Lect 1- maxillary sinus.pdf

The maxillary antrum Disorders  EM BRYOLOGY AN D ANATOMY The paranasal sinuses : air filled spaces, lined with mucous membrane, within some of the bones of the skull. They open into the nasal cavity, via the meatuses The paranasal sinuses comprise the maxillary, frontal, eth...

The maxillary antrum Disorders  EM BRYOLOGY AN D ANATOMY The paranasal sinuses : air filled spaces, lined with mucous membrane, within some of the bones of the skull. They open into the nasal cavity, via the meatuses The paranasal sinuses comprise the maxillary, frontal, ethmoidal, and sphenoidal air sinuses.  The maxillary sinus is the largest paranasal sinus and occupies the whole body of the maxilla. The maxillary antrum starts to develop in utero, and reaches its full development at the age 12 years.  It is pyramidal in shape, with A. its base(Medial wall) directed medially towards the lateral wall of the nose, and B. its apex directed laterally to the zygomatic process of the maxilla. C. Anterior wall = by anterior or facial wall of maxilla D. Posterior wall = by infra temporal surface of maxilla  It drains into the nasal cavity through a small ostium in the middle meatus. It receives its blood supply through the maxillary and facial arteries, and the whole lining is innervated by the maxillary nerve (V2). The apices of the roots of the second premolars, first and second molars are in close proximity to the floor of the maxillary antrum and rarely the first premolars and canines are related similarly.  Functions of Maxillary Sinus 1. Makes the cranium bone lighter in weight 2. Acts as a resonant bone 3. Regulates the temperature of the inspired air 4. Drainage 5. Pneumatization  Classification of the Disorders of Maxillary Sinus 1. Infection/Inflammatory:- i. Acute sinusitis ii. Chronic sinusitis 2. Trauma i. Oro-antral communication ii. Fracture of the maxillofacial skeleton iii. Foreign bodies within the antrum  Functions of Maxillary Sinus cont. 3. Cysts and tumors 4. Other bony abnormalities: i. Fibrous dysplasia ii. Paget's disease iii. Osteopetrosis  Diagnosis of the Disorders of Maxillary Sinus The diagnosis of the disorders is done by the combination of following methods: 1. Proper case history and clinical evaluation 2. Rhinoscopy - Examination of the maxillary sinus via the nasal cavity using nasal spectrum and headlights or mirror. 3. Nasoendoscopy - Narrow firbro optic endoscopes are used.  Diagnosis of the Disorders of Maxillary Sinus cont. 4. Transillumination test: 5. Bacteriological and cytological study of the aspirates 6. Radiography: Intraoral and extraoral radiographical techniques are used like occlusal radiographs, water's projection, tomography, MRI, ultrasound, scintigraphy.  STUDY OF SOME MAXILLARY SINUS DISORDERS Maxillary Sinusitis Inflammation of the mucous of the maxillary sinus is called as maxillary sinusitis. If all sinuses (maxillary, frontal, ethmoidal and sphenoidal) are involved, it is called as Pansinusitis.  MAXILLARY SINUS DISORDERS cont. Types 1. Acute maxillary sinusitis: It is sudden in onset and persists for less than 4 weeks. Needs only short term therapy. 2. Subacute maxillary sinusitis: Features persists for 4-12 weeks. 3. Chronic maxillary sinusitis: Features persists for more than 12 weeks. May need surgical correction swell  MAXILLARY SINUS DISORDERS cont. Acute Maxillary Sinusitis Clinical Features 1. Continuous nagging pain over antral cavity and headache 2. Facial pain and swelling 3. Nasal blockage with continuous purulent unilateral nasal discharge  MAXILLARY SINUS DISORDERS cont. Acute Maxillary Sinusitis clinical features 4. Fever, chill, fatigue, cough, sneezing 5. Fetid odour and halitosis due to fistulous discharge 6. Tenderness on percussion over maxillary tooth of involved area.  MAXILLARY SINUS DISORDERS cont. Acute Maxillary Sinusitis managment Management Proper diagnosis by combination of earlier mentioned methods.  MAXILLARY SINUS DISORDERS cont. Acute Maxillary Sinusitis managment Antral regime should be followed, this includes: 1. Nasal decongestants: A. 0.5 percent - 1 percent ephedrine sulfate, in normal saline every 6th hourly or B. 0.1 percent Xylometozolin hydrochloride, can be used as nasal drops. C. Tincture Benzoin or carvol, can be used as inhalation.  MAXILLARY SINUS DISORDERS cont. Acute Maxillary Sinusitis managment 2. Antibiotics: Procaine penicillin, Amoxicillin, clavulanic acid or cephlosporine can be given either by oral or parenteral route. 3. Mucolytics: Camphor, chlorbutal, menthol or karrol capsules can be used to provide easy drainage of the mucous by making it into a less viscous secretion.  MAXILLARY SINUS DISORDERS cont. Acute Maxillary Sinusitis managment 4. Analgesics: Paracetamol 500 mg - 750 mg or other NSAIDs can be used to reduce pains. An adjuvant of antihistamines like cetrizine and topical corticosteroids can also be used to give faster relief. Steam inhalation and hot fermentation is also helpful.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis Chronic Maxillary Sinusitis Clinical Features May be asymptomatic or with mild symptoms of fever, tiredness, facial pain, headache, nasal obstruction with prolonged mucopurulant discharge which does not subside despite antibiotic therapy.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Management After proper diagnosis an adjuvant pharmacologic regime is recommended as in case of acute sinusitis to reduce the symptoms. The focus of infection - either long standing dental infection, foreign body in sinus or oroantral fistula should be treated.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment The purulent content should be properly drained, either by irrigating in with antiseptic saline solution orby surgical drainage - using Caldwall Luc technique or nasal antrostomy or functional endoscopic sinus surgery(FESS)  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Nasal Antrostomy indication when the natural ostium is obstructed due inflammation. Procedure a nasal antral window is made under the inferior meatus for establishing a more dependent drainage. Use of mucolytics further facilitates sinus drainage. After this antral packing with iodoform gauge for 4-7 days is done.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Caldwell-Luc Operation It is a procedure of reaching the maxillary sinus via intraoral approach for various reasons. Indications 1. Retrieval of root or tooth from sinus 2. Enucleation of odontogenic cyst from sinus 3. Removal of odontogenic tumors from sinus  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Caldwell-Luc Operation cont. 4. Treatment of chronic maxillary sinusitis 5. Management of oroantral fistula 6. Repair of fracture of orbital floor or zygoma 7. Management of hematomas of the sinus with active bleeding through the nose.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Caldwell-Luc Operation cont. Procedures 1. Mostly done under general anesthesia after proper preoperative dental corrections are done. 2. An intraoral incision of 2.5 cm is made along the mucogingival sulcus in the canine fossa, lateral to upper canine and above the first premolar.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Caldwell-Luc Operation cont. 3. A hole is made at the centre of the canine fossa of the size of index finger using a bone gauge and ronguer. 4. Blood and pus is drained from the sinus, foreign bodies are removed and only the diseased mucosa is removed by antral curette.  MAXILLARY SINUS DISORDERS cont. chronic Maxillary Sinusitis managment Caldwell-Luc Operation cont. 5. Cavity is cleaned and soft tissues flap is replaced and sutured over the bone. 6. Nasal decongestants are recommended preoperative and postoperative to shrink the mucous membrane, thereby preventing development of gross edema.  MAXILLARY SINUS DISORDERS cont. Oro-antral Communications (Oro-antral Fistula) It is an unnatural communication between the oral cavity and maxillary sinus.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Etiology 1. Pushing of tooth or root into the sinus while extracting it (most common) 2. Periapical abscess, leading to destruction of bony floor of sinus 3. Improper use of instruments leading to damage of sinus floor. 4. Trauma to face  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. 5. Surgical removal of cysts, polyp or tumor of maxillary sinus 6. Osteomyelitis of sinus 7. Infected maxillary implant denture 8. Malignant diseases  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Clinical Features 1. Symptoms: i. Nasal discharge from posterior region of nasopharynx into the mouth, leading to fowl taste. ii. Epistaxis (unilateral bleeding from nose) iii. Change in voice due to enhanced column of air iv. Pain in the region v. Popping out of an antral polyp in chronic cases  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. 2. Signs: i. Tenderness over maxilla ii. Edema over cheek and infraorbital region. iii. Otitis media (middle ear injection) iv. Fowl odour and halitosis v. Nasal congestion  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Diagnosis clinically Part of bony floor of sinus seen along with extracted tooth apex Close nose and blow inward, bubbling of air in the oral opening of fistula or the blowing of cotton kept in the area is seen Radiographic evaluation Rhinoscopy  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Treatment The treatment of oro-antral fistula aims at: 1. Protect sinus from microorganism 2. Prevent escaped of fluid via communication 3. Establish drainage via inferior meatus 4. Eliminate existing pathology of sinus  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Treatment of early cases (Iatrogenic opening) (where fistula has not formed and only communication has occurred): Immediate primary closure by sliding buccal flap and acquiring enough soft tissues to cover the whole opening Supportive treatment of decongestants,mucolytics, antibiotics and analgesics is recommended.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Treatment measures to prolong surgical closure, especially when root piece has to be retrieved at a later date:- This is done by following ways: 1. Gauge packed in medicaments like white head varnish is sutured and held in the position till surgery. 2. Acrylic stent is placed in position till surgery.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. Treatment of delayed cases (chronic fistula): 1. If patient comes within 24 hours then the edge is cleaned and primary closure is achieved by sliding buccal flap technique. 2. If patient comes after 24 hours then postpone the treatment for 3-4 weeks until the gingiva has healed and fit for surgical procedure.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. 3. If patient comes after gingival has healed (chronic fistula) then surgical closure of the opening along with Caldwell Luc operation to retrieve root piece or to drain out the pusis done. The surgical closure can be done by advancing either buccal flap or palatal flap by combination of buccal and palatal flap.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. i. Buccal flap advancement procedure (Von Rehrmann flap): After excising the whole fistulous tract along with some soft tissue margin , a trapezoidal buccal flap is reflected to close the whole opening. Sutures are placed over firm bone and post operative care are taken.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. ii. Palatal flap advancement procedure: After excising the whole fistulous tract along with same soft tissue margin, a palatal flap of enough length and containing the anterior palatine artery for providing adequate blood supply is reflected. Iodoform gauge is placed over the raw healing palate and proper post operative care is taken.  MAXILLARY SINUS DISORDERS (Oro-antral Fistula) cont. iii. Metallic - foil closure of oroantral communication: Both facial and palatal mucoperiosteal flaps are reflected and the whole fistulous tract along with its margins are excised. A metallic - foil "Patch“ (usually gold foil) is adapted to cover the whole defect and positioned between alveolar process and overlying buccal and palatal mucoperiosteal flaps. The mucoperiosteal flap is then repositioned and sutured over the foil  MAXILLARY SINUS DISORDERS (Functional Endoscopic) Functional Endoscopic Sinus Surgery (FESS) It is a minimally invasive technique where the sinus air cells and sinus ostia are opened under direct visualization to restore the Normal functions of the paranasal air sinuses with mucocilliary activity.  MAXILLARY SINUS DISORDERS (Functional Endoscopic ) cont. identifying and correcting the primary cause of the disease, secondary disease in sinus will often improve spontaneously.  MAXILLARY SINUS DISORDERS (Functional Endoscopic ) cont. Advantages over conventional sinus surgery:- 1. Surgery is less extensive 2. Less removal of normal tissues 3. Surgery can be performed on an outpatient basis without the need for nasal packing. 4. Better visualization is obtained during surgery by the use of endoscopes.  MAXILLARY SINUS DISORDERS (Functional Endoscopic ) cont. Indications for FESS: 1. Chronic sinusitis 6. Orbital decompression 2. Nasal polyposis 7. Optic nerve decompression 3. Sinus mucoceles 8. Foreign body removal 4. Excision of selected tumors 9. Epistaxis control 5. CSF leak closure 10. Orbital abscess and cellulitis.