THE DISEASES OF MAXILLARY SINUS

INTRODUCTION:
Largest of the PNS

Also known as the antrum cave of Highmore English

physician described an infection of sinus in 1651.
First sinus to develop.
In addition to maxillary sinus, the other sinuses we haves
are:
o the ethmoids
o the sphenoids
o the frontals
The adult maxillary sinus is a pyramid which has a volume of approximately 15 ml
(34x33x23mm). The base of the pyramid is the nasal wall with the peak pointing toward the
zygomatic process. The anterior wall has the infraorbital foramen located at the midsuperior
portion with the infraorbital nerve running over the roof of the sinus and exiting through the
foramen. This nerve can be dehiscent (14%). The thinnest portion of the anterior wall is just
above the canine tooth--the canine fossa. The roof is formed by the orbital floor and transected
by the course of the infraorbital nerve. The posterior wall is unremarkable. Behind this wall is
the pterygomaxillary fossa with the internal maxillary artery, sphenopalatine ganglion and the
Vidian canal, the greater palatine nerve and the foramen rotundum. The floor, as discussed
above, varies in it's level. From birth to age nine the floor of the sinus is above that of the nasal
cavity. At age nine the floor is generally at the level of the nasal floor. The floor continues to
sink as the maxillary sinus pneumatizes. Because of the close relationship with the dentition
dental disease can cause maxillary infection, and tooth extraction can result in oral-antral
fistulae.

Embryology

3rd IU month - mucosal outpouching of the ethmoidal infundibulum (1 pneumatization

confined to mucosa of nasal capsule)
2 pneumatization - 5th IU month growth into adjacent maxilla
a. 7mm in AP length
b. 4mm in height and width
c. Volume 6-8ml.
Post natally- Sinus grows at yearly rate of 2mm vertically and 2mm AP.
a. By 4th or 5th month radiographically it appears.
Postnatal growth continues rapidly in all the three dimension
with 3 recognized growth spurts.
a. Birth-2.5yrs
b. - 7.5-10yrs
c. - 12-14yrs

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

The max. sinus is usually present at birth, it starts effectively around the age of 8.

By third year sinus extend laterally to underneath the infraorbital foramen where the
sinus floor is still above the nasal floor.
By 7yrs of age growth corresponds to the eruption of the permanent tooth. Final growth
spurt corresponds to the eruption of posterior teeth
With completion of all the maxillary permanent teeth expansion of maxillary sinus fill the
growing maxillary bone to produce the adult pyramidal shape of the sinus.
Floor of the sinus approximately 5-12mm below the nasal floor.
Between15-18yrs minimal changes takes place

Anatomy of maxillary sinus

Vascular supply
Branches of the internal maxillary artery supply this sinus. These include the infraorbital
(as it runs with the infraorbital nerve), lateral branches of the sphenopalatine, greater palatine,
and the alveolar arteries. Venous drainage runs anteriorly into the facial vein and posteriorly into
the maxillary vein and jugular vs. dural sinus systems.
Innervation
The maxillary sinus is innervated by branches of V2. Specifically, the greater palatine
nerve and the branches of the infraorbital nerve.

Horizontal pyramidal shape consists of a base an apex and four sides.

Base Vertical Lateral wall of the nasal cavity. Apex- Junction of the maxillary and zygomatic
bone
Medial wall
Also refer to the base of the sinus formed by- lateral wall of the nose, namely
Inferior nasal concha , Perpendicular plate of palatine bone, Uncinate process of the ethmoid
Descending part of the lacrimal bone
Wall is slightly convex towards the sinus
Pars membranacea
Clinical significance
Maxillary ostium
SUPERIOR/ ORBITAL WALL
Roof of the sinus and floor of the orbit
Superior wall most vulnerable among all sinus walls to trauma
Tumors of the sinus erodes this wall can cause proptosis, alteration of pupillary level, neurologic
symptoms associated with the infraorbital nerves
ANTERIOR/ FACIAL WALL
Anterior aspect of the maxilla piriform aperture medially to the zygomaticomaxillary suture
laterally, infraorbital rim superiorly to alveolar process and maxillary teeth inferiorly.

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

The maxillary sinus as a pyramid

Convex towards sinus. Thinnest portion over canine fossa - approach to the sinus via CaldwellLuc procedure
POSTEROLATERAL WALL
Made up of zygomatic bone and greater wing of sphenoid
Posterior superior alveolar nerves and vessels sometimes in close contact with the sinus mucosa.
Acute sinusitis pain in posterior upper posterior teeth
This wall is convex, bulging posteriorly
Access to the pterygopalatine fossa is accomplished by careful removal of this wall
FLOOR / BUCCOALVEOLAR WALL
Formed by the junction ant sinus wall and lateral nasal wall
Septa may be present in the alveolar recess of the sinus -. Of significance in root retrieval and
sinus drainage
Floor is 1-1.5 cm below to the nasal floor
Risk of creating oroantral fistula increases with age
Descending order of proximity to sinus: palatal root of 1st molar, 2nd molar, 1st molar, 3rd
molar, 2nd PM, 1st PM, canine

1. They humidify and warm the area .

2. They regulate the intranasal pressure increasing the surface area of the olfaction, so the
smell sense becomes better.
3. They lighten the skull; that's why ppl with sinusitis say " rase thaglan".
4. People notice their voice changes with upper respiratory tract infection which is the most
to cause cervical lymphadenopathy and it's viral most of the time ,, so their voice changes
because the resonance becomes different when the person has the flue .
5. They absorbing shock .
6. They contributes to the facial growth , cuz the facial growth is a cartillagenous growth
through the nasal septum and sphenooccipital synchondrosis which is elongation of the
base of the skull .

Physical Examination
Both the left and the right side should be examined simultaneously to compare the findings.
Crepitations, sensitivity to pressure, painful trigger points and change in texture of the
overlying skin and mucosa as well as deformations of neighboring structures
Rhinoscopy:
Anterior rhinoscopy should be performed with a normal speculum. The nasal speculum
should be held in the examiners left hand with the left index finger pressed firmly on the
ala of the nose to stabilize the position of the upper blade.
The examiners right hand should be used to position the patients head.

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

FUNCTION

Nasal Endoscopy:
These are rigid fibro optic instruments which provide information about areas not well
visualized by rhinoscopy. The advantage over rhinoscopy is the improved visualization and
illumination of the intra nasal structures.
Sinus Endoscopy:
Is indicated when there is high index of suspicion of an intra sinus pathologic
condition or if any therapeutic procedure is anticipated.
Aspiration:
Sinus aspiration is usually not necessary to establish a diagnosis of either a/c chronic
sinusitis because non-invasion means are usually adequate.
This is indicated in case of sinusitis that are unresponsive to multiple course of antibiotic
as well as when there is severe unremitting pain or an orbital or intra-cranial complication
of sinusitis.
Trasnillumination
Is performed in a darkened place by a lightened instrument into the with the pt lip close
tightly oral cavity

Observation then can be made as to how well the ant wall of the sinus transilluminates

When findings in the both antra are markedly different,the dull side suggest that the
sinus mucosa may be thickened or sinus contain fluid or mass

Most commonly used as a screening tool

Standard radiograph
Plain film evaluation of the max sinus should include at least 3 standard views:
Caldwel,
Waters
lateral view.
CT:
THREE DIMENSIONAL CT
MRI
CLASSIFICATION OF MAXILLARY SINUS PATHOLOGY
INFLAMMATORY CONDITIONS
MAXILLA RY SINUSITIS
-ACUTE
-CHRONIC
CYSTICCONDITIONS
*INTRINSIC
-MUCOCELE
*EXTRINSIC
-OKC
-RC

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

DIAGNOSTIC IMAGING

BENIGN TUMOURS
*PAPILLOMAS
*JUVENILE ANGIOFIBROMA
*AMELOBLASTOMA
*ODONTOGENIC MYXOMA
*PLEOMORPHIC ADENOMA
*OSSIFYING FIBROMA
MALIGNANT TUMOUR
*SCC
*ADENOCYSTIC
CARCINOMA
*OSTEOSARCOMA
*FIBROSARCOMA
*LYMPHOMA

ORO ANTRAL FISTULA

*OAC
*DISPLACED ROOT TIPS
*# TUBEROSITY
*FOREIGN BODY IN SINUS
*RESORPTION DUE TO EXPANSILE LESIONS

Maxillary Sinusitis
Sinusitis is a condition involving inflammation of paranasal sinus mucosa, the term is usually
restricted to conditions that are primarily inflammatory, cause subjective symptoms and persist
longer than 7 days.
CLASSIFICATION OF SINUSITIS
1. Clinical
Acute Sinusitis
Chronic Sinusitis
Nosocomial Sinusitis
Odontogenic Sinusitis
Immunocompromise Sinusitis
Cystic fibrosis Sinusitis
2. Based on duration (American association of otolaryngology & Head & neck Surgery)
Acute sinusitis < 4wks
Subacute sinusitis 4 12wks

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

RARE CONDITIONS
*PHYCOMYCOSIS
*LYTIC OSTEITIS
*WEGNERS GRANULOMATOSA
*ANTROLITH

Chronic sinusitis > 12wks

Causes Of mucostasis
1. Cilliary dismotility
2. Thickened mucous secretion
3. Anatomical abnormalities
Concha bullosa
DNS
Malformed uncinate process
4. Space occupying lesions
Tumours
Cysts
Polyps
Mucoceles
Parasitic sinusitis
Reported only in AIDS patients
Microsporadium
Cryptosporadium
Acanthamoeba
SIGNS & SYMPTOMS

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Heavy feeling in the head

Constant pain in upper part of the cheek
Maxillary teeth on affected side may be painful
Unilateral foul nasal discharge
Unilateral nasal obstruction on affected side
Tenderness to pressure or swelling over the involved sinus
Sensitivity of tooth on percussion
Fever, chills, malaise
Extension in orbit or intracranial cause enopthalmous and meningitis

MANAGEMENT
Medical management
Surgical Management

ANTIBIOTICS
Acute sinusitis
Amoxicillin is the drug of choice (3to 10 days course is indicated)
Pencilin allergic patient- TMP-SMX is the first line drug
Amoxycillin fails to improve clinical situation- augmentin should be
considered
Azithromycin, erythromycin,doxycycline can also be given
Chronic sinusitis
Antibiotic coverage is shifted towards covering oral anaerobes
Pencillin with metranidazole
Clindamycin
Nosocomial
ampicillin/ sulbactum,
Should be culture specific if possible

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

The medical or conservative management is preferred over the surgical one

MEDICAL MANAGEMENT
ANTIBIOTICS

ANALGESICS
SYSTEMIC DECONGESTANTS
TOPICAL DECONGESTANTS
ANALGESICS
TOPICAL STEROIDS
ANTIHISTAMINES
SALINE LAVAGE
MUCOLYTICS

Surgical Management
Sinus Aspiration & Lavage
Caldwell-luc approch
FESS

The fractures involving max sinus can be classified as a single wall fracture (isolated), as a part
of complex fractures, or as a component of a transfacial fractures
Isolated fractures
Isolated wall
fractures are uncommon but can result from a direct blow, that involve the
max roof
Blow out fractures
On plain film trap door
effect
There may be one or more free bone fragments, or one end of a single fragment may be in
contact with the remaining wall
Hanging drop effect
TRANSFACIAL FRACTURES
LeFort I involves medial and lateral walls of the sinus
LeFort II involves the roof, anterior, and posterolateral walls
COMPLEX FACIAL FRACTURES
Tripod (trimalar) fracture involves sinus. Involves orbital floor, anterior and posterior
walls, zygomatic arch, and zygomaticofrontal suture
ZMfracture is Similar to trimalar fracture but is more extensive along with involvement
of pterygoid
Displacement of tooth or root
Displacement of a root tip in the maxillary sinus during extraction is a common
complication.
Commonly 1st molar ( almost 80%)
2nd molar (20%) and sometimes 3rd molar premolar and rarely canines.
Palatal Roots
When occurs
First maneuver is to place the patient in upright position.
-Location must be determined.
Some instances:
-Root tip slipped between the outer wall of the maxilla and the periostium.

-May penetrate the periostium and become located sub periosteally.

-Also possible that the root tip is located in the antrum but is beneath the intact sinus
membrane.
The first consideration is whether there is buccal displacement,( often determined by
manual palpation.)
Next is to determine the antral perforation,( determined by patient blow air through the
nose with nostrils closed).
The socket should never probe in an attempt to determine a perforation because this could
cause a perforation when one dose not exist or further movement of the root tip.

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Trauma

Panoramic and periapical radiograph can be used to locate the position of the displaced
root tip.
Once it is determined that the root tip is in the sinus
-Gently place the suction tip in the socket.
- Sinus can be irrigated with a sterile saline solution and suction applied.
If the root is still inside the sinus, surgical management can be planned.

Benign lesions
CYSTS
Intrinsic origin
Mucus retention cyst
Mucocele
Cholesteatoma
Pseudocyst

Extrinsic origin
Ameloblastoma
OAT
Odontoma
Odontogenic myxoma
Surgical approaches
FESS
CALDWELL- LUC
LATERAL RHINOTOMY AND MEDIAL MAXILLECTOMY
WEBER- FERGUSSION APPROACH FOR MAXILLECTOMY

Malignant lesions
In the PNS malignant tumors comprises less than 1% of all malignancies
Neoplasm arises fundamentally from the epithelial origin
Metaplastic type of epithelium- squamous cell lesion

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Extrinsic Origin
Odontogenic keratocyst
Dentigerous cyst
Radicular cyst
Calcifying odontogenic cyst
TUMORS
Intrinsic origin
Squamous papilloma
Inverted papilloma
Juvenile angiofibroma
Vascular lesions
Myxoma
Giant cell tumor

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Glandular type- adenocarcinoma group

`mean age-50-65yrs

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Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Treatment
-Surgery
Maxillectomy
medial
segmental
midfacial deglowing
with orbital exenteration
Radiation therapy
Chemotherapy
combined therapy

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Surgical approaches

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OROANTRAL FISTULA
An oro antral perforation is an unnatural communication between the oral cavity and maxillary
sinus.
An oro antral fistula is an epithelized unnatural communication between these two cavities.
ETIOLOGY
Extraction of teeth
Destruction of the floor of the sinus by periapical lesions.
Perforation of the floor of the sinus and sinus membrane with injudious use of instruments
SYMPTOMS OF A FRESH ORO-ANTRAL COMMUNICATION
regurgitation of the liquids from the mouth into the nose in the extracted side
unilateral epistaxis
escape of air from mouth into the nose and alteration in vocal resonance
inability to blow out the cheek
excruciating pain
SYMPTOMS OF AN ESTABLISHED ORO-ANTRAL FISTULA
Once a fistula is created superimposed infection of the sinus ensues due to oral organism.
Post nasal mucus drip accompanied by a nocturnal cough, hoarseness, ear ache or
catarrhal deafness.
Pain may be severe, throbbing or dull ache
Malaise, fever, anorexia

RECENTLY CREATED COMMUNICATION

Surgery in the vicinity of the maxillary sinus such as extraction of the maxillary
posterior teeth

Attempted extraction of maxillary molar root which

disappears as soon as force is
applied
Attempted extraction of a partially erupted third molar
TEST TO ESTABLISH THE PRESENCE OF ORO-ANTRAL FISTULA
-Nose blowing test
-Escaping air bubbles, blood, mucopus at the oral orifice
-A wisp of cotton held just below the alveolar opening will usually be deflected by the air stream
MANAGEMENT
IMMEDIATE TREATMENT FOLLOWING THE CREATION OF AN ORO-ANTRAL
COMMUNICATION
-The closure of the oro-antral fistula should be performed
-To protect the sinus from oral microbial flora
-To prevent escape of fluids and other contents across the communications

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

PHYSICAL SIGNS
those presenting immediately after the formation of the fistula
those relevant to an established oro-antral fistula

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-To eliminate existing pathology

-The ideal treatment following the creation of oro-antral communication is to perform an
immediate surgical repair so that primary closure can be combined with antibiotic prophylaxis to
prevent sinus infection.
If the oro-antral communication is complicated by the deflexion of the tooth or root in
the maxillary sinus and is in convenient position, it should be recovered
In all cases in which there has been an immediate closure following penetration of the
antrum. Action supporting measures should be instituted
.this includes
Antibiotics
Analgesics
Nasal decongestants
TEMPORARY THERAPEUTIC MEASURES BEFORE SURGICAL CLOSURE
This includes
Pack
the ribbon gauge pack is positioned at the socket and held securely by a suture frame work
denture plate
this is indicated if the surgical repair of the fistula is to be deferred

TREATMENT OF OAF PRESENT MORE THAN ONE WEEK

IN these cases fistulous tract is well epithelised. At this stage surgical

closure is necessary. Pt presents with symptoms 2-3 wks after extraction complains of
foul taste in the mouth. Pus discharge from fistula into the mouth. Drainage of the sinus
should be re established through the fistula by enlarging it surgically and the sinus
should be gently irrigated daily until it is clear.
SURGICAL APPROACHES
LOCAL FLAPS
BUCCAL FLAP

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

TREATMENT OF DELAYED CASES

If an OAF is referred after a period of 24 hrs of its occurrence

When a period of 24 hrs has elapsed the soft tissue margins often get infected .
it is preferably to defer the treatment till the gingival edges shows sound healing

Prophylactic treatment consist of antibiotic along with local de

congestants and analgesics should be prescribed

If the pt produces a purulent discharge from the fistula or develop signs

of a/c or chronic sinusitis the sinus should be gently irrigated with warm normal saline

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Rehrmann Buccal Advancement Flap

Moczair Buccal Sliding Flap

Schchard Transversal Flap & Egyedi Bipedicle Flap

Straight advancement flap

& ashley Rotational falp.

Ito & Hara submucosal conective tissue flap

& Hendersen pedicle flap

Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Palatal Flaps

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Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

Combined flaps

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Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

TEMPORALIS FLAP

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Diseases Of Maxillary Sinus: DR. JOSEPH JOHN K. POTHANIKAT

NOTES:

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