Dr. Manish Sharma
Dr. Nida Gaba
MAXILLARY AIR SINUS:
Function of air sinus
Clinical importance of maxillary air sinus
Disease of the maxillary sinus
These are air filled hollow space present within the bone
around the nasal cavity called as paranasal air sinuses.
The sinuses are – (1) Frontal air sinus
(2) Maxillary air sinus
(3) Sphenoidal air sinus
(4) Ethmoidal air sinus
These sinus forms various boundaries of the nasal cavity & all
these sinus communicate with each other and open into the
lateral wall of the nasal cavity.
The sinus are rudimentary or even absent at birth.
They enlarge rapidly at the age of 6 to 7 months.
The maxillary air sinus formed first among the other
It start as a shallow groove on the medial surface of the
maxilla during the fourth month of intrauterian life.
Present as small cavity at birth.
From birth to adult life the growth of sinus due to
enlargment of bone.
It reach maximum size by around 18 years of age.
In old age it enlarge due to resorption of the surrounding
FUNCTION OF AIR SINUS :
The function of air sinus are
(1)Humidification of inspired air
(2) It provides resonance to voice.
(3) It lightens the bone.
(4) It act as thermal insulator to protect organ such as the eye
and cranium from variation in intranasal temperature.
(5) Sinus increase the surface area of the skull.
MAXILLARY AIR SINUS :
Definition: An antrum is a hallow cavity within the bone called maxillary
air sinus. Maxillary air sinus known as antrum of Highmore, named after an
English anatomist Nathaniel Highmore who described it. It is one of the
largest paranasal sinus.
ANATOMY OF THE MAXILLARY AIR SINUS :
It is basically pyramidal in shape with the base of the pyramid forming the
lateral nasal wall and apex at the root of the zygoma.
Capacity : 10-15 ml (in adult antrum)
Size : Dimension of sinus are
Height – 3.5 cm
Width – 2.5 cm
Anteroposterior Depth – 3.2 cm
ROOF OF THE ANTRUM :
- Formed by floor of the orbit.
- Thin plate of orbital plate of maxilla.
FLOOR OF THE SINUS:
- Alveolar process of the maxilla.
- its level is lower than the level of the floor of the nose.
- Closely related to root apices of the maxillary premolar and
-Formed by the facial surface of the maxilla.
- Canine fossa is an important structure of this wall.
- Formed by sphenomaxillary wall.
- A thin plate of bone separate the antral cavity from the
MEDIAL WALL :
- Lateral wall of the nasal cavity.
- The opening of the sinus is closer to the roof and thus at a
higher level than the floor.
Lymphatic Drainage : - submandibular lymph node.
Nerve supply: - Infraorbital nerve
- Anterior superior alveolar nerve
- Middle superior alveolar nerve
- posterior superior alveolar nerve
CLINICAL IMPORTANCE :
Dental infection: Infection from the maxillary premolar and
molars can easily communicate and infect the maxillary antrum.
Oroantral Communication: Traumatic extraction of maxillary
teeth can cause oroantral communication.
Root Pieces: Root pieces of maxillary teeth may sometimes be
accidentally forced into the maxillary antrum.
Maxillary Sinusitis : Because of the thickned and inflammed
sinus lining compresses the nerve supply of the maxillary
posterior teeth causing tenderness of the maxillary teeth.
The infraorbital and superior alveolar vessels are freqently
ruptured in maxillary fracture causing the hemotoma formation
in the antrum.
NORMAL RADIOGRAPHIC ASPECT
LARGE MAXILLARY AIR SINUS
SMALL MAXILLARY AIR SINUS
maxillary sinusitis: It is the inflammation of the maxillary
It may be supurrative or non supurrative inflammation of the
It is the most freqently infected of the paranasal sinus.
(1)Nasal Infection (most common) : Viral rhinitis and influenza
are the common infection.
(2) Dental Infection:
Infection from the maxillary posterior teeth can easily spread
to the maxillary sinus as the plate of bone dividing the root
apices from the sinus .
(3)Contaminated Swimming water :
Diving in such water forcibly directs water into the nasal cavity
and then into the sinus.
Fracture of the maxilla or zygoma, gun shot wound or
penetrating injuries can lead to sinusits.
During early phase of inflammation, intial vasodilation leads to
increases production of mucosa from the mucosa gland.
The mucosa consequently exert pressure within the lumen of
The patient gives history of `catching cold’ 3 to 4 days earlier.
Nasal block secondary to rhinitis.
Increase in purulent, thick, discoloured and foul smelling
nasal discharge is prominenant features.
A sense of fullness and pain on cheek on bending forward.
Patient producing cough secondary to the nasal discharge
with onset of pharyngitis.
The related maxillary teeth are tender on percussion.
Nasal resonance- change in the voice due to blocking of sinus.
Constitutional symptoms – Fever, Headache, Malaise,
difficulty in breathing.
(1) Water view radiograph.
(2) Transillumination test: Shows opacity involved sinus.
(3) Culture: Nasal secretion may be for culture sensitivity test to
see the organism involved.
Waters' view of the sinuses showing partial opacification of
the right maxillary sinus, with an air-fluid level.
1) Antibiotics: Broad spectrum antibiotics.
2) Decongestant: Decreases the congestion and edema of the
nasal sinus. Help in the drainage of the sinus.
3) Analgesics: Paracetamol provide symptomatic relief.
4) Steam inhalation: Steam+ Menthol+ Tincture.
After Decongestion for 15 to 20 minutes.
Helps in drainage.
5) Hot Fomentation: Local heat application is soothing to the
Acute maxillary sinusitis usually responds well to medication.
It is basically involves inserting a canula into the maxillary sinus trough
the inferior meatus.
Luke warm water is irrigated through the sinus and this drains out
through the osteum along with the sinus exudates.
- Chronic sinusitis
- Osteomylelitis of the maxilla
- Orbital cellulites
- Middle ear infection
- Spread to the other sinus.
SUBACUTE MAXILLARY SINUSITIS:
It is the intermediate stage between acute and chronic
There is pain only in the form of the local discomfort.
patient has persistent discharge.
The voice is nasal, throat is sore with constant irritating
Patient can not sleep well.
The disease may take a long course over week or months.
Infection of the that last for months or year is called chronic
It is most commonly is an extension of an acute sinusitis
which failed to resolve completely.
CAUSATIVE ORGANISM: - Aerobic organism
- Anaerobic organism.
Ciliated epithelium gets destroyed
Prevent drainage of secretion from the maxilla
Pooling and stagnation of mucopurulent in sinus
Progression of infection
Cilliary damaged and edema
Mucosa may become thick and polypoidal.
Symptoms are non specific unlike acute sinusitis.
Patient not having pain or tenderness.
Purulent nasal discharge may be foul smelling.
Block of nasal and change in voice due to loss of resonance.
Water’s view radiograph.
Culture of the discharge from the sinus.
I. Treat any dental infection if present.
II. Antral leavage: If more than three successive punture have
purulent fluid than the treatment should be more radical.
III. Intra nasal Antrostomy : A window or opening is created in
the inferior meatus of facilltates drainage of the sinus.
IV. Cald Well luc Operation.
George Caldwell in 1893 from New York described a method of
gaining entry into the maxillary sinus via canine fossa with
Henri Luc in 1897 also reported the same procedure .
Later on the procedure was accepted as Caldwell-Luc operation
CALDWELL LUC OPERATION:
This is the procedure by which the antrum is entered intraorlly
through the anterior wall and all irreversible disease is
This is followed by an antrostomy to promote permanent cure.
• Chronic maxillary sinusitis.
• Removal of foreign bodies in the antrum such as root pieces.
• Treatment of oroantral fistula that fails to heal.
• treatment of benign dental cyst tumor.
• Biopsy procedure for a suspected malignancy in the antrum.
• Recurrent antrachoanal polyp.
• Approach to pterygopalatine fossa, sphenoidal sinus,
It is the thickened mucous membrane of a chronically inflamed sinus
frequently forms into irregular folds called Polyps.
• Polyps may cause displacement or destruction of bone
• Polyps are soft, painless, noncancerous growths on the lining of your
nasal passages or sinuses.
• They result from chronic inflammation due to asthma, recurring
infection, allergies, drug sensitivity or certain immune disorders.
• Small nasal polyps may not cause symptoms. Larger growths or groups
of nasal polyps can block your nasal passages or lead to breathing
problems, a lost sense of smell, and frequent infections.
• Polyps usually occurs with a thickened mucous membrane lining because
the polypoid mass is no more than an accentuation of mucosal thickening.
• Bone destruction or displacement associated with polyps may mimic a
benign or malignant neoplasm.
• Bone destruction associated with radiopacification.
Retention pseudocyst is used to describe several related conditions, one etiology
suggests that blockage of the secretory ducts of seromucous glands in the sinus
mucosa which results in a pathologic submucosal accumulation of secretions
resulting in swelling of tissues.
A second theory suggests that the serous nonsecretory retention cyst arises as a
result of cystic degeneration within an inflamed, thickened sinus lining
Both types of lesions are called pseudocysts because they are not lined by
Arrows pointing to domeshaped radiopaque mass on
floor of the maxillary sinus
Mucous retention cyst producing a dome shaped soft tissue radiopacity emanating from
the floor of the maxillary sinus. The cyst may disappear spontaneously due to rupture
and may reappear after a few
The mucosal lining of the paranasal sinuses is composed of respiratory epithelium
and is normally about 1mm thick. Normal sinus mucosa is not visualized on
radiographs however when the mucosa becomes inflamed from infection or allergic
process it may increase in thickness 10 to 15 times which is seen radio graphically.
The inflammatory change is referred to as Mucositis.
• The thickness of sinus mucosa in an asymptomatic individual may vary
considerably over a relatively short period of time.
• Most of the inflammatory episodes that result in thickening of the mucosal lining of
the sinuses are unrecognized by the patient and are discovered only accidentally on
• The image of thickened mucosa is readily detectable in the radiograph as an
noncorticated band more radiopaque than the air-filled sinus.
• Floor of maxillary sinus adjacent to an area of inflammation.
Arrows pointing to localized thickening of the mucosa of the maxillary
Antroliths occur within the maxillary sinuses and are the result of deposition
of mineral salts such as calcium phosphate, calcium carbonate and
magnesium around a nidus which may be introduced into the sinus
A calcification in the maxillary sinus. This calcification may be of long standing
mucous or foreign bodies, including tooth fragments.
• The smaller antroliths are usually asymptomatic and usually are discovered as
incidental findings on radiographic examination.
• If they continue to grow, the patient may have associated sinusitis, blood-stained
nasal discharge, nasal obstruction or facial pain.
• Occur within the maxillary sinus and are positioned above the floor of the maxillary
• They have a well-defined periphery and may have a smooth or irregular shape.
• Radiopaque, may have a ‘laminated’ appearance with radiopaque and radiolucent
bands evident due to continued laying down of calcium salts. (This looks similar to
layers of an onion.
arrow pointing to well-defined
radiopaque area not attached to the
border of the maxillary sinus
superior to the maxillary right first molar
A Mucocele is an expanding, destructive lesion that results from a blocked sinus
• A mucocele in the maxillary sinus may exert pressure on the superior alveolar
nerves and thus cause radiating pain.
• The patient may first complain of a sensation of fullness in the cheek, and the
area may swell.
• If the lesion expands inferiorly, it may cause loosening of the posterior teeth in
• If the medial wall of the sinus is expanded, the lateral wall of nasal cavity will
deform and the nasal airway may b obstructed.
• If it expands into the orbit it may cause diplopia or proptosis.
• It is rare in maxillary and sphenoid sinus. 90% of mucocele occur in the
ethmoidal and frontal sinuses
• When size of mucocele increases it becomes more circular.
• It is uniformly radiopaque.
Treatment of the mucocele is usually surgical, using a caldwell-lue operation to
allow excision of the lesion
The epithelial papilloma is a rare neoplasm of respiratory epithelium that
occurs in the nasal cavity and paranasal sinuses.
Unilateral nasal obstruction, nasal discharge, pain and epistaxis may
• It is usually in the ethmoidal or maxillary sinus.
• Appears as a homogenous radiopaque mass of soft tissue density
The osteoma is the most common of the mesenchymal neoplasm in the paranasal
• Occurs both in male and female
• most commonly occurs in second, third and fourth decades
• They may cause nasal obstruction, when present in the maxillary sinus.
• Produce swelling of the cheek and the hard palate.
• In cases extending to the orbit, the ma patient may have proptosis
• The incidence in the maxillary antrum varies between 3.9% and 28.5% of the
incidence in all paranasal sinuses.
• Lobulated or rounded and has sharply defined margin
• Homogenous and extremely radiopaque.
Antrolith, mycolith, teeth or odontogenic neoplasm
Osteoma in the floor of
the maxillary sinus.
Notice the distinguishing
presence of the
trabeculae in the lesion.
Osteoma is the most
common of the benign
nonodontogenic tumors in
the paranasal sinuses.
MALIGNANT NEOPLASMS OF MAXILLARY SINUS
These are rare in occurrence accounting for less than 1%
of all malignancies in the body. Squamous cell
carcinoma comprising 80% to 90% of cancers in this site,
most common primary neoplasm of maxillary sinus.
SQUAMOUS CELL CARCINOMA likely originates from
metaplastic epithelium of the sinus mucosal lining.
• The most common symptoms of cancer in the maxillary
sinus are facial pain or swelling, nasal obstruction and a
lesion in the oral cavity.
• Mean age of the patient is 60yrs, men are more
• The medial wall is the first to get eroded, leading to
nasal signs and symptoms as obstruction,discharge,pain.
• Lesions that arise on the floor of the sinus and produces dental signs and symptoms
like expansion of the alveolar process, unexplained pain and altered sensation of teeth.
• Involvement of sinus roof and floor of the orbit cause signs and symptoms related to
eye: diplopia, proptosis, pain and hyperesthesia and pain over the cheek and upper
• Most carcinoma occur in the maxillary sinuses, but involvement of the frontal and
sphenoid sinuses is comparatively common,
• The internal aspect of the maxillary sinus has a soft tissue radiopaque appearance.
• As the lesion enlarges it may destroy sinus walls cause irregular radioucent areas in
• The medial wall of maxillary sinus is thinned or destroyed.
Squamous cell carcinoma in the right maxillary
sinus producing destruction of the sinus floor and
walls. Clinically the lesion extended into the oral
soft tissues. Squamous cell carcinoma is the
most common malignant tumor of the paranasal
Squamous cell carcinoma of the left maxillary. Notice the
the walls and floor of
It is a descriptive name for a group of apparently related diseases of fungal origin that
occur in the paranasal sinuses and other parts of neck.
• Pseudotumour occurs after a series of recurent infections.
• Their may be recurring pain and a mass simulating a neoplasm
• The mass can cause erosion of the walls of involved sinus and proptosis if orbit is
• Mostly occurs in immunocompromised or those who have systemic diseases like
diabetes mellitus etc.
• It involves masses simulating neoplasms that cause erosion of bony walls of involved
The exudate from dental inflammatory lesion can diffuse through the cortical
boundary of the antral floor. These products can elevate the periosteal lining of
the cortical bone of the floor of the maxillary antrum, stimulating the periosteum
to produce a thin elevated layer of new bone adjacent to the root apex of the
involved tooth, the presence of a halo like layer of new bone indicates
inflammation of the periosteum.
•The periosteal tissue is not visible on radiographs this is referred to as
periosteal new bone formation.
•This ne bone may take the form of one thin radiopaque line or it may be very
thick or rarel laminuted.(similar to onion skin)
•The cyst may dispalce the floor of maxillary antrum.
•Odontogenic cyst are the most common group of extrinsic lesions that
encroach on the maxillary sinuses.
•These cysts that originates outside of the maxillary sinuses encroach on the
space of the sinuses by displacing the sinus borders.
•The cyst enlarges, the sinus decrease in size.
•The result is a radiopaque line between the cyst and the air space of the sinus.
•Radicular cysts commonly encroaching up on the space of the maxillary
•Sinus arise from the first molar and lateral incisors
•Dentigerous cyst most commonly are related to the third molar.
•Large cysts can displace third molars as far as the floor of the orbit
•The invaginating cyst has a curved or oval shaped.
•The internal of the cyst is homogenous and radopaque relative to the sinus
• The cysts displaces the floor of maxillary antrum, large dentigerous or
odontogenic keratocyst can displace third molars as far as the floor of the orbit
• In some cases the cyst may enlarge to the point that it has encroached on
almost the entire sinus and the residual spaces may appear as thin crescent of
air adjacent to the cyst.
Waters' view showing a dentigerous cyst in
the maxillary right sinus. A careful
examination of the radiograph shows a
tooth in the sinus. Any odontogenic cyst
(primordial, dentigerous, radicular,
or keratocyst) can encroach upon the
A radicular cyst at the
apices of the first
molar and extending
into the maxillary
Fibrous dysplasia arises adjacent to any of paranasal sinuses and cause
displacement of sinus borders and results in a smaller sinus on the
• Involvement of facial skeleton with fibrous dysplasia can result in facial
asymmetry, nasal obstruction, proptosis, impingement on cranial nerves
and sinus obliteration.
• Sinus obliteration results when the expanding dysplastic bone
encroaches on it.
• The lesion may displace roots of teeth and cause teeth to separate or
• Posterior maxilla is the most common location for fibrous dysplasia.
• The lesion is not very well defined, tending to blend into the surrounding bone.
• Sinus floor is intact but displaced.
• The normal maxillary antrum may be partially or totally replaced by increased
radiopacity of this lesion.The radiopaque areas have the characteristic ‘’ground
glass’’ appearance on extaoral radiographs.
Fistula: It is an abnormal connection or passageway between two
epithelium-lined organs or vessels that normally do not connect.
Definition: It is the pathological communication between
oral cavity and maxillary antrum.
- Fresh communication will have the epithelium lining while
long standing ones known as chronic oroantral fistula have
epithelized fistulous tract.
1) Extraction of teeth:
- Occurs as a result of a traumatic extraction of maxillary
posterior teeth whose root may be inclose proximity to the
floor of the maxillary antrum.
- Tuberosity fracture as a result of upper third molar
- In advert curettage of maxillary tooth
2) Facial Trauma: Maxillofacial trauma and penitrating injury.
3) Surgical removal of the cyst and tumor associated with the
maxillary alveolar region extending into the antrum.
4) Osteomylities of the maxilla or following irradication.
5) palatal gumma (syphilis)
6) Malignant tumor such as wegenere’s granulomatosis wich
may perforate the palate.
7) Implant surgery in the maxillary posterior region.
ACUTE OROANTRAL FISTULA:
Symptoms- History of recurrent surgery in the vicinity of
Escape of air and fluids through the nose and mouth.
pain may be severe throbbing ordull aching pain.
Enhanced column of air causing change in the vocal
resonance and consequently change in the voice.
IMIDIATED SIGNThe part of the bony part of the sinus may be adhearent to
the root tip on extraction.
Maxillary tuberosity fracture.
Root tip in the maxillary antrum.
DIAGNOSIS OF OROANTRAL FISTULA:
• - A large fistula is easily seen on inspection.
• - Nose blowing test: The patient is placed to close his
nostril and blow gently down the nose with nose open.
Whistling sound as air passes down the fistula in the
• - cotton wisp test: The escape of air through the nose can
be tested by placing a wisp of cotton near the orrifice.
• - Mouth mirror fogging test: A mouth mirror placed at the
oroantral fistula causing the fogging of the mirror.
• - Unilateral epistaxis may sometimes be seen
• - some time the oroantral fistula can blocked by the an
Aim: - To prevent nasal regurgitation of fluides.
- To prevent infection of the maxillary antrum from the
CLOUSURE OF OROANTRAL COMMUNICATION:
Aim: - Primary repair to close the communication.
- Antibiotics to cure the sinus infection
I. Irrigation of the antrum with saline.
II. Simple suturing of the socket.
III. A well fitting denture base may be constructed with a
flenge extention to cover the oppening completely.
IV. This prevent contamination of the oral cavity and antral
cavity and thus enabled healing.
V. Once a communicate is formed between the oral and
antral cavity, ther are the chance of infection of the
VI. Supportive measure are required for treatment of the
CHRONIC OROANTRAL FISTULA:
This occur due to the persistence of the communication
between the oral cavity and the maxillary antrum.
- Persistent unilatral foul discharge.
- Post nasal drip with the discharge trickle down the phrynx
from the posterior nares resulting in foul smell and
- Systemic sequeles due to swallowed pus in the form of
-Pyrexia, malaise, Headache,
- Pain is diminish consiberabely.
- Polyp projecting form the antrum into the oral cavity
prevents the fistulous tract to heal spontaneosly.
- Intra oral periapical radiograph is taken with the silver
probe placed into the fistula tract to determine the
frequency of the tract.
- Maxillary sinus radiograph of the skull.
- Routine evalution.
If fistulous persist for more than 2 to 3 months the fistula tract
would have been epithelized.
METHOD OF CLOSURE TECHQUINE;
1. Buccal flap – Buccal advancement flap
- Buccal sliding trepezoid flap
- Bipedic flap
2. Palatal Flap- Palatal advancement flap
- Palatal rotational advancement flap
Submucosal connective tissue pedicle
- Pedicle island flap
- Anterior based flap
3. Combination of buccal and palatal flap
GRAFT- Buccal fat pad
- Bone graft.
Oro-antral fistula formed by
a break in the floor of the
maxillary sinus between the
premolar and molar. It is a
pathologic tract that
connects the oral cavity to
the maxillary sinus. The
patient complained of
regurgitation of food
through the nose while
eating. The patient also felt
air entering his mouth
during eating and smoking.
Oro-antral fistula at the site of the
extracted second premolar and first molar.
Patient had the usual complaint of
regurgitation of food through the nose.
Oro-antral fistula at the site of the
extracted first molar and second
premolar. The mucosa of the
sinus has proliferated
over the fistula