Dr. Bhavik Miyani Resident Doctor- Oral and maxillofacial suregry Narsinhbhai Patel Dental College & Hospital

1. NASAL AND PARANASAL
SINUSES
PRESENTED BY,
DR. BHAVIK MIYANI
GUIDED BY,
DEPARTMENT OF OMFS

2. CONTENTS
• INTRODUCTION
• NOSE
• MAXILLARY SINUS
• FRONTAL SINUS
• SPHENOIDAL SINUS
• ETHMOIDAL SINUS
• DIAGNOSTIC EVALUATION
• APPLIED ANATOMY

3. THE NOSE
• The nose consists of the
external nose and the
nasal cavity,
• Both are divided by a
septum into right and left
halves.

4. EXTERNAL NOSE
• The external nose has two
elliptical orifices called the
naris (nostrils), which are
separated from each other by
the nasal septum.
• The lateral margin, the ala
nasi, is rounded and mobile.

5. EXTERNAL NOSE

6. • The framework of the external
nose is made up above by the
nasal bones, the frontal processes
processes of the maxillae, and the
the nasal part of the frontal bone.

8. BLOOD SUPPLY OF THE EXTERNAL NOSE
• The skin of the external nose is supplied by
branches of the ophthalmic and the
maxillary arteries.
• The skin of the ala and the lower part of the
septum are supplied by branches from the
facial artery.

9. • The infratrochlear and external nasal
branches of the ophthalmic nerve (CN
V) and the infraorbital branch of the
maxillary nerve (CNV).
NERVE SUPPLY OFTHE EXTERNAL
NOSE

10. NASAL CAVITY
“Nasal cavity, it extends from the external nares (nostrils)
to posterior nasal apertures and is subdivided into right and
left halves by the nasal septum.”
Each half has a floor, roof, medial and lateral walls.
• Measures about
• Height- 5 cm
• Length- 5-7 cm
• Width- 1.5 cm(floor) 1-2 mm(roof)

11. FLOOR OF NOSE
Floor of the nasal cavity is concave from side to side,
flat and almost horizontal antero-posteriorly.
 Anterior 34th  Palatine process of maxilla.
 Posterior 14th Horizontal part of the palatine
bone.

12. ROOF OF NOSE
Roof of The Nasal Cavity: is narrow from side to side, the
ethmoidal part is horizontal but the frontonasal & sphenoid part
slope downwards and forwards & downwards and backwards
respectively.
Nasal Cartilages, Nasal, Frontal, Ethmoid, Sphenoid Bones

13. MEDIAL WALL OF NOSE
■ The Nasal Septum
■ Divides the nasal cavity into right
and left halves
■ It has osseous and cartilaginous
parts
■ Nasal septum consists of the
perpendicular plate of the ethmoid
bone (superior), the vomer (inferior)
and septal cartilage (anterior)
Perpendicular
Plate (ethmoid)
Septal
Cartilage
Vomer

14. LATERAL WALL OF NOSE
■ The lateral wall of the nose is irregular
owing to the presence of 3 shelf like
bony projections called conchae.
■ The lateral wall separates the nose
a) From the orbit above, with the
ethmoidal air sinuses intervening
b) From the maxillary sinus below
c) From the lacrimal groove and
nasolacrimal canal in the front

16. Openings Into the Nasal Cavity
1. Superior meatus: Posterior
ethmoid sinuses
2. Inferior meatus: Nasolacrimal duct
3. Middle meatus:
• Maxillary sinus
• Frontal sinus
• Anterior ethmoid sinuses
4. Sphenoethmoidal recess:
Sphenoid sinus

17. ARTERIAL SUPPLY OF NOSE
 The anterosuperior quadrant is
supplied by the anterior
ethmoidal artery assisted by the
posterior ethmoidal and facial
arteries
 The anteroinferior quadrant is
supplied by the branches of facial
and the greater palatine arteries
 The posterosuperior quadrant, is
supplied by sphenopalatine artery
 The posteroinferior quadrant is
supplied by the branches from
the greater palatine artery.
Lettle’s
area(kiessel
bach’s
plexus)

18. VENOUS DRAINAGE OF NOSE
The veins form a plexus which drains
 Anteriorly into the facial vein
 Posteriorly into the pharyngeal plexus of veins
Lymphatic drainage
 From the anterior half into the submandibular nodes
 From the posterior half to the retropharyngeal and upper deep
cervical nodes

19. NERVE SUPPLY OF NOSE
 General sensory nerves ( derived from the
trigeminal nerve ) are distributed to whole of
the lateral wall .
 The anterosuperior quadrant – anterior
ethmoidal nerve ( branch of opthalmic
nerve)
 The anteroinferior quadrant – anterior
superior alveolar nerve ( branch of maxillary
nerve )
 The posterosuperior quadrant --posterior
superior lateral nasal branches from the
pterygopalatine ganglion ( maxillary nerve )
 The posteroinferior quadrant ---anterior
palatine branch from the pterygopalatine

20. THE NASOLACRIMAL CANAL
The Nasolacrimal Canal
conveys tears from the
orbit to the inferior nasal
meatus.

21. PARANASAL SINUSES
Frontal
Ethmoid
Maxillary
Sphenoidal
Air filled spaces present within the
some bone around the nasal cavity,
They are called the paranasal sinuses.

22.  The paranasal sinuses are
cavities found in the interior
of the maxilla, frontal,
sphenoid, and ethmoid bones
.
 They are lined with muco-
periosteum and filled with air.
 They communicate with the
nasal cavity through relatively
small apertures.

23. Drainage of Mucus and Function of
Paranasal Sinuses
 The mucus produced by the mucous membrane is
moved into the nose by cilliary action of the columnar
cells.
 Drainage of the mucus is also achieved by the siphon
action created during the blowing of the nose.

24. FUNCTIONS
1) Humidifying and warming inspired air
2) Regulation of intranasal pressure
3) Increasing surface area for olfaction
4) Lightening the skull
5) Resonance
6) Absorbing shock
7) Contribute to facial growth

25. DEVELOPMENT & GROWTH OF PARANASAL
SINUSES Status at birth Growth 1st radiologic evidence
Maxillary Present at birth Rapid growth from birth to
3 years and 7-12 years.
Adult size-15 years
4-5 month after birth
Ethmoid Present at birth
Ant. Group: 5×2×2mm
Post. Group:5×4×2mm
Reach adult size at 12
year
1 year
Frontal Not present Invades frontal bone at the
age of 4 years. Size
increases until teens
6 years
Sphenoid Not present Reaches sella turcica by
the age of 7 year dorsum
sellae by late teens and
basisphenoid by adult age.
Reaches full size between
15 year to the adult age
4 years

26.  Clinically, paranasal sinuses are:-
 Anterior group
o Maxillary sinus
o Frontal sinus
o Ant. Ethmoidal sinus
 Posterior group
o Post. Ethmoidal sinus
o Sphenoidal sinus

27. MAXILLARY SINUS
 Also known as Antrum of Highmore, Sinus Maxillaris.
“Maxillary sinus is a pneumatic space that is lodged
inside the body of the maxilla & that communicate with
the environment by way of the middle nasal meatus and
the nasal vestibule.”
 The maxillary sinus is the largest paranasal sinus.

28.  Pyramidal in shape.
 Volume of approximately 15 -30 ml.
 Sizes:-
 Height 3.5 cm
 Width 2.5cm
 Depth 3.5cm(anteroposterior)
 Apex is directed lateralward, is formed
by the zygomatic process.
 Base(4-sided) : Lateral nasal wall

29. • Medial wall : Lateral wall of
nose
• Superior wall (roof): Orbital
wall
• Anterior wall : Facial wall of
maxilla
• Posterolateral: Infratemporal
wall
• Inferior (floor): Alveolar
process of the maxilla.

30. The Floor:
Projecting into the floor of the antrum are several
conical processes, corresponding to the roots of the first
and second molar teeth; in some cases the floor is
perforated by the roots of the teeth.
Because of the close relationship with the dentition
dental disease can cause maxillary infection, and tooth
extraction can result in oral-antral fistulae.

31. • The Roof :
Related to the intraorbital vessels and nerves
and tear ducts.
The infraorbital canal usually projects into the
cavity as a well-marked ridge extending from the
roof to the anterior wall.

32. Communicates with the middle meatus of the
nose.

33. BLOOD SUPPLY OF MAXILLARY SINUS
Arterial Supply:
■ Mucosal: Sphenopalatine artery, anterior & posterior lateral nasal
(ethmoidal).
■ Osseous: Facial, Infraorbital, greater palatine arteries.
The bony wall receives dual blood supply from periosteum on
both sides.
Venous Drainage:
■ Veins accompanying arteries – Anterior facial – pterygoid plexus.
■ Medial wall via sphenopalatine vein

36. Lymphatic drainage: Submandibular or deep cervical nodes.
Nerve Supply: Superior & inferior posterior lateral nasal branches of
V2; posterior, middle & anterior superior alveolar

37. MICROSCOPIC FEATURES
■ From inward outward the sinus is lined with 3 layers. Epithelial layer, basal lamina and sub
epithelial layer including periosteum.
■ Epithelium: -
– Pseudostratified columnar and ciliated (derived from olfactory epithelium of middle
meatus) containing mucous secreted goblet cells.
– Basal cells, columnar non ciliated.
– Cilia is composed of microtubules and provide mobile apparatus.
■ By ciliary beating, the mucous blanket lining the epithelial surface move from interior of
the sinus toward the nasal cavity.
■ Mucociliary Flow:
■ There are 3 types:
– Smooth: moving at 0.58 cm/min.
– Jerky: moving at 0.3 cm/min.
– Mucostasis: moving less than 0.3 cm/min.

38. FRONTAL SINUS
 Rarely symmetrical.
 Contained within the frontal bone.
 Separated from each other by a bony
septum.
 Each sinus is roughly triangular.
 Extending upward above the medial
end of the eyebrow and backward
into the medial part of the roof of
the orbit.
 Opens into the middle meatus.

39. • Height, width and anteroposterior depth are
about 2.5 cm
• Better develop in male
• Arterial supply:- Supraorbital artery
• Venous drainage:- Anastomotic veins in the
supraorbital and superior opthalmic vein
• Nerve supply:- Supraorbital nerve
• Lymphatic drainage:- Submandibular nodes.

40. SPHENOID SINUS
• Began as outpunching's of the
superior nasal vault around the
fourth month of gestation
• Rarely present at birth, usually
seen around age 4
• Drain into the superior meatus
in the spheno-ethmoidal
recess
• Ostia of variable size.

41. • Arterial supply :- Posterior ethmoidal and
internal carotid artery
• Venous drainage :- Pterygoid venous plexus
and cavernous sinus
• Nerve supply :- Posterior ethmoidal nerve
and orbital branch of the pterygopalatine
ganglion.
• Lymphatic drainage :- Retropharyngeal
nodes

42. ETHMOIDAL SINUSES
• Ethmoidal sinus are numerous
small intercommunicating spaces
which lies within the labyrinth of
the ethmoid bone.
• Divided in three group
o Anterior group
o Middle group
o Posterior group

43. ANTERIOR GROUP
• Made up of 1 to 11 air cell
• Open into anterior part of hiatus semilunaris of the
nose
• Supplied by anterior ethmoidal nerve and vessel
• Lymph:- Submandibular lymph nodes

44. MIDDLE GROUP
• Made up of 1 to 7 air cell
• Open:- Middle meatus of nose
• Supplied by the posterior ethmoidal nerve and vessel
and the orbital branch of the pterygopalatine
ganglion
• Lymph:- Submandibular nodes

45. POSTERIOR GROUP
• Made up of 1 to 7 air cell
• Open:- Superior meatus of nose
• Supplied by the posterior ethmoidal nerve and
vessel and the orbital branch of the
pterygopalatine ganglion
• Lymph:- Retropharyngeal nodes

46. DIAGNOSTIC EVALUATION
 Detailed medical and dental history.
 Clinical evaluation (inspection,
palpation, percussion, and
transillumination).
 Radiographs (Conventional, CT, MRI).
 Ultrasound.
 Special test (endoscopy).

47. CLINICAL EVALUATION
 Clinical evaluation should include the
following:
 Middle 3rd of the face should be inspected
for:
 Asymmetry
 Deformity
 Erythema
 Ecchymosis or hematoma.

48. PALPATION
■ Palpation of the lateral wall
of sinus over prominence of
cheek and intraorally on
lateral surface of maxilla
between canine eminence
and zygomatic buttress
■ Affected sinus is markedly
tender to gental tapping or
palpation.

49. TRANSILLUMINATION
■ Transillumination of maxillary sinus is done
by placing flash or fiber optic light against
the palatal or facial surfaces of the sinus
and observing transmission of the light
through the sinus in the darkened room.
■ The affected sinus shows less transmission
of light due to accumulation of fluid, debris,
pus and thickening of antral wall mucosa.
■ The test helps to distinguish between sinus
disease that may cause radiating pain to
upper teeth and exposure or abscess related
to molars or premolars.

50. RADIOGRAPH
■ Normal sinus appears as a radiolucent cavity with well defined dense
radiopaque walls.
■ INTRAORAL:
– Periapical
– Occlusal
– Lateral occlusal
■ EXTRAORAL:
– Waters view(15’ or 30’ occipitomental view)/ PNS view
– Submentovertex view
– PA skull view
– Lateral skull view

51. WATERS VIEW

52. LATERAL VIEW

53. ULTRASOUND/ CT SCAN/ MRI SCAN
 Ultrasound is a non-invasive, safe and quick
diagnostic screening tool.
 High resolution axial and coronal CT & MRI
examinations are most revealing non- invasive
techniques for paranasal sinuses.

54. ENDOSCOPY
 Allows direct optical evaluation of the antral floor region.
 It is an optimal method for the assessment of the foreign
body such as root filling materials and root tips that have
penetrated the maxillary sinus.
 APPROACHES:
 Trans-oral via canine fossa
 Trans-alveolar via oroantral communication or fistula.

55. APPLIED ANATOMY
■ Lesions within the sinus may penetrate through anterior and
posterior walls as they are thin walls.
■ Lesions may also penetrate through palatal or appear as swelling
in the buccal vestibule.
■ Lesions may resorb the alveolar bone and result in loosening of
maxillary post teeth.
■ Anterior, middle and posterior superior alveolar nerves pass
through the sinus wall, therefore pathosis of the sinus may result in
pain radiating to the teeth or facial bones at the side of the sinus.
– Lesions may press on the pulp of the teeth in the affected side
resulting in pulp necrosis.

56. CONT..
– Post. wall penetration by tumors may result in paresthesia of the
gum in post. segment due to destruction of posterior superior
alveolar nerve.
– According to the fact that venous drainage of the sinus is a part of
maxillary drainage, joining facial and jugular veins may drain in
upward direction transferring infection to ethmoidal, frontal and
cavernous sinuses and may infect anterior cranial fossa.
– Pneumatization of the sinus into alveolus or approximation of the
roots of the teeth to the sinus or even senile bone resorption may
result in OAC during extraction or surgery.
– Infections related to the teeth that are close to the sinus, when
progress resorb bone and transfer infection to the sinus or may
cause perforation in the sinus floor.

57. MAXILLARY SINUS INFECTION
 “When inflammation develops in the sinus either due to
infection or allergy, it is defined "sinusitis" and it's the most
common disease of the sinus.”
 Maxillary sinusitis could be broadly divided into:
 Acute
 Sub-acute
 Chronic

58. ACUTE SINUSITIS
■ ETIOLOGY :-
 Bacterial
 Viral
 Fungal
 Allergic rhinitis
 Odontogenic infection
 Maxillofacial trauma
 Iatrogenic

59. CLINICAL FEATURES
 May occur at any age and has rapid onset
 Feeling of pressure, pain or fullness in the vicinity of the affected sinus
 Headache is common especially in the morning
 Discomfort increases in intensity and is accompanied with facial erythema &
swelling, malaise and fever
 Drainage of foul smelling mucopurulent material into nasal cavity and
nasopharynx
 Pain is exacerbated on lying down or bending , due to increased intracranial
pressure from blood flow
 Dull pain may be present over premolars and molars upon mastication.
 Tenderness to percussion in the affected side
 Nasal blockage and discharge
 Nocturnal cough

60. INVESTIGATIONS
 Anterior Rhinoscopy- reveals erythema and edema of mucosa
with mucopurulant discharge.
 Transillumination- affected side, which is full of pus, will not
transmit the fiber optic light.
 PNS view X-Ray- affected antrum is uniformly opaque and there
is > 4 mm of mucosa thickening.
 CT & MRI Scans.

61. TREATMENT PROTOCOL
CONSERVATIVE SURGICAL
• Classical antral regimen • Antral drainage or wash
• Nasal decongestant
• Antibiotic
• Mucolytic therapy
• Culture and sensitivity

62. NASAL DECONGESTANTS
 Ephedrine sulpahate -0.5% or 1% in normal saline –
dispensed as drops 6 hourly.
 Phenylephrine –0.25%.
 Xylometazoline HCL -0.1%. Reduces the increased
vascularity.
 Antihistaminic like pseudoephedrine or Levocetrizine
 Are administered orally.

63. ANTIBIOTICS
 Empirical therapy is started with amoxicillin 500 mg, TDS for
10-13 days (Oral).
 Others Include:
 Trimethoprim-Sulfamethoxazole (in 1st time cases)
 Amoxicillin with Clavulanate (Augmentin), Cefuroxime
axetil & Clarithromycin
 If Pt. fails to respond tiothe initial treatment within 72
hours
 Culture and sensitivity should be considered.
 For Nosocomial infections (Staph. Aureus and gram
negative bacilli)- Broad spectrum IV therapy eg. Naficillin

64. MUCOLYTIC AGENT
 Tincture Benzoin compound in boiling water (Steam
Inhalation)- 6 hourly.
 Camphor,Chlorbutol & Menthol (Karvol Plus)

65. ANALGESICS
 Significant amount of pain is experienced in sinusitis. Thus
analgesics like (NSAID's) or opioids must be given to pt. after
establishing a complete medical history.
 Nasal irrigation with saline, or other therapeutic solutions, is
directed towards the medial canthus(inner margin of the eye).
 This aims the irrigant towards the site of drainage of the
frontal, ethmoid and maxillary sinuses into the nose.

66. CHRONIC SINUSITIS
 Pt. may be asymptomatic but will have repeated
attacks of actual mucopurulent rhinitis.
 Pain and tenderness are not common except in acute
exacerbation of chronic disease.
 Foul unilateral discharge is confined to post nasal
discharge

67. DIAGNOSIS
 It is confirmed by history and inspection of
oropharynx which shows pharyngeal exudates.
 PNS view X-rays.

68. TREATMENT
 Eradication of predisposing factors(dental if
any).
 Surgical removal of polyps if present.
 Long term antibiotics , decongestants , and
antihistaminics are prescribed to the patient

69. DENTAL IMPLICATION OF MAXILLARY SINUS
 Maxillary sinusitis of dental origin.
 Toothache of sinus origin.
 Odontogenic pain versus sinusitis.
 Oro-antral communication and fistula.
 Foreign body of dental origin in max. sinus
 Sodium hypochlorite.
 Zinc oxide based cement.
 Gutta-percha.
 Peri-radicular surgery

70. ORO-ANTRAL COMMUNICATION & FISTULA
■ Oro-Antral Communication:
(OAC) Is an abnormal connection
between the oral cavity and
antral cavity (maxillary sinus) as
a result of loss of the soft and
hard tissues that normally
separate both compartments.

71. ■ Oro-Antral Fistula: (OAF) is a
pathological fistular canal
lined with epithelium
(stratified squamous
epithelium) which may or may
not be filled with granulation
tissue or polyposis of the sinus
mucous membrane.

72. Factors influencing creation of OAC:
 Teeth size and configuration of the roots.
 Hypercementosis and bulbous roots.
 Density of alveolar bone and thickness of sinus floor.
 Size of the sinus.
 Fracture that may involve sinus walls.
 Relation of sinus to the root of upper teeth.
 Rough extraction and misguided manipulation.
 Apical pathosis.
 Periodontal diseases which may erode sinus floor.
 Presence of cysts and neoplasm.
 Invasive surgery e.g. cleft and dental implants placement.

73. Signs and Symptoms of OAC:
Signs Symptoms
 Visible defect between mouth and
antrum.
 Salty tasting discharge or unpleasant
smell.
 Bone fragment with small concave
upper surface (antral floor) adhering to
the apex of the extracted tooth.
 Food and drink rhinorrhea.
 Air bubbles at the socket.  Discharge into the mouth.
 Bubbling of blood from the socket or
nostril.
 Escape of air when blowing the nose.
 Change in speech tone and resonance.  Difficulty playing a wind instrument or
sucking.
 Radiographical evidence of sinus
involvement.
 Symptoms of acute or chronic sinusitis.

74. DIAGNOSIS
 History : Patient’s complain
 Inspection:
 Communication or fistula is
visualized.
 Radiographic examination (radio-
opaque probe/gutta-percha).
 Air bubbles.
 Fluid test.
 Valsalva test.

75. TREATMENT
■ General principles:
1. OAC 2mm or less- Don’t panic.
 If antral membrane is intact avoid puncture.
 Heals spontaneously without surgical intervention.
 Patient instructions: 10-14 days
a. Avoid blowing the cheek or nose.
b. Avoid sucking straw.
c. Avoid smoking.
d. Open the mouth during sneezing.
e. Avoid catching cold.

76. ■ Antibiotics.
e.g. penicillin or penicillin derivatives.
■ Analgesics and NSAIDS
e.g. paracetamol, profen (PRN)
■ Nasal decongestant
e.g. ephedrine or otrivin (oxymetazoline hydrochloride) nasal drops
3 drops/ 3 times daily/ 7 days
■ Steam inhalation
e.g. menthal and benzoin 40 good sniffs should follow nasal
drops.

77. 2. OAC more than2mm-
-Surgical intervention

78. Keys for successful OAC closure
1. A disease free sinus.
2. Coverage of OAC with vascularized tissue.
3. Tension-free closure.
4. Aggressive antibiotic coverage.
5. Emphasize firmly on patient's instructions.
6. Any evidence of sinus infection
Don’t close drainage first, With antibiotic coverage and culture
and sensitivity test if needed and when the infection is controlled then
you can now surgically close.

79. CHRONIC ORO-ANTRAL FISTULA /
PERSISTENT OAC
 It might be a complication of:
 Unrecognized (overlooked) fistula.
 Untreated OAC.
 Failure of spontaneous closure of OAC.
 Failure of surgically repaired communication.

80. Primary management of Chronic OAF
■ It is aimed to eliminate any sinus infection:
– Excision of any mucosal polyp or purulent
granulation to promote drainage.
– Regular irrigation with warm water or saline.
– Single course of antibiotics and nasal inhalation
and decongestant.
– Acrylic base plate (surgical stent).

81. Surgical management
 Principles & requirements:
 Success of operation is not always granted.
 Flap should have good blood supply.
 Flap tissue must be handled gently.
 Flap should lie in its new position without tension.
 Good homeostasis must be achieved before discharging the patient.
 Types of repair:
 Buccal advancement flap.
 Bridge (pedicle) flap.
 Palatal rotation flap.
 Tongue based flap.
 Buccal fat pad.

84. Displacement of A Root or Tooth into Maxillary
Sinus Lining or Sinus Proper
■ It is basically a mishap incident
results from a neglected act by the
operator while applying wrong force.
■ Occurs rarely but the 3rd molar and
2nd premolar are the most at risk of
dislodgement.
■ May occur with severe maxillofacial
injuries.

85. Immediate Investigation &
Management
■ Confirm the existence of oro-antral fistula and the presence of tooth or
root in sinus using dental, occlusal, panoramic and occipitomental
radiographs.
■ Locate the precise position of the foreign body within the sinus lining
or in the sinus cavity proper.
■ Reflect mucoperiosteal flap.
■ Reduce alveolar bone height.
■ Retrieve the tooth or the root by permitting their movement away from
the sinus.
■ If root or tooth dislodged into the sinus proper, consider Caldwell-luc
approach.

86. CALDWELL–LUC OPERATION
George Caldwell in 1893 & Henry Luc in 1897
■ Definition :-
“This procedure involves making a temporary opening into the
maxillary sinus and reestablishing an opening into the sinus from
the nose if necessary.”
 Purpose of Procedure
 This procedure is done for several reasons:
 To remove abnormal tissue growths,
 To treat infection,
 To assist in repair of an injury to the extraction socket.

87. PROCEDURE
■ First of all the incision is made from lateral
incisor to the second molar tooth.
■ Then the flap of mucosa and periosteum is
elevated and dissected to expose the anterior
wall of sinus and then anterior wall is opened
in the canine fossa where the bone is relatively
thin with the drill.
■ The opening can be enlarged by hayek or
kerrison punch forceps to produce hole
sufficiently large to provide access for example
to allow removal of sinus mucosa or
introduction of an endoscope and instruments.

89. ■ The entire lining of sinus is dissected and removed as the
success of the operation in chronic rhinosinusitis. Packing
of nasal cavity and sinus is sometime required.
■ Suturing of buccal incision is recommended with
absorbable suture material.
■ The patient should be advised against overenthusiastic
blowing of the nose for at least a week

91. NASAL BLEEDING( EPISTAXIS)
■ ETIOLOGY- TRAUMA
SYSTEMIC DISTURBANCES
(thrombocytopenia)
Anterior part (injury to Kisselbach’s
plexus)
BLEEDING
Posterior part (in inferior meatus)
vessel involved is Int.max.artery

92. REFERENCES
1. B.D. CHAURASIA’S HUMAN ANATOMY- VOL.3 – 7TH EDITION
2. THE MAXILLARY SINUS- MEDICAL & SURGICAL MANAGEMENT
BY JAMES A. DUNCAVAGE.
3. TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY BY
NEELIMA ANIL MALIK – 4TH EDITION.