Maxillary Sinus Diseases: Sinusitis

• Maxillary sinus diseases encompass several conditions affecting the sinus.

Sinusitis

• Acute sinusitis and Chronic sinusitis are among the maxillary sinus diseases
• Sinusitis is defined as inflammation of the sinus mucoperiosteum.
• Blockage of the ostium due to thickened mucosa is a common cause, preventing drainage into the middle meatus.
• Decreased ciliary action of respiratory epithelial cells and mucous secretions are important factors in sinusitis.
• Many acute cases follow rhinovirus infections, such as the common cold
• Bacteria from the upper respiratory tract can cause sinusitis

Acute Sinusitis

• Pain and stuffiness can occur
• Sinus walls are often tender to pressure.
• Pain might be referred to maxillary molars or premolars, worsening with percussion, requiring the ruling out of dental disease.
• Thick nasal discharge with blood and pus can occur; this is more common in adults.
• Fever, chills, malaise, and an elevated WBC count are systemic symptoms.
• Radiographic features include an air-fluid level.
• This presents as a horizontal, faintly radiopaque line in the sinus, showing the junction of air and fluid along the inferior aspect
• There is usually no alteration in the sinus bony wall.

Bacterial Causes

• S. pneumoniae is the most common bacterial cause
• H. influenzae can cause sinusitis
• Moraxella catarrhalis also causes sinusitis

Chronic Sinusitis

• It often is a sequela of acute sinusitis, but may arise without an acute phase.
• Symptomatic sinus disease lasting longer than 3 months defines chronic sinusitis
• Bacteria that can cause it are usually anaerobes, like Streptococci, Bacteroides, or Veillonella species.
• Radiographic indicators include localized or generalized thickening of the mucosa along the sinus walls
• Diffuse radiopacity throughout the entire sinus occur
• The sinus walls usually remain intact.

Odontogenic Sinusitis

• Mucositis results from periapical inflammation or periodontitis
• It is a thickening and inflammation of the mucoperiosteum in the sinus.
• Symptoms may resemble chronic sinusitis or be asymptomatic in some cases.
• Vague stuffiness in the sinus can occur
• Pus can form in the lesion
• It accounts for 25% to 40% of all chronic sinusitis cases
• Radiographic features include location on the floor or inferior aspects of the sinus wall
• It has an epicenter over the area of periapical or periodontal inflammation
• Periapical mucositis presents as thickening and increased radiodensity of the mucosa along the walls.
• Periapical osteoperiostitis may present a "halo" of bone around the tooth apex, resulting from periosteal proliferation.

Periapical Mucositis

• Symptomatic or asymptomatic apical periodontitis, in direct contact with or adjacent to the antral mucosa, will typically produce localized edema.
• Mucosal thickening or dome-shaped soft tissue expansion can occur in the floor of the sinus directly adjacent to the infected root apex.

Periapical Osteoperiostitis

• Apical periodontitis of the maxillary sinus cortical floor expands the sinus periosteum and displaces it upward into the sinus.
• A periosteal reaction is induced, with continuous deposit of a thin layer of new bone on the inner periphery of the periosteum as it expands
• Periapical osteoperiostitis (PAO) forms a thin, hard-tissue dome on the sinus floor
• PAO presents on radiographs and CT images as a radiopaque "halo" appearance

Differential Diagnosis and Treatment of Odontogenic Sinusitis

• Chronic sinusitis lacks a dental or periodontal source
• Treatment involves addressing the dental or periodontal disease, which often leads to resolution of the sinus lesion.
• ENT treatment may be needed for painful lesions not alleviated with dental care.

Fungal Sinusitis

• It involves infection by invasive fungi and usually occurs in debilitated patients
• Predisposing factors include diabetes mellitus, immunosuppression (HIV/AIDS), leukemia, and chronic corticosteroid therapy.

Mucormycosis (Phycomycosis)

• Rhinocerebral form develops in the nose and sinuses
• A bloody discharge from the nose, pain in the sinus, proptosis, and expansion of the palate occurs
• Extensive necrosis can happen
• On radiographs, opacification of the sinus with destruction of the walls occur
• Differential diagnoses include malignant tumors of the sinus and granulomatous inflammation
• Histologic features include necrotic soft tissue interspersed with large (6 to 30 microns) branching non-septate hyphae.

Aspergillosis

• Noninvasive form can affect healthy people
• Invasive form usually affects people with poor immune function (diabetes, HIV)
• Symptoms may resemble asthma
• It may be painful, especially after tooth extraction or RCT
• Pain, swelling, tenderness to pressure, and nasal discharge occur in more severe forms
• On radiographs, thickened mucoperiosteum with focal soft tissue masses (aspergillomas) can be seen.
• Prominent calcifications of masses of fungi may appear as antroliths
• Differential diagnoses include malignant lesions and granulomatous inflammation
• Histologically, sheets of branching septate hyphae, 3 to 4 microns occurs
• Commonly found near or in blood vessels
• The name comes from the aspergillum, a holy water dispenser in the Roman Catholic Church.

Sinusitis Treatment and Prognosis

• Acute sinusitis is treated with antibiotic therapy and removal of the cause of infection
• Chronic sinusitis is treated with surgery to open the ostium, if symptomatic
• No treatment if asymptomatic
• Fungal sinusitis requires surgical debridement, corticosteroids, and antibiotics.

Antral Pseudocyst and Mucous Retention Cyst

• Serous inflammatory exudate accumulates under the periosteum, resulting in a sessile elevation of the lining
• AP lacks an epithelial lining (pseudocyst), while MRC has an epithelial lining (true cyst).
• AP caused by inflammatory exudate, MRC caused by blockage of seromucinous glands
• AP is typically solitary, and MRC can be multiple
• Usually asymptomatic, but vague stuffiness of the sinus can occur
• Large lesions can prolapse through the ostium into the nose, causing nasal discharge
• They are faintly radiopaque, homogeneous, and dome-shaped masses, usually sessile and no more than 2 cm in size
• Differential diagnosis are difficult to distinguish between AP and MRC
• There is typically no disruption of the sinus wall
• AP needs no treatment because lesions resolve spontaneously
• MRC needs surgical removal if symptomatic
• Differential diagnosis includes odontogenic sinusitis and antral polyps
• It is different from mucocele, which involves destruction of sinus walls

Antral Polyp

• Thickened mass of chronically inflamed mucous membrane
• Produces irregular folds or nodular masses arising out of a generalized thickened mucosa
• May be solitary or multiple
• Can cause displacement or destruction of sinus walls.
• Occurs in a chronically inflamed sinus lining
• Adjacent mucosa is usually normal in patients with antral pseudocyst
• If polyps occur in association with bone destruction, the patient should be referred to a physician.
• Destruction of sinus walls can indicate aggressive inflammatory or neoplastic processes.

Antrolith

• It is a calcification of a nidus in the sinus
• The nidus can be intrinsic, such as stagnant mucus or a fungus ball
• It can be extrinsic, such as a foreign object
• Small antroliths are asymptomatic
• Larger lesions may cause symptoms of sinusitis, such as discharge or pain
• They are faintly to extremely radiopaque, homogeneous or varied in density
• They are well-defined, usually round or oval, and range in size from a few millimeters to centimeters
• No alteration of sinus walls is observed on radiographs
• A differential diagnosis is root fragments
• Treatment of small, asymptomatic antroliths isn't needed
• Larger/symptomatic ones must be removed by an ENT

Mucocele

• Expansile, destructive lesion
• Blockage of the ostium, either inflammatory or neoplastic, results in a mucocele.
• Mucous secretions fill the sinus
• Thins and expands the sinus walls
• It can cause perforation
• Swelling and a sensation of fullness occurs in areas where the sinus wall is altered
• The lesion can expand inferiorly, leading to loosening of posterior teeth
• Superiorly, diplopia or proptosis
• Medially, obstruction of the nasal cavity is seen
• Fullness is perceived in the mucobuccal fold laterally
• Most commonly in the ethmoid and frontal sinuses
• Less common in the maxillary sinus.
• They appear as well-defined, round or irregular, faintly radiopaque masses isodense to soft tissue
• The sinus walls are resorbed and expanded and may be perforated
• Odontogenic cyst is a differential diagnosis
• Origin occurs in the alveolar process, with no blockage of the ostium,
• Antral carcinoma is also similar to mucocele
• Treatment involves surgical intervention (Caldwell-Luc procedure)
• Prognosis is excellent with treatment

Antral Carcinoma

• Malignancy of the sinus mucosa
• Cause is unknown; not related to tobacco use, sinonasal inflammation, or polyps
• Risk factors include wood dust, nickel, and chromium
• The lesion grows while still confined to the sinus, leading to no symptoms
• Often discovered only late in the disease
• Almost exclusively in adults average of 60 years
• More common in males
• Unilateral nasal stuffiness or obstruction, palatal enlargement, tooth displacement, or eye alteration is depending on involved wall
• Pain occurs late in the disease
• Radiographic features consist of a solitary lesion arising in the mucoperiosteum along the walls with irregular soft tissue radiopacity.
• Destruction of the sinus wall with poorly-defined radiolucency in the alveolar process and palate is seen
• Teeth loosened, rotation of the eye, and disruption of fascial planes on CT (if the lesion has spread) occurs
• A CT scan is mandatory for lesions with sinus wall destruction
• Differential diagnoses include antral mucocele, odontogenic cysts and tumors, and salivary gland malignancies
• It is poorly differentiated squamous cell carcinoma (>90%)
• Some lesions are adenocarcinoma.
• Treatment encompasses maxillectomy if lesions are confined to the sinus.
• Another treatment method is radiation therapy with or without surgery if lesions are extended through the wall
• Prognosis is very poor with 10% to 30% survival rate at 5 years
• Patients with metastases in the lymph nodes or pterygopalatine fossa have a survival rate lower than 10%.

Overview of maxillary sinus diseases, primarily focusing on sinusitis. It covers acute and chronic sinusitis, causes such as ostium blockage, decreased ciliary action, and bacterial infections. Symptoms include pain, stuffiness, nasal discharge, and systemic symptoms like fever.