BDS 7260 The Maxillary Sinus Diseases PDF

BDS 7260 The Maxillary Sinus Diseases Aims: At the end of this lecture students should understand the diagnosis, assessment and treatment planning of oro-antral communications, fistulae and diseases of the maxillary sinuses. Objectives: On completion of this lecture, the student should un...

BDS 7260 The Maxillary Sinus Diseases Aims: At the end of this lecture students should understand the diagnosis, assessment and treatment planning of oro-antral communications, fistulae and diseases of the maxillary sinuses. Objectives: On completion of this lecture, the student should understand: 1. The definition of an oro-antral communication and an oro-antral fistula; 2. The aetiology of oro-antral communication and an oro-antral fistula, including appropriate assessment of clinical cases; 3. The techniques for minimising the risk of antral complications; 4. The recognition and management of oro-antral communications and fistula; 5. The signs and symptoms of acute and chronic sinusitis; 6. The management of retrieving a foreign body, tooth, root or instrument from the antrum 7. The features of malignant disease of the maxillary antrum.  Definition: It is pyramidal – shaped air space which occupies the body of the maxilla. Anatomy of the maxillary sinuses: Frontal air sinus. Ethmoidal air sinus. Maxillary air sinus. anatomy of maxillary air sinus It is pyramidal in shape with its base directed medially and its apex directed laterally. – The roof of the sinus (forms the floor of the orbit). – Apex of the sinus. – Floor of the sinus (lies 1 cm below the level of the floor of the nasal cavity). – Base of the sinus (formed by the lateral wall of the nasal cavity). Orifice of the maxillary sinus. It lies in the upper part of the base of the sinus and opens into the middle meatus of the nose. 1. Orifice of maxillary sinus. 2. Floor of the sinus. Nerves related to the maxillary sinus 1. Anterior superior alveolar nerve (in the anterior wall). 2. Infra-orbital nerve (in the roof). 3. Greater palatine nerve (behind the sinus). 4. Posterior superior alveolar nerve (in the posterior walls). 5. Middle superior alveolar nerve (in the lateral wall). Function of the maxillary sinus: Warm inspired air and to decrease the weight of the skull. Improve sound resonance. grows mainly due to pneumatization and attains its full size between 14, 18 years of age. Teeth related to maxillary sinus: First molar, second molar, second premolar, third molar, first premolar in that order. Maxillary sinus is generally larger than any of the other sinuses and lies chiefly in the body of the maxilla, its called also maxillary antrum, meaning a cavity or hollow space.  Diagnosis of maxillary sinus affection 1. History e.g. diffuse tooth ache with history of common cold. 2. clinical examination: percussion, palpation and trans- illumination. 3. Radiographic examination. a. Intra-oral periapical and occlusal film. b. Panoramic x-ray. C- Water's view: occipito-mental produce verify clear unobstructed view of both sinuses for simultaneous comparison of both sinuses on the same radiograph. Intra-oral Panoramic x. ray periapical Water’s view  Radio-opaque dyes: As lipodol used occasionally in radiographic investigation of the sinus. e. Computerized tomography scanning (C.T. scanning). 4. Sinoscopy: Its recent investigation method which will have a role in diagnosis of pathological conditions of maxillary sinus. Maxillary sinoscopy Ct scan  Maxillary Sinus Affections 1- inflammatory 2-trauma 3-calcifications 4-cysts 5-tumors  1-Inflammatory Affections Maxillary sinusitis: May be either acute, subacute or chronic depending on: 1. Virulence of infective microorganisms. 2. Local condition. 3. Resistance of individual.  Etiology of Maxillary Sinusitis: 1. Nasal origin e.g. common cold and influenza. 2. Dental Origin: a.Spread of infection from dental abscess of related teeth. b. Infected benign cystic lesion of related teeth. c. Dental material pushed into the sinus. d. Tooth or root pushed in the sinus. E-oro antral fistula f. Facial fracture involves the sinus.  Acute Maxillary sinusitis Clinical features: 1. pain usually referable to the specific sinus area and it increased by bending the head downwards. 2. Interference with smell. 3. Dental pain or pain of the teeth related to the sinus. 4. Foul unilateral nasal discharge or nasal obstruction 5. In the presence of oro-antral fistula patient complains of a foul or salty taste, yellowish green pus oozing intra-orally. 6. Water’s view reveals opaque sinus and same times fluid level is seen. WATER’S VIEW Treatment: 1. Antibiotics: Daily injection of penicillin, I.M. for 5-7 days, or erythromycin or ampicillin or culture sensitivity test. 2. Decongestants to shrink the mucosa lining e.g. tinct benzoin or nasal drops of ephedrine solution. 3. Analgesics to relief pain. 4. Removal of the cause e.g. closure of oro-antra fistula.  Chronic Maxillary Sinusitis Clinical features: 1. No pain. 2. smell is often impaired. 3. Foul odor. 4. presence of oro-antral fistula or polypoidal reddish mass coming out as a lump on the gum. 5. Trans-illumination reveals opacity of the affected side. 6. X-Ray show opacity of the sinus and marked thickening of the lining. Treatment: - In some cases the sinus will return to normal condition after removable of dental cause. -If the lining damage is irreversible with presence of antral polyps the thickened lining should be removed through a caldwell-luc operation.  2-Traumatic affections 1. Occurs with fractures of the middle third of the face. 2. Fracture tuberosity of floor of the sinus during extraction. 3. may occur from nasal operations. Hematoma of Maxillary Sinus: -fracture of the middle third of the face. -In most instances the haemorrhage causing the Hematoma stops spontaneously. -In rare cases, the vessel may slowly feed the hematoma causing continuous nasal bleeding. Treatment of hematoma 1-Cold application to stop bleeding and decrease swelling. 2-Drainage of the sinus through inferior turbinate puncture. 3-Continuous bleeding need interference by Caldwell-Luck Operation and inserting a pressure pack with haemostatic agent (e.g. Dycinon Vial) or by tying bleeding vessel  Tooth or Root in Maxillary Sinus The most common tooth is the impacted third molar while the most common root is the palatal root of 1st molar or any root closely approximated. The event occurs during extraction, accidently or application of mouth gage to conically rooted tooth of 2nd premolar. Diagnosis: History , Clinical and radiographic examination: 1. Periapical view: It is quite sufficient o It will shows the following: discontinuity of the white cortical line representing the antral floor. Presence of root canal in the pushed root. Immediate vicinity of an empty socket.  If the remaining root fragment is less than 2-3 mm and uninfected it is left in place after informing the pt. and taking his approval If the remaining root fragment is more than 2-3 mm or has some visible pathology should be removed. A periapical x.ray should be done to localize root position. Also nasal blowing test confirm the diagnosis: Ask the pt to blow air gently while holding the nostrils together with mouth open,bubbling of air will be seen in the socket  There are several tricks to remove the root from the sinus: 1-ask the pt to blow air through the nose with nostril closed and watch the perforation, if root appears could be grasped by hemostat. 2- use suction tip covered by a piece of gauze 3- a long piece of gauze packed into the sinus and pulled out in one stroke, the root may come out by friction 4- if the root can not be removed by any of the previous methods surgical removal should be done B- Caldwell luc operation: Through a large flap to expose the lateral aspect of the sinus and the root is approached through a buccal window  ORO ANTRAL communication: It is the communication between maxillary sinus cavity and oral cavity throw a perforation in the sinus floor. Etiology: Accidental antral opening after extraction or pushing of root into the sinus during trial to remove it from the socket. Massive trauma to the middle third of the face especially gun shot injuries. after surgical excision of a large cyst or tumor related to the sinus. malignant tumor affecting the sinus or the oral cavity. Osteomylitis of the maxilla. Accidental minute fistula which fails to heal due to infection. Unhealed Caldwell-Luc operation  Clinical Features: Regurgitation of liquids, from the mouth into the nose which is the most common complaint of the patient. Unilateral epistaxis. Alteration in vocal resonance. Inability to blow-out the cheek. Foul or salty unpleasant taste. In chronic fistula after several weeks or months the patient may complain of the presence of painless lump at the site of extraction. The nose blowing test -The previous test will cause deflection of a wisp of cotton-wool held just below the socket in an old fistula. - When the patient performs the previous test and a dental mirror is placed in front of the fistula, the surface of the mirror becomes cloudy. -When the patient rinses his mouth with water some of the water is seen to run-out from the nostril. -In chronic fistula there are signs of sinusitis and blowing more test will cause escape of pus out of the fistula.  X-ray films (periapical and water's view) reveals the presence of fistulous tract connecting the oral cavity from the site of the fistula with maxillary sinus. Injection of radio-opaque material is of high value.(e.g lipidol) GUTTA PERCHA TEST: PLACEMENT OF GUTTA PERCHA then making x ray will help to detect the exact location and extension of the fistula Small perforation(1-2 mm): -Blood clot will fill it and closed automatically unless infected -placement of haemostatic agent gelatin sponge may aid in the clot stabilization- Medium sized perforation(2- 5 mm) Operator should close it immediately by approximation of buccal and palatal tissues with tight sutures after reduction of buccal and palatal alveolar process height Also gel foam may be used to fill the socket. large perforation 5mm or more: Surgical closure is needed for closure  Types of flaps: Local flaps Regional Flaps Distant Flaps  Local flaps: Buccal palatal flaps flaps Both flaps  BUCCAL FLAPS MOCZAIR FLAP BUCCAL ADVANCEMENT FLAPS Advantages: 1-simplicity 2-Lower post operative pain and discomfort if compared to those of the palatal flaps Disadvantages: Obliteration of the buccal vestibule , needs secondary vestibuloplasty  palatal flaps: Types : 1- palatal pedicle flaps 2- palatal rotational flaps 2-palatal submucosal island flaps Advantages: More tissues with less tension during closure Firmer and thicker than buccal flaps resistant to trauma and infection Could be used with large defects Preserve buccal vestibular depth  Disadvantages: 1- leaving a bare area of the palatal bone that takes from 2-3 weeks to heal spontaneously (better to be covered by perio pack or palatal stent) Also palatal stent is used to support flap against gravity  Regional flaps: Tongue flaps (from dorsal or side surface ): Dorsal surface tongue flaps  3-DISTANT FLAPS: TEMPORALIS FLAPS Advantages of regional and distant flaps: 1-abudant highly vascular tissues 2- could be epithilialized within 2 weeks 3-could be used for closure of huge maxillary defects e.g post resection segmental defects after tumor excision  Maxillary Sinus Affections 1- inflammatory 2-trauma 3-calcifications 4-cysts 5-tumors  3- Calcifications : Antral Rhinoliths Its hard calcified bodies with rough irregular surface, brownish of blackish – gray in colour. The calculi consists of central nucleus either endogenous (blood clot, pus or mucous cells, bone fragment or root). It also may be due to exogenous nucleus (cotton wool, filling or prosthetic material). Inorganic salt from antra discharge or inflammatory exudates will deposit mineral salts calcium phosphate, calcium carbonate and manisun carbonate to form stone  Signs and symptoms: It is asymptomatic and discovered on routine radiography as radio-opaque mass. It became secondary infected causing maxillary sinusitis. Its rarely appears as a hard mass under the mucosa intra orally due to destroying adjacent bone. Treatment: Removal through a buccal antrostomy or Caldwell-Luc operation.  Buccal antrostomy It is a technique of making an artificial ostium to the maxillary sinus in the inferior meatus of the nose. Uses a combination of rigid endoscope  Cysts affecting Maxillary Sinus Cyst of the maxillary sinus may arise in connection with its mucosa or from an out side source on which the cyst encroaches into the sinus. Types of Cysts: 1-Cysts occurring in the sinus: Benign mucosal cysts are usually asymptomatic and are discovered as one incidental findings following routine x-ray it appears like round shadow in x-ray. 2.Cysts encroaching on the sinus: Periodontal cyst. Dentgerous cyst. Odontogenic keratocyst.  Clinical pictures of cysts: Usually asymptomatic. Discovered by routine x-ray examination. discomfort in the cheek or maxilla may be present. Buccal expansion of maxillary sinus may be reported causing Egg shell crackling of the lateral surface of the maxilla Nasal obstruction and post nasal discharge pressure symptoms causing neurologia. There may be building of one of the walls produces external deformity of the face.  Radiographic picture: The cyst appears as rounded, lightly opaque shadow partially obliterating the sinus  Treatment: Enucleation: Complete removal of the cystic lesion Cyst enucleation  2-Marsupilization : It is deroofing of the cystic cavity aiming at decompresion of the cystic content to decrease its overall size 3- marsupilization followed by enucleation  5-Tumors of the Maxillary Sinus Antral tumors may be benign of malignant I. Benign Tumors A) Non odontogenic: 1. Osteoma. 2-Fibro-osteoma. 3-Ossifying fibroma. 4.Fibroma. Odontogenic: 1. Ameloblastoma. 2. Adeno-ameloblastoma 3. Odontoma..Treatment Surgical excision Malignant tumors: Affecting the sinus are: Epidermoid carcinoma. Adeno-carcinoma. Malignant lymphoma. Metastatic deposits from breast or lung carcinoma. Malignant granuloma "Lethal granuloma or wegner" granulomatosis. Treatment: Radical resection by maxillectomy or hemimaxillectomy. Irradiation. Cytotoxic drugs and corticosteroid may helpful in malignant granuloma. Aims: At the end of this lecture students should understand the diagnosis, assessment and treatment planning of oro-antral communications, fistulae and diseases of the maxillary sinuses. Objectives: On completion of this lecture, the student should understand: 1. The definition of an oro-antral communication and an oro-antral fistula; 2. The aetiology of oro-antral communication and an oro-antral fistula, including appropriate assessment of clinical cases; 3. The techniques for minimising the risk of antral complications; 4. The recognition and management of oro-antral communications and fistula; 5. The signs and symptoms of acute and chronic sinusitis; 6. The management of retrieving a foreign body, tooth, root or instrument from the antrum 7. The features of malignant disease of the maxillary antrum.  Reading material 1. Hupp et al, Contemporary Oral and Maxillofacial Surgery, Mosby 2014 pp 382- 393 2. Coulthard P et al. Master Dentistry Volume 1. Churchill Livingstone 2003 pp 159-169 3. Fragiskos D, Oral Surgery, Springer 2007 pp 189-191  NEWGIZA UNIVERSITY Thank You