MAXILLARY SINUS

SYNONYMS OF MAXILLARY SINUS

1-ANTRON[GREEK WORD]--CAVE
2-ANRUM OF HIGHMORE----after NATHANEIL HIGHMORE
( ENGLISH PHYSICIAN)

ANATOMY OF THE MAXILLARY SINUS

Largest of the paranasal sinuses

Lies in the ----Maxilla
May extend---Palatine & zygomatic bone

Size of average maxillary sinus

# Anteroposterior (width) -----35.6mm
# Mediolateral-------27mm
#Superoinferior(Height)------37mm

Average volume
4.56 cm3 -----35.21 cm3
Mean volume------ 14.71 cm3 (age 20yr)
SHAPE ----Horizontal Pyramidal shape
I.e. Consist of a base,an apex and four
sides

The growth of
the maxillary
sinus from birth
to adulthood

Maxillary sinus classified into four types

1-Semi-ellipsoid (15%)
2-Paraboloid (30%)
3-Hyperbolic (47%)
4-Cone-shaped(8%)
Thickness of bony wall
average---2-5mm

Shape:
Horizontal pyramidal shape i.e., consist of a base, an apex
and four
sides.
Base nasal cavity
Apex junction of maxillary and zygomatic bone
Superior wall roof of the sinus
Anterior wall facial portion of maxillary bone
Posterolatera wall forms maxillary tuberosity

Medial wall:

Maxillary process

of the inferior nasal conchae

below
Perpendicular palate of the palatine bone behind
Uncinate process of the ethmoid and
descending part of the lacrimal bone
above.

Clinical significance of medial

wall:
It includes:
Sinus ostrium
Hiatus semilunaris
Ethmoidal bulla
Uncinate process
Infundibulum

Superior Wall:
Formsroofofthesinus.
Posterolateral wall:
Itismadeupof
-Zygomaticbone
-Greaterwingofsphenoidbone
Anterior wall:
-ItismadeupofAnterioraspectofmaxilla.

Ohngrens line from the

medial canthus of the eye
to the angle of the
mandible. The
infrastructure of the
maxillary sine lies anterior
to this line and tumors of
this area have a better
prognosis.

FUCNTION OF THE MAXILLARY SINUS:

-Insulation and humidifying and warming of
inspired air.
Shaping the spectral characteristics of human
nasal sounds
Reduction of the weight
Help in absorbing the shock of blows to the
face.

AARTERIAL SUPPLY:
1.Nasal mucosal vasculature
-Arteries of the middle meatus
-Ethmoid arteries
2.Osseous vasculature
-Infraorbital artery
- Facial artery
-Palatine artery

Venous supply:
The medial sinus wall sphenopalatine vein
The other sinus walls pterygomaxillary plexus
Lymphatic drainge:
Via collecting vessels in the middle meatal mucosa
Innervations:
- Nasal mucosal nerves.
- contributions from the lateral posterior superior nasal branches of
maxillary nerve.
- Additional branches from the superior alveolar nerves and
infraorbital nerve.

MAXILLARY SINUSITIS
ETIOLOGY:

Decreased drainage of the sinus ostium leads to

subsequent mucostasis, causes are
1)mucosal swelling from viral infection or allergic
rhinosinusitis,
2)ciliary dysmotility ,
3)Thickened mucus secretions,
4)anatomic abnormalities,
a)concha bullosa
b)DNS
c)paradoxical turbinate
d)malformed uncinate process
5)facial trauma
6)maxillary osteotomies
7)prolonged nasal intubation
8)space occupying lesions such as tumors, cysts,
polyps,

MAXILLARY SINUSITIS

Acute maxillary sinusitis are caused by haemophilus

influenzae, streptococcus pneumoniae, or maraxella
catarrhalis.
chornic sinusitis caused by anaerobic and polymicrobial
and more likely to involve staphylococcus aureus.
odontogenic etiology related with first molar infection
with mucostasis of other cause.
Clinical condition associated with increased incidence of
sinusitis, cystic fibrosis, immune deficiency, kartageners
syndrome, youngs syndrome, samters triad, rhinitis
medicamentosa,
cocaine
abuse,
wegeners
granulomatosis,

MAXILLARY SINUSITIS

DIAGNOSIS:
SYMPTOMS:: maxillary pain, pressure, pain similar to
toothache,
CLINICAL FINDINGS: fever, throat-clearing cough,
purulent rhinorrhea, hyposmia, headache, malaise,
maxillary anterior wall tenderness to percussion,
purulence noted, in cases associated with cellulitis facial
swelling , and erythema seen ,
RADIOGRAPH: waters
maxillary sinus
CT SCAN

view,

fluid

opacification

of

SIGNS AND SYMPTOMS OF ACUTE MAXILLARY

SINUSITIS
SIGNS:

Pain on pressure over the anterior maxillary sinus wall.

Purulent discharge over the inferior nasal turbinate.
Fever
Malaise
Inability to work.

SYMPTOMS

Cheek pain with referral to frontal region.

Increased pain on bending.
Maxillary posterior teeth free like pegs
Hyposomia

MELENS CRITERIA FOR CHRONIC SINUSITIS :

Facial pain nasal congestion or abnormal

secretions remain or reappear during a period of
at least 3 months.
Sinus radiography or sinus endoscopy reveals
persistent localized or generalized mucosal
swelling with or without secretions.
Chronic maxillary sinusitis of rhinogenous origin
that does not heal after conservative treatment.
Chronic maxillary sinusitis of dental origin.

MAXILLARY SINUSITIS

According to American association of otolaryngology - head and

neck surgery, taking into consideration of persistence of
symptoms:

Acute
sinusitis

Less than
4 weeks

Subacute
sinusitis

4-12 weeks

Chronic
sinusitis

More than 12
weeks

MAXILLARY
SINUSITIS

MEDICAL MANAGEMENT OF MAXILLARY SINUSITIS:

(1)Antibiotics
ACUTE:
Amoxacillin
Augmentin (Amoxacillin/clavulanate)
Azithromycin,
erthromycin plus sulfonamide,
cefuroxime,
cefprozil,
cefpodoxime,
doxycycline,
CHRONIC:
Amoxacillin /clavulanate,
Clindamycin,
cephalosporin,
dicloxacillin,

ODONTOGENIC:
Clindamycin,
pencillin and
metrindazole,
amoxicillin/
clavulanate

NOSOCOMIAL:
Ampicillin/sulbactam
cephalosporin,
Culture specific if
possible

MAXILLARY SINUSITIS

(2) Systemic Decongestants

phenylpropanolamine and pseudoephedrine- alpha adregenic
agonists reduce blood flow in the sinonasal mucosa, in the area of
inferior turbinates.

the

(3) Topical Decongestants

Nasal drops or sprays - phenylephrine HCL, or oxymetazoline HCL , vasoconstriction of the sinonasal mucosa, in the area of the inferior
turbinates,When used more pathological rebound occurs rhinitis
medicamentosa
(4) Analgesics
ACUTE: acetaminophen with codeine, hydrocodone, or propoxyphene
CHRONIC: NSAIDs or acetaminophen
(5) Topical Corticosteroids
Used prevention of the rhinosinusitis, in patients with allergic
histamine based mucosal swelling and sinonasal polyposis,

MAXILLARY SINUSITIS
(6) Antihistamines
terfenadine, astemizole, mequitazine, --dry nasal
mucosa, beneficial in the chronic sinusitis with allergic
etiology,
(7) Saline Lavage And Steam Treatments
hot water vapor, vaporizer, sauna, improve sinonasal
rainge and nasal airway patency
(8)Pneumovax
raises the IgG2 response, resist pneumococcal infections,
(9) Hydration
(10) Mucolytics
Guafenesin, and potassium iodide, --liquefy mucus
secretions

MAXILLARY SINUSITIS

SURGICAL MANAGEMENT OF MAXILLARY

SINUSITIS:

INDICATIONS FOR SURGICAL TREATMENT OF

RHINUSINUSITIS

Bilateral extensive and massive obstructive nasal polyposis

with complications,
Complication of adult rhinosinusitis ,
Chronic adult rhinusinusitis with mucocele or mucopolycele
formation,
Invasive fungal adult rhinusinusitis
Diagnosis of a tumor of nasal cavity or paranasal sinuses , and
Cerebrospinal fluid rhinorrhea

MAXILLARY SINUSITIS

(1)Sinus Aspiration And Lavage

(2)Sinus Aspiration And Lavage Maxillary Needle

Sinusotomy Technique
Transcutaneous
approach for maxillary
needle sinusotomy. This
approach is superior to
the transnasal or
transoral approach from
the standpoint of
decreased bacteria
contamination of the
specimen

MAXILLARY SINUSITIS

CALDWELL-LUC SINUSOTOMY:

First described by George Caldwell in USA in 1893 and then Henri Luc
of france in 1897.

IINDICATIONS
Excisionofbiopsyofasuspectedmalignant

tumorofthemaxillarysinus
Mycoticmaxillarysinusitis,
Multipleseptateantrallesions.
Antrochoanalpolyp.

Reduction of orbital and zygomatic fracture,

Closure or oro antral fistula.
Removal of an antral foreign body,tooth or root
Antral revision procedures.
Surgical approach for transantral
sphenoethmoidectomy , orbital decompression,
and pterygomaxillary space surgery,
Management of chronic sinusitis
Enucleation/Marsupilization of cysts
Sinus lift procedures

MAXILLARY SINUSITIS

CALDWELL-LUC SINUSOTO

MAXILLARY SINUSITIS

FUNCTIONAL ENDOSCOPY SINUS SURGERY

(FESS TECHNIQUE)

FESS is classically described as an intranasal endoscopic technique

that allows the establishment of adequate sinus drainge without
a negative impact on sinus mucosal physiology and function.

The ideas of FESS is to stop the sinusitis cycle, which begins with
ostium blockage that leads to chronic sinusitis via stagnated
secretions, tissue inflammation, and bacterial infection.

FESS concentrates on opening the OMC, thereby allowing

adequate ventilation and drainge of the maxillary, anterior and
middle ethmoidal and in most cases, the frontal sinuses.

Kennedy coined the term FESS for surgical procedure that involves
precise resection of inflamed mucosa in the anterior ehtmoidal
cells combined with widening of the natural middle meatal
ostium
of the maxillary sinus, the hiatus semilunaris.

FESS
TECHNIQUE
Rigid endoscopes with various angled lenses of 0 o, 30o & 70oare used. Once
adequate intranasal vasoconstriction has been achieved, the procedure is begun
by removing the unicinate process.

MAXILLARY SINUSITIS

The anterior ethmoid cells including ethmoid bulla, are then opened to intranasal
space using sharp dissection with rongeur under endoscopic vision.

Microdebriders, which are powered rotary shaving devices, also can be used to
resect tissue precisely during such dissection.

Medial wall of the orbit is then identified and this serves as the lateral limit of the
surgical dissection. This area is opened caudally by removing the anterior
ethmoidal cells, including the natural ostium of the maxillary sinus.

The frontal recess may then be approached by proceeding along the ethmoidal
roof from a posterior to anterior direction.

FESS
TECHNIQUE
Such endoscopically assisted surgery allows vision and surgical access to areas that
were

MAXILLARY SINUSITIS

previously only approached externally with procedures such as the external ethmoidectomy, frontal
sinus external sinusotomy, transnasal radical sphenoidectomy and the Cadwell-Luc maxillary
sinustomy.
Minor Complications:
Hemorrhage
Scarring
Hyposmia
Epiphoria
Orbital ecchymosis or emphysema
Dental hypesthesia
Major Complications:
Cerebrospinal fluid rhinorrhea and meningitis
Intracranial injury
Orbital trauma with possible diploplia or visual loss
Even death from carotid artery injury (the internal carotid
artery can be found in the
lateral wall of sphenoid sinus)

MAXILLARY SINUSITIS

COMPLICATIONS OF MAXILARY SINUSITIS:

Facialcellulitis
Orbitalextension
Intracranialextension

OROANTRAL FISTULA

DISPLACED ROOT OR TOOTH INTO THE

SINUS

Displacement of a root tip into the maxillary sinus during

tooth extraction is a relatively common complication.

Although the root of maxillary 2nd molar are closest to the

antral floor followed closely by 1st molar, 3rd molar, 2nd
premolar. The most commonly displaced roots are
those of the 1st molar (80%) with slightly less than 20 % are
2nd molar and the remainder involving the 3 rd
molar and
2nd premolar and rarely the canines.

Displacement of the palatal root exceeds that of the

buccal roots by a ratio of more than 2:1

OROANTRAL FISTULA

DISPLACED ROOT OR TOOTH INTO THE

When a root # during tooth extraction and the tip suddenly disappears
during attempted removal, the first maneuver is to
place the patient in
an upright position so as to avoid having the
fragment become
displaced posteriorly.

Then its location must be determined. The possible location might be:
The root tip may have slipped between the antral wall of the
maxilla and the periosteum.
It may have penetrated the periosteum and become
located
suspended.
Root tip is located in the antrum beneath the intact sinus membrane.
Root tip was forced the membrane and into antrum but still
attached to the socket by the apical periodontal fibres.

OROANTRAL FISTULA

DISPLACED ROOT OR TOOTH INTO THE

Procedure for removal of root tip:

The first consideration is whether this is buccal displacement

Determine antral perforation
Panoramic or periapical radiograph.
If determined that the root tip is within the sinus, the next
step is to place a small suction tip gently in the socket.
It this failed, the sinus can irrigated with a sterile saline
solution and suction applied.
Another technique of root tip removal is that which involve
packing a long strap of 0.5-inch idoform gauze into the
antrum through socket. Then pull it out in single stretch.
If above procedures fail, then direct vision of the sinus
should be used (Caldwell-Luc procedure).

OROANTRAL FISTULA

DISPLACED ROOT OR TOOTH INTO THE

Procedure for removal an entire tooth:

This occur during elevation of an unerupted /

impacted 3rd molar or while extracting a
conically rooted erupted 3rd molar without
properly gripping with forceps.
If the opening is large, an attempt can be
made to grasp the tooth and remove.
If the opening is small, Caldwell-Luc approach
is used to remove

OROANTRAL FISTULA

DISPLACED ROOT OR TOOTH INTO THE

SINUS EXPOSURE AFTER # OF THE

MAXILLARY
TUBEROSITY

Exposure of the maxillary sinus can occur when

tuberosity or # during attempt of removal of the 2 nd or
3rd molar.
Prevention:
1.Preliminary expansion of the socket with either an
elevator or a small osteotome before attempting tooth
extraction and by avoiding excessive distal elevation of
these teeth.
2.When multiple extraction are performed in the molar
region, the 3rd molar should be extracted
1s, because
prior removal of the adjacent teeth
further weakens
the tuberosity and increase the chance of a fracture.

OROANTRAL FISTULA

# OF THE MAXILLARY
TUBEROSITY

Discontinue extraction
If there is only slight mobility of the bone no fixation is necessary
After wire fixation can be accomplished by use of an arch bar, acrylic
splint or an orthodontic appliance. After allowing 4-6 weeks for the
fracture to heal, the toot can be extracted.
If the presence of pain or infection is seen, it required immediate
tooth extraction, despite the fractured tuberosity is not healed
properly
If the teeth cannot be separated from the bone and if extraction is
impractical, the outer segment should be removed. Extreme caution
should be taken to avoid tearing the gingiva and particularly the
antral lining, because this creates an opening into the sinus

MANAGEMENT OF OROANTRAL FISTULA AND

OTHER SINUS RELATED COMPLICATIONS

Some of the commonly encountered

conditions are
1.Displacement of root or tooth into
antrum during tooth extraction.
2.# of the floor of the antrum
3.Oroantral fistula
4.Oroantral communication
5.Foreign bodies in the sinus

OROANTRAL FISTULA

ACUTE OROANTRAL
COMMUNICATIONS

Accidental opening into the maxillary sinus is a common

occurrence during extraction of the posterior maxillary
teeth.
Causes:
1.When the tooth appears project into
antrum and
they are covered by little or no
bone.
2. It may occur when a fractured tip is being
removed with an elevator.
3.When a chronic odontogenic infection has
destroyed the bone between the root and sinus.

OROANTRAL FISTULA

ACUTE OROANTRAL
COMMUNICATIONS

In most instances the perforation is small and blood clot fills

the extraction site and it usually heals such small perforation.
Sutures should be placed when one notices a small opening
and approximate the gingival tissue as closely as possible and
to support blood clot.
It is also recommended that a small piece of absorbable
gelatin sponge be placed in the occlusal third of the socket.
This is advised when the gingival margin cant be
approximated.
Approximation of gingiva can also be done by removal of
small amount of the buccal alveolar processes.

OROANTRAL FISTULA

ACUTE OROANTRAL
COMMUNICATIONS

Postoperative care:
Should not blow the nose for a
week.
To keep the mouth opened while
squeezing.
To avoid vigorous rinsing.
To eat soft diet for several days.

OROANTRAL FISTULA

OROANTRAL
FISTULA

Although most acute oroantral communication heals

spontaneously or after surgical procedure some do
present and result in oroantral fistula.
Causes:
1.When there is infection in the antrum.
2.The defect larger than 5 mm in diameter.
3.The gingival tissues are not approximated.
4.The wound is dehisced.
5.Patient does not follow postoperative instructions.
6.After larger traumatic defect.

7.After surgical removal of cyst or neoplasm that encapsulate

on the sinus.

OROANTRAL FISTULA

Closure of oroantral fistula:

Procedures involved in closing of oroantral
fistula include:
A.Local flap procedures
1.Buccal flaps
2.Palatal flaps
3.Combined flaps
B.Distant flap
C.Bone grafts
D. Alloplastic materials

OROANTRAL FISTULA

Buccal flaps:
The defects can be closed by
a.Advancement flaps
b.Sliding flaps

OROANTRAL FISTULA

Buccal flaps

Advancement flap:
It was first described by Rehsmann and popularized by Berger.

OROANTRAL FISTULA

Buccal flaps

Sliding flap:
Morzari described a trapezoidal sliding buccal flap.
This procedure is suitable when the surgical site is
edentulous.

OROANTRAL FISTULA

Modified buccal advancement flap

Laskin and Robinson described it first

Buccal flaps

OROANTRAL FISTULA

Buccal flaps

Modification for buccal fat pad

A modification of the buccal flap technique that
that allows creation of a buccal fat pad
advancement flap to close the oroantral fistula,
followed by replacement of the buccal flap in
its original position.
But this procedure is more complex operation
that does not seem to make any advantages
than use of the buccal flap alone.

OROANTRAL FISTULA

Palatal flaps:
These includes
a.Straight advancement
b.Rotational advancement
c.Island palatal flap
d.Hinged palatal flap

OROANTRAL FISTULA

Palatal flaps

.
Straight advancement flaps:
Has limited usefulness because the inelastic palatal
tissue reduces its lateral mobility.

OROANTRAL FISTULA

Palatal flaps

Rotational advancement flap:

This has disadvantages like straight advancement flaps.
Kruger suggested V-shaped excision of tissue on the
lesser
curvature to minimize folding the flap.

OROANTRAL FISTULA

submucosal

Palatal flaps

connective tissue flap:

Ito and Hara described elevation of full-thickness palatal

flap followed by creation of a submucosal connective
tissue flap to close the fistula and return of the
remainder of the flap to lower the original donor site.

OROANTRAL FISTULA

Palatal flaps

Island palatal flap:

Hendersen has described the use of a palatal pedicle island

flap.

Because of the mobility of this flap and its excellent blood supply
it
can be used to close larger defect.
James suggested that sectioning the island should be done best
so that the tissue can still be used as a rotational
advancement
flap or rotational to tits original site will cause
injury to its vessels.
Gullane and Arena described a modification of the island flap that
obtains approximation of extra length by feeling the vessels at
the greater palatine foramen.

OROANTRAL FISTULA

Hinged flap:

Palatal flaps

The mucoperiosteum on the palatal aspect of the oroantral

fistula can be used as a hinged flap to close small opening.

OROANTRAL FISTULA

Combined local flaps:

They are
Simple
Transverse
Bipedicled
Buccopalatal flap
These are practiced where there is sufficient large
edentulous surface.

OROANTRAL FISTULA

Combined local flap

The flaps have large new area to heal.

Because attempts to close large defect with single
local flaps, sometimes they may lead to failure.
Various double-layered closure using local tissue have
been used. They include
Combination of inversion and rotational
advancement
flaps.
Double hinged flaps.
Double island flaps.
Superimposed reverse palatal buccal flaps.

OROANTRAL FISTULA

Distant flaps
The limited size of local flaps makes it difficult to
close large fistulas. Therefore distant flaps have been
are used. They are
1.Flap from extremities
2.Flap from forehead
3.Tongue flap
4.Temporalis flap
5. Buccal fat pad flap

OROANTRAL FISTULA

Tongue flap:
It can be
Anteriorly
Posteriorly
They can be taken from the dorsum or laterally.

Distant flap

OROANTRAL FISTULA

Distant flap

. Temporalis flap:
Advantages:
Proximity to the oral cavity.
Safety of it vascular pedicle.
Its pliability
Minimal functional and esthetic sequelae.
Less dysfunction during healing.
The muscle is approached through a hemicoronal incision. The flap is
outlined and the Temporalis fascia with sectioned a sure the arch to
permit flap rotation and brought at the oral cavity. This tunnel created in
the infra temporal fossa and can be facilitated by removing a section of
zygomatic arch pouch is replaced and fixed with mini plates after flap was
moved

OROANTRAL FISTULA

Distant flap

Buccal fat pad:

Advantages
Readily accessible
Excellent blood supply
It is access via a horizontal vestibular incision in the
3rd molar region. The fat pad is then gently teased out
of its bed and advanced into the defect where it is
sutured. Split thickness / lyophilized porcine dermis is
used to cover but is unnecessary because to
transposed fat becomes epitheliazed in 2-3 weeks.

OROANTRAL FISTULA

Bone grafts:
Coverage of the antral surface is achieved by inversion of the

gingival tissue surrounding the opening and the oral surface is

covered with buccal or palatal or tongue flaps.
For large defects in which adjacent mucosa cant be used for
linking the antral surface. Vuillemin et al used bone and buccal fat
pad to isolate the raft from sinus.
The disadvantages are it requires a second surgical method to
obtain bone graft.
Brusate described a procedure by using bone from the lateral wall
of the antrum pedicled on the periosteum to close the alveolar defect.
Another disadvantage is using of exposure of bone graft on the
antral side that can lead to infection, loss of the graft and persistence
of the fistula.

OROANTRAL FISTULA

Alloplastic materia

Alloplastic materials:
A variety of alloplastic and
allogenic materials have been used.
old foil
Tantalum
Polymehtyl methaacrylate
Lyophilized porcine collagen
Hydrooxylapatite block
Fibrin glue

OROANTRAL FISTULA

Alloplastic materia

Fibrin glue: Stajac et al have described the use of fibrin

glue to close small oroantral communication
recognized at the time of tooth extraction.
After preparation of the material, it is injected
through socket. The needle should be few
millimeters below the floor of the antrum. Then
material is injected in the socket.

OROANTRAL FISTULA

Alloplastic materia

Other materials:

After a mid crestal incision and excision of the fistulas tract, the
buccal and palatal mucosa are reflected at crest of tooth and
exposure of fistula is done to create mucoperiosteal flaps without
relieving incisions.

The implant is closely adapted to the ridge with margin, which

supported by the underlying bone. Then mucosal flaps are
approximated.

When metal foil is used, tissue grows across the antral surface,
resulting in closure of the fistula. Generally the foil is gradually
exfoliated the mucosal incision and then removed. However if the
material does not become exposed, it is left in place permanently.
When collagen is used, it is incorporated into the tissues