

material & flaps are sutures over that alloplastic

material.

o The sinus lining & bone heal over the

superior surface of these alloplastic

materials.

o Alloplastic Material; Gold foil, Titanium foil, collagen membrane. (Read Description; Figure 20 – 19).

THE END Written By:

Dr. Sarang Suresh Hotchandani (BDS) Bibi Aseefa Dental College, SMBBMU. Larkana, Sindh, Pakistan. Email: [email protected]

mailto:[email protected]

Odontogenic Disease of Maxillary Sinus (Study Notes: Oral & Maxillofacial Surgery)

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Transcript of Odontogenic Disease of Maxillary Sinus (Study Notes: Oral & Maxillofacial Surgery)