Instructor:- Dr. Jesus George
- described by Nathaniel high more also
known as Antrum of high more.
They are 2 in No. one on either side of
Largest paranasal sinus.
Communicate with other sinuses through
the lateral wall of nose.
Ostium opens into middle meatus
Diamension: Anteroposterior 3.5
Pyramidal in shape.
Base- lateral wall at the nose.
Apex- zygomatic process of maxilla.
Four walls- Floor of orbit or roof of
antrum, Alveolar process of maxilla-
floor, infratemporal surface of maxilla
Facial, maxillary, infraorbital and
greater palatine arteries.
Anterior facial vein, pterigoid plexus
Submandibular and deep cervical
Superior dental nerve, anterior, middle
and posterior greater palatine nerve.
Branches of maxillary division of
3/12 weeks IUL - Out pouching in
Birth - Tubular 2x 1 x 1 cmm growth.
9 years - 60% of adult size.
12 years - Antral floor parallels nasal
18 years - Adult size
Lined by respiratory epithelium
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
Applied surgical anatomy
Relation of the root apices with
floor of sinus
In adults 1-1.5cm between floor of
sinus and root apices of maxillary
Low incidence of oroantral fistula in
children-under fifteen years.
Sinus reaches its normal size by the
age of 18 years.
Circumstances with increased
likelihood of oroantral fistula
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.
Tooth lies in close proximity to sinus
heading to inadvertent displacement to
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.
Lining of maxillary sinus
Breach in continuity is obtained by
occipitomental radiograph- showing
radioopacity in sinus persist for 10
days to 2 weeks.
Cracks and fractures in bony floor of
If there is tear in sinus lining it will heal its
If clot breaks down> oroantral
communication with in 10 days> oroantral
fistula> foul smelling discharge of pus
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.
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,
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
Involvement of roof causes
anaesthesia of inferior orbital nerve.
Encroachment on orbit causes
alteration of papillary level eye is lifted
Paraesthesia in maxillary teeth following
Mainly in the lateral wall of antrum most
cases return to normal.
Is done in middle meatus in children.
Inferior meatus in adult.
Floor of sinus is 1.5 cm below floor of
Used for- Diagnostic aspiration
Cald well-LUC operation
Fractures of middle third of face
Usually involve maxillary sinus
Placing a strong light in center of mouth
with lips closed.
Normal sinus: Definite infraorbital
crescent of light, brightly lit eye glossy
If antral cavity contains pus, mucus,
polyps, blood thickened linig, fibrosseous
lesions, tumour will not lit as in normal.
It is the inflammation of mucosa of any of
Inflammation of most or all paranasal
Maxillary sinusitis in usually Odontogenic
Teeth involved, IPM, IM, IIM
Severe throbbing pain
Slight swelling of check
Mobile tooth -if involved periodontally
Total radiopacity or fluid level in radiography
Extraction of offending tooth
Decongestants: Nasal inhalation or drops
A/C maxillary sinusitis
May be suppurative or non suppurative
inflammation of antral mucosa
Infection: common cold, Upper resp. Tract
Trauma: Fracture of antral floor and walls
Oroantral communication & fistula.
Displaced tooth or root
Tenderness over check
Anesthesia of check
Mild swelling in severe cases
Percussion pain of maxillary teeth
Extrusion of oroantral fistula with or in to
Discharge of pus to mouth from fistula.
Thick, mucopurulant, foul smelling, discolored
Heavy feeling in head.
Constant throbbing pain in cheek or face more
severe in morning and evening.
Max. teeth of affected side painful.
Difficulty in breathing
Edema & erythema of mucosa pus discharge
on to inferior turbinate bone.
Do not transmit high
Radiograph: Water's view- occipitomental
Uniform opacity or fluid level.
Plenty of fluids
Antral regime for 5-7 days
Macrolides: erythromycin 250kg 6th
hrly for 5
Broad spectrum: amoxicillin 250-500mg 8th
for 5 days.
Nasal drop or spay. Ephedrine sulphate
0.5-1% in Normal saline 6th
Xylomethozoline hydrochloride 0.1%
C/C maxillary sinusitis
C/C Infection in frontal & Ethmoid sinus.
Due to C/C infection the mucous membrane of
sinus may develop hyperplasia or atrophy.
Degeneration of epithelium
H/o: Repeated attacks of A/c mucopurulent
Long- standing nasal or postnasal discharge.
Anterior rhinos copy: shows nasal congestion
& mucopurulent material in middle meatus.
Oro pharynx shows descending pharyngeal
Oral antral fistula may me there.
Prolapse of polypoidal mass into mouth.
Radiopacity on affected side.
Presence of fluid level
Thickened lining membrane
If the cause is tooth or root in sinus remove the
cause prior to any other treatment.
Antral polyp is removed
C/C sinusitis due to oro antral fistula require closure
of Oro antral fistula
Topical anaesthesia is applied to cotton wool
and inserted along the nasal floor near inferior
Sharp trocar and cannula is
introduced inferior to inferior
Antrum wall is punctured.
Trocar with drawn
Pus is drained using suction
Warm saliva irrigation daily till
symptoms are settled down
Oro Antral Communication &
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.
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
Isolated posterior teeth in edentulous arch
more risk of causing destruction of floor of
Surgical removal of impacted teeth also have
Abcess, granuloma, cyst
Injudicious use of instruments.
Forcing a tooth or root into sinus during
Trauma of face.
Trauma of middle 1/3 of face. Due to
missiles or sharp objects gunshot
Surgery of sinus
Surgical treatment of large abscess or
cyst. Improper incision in Caldwell luc
zygomatic complex #
Gumma involving palate
Infected implants in maxilla
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
Enhanced column of air- Change in voice.
Excruciating pain- Around the region of
Symptoms- in late stage - OAF 5ps.
Persistence purulent or mucopurulent
Post nasal drip.
Possible Sequelae of general, systemic
Popping out of an antral polyp.
Confirmation of presence of oro antral
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
A fistulous tract persist for more than 14
days is considered as C/c fistula.
Treatment of early cases
Immediate surgery repair for primary
Reduction of buccal & palatal socket for
adaptation of buccal and palatal flap to
close the defect.
Protective acrylic denture.
Penicillin: initially 1/V than oral penicillin V
Ephedrine nasal drop
Aspirin 500mg 4 times/day
Paracetamol 500mg 3 times/day
Ibuprofen 400 mg 3 times/day
White head's varnish pack: packed over the
socket and secured with sutures.
White head's varnish
Balsam of tolu- 5%
Lodoform - 10%
Solvent - Ether- 67.5%
Denture plate: Socket is covered with gauzes
a plate is placed.
Treatment of delayed cases
OAF with in 24 HRS
If the edges of wounds are clean close
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.
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
Established by enlarging fistula
Sinus in irrigated with normal saline until it is
When symptoms subside surgical closures.
Surgical closure of OAF 3 types
Combination of both
Essential features of flap
Free end of flap should have adequate blood
Base should be wider than apex for buccal
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
Buccal flap advancement
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
Advancement of buccal flap:
If flap is not covering fistula, flap is advanced
horizontal incision is made in preventing it’s
Inspection of maxillary sinus for infection.
If any polypoidal mass or other diseased tissue
Irrigate with warm normal saline.
If any pathology - cald well Luc procedure done.
Arrest of hemorrhage
Closure of wound with interrupted sutures
Postoperative medication: Antibiolgics
Instruction to patient: Avoid sneezing
Not to explore wound with tongue
Avoid sucking of fluid and air
Removal of suture 7-10 days postoperatively
Modified rehrmann's buccal
After mobilization of buccal flap & releasing
incision in free end of flap.
A step is created by removing 1-2mm mucosal
The denuded margin is sutured below palatal
flap by vertical mattress suture
Mucosa is sutured with palatal flap by
interrupted suture, provides double layer
It is done to close an OAF & to remove tooth
or root from sinus.
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.
Remove 1cm of medical wall of antrum, that
bulges into sinus below inferior turbinate this is
extended to floor of nose.
Palatal pedicle flap: Rotational
Advancement flap ashley's
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.
Suturing- Interrupted suture.
Denuded bone in palate is covered by guaze
pack soaked white head's varnish and secured
Combination of buccal & palatal
Used to close large defect.
Used when there is H/o earlier repair with failure.
It is the combination of inversion and rotational
We will get a double layer closure.
There is mobilization of both palatal flaps.
Cald well LUC operation
By George Cald Well
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
Zygomatic complex # involving floor of orbit and anterior
wall of sinus.
OAF with c/c sinusitis
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
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.
Pus is sucked a ways irrigated with copious saliva
Inspection of sinus
Removal of tooth, root, guaze, cotton, stone,
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
Antral cavity is again irrigated and packed with l0
doforun ribbon guaze.
Post operative management:
Anti inflammatory drugs for 5 days
Pack removed on 5th
Tincture benzoic inhalation 3 times/day