Maxillary Sinus Diseases PDF

Maxillary Sinus Diseases Maxillary Sinus Diseases  Sinusitis  Acute sinusitis  Chronic sinusitis  Odontogenic sinusitis  Periapical mucositis  Periapical osteoperiostitis  Fungal sinusitis  Mucormycosis  Aspergillosis Maxillary Sinus Diseases ...

Maxillary Sinus Diseases Maxillary Sinus Diseases  Sinusitis  Acute sinusitis  Chronic sinusitis  Odontogenic sinusitis  Periapical mucositis  Periapical osteoperiostitis  Fungal sinusitis  Mucormycosis  Aspergillosis Maxillary Sinus Diseases  Antral pseudocyst  Mucous retention cyst  Antral polyp  Antrolith  Mucocele  Antral carcinoma  Sinusitis: Normal Anatomy www.sinuses.com www.jdavidruggiero.com Maxillary sinus drains through Arrow: Ostium the ostium (green arrow) Arrowhead: Uncinate process into the middle meatus (MM) Sinusitis  Inflammation of sinus mucoperiosteum  Usually related to blockage of ostium by thickened mucosa, preventing drainage into the middle meatus  Decreased ciliary action of respiratory epithelial cells and mucous secretions also important Sinusitis  Many cases (especially acute) follow rhinovirus infections (common cold)  Bacteria from URT can also cause sinusitis:  S. pneumoniae most common  H. influenzae  Moraxella catarrhalis Sinusitis: Clinical Features  Acute sinusitis:  Pain and stuffiness  Sinus walls tender to pressure  Pain may be referred to maxillary molars or premolars, worse with percussion: must rule out dental disease  Often thick nasal discharge with blood and pus (in adults)  Fever, chills, malaise, elevated WBC count Acute Sinusitis  Sinusitis: Radiographic Features  Acute sinusitis:  Air-fluid level – a horizontal, faintly radiopaque line in sinus representing junction of air above and fluid (mucus, blood, pus) along inferior aspect  Usually no alteration Air-fluid level in bony wall of sinus Acute Sinusitis Air-fluid levels in acute sinusitis Acute Sinusitis Sinusitis: Clinical Features  Chronic sinusitis:  Often a sequella of acute sinusitis  May arise without an acute phase  Defined as recurrent incidents of acute sinusitis or symptomatic sinus disease lasting longer than 3 months  Bacteria are usually anaerobes (Streptococci, Bacteroides, or Veillonella species) Sinusitis: Radiographic Features  Chronic sinusitis:  Localized thickening of mucosa along portion of sinus wall  Generalized thickening of mucosa along walls  Diffuse radiopacity throughout entire sinus  Sinus walls usually intact Chronic Sinusitis  Chronic Sinusitis www.clevelandclinicmeded.com Odontogenic Sinusitis  Mucositis resulting from periapical inflammation or periodontitis  Thickening and inflammation of mucoperiosteum in sinus  May have no symptoms but may have symptoms similar to chronic sinusitis  May cause vague stuffiness in sinus  Pus can form in the lesion  25% to 40% of all chronic sinusitis Odontogenic Sinusitis Odontogenic Sinusitis: Radiographic Features  Location:  Floor or inferior aspects of sinus wall, with epicenter over area of periapical or periodontal inflammation  Observations:  Periapical mucositis: Thickening and increased radiodensity of mucosa along walls  Periapical osteoperiostitis: “Halo” of bone can occur around tooth apex as a result of periosteal proliferation Odontogenic Sinusitis: Periapical Mucositis  Symptomatic or asymptomatic apical periodontitis in direct contact with or adjacent to the antral mucosa will typically produce a localized mucosal tissue edema termed periapical mucositis  Mucosal thickening or dome-shaped soft tissue expansion in the floor of the sinus directly adjacent to the infected root apex Odontogenic Sinusitis: Periapical Mucositis Odontogenic Sinusitis: Periapical Mucositis Odontogenic Sinusitis: Periapical Mucositis Odontogenic Sinusitis: Periapical Mucositis Odontogenic Sinusitis: Periapical Osteoperiostitis  Apical periodontitis adjacent to the maxillary sinus cortical floor will often expand the sinus periosteum and displace it upward into the sinus  Subsequently induces a periosteal reaction that continues to deposit a thin layer of new bone on the inner periphery of the periosteum as it expands Odontogenic Sinusitis: Periapical Osteoperiostitis  Periapical osteoperiostitis (PAO) forms a thin, hard-tissue dome on the sinus floor and presents on radiographs and CT images as a radiopaque “halo” appearance Odontogenic Sinusitis: Periapical Osteoperiostitis Odontogenic Sinusitis: Differential Diagnosis and Treatment  Differential Diagnosis  Chronic sinusitis:  Lacks a dental or periodontal source  Treatment  Treat dental or periodontal disease  Sinus lesion often resolves after successful treatment  May need ENT treatment for painful lesions not alleviated by dental care Fungal Sinusitis  Infection by invasive fungi  Usually occurs in debilitated patients:  Diabetes mellitus  Immunosuppression (HIV/AIDS)  Leukemia  Chronic corticosteroid therapy Fungal Sinusitis  Mucormycosis (Phycomycosis):  Rhinocerebral form in nose, sinuses  Bloody discharge from nose  Pain in sinus  Proptosis, expansion of palate  Extensive necrosis Fungal Sinusitis: Mucormycosis  Radiographic Features:  Can see opacification of sinus with destruction of walls  Differential Diagnosis:  Malignant tumors of sinus  Granulomatous inflammation (Wegener, etc.)  Histologic Features:  Necrotic soft tissue interspersed with large (6 to 30 microns) branching non-septate hyphae Fungal Sinusitis: Mucormycosis Neville et al. Oral & Maxillofacial Pathology, 2nd ed Fungal Sinusitis: Mucormycosis Fungal Sinusitis: Mucormycosis Neville et al. Oral & Maxillofacial Pathology, 2nd ed Fungal Sinusitis  Aspergillosis:  Noninvasive form can affect healthy people  Invasive form usually affects people with poor immune function (diabetes, HIV)  Symptoms may resemble asthma  May be more painful, especially after tooth extraction or RCT  Pain, swelling, tenderness to pressure, nasal discharge in more severe forms Fungal Sinusitis: Aspergillosis  Radiographic Features:  Thickened mucoperiosteum with focal soft tissue masses (aspergillomas)  Prominent calcifications of masses of fungi can appear as antroliths  Differential Diagnosis:  Malignant lesions  Granulomatous inflammation (Wegener, etc.)  Histologic Features:  Sheets of branching septate hyphae, 3 to 4 microns  Often near or in blood vessels Fungal Sinusitis: Aspergillosis Neville et al. Oral & Maxillofacial Pathology, 2nd ed  Fungal Sinusitis: Aspergillosis  Calcified “fungus ball” LeBoime A et al. Arthritis Research & Therapy 2009, 11:R164 Fungal Sinusitis: Aspergillosis  Septate hyphae (arrows)  Blood vessel (large arrow) Fungal Sinusitis: Aspergillosis Neville et al. Oral & Maxillofacial Pathology, 2nd ed Aspergillosis  Named for the aspergillum: holy water dispenser in the Roman Catholic church  Has rounded head with perforations  Aspergillus resembles the aspergillum Aspergillum Aspergillus flavus http://www.doctorfungus.org Genus/Species: Aspergillus flavus Title: Stages in development of fruiting bodies Image Type: Microscopic Morphology Disease(s): Aspergillosis Legend: Stages in development of fruiting bodies. Differential interference contrast microscopy, 630X. Sinusitis: Treatment and Prognosis  Acute sinusitis:  Antibiotic therapy  Remove cause of infection if possible  Chronic sinusitis:  Surgery to open ostium if symptomatic  No treatment if asymptomatic  Fungal sinusitis:  Surgical debridement  Corticosteroids  Antibiotics Antral Pseudocyst and Mucous Retention Cyst  Serous inflammatory exudate accumulating under periosteum, causing sessile elevation of lining  Histologically different:  AP lacks an epithelial lining (pseudocyst)  MRC has an epithelial lining (true cyst) Antral Pseudocyst and Mucous Retention Cyst  Causes:  AP caused by inflammatory exudate  MRC caused by blockage of seromucinous glands  Number:  AP is usually solitary  MRC can be multiple Antral Pseudocyst and Mucous Retention Cyst: Clinical Features  Usually asymptomatic, but may cause vague stuffiness of sinus  Large lesions may prolapse through ostium into nose, causing nasal discharge Antral Pseudocyst and Mucous Retention Cyst: Radiographic Features  Location:  Solitary (AP) or multiple (MRC)  Inferior aspect of sinus wall  Observations:  Faintly radiopaque, homogeneous dome-shaped mass  Usually sessile  Usually no more than 2 cm  Difficult to distinguish AP from MRC  General effects:  No disruption of sinus wall Antral Pseudocyst and Mucous Retention Cyst Antral Pseudocyst and Mucous Retention Cyst Antral Pseudocyst and Mucous Retention Cyst  Antral pseudocyst in right sinus (arrow)  Note inflammatory polyp in left sinus Antral Pseudocyst and Mucous Retention Cyst: Differential Diagnosis  Odontogenic sinusitis:  Obvious dental source  Antral polyps  Arise in a thickened mucosa  Usually multiple  Mucocele:  Destruction of sinus walls Antral Pseudocyst and Mucous Retention Cyst : Treatment and Prognosis  AP:  No treatment needed  Lesions may resolve spontaneously  MRC:  May need surgical removal if symptomatic Antral Polyp  Thickened mass of chronically inflamed mucous membrane  Produces irregular folds or nodular masses arising out of generalized thickened mucosa  May be solitary or multiple Antral Polyp  Clinical features:  May cause displacement or destruction of sinus walls  Radiographic features:  Polyp usually occurs in chronically inflamed sinus lining  Differs from antral pseudocyst, in which the adjacent mucosa is usually normal Antral Polyp  Sessile mass of soft tissue arising out of thickened mucosa Antral Polyp  Management:  If polyps occur in association with bone destruction, refer the patient to a physician  Destruction of sinus walls can indicate aggressive inflammatory or neoplastic disease Antrolith  Calcification of nidus in sinus  Nidus can be intrinsic: stagnant mucus, fungus ball  Nidus can be extrinsic: foreign object in sinus  Small antroliths are asymptomatic  Larger lesions may cause symptoms of sinusitis (discharge, pain) Antrolith: Radiographic Features  Location:  Solitary or multiple, in mucoperiosteum  Observations:  Faintly to extremely radiopaque  May be homogeneous or varied in density  Well-defined, usually round or oval  Size from a few millimeters to centimeters  General effects:  Usually no alteration of sinus walls Antrolith drgstoothpix.com Antrolith: Differential Diagnosis and Treatment  Differential Diagnosis:  Root fragments  Can identify pulp space  Treatment:  No treatment needed for small, asymptomatic antroliths  Larger or symptomatic lesions may need to be removed by ENT Mucocele  Expansile, destructive lesion  Results from blockage of ostium  Inflammatory or neoplastic blockage  Mucous secretions fill sinus  Causes thinning and expansion of sinus walls; perforation can occur Mucocele: Clinical Features  Swelling and sensation of fullness in areas where sinus wall is altered  Can expand through walls:  Inferiorly: loosening of posterior teeth  Superiorly: diplopia and/or proptosis  Medially: obstruction of nasal cavity  Laterally: fullness in mucobuccal fold Mucocele: Radiographic Features  Location:  Most in ethmoid and frontal sinuses; less common in maxillary sinus  Observations:  Well-defined, round or irregular, faintly radiopaque mass isodense with soft tissue  General effects:  Sinus walls resorbed and expanded; may be perforated  Mucocele www.entusa.com www.head-face-med.com Mucocele: Differential Diagnosis and Treatment  Differential Diagnosis:  Odontogenic cyst  Origin in alveolar process, no blockage of ostium  Antral carcinoma  Very similar to mucocele  Treatment:  Surgical (Caldwell-Luc procedure)  Prognosis is excellent Antral Carcinoma  Malignancy of sinus mucosa  Cause unknown: not related to tobacco use, sinonasal inflammation, or polyps  Risk factors include:  Wood dust  Nickel  Chromium Antral Carcinoma  Lesion can grow large while still confined to sinus, producing no symptoms  Often discovered only late in disease: “silent killer” Antral Carcinoma: Clinical Features  Almost always in adults (average age 60)  Large majority in males  Unilateral nasal stuffiness or obstruction, palatal enlargement, tooth displacement or eye alteration, depending on which wall of the sinus is involved  Pain simulating a toothache can occur late in disease Antral Carcinoma Antral Carcinoma Antral Carcinoma: Radiographic Features  Location:  Solitary lesion  Arises in mucoperiosteum along walls  Observations:  Irregular soft tissue radiopacity in sinus Antral Carcinoma: Radiographic Findings  General effects:  Sinus wall destroyed  Poorly-defined radiolucency in alveolar process and palate  Teeth loosened (“floating in space”) if lesion is extensive  Rotation of eye, causing diplopia  Disruption of fascial planes on CT when lesion extends beyond sinus  CT mandatory for lesions with sinus wall destruction Antral Carcinoma www.jomfp.in Antral Carcinoma Antral Carcinoma: Differential Diagnosis  Antral mucocele:  Can cause destruction of sinus walls  Odontogenic cysts and tumors:  Can extend into sinus, destroying wall  Origin in alveolar process, not sinus  Salivary gland malignancies:  Can perforate palate and invade sinus  Antral Carcinoma: Histologic Features  Poorly differentiated squamous cell carcinoma (> 90%)  Some lesions are adenocarcinoma Antral Carcinoma: Treatment and Prognosis  Maxillectomy if lesion confined to sinus  Radiation therapy with or without surgery if lesions have extended through sinus wall  Prognosis very poor:  10% to 30% survive 5 years  If metastases in lymph nodes or pterygopalatine fossa, fewer than 10% survive five years That’s All, Folks!!