Maxillary Sinusitis

• Inflammation of the maxillary sinus either due

to infection or allergy is called Maxillary
sinusitis
• Inflammation of most or all of the paranasal
sinuses simultaneously is known as
Pansinusitis
 Causes of Maxillary Sinusistis
1. Spread of infection from a dental abscess
eg: periapical or periodontal abscess of any
maxillary tooth with roots in intimate relation to
the floor of the antrum

2. Foreign body in the maxillary sinus

eg: tooth or roots,
endodontic materials
endosseous implants
plastic, wood or glass pieces entrapped
during maxillofacial injury
bone sequestration following osteotomies
3. Oroantral Fistula
4. An infected jaw cyst
5. Facial fractures involving the maxillary sinus
 Acute Maxillary Sinusits
• “Heavy feeling” in the face
• Aching or throbbing pain in the upper part of the
cheek or over the entire side of the face
• Pain exacerbated by bending the head down
• Dental pain often precedes the pain in the cheek
• Foul unilateral nasal discharge
• Maxillary ostium may be occluded or nasal
passage may be blocked with congealed
secretions resulting in nasal obstruction on the
affected side
 Investigations
Transillumination test
• Will reveal an opacity on the affected side
• When the sinuses are full of pus the light is
not transmitted through the tissues
Radiography (15°occipitomental view or
Water’s view)
• Uniform opacity of the affected sinus
• Sometimes fluid level can be appreciated
 Treatment
• Antibiotic therapy
Erythromycin 250mg 6 hourly for 5 days
Ampicillin/ Amoxycillin for 5 days
• Decongestants – in the form of nasal
inhalation
• Steam inhalations
• Analgesics to control pain
 Chronic Maxillary Sinusitis
• Transition of a chronic state occurs after a period
of 2 weeks
• History of repeated attacks post nasal or nasal
mucopurulent discharge
• An obvious oroantral fistula may present with
prolapse of a polypoidal reddish mass into the
mouth
• Transillumination will reveal an opacity of the
affected side
• Radiograph will reveal a thickened lining
membrane or opaque air space may enclose
masses of polyps
 Treatment

• Removal of the source of infection

• Removal of the antral polyp if present
• Gentle irrigation of the air space and proper
closure of the wound
• Postoperative antibiotics, nasal decongestants
and steam inhalations
• Caldwell-Luc Procedure as the last resort
 Caldwell – Luc Operation
Indications
• Chronic Maxillary sinisitis
• Removal of foreign bodies, eg: teeth, tooth
roots etc
• Exploration and management of certain
zygomaticomaxillary or orbital floor fractures
• Management of oroantral fistula
• Biopsy and excision of benign lesions
 Procedure
• Anaesthesia: General or local anesthesia
• Incision: 2-3 cm long curvilinear full thickness
incision, 2-3 mm above the mucogingival
junction, with anterior limit at the cuspid
eminence
• Reflection of the mucoperiosteal flap
superiorly upto the infraorbital foramen
• Creation of a bony window 3-4 mm above the
apices of the adjacent premolars and molars
• Size of the bony window should be approx 1.5
×1.5 cm
• Excision of the antral mucosa at the window
• Purpose of the sugery achieved
• Thorough irrigation of the antrum and
hemostasis
• Nasal antrostomy
• Packing the antrum with ribbon gauze
impregnated with antibiotic ointment
• One end of the ribbon gauze delivered through
the nasal antrostomy or the incised wound itself
• Closure of the wound
 Complications

• Injury to the infraorbital nerve

• Injury to the floor of the orbit
• Injury to the roots of the teeth
• Subcutaneous emphysema
• Iatraogenic oroantral communication
Oroantral Fistula/Communication
An oro-antral fistula is an unnatural
communication between the oral cavity and
the maxillary sinus
 Causes
• Extraction of maxillary teeth
• Destruction of the portion of the floor of the sinus
by periapical lesions
• Perforation of the floor of the sinus and sinus
membrane with injudicious use of instrument
• Forcing a tooth or root into the sinus during
attemted removal
• Massive trauma to the face
• Surgery to the maxillary sinus
• Osteomyelitis of the maxilla
• Infected upper implant dentures
• Gumma involving the palate
• Malignancies of maxillary sinus
 Symptoms
• Regurgitaion of liquids from the mouth into the
nose
• Unilateral epistaxis due to blood in maxillary
sinus escaping through the ostium
• Escape of air from mouth into the nose
• An alteration in vocal resonance
• Inability to blow out the cheeks
• Unilateral purulent or mucopurulent nasal
discharge in long standing case
• A foul salty or sweetish fetid taste
 Tests to establish the presence of an oronatral
fistula
Nose blowing test
• Compression of the anterior nares followed by gently
blowing the nose with the mouth open causes the air
to escape and bubble the blood or pus out through
the oral orifice
• A wisp of cotton held just below the alveolar opening
will usually be deflected by the air stream
• A mouth mirror held just below the alveolar opening
will get covered by the warm inspired air escaping
through the fistula into the oral cavity
 IMMEDIATE TREATMENT
If small ( ≤ 2mm ) in diameter
a) Ensure formation of high quality clot,
b) Advise for sinus precaution for 10 -14 days
c) Antibiotics
d) Systemic decongestants for 7 -10 days
If moderate (2-6mm) in diameter
a) Figure of eight suture over tooth socket
b) Advise for sinus precaution
c) Antibiotics
If large ( ≥ 7mm) in diameter)
a) flap procedure
 Treatment of delayed cases
[established oroantral fistula]

Surgical closure
 LOCAL FLAP PROCEDURE
• Buccal flap
• Palatal flap
• Combination of buccal & palatal flap
 BUCCAL MUCOPERIOSTEAL FLAP

Types

• Advancement flap
• Sliding flap
 Buccal flap advancement operation
• Originally described by Von Rehrmann in 1936.
• Most satisfactory method of closing oroantral
communication.
Procedure
• Injection of LA in the mucobuccal fold
• Excision of the fistulous tract.
• Elevation of the buccal mucoperiosteal flap, with flap
released to depth of labial vestibule.
• Buccal mucoperiosteal flap is advanced over alveolar
process & sutured to palatal mucosa to close fistulous
tract.
Rehrmann’s buccal advancement flap
•Simple, well tolerated & common
buccal flap procedure for the
closure of fistula.
•Has broad base & ensures
adequate blood supply.
•Improved flap mobility due to
parallel incisions in the periosteum
at the base of flap.
•Donor site closes exactly with no
denuded area for granulation
Moeziar Buccal sliding flap

•It necessities shifting the flap

one tooth distally from the
area of fistula causing greater
amount of dentogingival
detachment in order to
facilitate the shift.
•May cause variable degree of
periodontal diseases.
•More suitable in edentulous
patient.
 Palatal flap
• Straight advancement flap
• Veau/rotational advancement flap,
 Straight advancement Rotational
flap advancement flap
• Doesn’t offer much • Does offer much greater
greater mobility. mobility.
• Suitable for closure of • Suitable for closure of
minor palatal / alveolar larger alveolar / palatal
defect. defect
• Mobilization of small • Mobilization of large
amount of palatal tissue amount of palatal tissue
so no kinking present. so often kinks following
the flap rotation.
 Buccal flap Vs palatal flap
Buccal flaps Palatal flaps
•Are thin so more liable to • Thicker
tear.
•More elastic •It is less elastic as
compared to buccal flaps
•Believed to decrease the •Does not affect the
buccal vestibular height. vestibular height.
•Less vascularised. •More vascularised.
•Simple & widely accepted •Used when buccal flap is
technique not possible.
Combined local flaps
 Distant flaps procedures
Indication
close larger fistulas which are technically
difficult to close by the local flaps.

Types
• Tongue flap
• Buccal fat pad
• Nasolabial flap
 Anteriorly based partial Posteriorly based full
thickness dorsal tongue flap thickness lateral tongue flap
Buccal fat pad graft