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10 maxillary sinus

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  • 1. Maxillary sinus Instructor:- Dr. Jesus George 1
  • 2. Anatomy 2  1st - described by Nathaniel high more also known as Antrum of high more.  They are 2 in No. one on either side of maxilla.   Largest paranasal sinus.  Communicate with other sinuses through the lateral wall of nose.  Ostium opens into middle meatus  Volume 15-30ml
  • 3. Cont. 3  Diamension: Anteroposterior 3.5 Height 3.2 Width 2.5  Pyramidal in shape.  Base- lateral wall at the nose.  Apex- zygomatic process of maxilla.
  • 4. Cont. 4 Four walls- Floor of orbit or roof of antrum, Alveolar process of maxilla- floor, infratemporal surface of maxilla anterior.  Blood supply Facial, maxillary, infraorbital and greater palatine arteries.   Anterior facial vein, pterigoid plexus
  • 5. Cont. 5  Lymphatic drainage   Submandibular and deep cervical lymph nodes.   Nerve supply  Superior dental nerve, anterior, middle and posterior greater palatine nerve.  Branches of maxillary division of trigeminal nerve.
  • 6. Cont. 6  Embryology: 3/12 weeks IUL - Out pouching in middle meatus Birth - Tubular 2x 1 x 1 cmm growth. 9 years - 60% of adult size. 12 years - Antral floor parallels nasal floor 18 years - Adult size
  • 7. Cont. 7  Physiology: Lined by respiratory epithelium  Functions: Impart resonance to the voice. Increase the surface area & lighten skull Moisten and warm inspired air. Filter debris from inspired air. They provide thermal insulation to the tissue above.
  • 8. Applied surgical anatomy 8  Relation of the root apices with floor of sinus  In adults 1-1.5cm between floor of sinus and root apices of maxillary posterior teeth.  Low incidence of oroantral fistula in children-under fifteen years. Sinus reaches its normal size by the age of 18 years.
  • 9. Cont. 9 Circumstances with increased likelihood of oroantral fistula Large Sinuses: Floor is thinned out Risk of # when force is applied during maxillary posterior teeth extraction. Floor is descending down between adjacent teeth and also in between roots of individual tooth.
  • 10. Cont. 10  Tooth lies in close proximity to sinus heading to inadvertent displacement to sinus.  Tooth has conical roots.  Unerupted III molar in tuberosity forms a line of weakness, if adjacent II molar is extracted it result in # of tuberosity.
  • 11. Cont. 11 Lining of maxillary sinus  Breach in continuity is obtained by occipitomental radiograph- showing radioopacity in sinus persist for 10 days to 2 weeks.
  • 12. Cont. 12  Unilateral epistaxis   Cracks and fractures in bony floor of maxillary sinus.  If there is tear in sinus lining it will heal its own.  If clot breaks down> oroantral communication with in 10 days> oroantral fistula> foul smelling discharge of pus
  • 13. Cont. 13  Periapical involvement:  A/c or C/c periapical abcess in relation to teeth close proximity with sinus may secondarily involve sinus.   Pus may discharge into sinus causing a fluid level extraction of such tooth cause infection of blood clot> oroantral fistula.
  • 14. Cont. 14  Pressure on nerves with in antrum  Occurs in A/c sinusitis.  Pus is not able to escape through Ostium in to nose because of its occlusion by inflammation of adjoining mucosal lining.   Tumours in maxillary antrum  Seen as swelling in cheek, palate, buccal sulcus.
  • 15. Cont. 15 Teeth maxillary get loosened due to bone destruction interference in blood supply causing pulp necrosis & A/c apical abscess. Pressure on posterior valve causes destruction of posterior superior alveolar nerve & anaesthesia of gingival & teeth in maxillary molar area
  • 16. Cont. 16  Involvement of roof causes anaesthesia of inferior orbital nerve.  Encroachment on orbit causes alteration of papillary level eye is lifted up proptosis.
  • 17. Cont. 17  Paraesthesia in maxillary teeth following surgical procedures Mainly in the lateral wall of antrum most cases return to normal.  Antral puncture Is done in middle meatus in children. Inferior meatus in adult. Floor of sinus is 1.5 cm below floor of nose.
  • 18. Cont. 18  Canine fossa  Used for- Diagnostic aspiration  Cald well-LUC operation  Fractures of middle third of face  Usually involve maxillary sinus
  • 19. Transillumination 19   Placing a strong light in center of mouth with lips closed. Normal sinus: Definite infraorbital crescent of light, brightly lit eye glossy pupil. If antral cavity contains pus, mucus, polyps, blood thickened linig, fibrosseous lesions, tumour will not lit as in normal.
  • 20. Radiographs 20 Extra oral: Occipitomental Lateral skull Submento vertex Orthopantemography CT Intra Oral: Occlusal Periapical
  • 21. Infections of maxillary sinuses 21  Odontogenic sinusitis  A/C maxillary sinusitis  C/C maxillary sinusitis
  • 22. Odontogenic sinusitis 22  Definition:  It is the inflammation of mucosa of any of paranasal sinuses.  Inflammation of most or all paranasal sinuses pansinusitis.  Maxillary sinusitis in usually Odontogenic in origin.
  • 23. Cont. 23  Clinical Features  Teeth involved, IPM, IM, IIM  Severe throbbing pain  Slight swelling of check  Mobile tooth -if involved periodontally  Diagnosis:  Total radiopacity or fluid level in radiography
  • 24. Cont. 24  Management:  Extraction of offending tooth  Antibiotics  Decongestants: Nasal inhalation or drops
  • 25. A/C maxillary sinusitis 25  May be suppurative or non suppurative inflammation of antral mucosa  Etiology: Infection: common cold, Upper resp. Tract infection Trauma: Fracture of antral floor and walls  Allergy Neoplasm
  • 26. Cont. 26  Oroantral communication & fistula.  Displaced tooth or root Clinical features  Signs  Tenderness over check  Anesthesia of check  Mild swelling in severe cases   Percussion pain of maxillary teeth
  • 27. 27  Extrusion of oroantral fistula with or in to socket  Fetor oris  Discharge of pus to mouth from fistula.  Symptoms:  H/o cold  Nasal blocking
  • 28. Cont. 28  Thick, mucopurulant, foul smelling, discolored nasal discharge  Heavy feeling in head.  Constant throbbing pain in cheek or face more severe in morning and evening.  Max. teeth of affected side painful.  Generalized symptoms:  Chills  Fever
  • 29. Cont. 29  Sweating  Nausea  Difficulty in breathing  Anorexia  Rhinoscopy  Edema & erythema of mucosa pus discharge on to inferior turbinate bone.
  • 30. Cont. 30  Tran illumination: Do not transmit high  Radiograph: Water's view- occipitomental 15o . Uniform opacity or fluid level.  Management: Bed rest Plenty of fluids Oral hygiene Antral regime for 5-7 days
  • 31. Antral Regime 31  Antimicrobials Macrolides: erythromycin 250kg 6th hrly for 5 days. Broad spectrum: amoxicillin 250-500mg 8th hrly for 5 days.  Decongestants  Nasal drop or spay. Ephedrine sulphate 0.5-1% in Normal saline 6th hrly. Xylomethozoline hydrochloride 0.1%
  • 32. Cont. 32  Mucolytic agents  Tincture benzoin  Camphor  Menthol  Steam inhalation    Nsaids  Aspirin  Paracetamol  Ibuprofen
  • 33. C/C maxillary sinusitis 33 Causes  Dental infection C/C rhinitis C/C Infection in frontal & Ethmoid sinus. Allergy Pathophysiology Due to C/C infection the mucous membrane of sinus may develop hyperplasia or atrophy. Multiple polyps Degeneration of epithelium
  • 34. Cont. 34  Diagnosis:  H/o: Repeated attacks of A/c mucopurulent rhinitis.  Long- standing nasal or postnasal discharge.   Anterior rhinos copy: shows nasal congestion & mucopurulent material in middle meatus.  Oro pharynx shows descending pharyngeal exudates.
  • 35. Cont. 35 Oral antral fistula may me there. Prolapse of polypoidal mass into mouth. Radiography Radiopacity on affected side. Presence of fluid level Thickened lining membrane
  • 36. Cont. 36  Management:  If the cause is tooth or root in sinus remove the cause prior to any other treatment.   Antral polyp is removed  Antibiotics  Decongestants  Analgesics  C/C sinusitis due to oro antral fistula require closure of Oro antral fistula  Surgical Drainage: Topical anaesthesia is applied to cotton wool and inserted along the nasal floor near inferior turbinate.
  • 37. Cont. 37 Sharp trocar and cannula is introduced inferior to inferior turbinate. Antrum wall is punctured. Trocar with drawn Pus is drained using suction Warm saliva irrigation daily till symptoms are settled down
  • 38. Oro Antral Communication & Fistula38  Oro antral per formation:  It is an unnatural communication B/w oral cavity & maxillary sinus.   Oro antral fistula  It is an epithelized, pathological, unnatural communication b/w oral cavity and maxillary sinus.
  • 39. Cont. 39 Etiology: Extraction of teeth Palatal root of I molar when broken most frequently causes oroantral communication Conical maxillary III molar-during extraction there will be # of tuberosity oro antral communication. Isolated posterior teeth in edentulous arch more risk of causing destruction of floor of sinus. Surgical removal of impacted teeth also have high risk.
  • 40. Cont. 40 Periapical lesions Abcess, granuloma, cyst Apicoectomy Blind instrumentation Injudicious use of instruments. Forcing a tooth or root into sinus during removal Trauma of face. Trauma of middle 1/3 of face. Due to missiles or sharp objects gunshot injuries
  • 41. Cont. 41 Surgery of sinus Partial maxillectomy Surgical treatment of large abscess or cyst. Improper incision in Caldwell luc operation. zygomatic complex # Osteomyelitis: Gumma involving palate Infected implants in maxilla Malignant diseases
  • 42. Cont. 42 Symptoms Fresh Oro antral communication 5 ES Escape of fluids- from mouth to nose when patient rinse or gargle. Epistaxis (unilateral) - Bleeding from nose. Escape of air - From mouth to nose on sucking, inhaling. Enhanced column of air- Change in voice. Excruciating pain- Around the region of involved sinus.
  • 43. Cont. 43  Symptoms- in late stage - OAF 5ps.  Pain.  Persistence purulent or mucopurulent discharge  Post nasal drip.  Possible Sequelae of general, systemic toxemic condition:  Fever  Malaise  Anonexia 
  • 44. Cont. 44  Popping out of an antral polyp.    Confirmation of presence of oro antral communication fistula   If large; Assessed by inspection  If small: nose blowing test Compression of anterior nares & gently blow nose produces a whistling sound, escape of air bubble blood or pus. At the oral orifice.
  • 45. Ont. 45 Management: A fistulous tract persist for more than 14 days is considered as C/c fistula.  Treatment of early cases Immediate surgery repair for primary closure.  Reduction of buccal & palatal socket for adaptation of buccal and palatal flap to close the defect. Protective acrylic denture.
  • 46. Cont. 46 Antibiotics Penicillin: initially 1/V than oral penicillin V 250-500ng 6th hrly  Nasal decongestants Ephedrine nasal drop Steam inhalation. Tincture benzoin Menthol inhalation
  • 47. Cont. 47 Analgesics. Aspirin 500mg 4 times/day Paracetamol 500mg 3 times/day Ibuprofen 400 mg 3 times/day Temporary measures White head's varnish pack: packed over the socket and secured with sutures.
  • 48. Cont. 48  White head's varnish Benzoin- 10% Storaly-7.5% Balsam of tolu- 5% Lodoform - 10% Solvent - Ether- 67.5%  Denture plate: Socket is covered with gauzes a plate is placed.
  • 49. Cont. 49  Treatment of delayed cases  OAF with in 24 HRS  If the edges of wounds are clean close immediately.  Postoperative antibiotics, decongestants can be closed by buccal flap  OAF after24 HRS  Tissue margins often get infected, so defer surgical closure until gingival edges show healing- 3 weeks.
  • 50. Cont, 50  Antibiotics, analgesics, decongestants.  If purulent discharge or c/c sinusitis irrigate sinus with warm normal saliva.  OAF more than 1 month  Fistula is well epithelized surgical closure  Surgical drainage: Established by enlarging fistula Sinus in irrigated with normal saline until it is clear.
  • 51. Cont. 51 Supportive care When symptoms subside surgical closures.  Surgical closure of OAF 3 types  Buccal flap  Palatal flap  Combination of both
  • 52. Cont. 52  Essential features of flap  Free end of flap should have adequate blood supply  Base should be wider than apex for buccal flap  palatal flap is designed in such a way that greater palatine vessels are incorporated in the transposed tissue enclose the fistula.  Suture line is supported by sound bone  There should not be any tension along the
  • 53. Buccal flap advancement operation-rehrmann53  Inject LA in to mucobuccal fold  Excision of fistulous tract: incision is made around fistulous tract 3-4mm marginal to orifice. Epithelial zed tract with associated antral polyps dissected gum margins freshened with blade no: 11  Two divergent incision are done with blade No. 15 from each side of orifice into buccal sulcus (2.5cm). Till bone flap is reflected.  Reduction & smoothening of alveolar bone is done.
  • 54. Cont. 54  Advancement of buccal flap:  If flap is not covering fistula, flap is advanced horizontal incision is made in preventing it’s advancement.  Inspection of maxillary sinus for infection.  If any polypoidal mass or other diseased tissue removed.  Irrigate with warm normal saline.  If any pathology - cald well Luc procedure done.  Arrest of hemorrhage  Closure of wound with interrupted sutures
  • 55. Cont. 55  Postoperative medication: Antibiolgics  Analgesics  Decongestants  Inhalation  Soft diet  Instruction to patient: Avoid sneezing  Not to explore wound with tongue  Avoid sucking of fluid and air  Removal of suture 7-10 days postoperatively
  • 56. Modified rehrmann's buccal advancement flap56   After mobilization of buccal flap & releasing incision in free end of flap.  A step is created by removing 1-2mm mucosal layer.  The denuded margin is sutured below palatal flap by vertical mattress suture  Mucosa is sutured with palatal flap by interrupted suture, provides double layer closure.
  • 57. Intranasal antrostomy 57  It is done to close an OAF & to remove tooth or root from sinus.   Surgical procedure:  A small osteotome or gouge is pushed through the inferior meatus to max-sinus.  Iodoform gauze pack is grasped into beaks of big curved artery forceps and is passed through the opening is pulled out into nostril.  A single knot at one end of guaze will keep it in nostril other end is used to pack sinus, after achieving hemostasis.
  • 58. Cont. 58  Remove 1cm of medical wall of antrum, that bulges into sinus below inferior turbinate this is extended to floor of nose.
  • 59. Palatal pedicle flap: Rotational Advancement flap ashley's operation.59   LA  Excision of fistulous tract  Marking of proposed palatal flap  Raising palatal mucoperiosteum  Inspection of sinus and irrigate with betadine and normal saline.  Trimming of buccal mucoperiosteum  Rotational advancement of palatal pedicle flap to approximate buccal margin.
  • 60. Cont. 60  Suturing- Interrupted suture.  Denuded bone in palate is covered by guaze pack soaked white head's varnish and secured with suture.
  • 61. Combination of buccal & palatal flap61  Used to close large defect.  Used when there is H/o earlier repair with failure.  It is the combination of inversion and rotational advancement flap  We will get a double layer closure.  There is mobilization of both palatal flaps.
  • 62. Cald well LUC operation 62  By George Cald Well  Indication:  For removal of root fragments, teeth foragin body stone from maxillary sinus.  To treat c/c sinusitis with hyper plastic lining & polypoid degeneration of mucosa  Removal of cyst and benign growth in sinus.  Mangement of hematoma in sinus to control post traumatic hemorrhage.  Zygomatic complex # involving floor of orbit and anterior wall of sinus.  OAF with c/c sinusitis
  • 63. Cont. 63  Surgical procedure:  Performed under LA or GA  Semilunar incision in buccal vestibule from canine to II molar above gingival attachment.  Mucoperiosteal flap is elevated till the infra orbital ridge.  An opening is created in anterior wall of sinus with gouges, drill or chisel.  Opening is enlarged in an directions with roungeur up to the size of index finger.  Opening should be away from roots of maxillary teeth.
  • 64. Cont. 64  Pus is sucked a ways irrigated with copious saliva wash  Inspection of sinus  Removal of tooth, root, guaze, cotton, stone, bone.  Thickened infected lining of sinus is elevated, removed and sent for histopathologic examination.  If profuse bleeding in sinus, it is packed with ribbon guaze soaked in adrenaline 1:1000 for l or 2 min.  Antral cavity is again irrigated and packed with l0 doforun ribbon guaze. 
  • 65. Cont. 65  Post operative management:  Antibiotics  Analgesics  Anti inflammatory drugs for 5 days  Pack removed on 5th day  Tincture benzoic inhalation 3 times/day  Soft diet.