Paranasal Sinuses - an overview

1. Check out ppt download link in description Or Download link : https://userupload.net/68y6c1yik0f3

2. CONTENTS INTRODUCTION DEFINITIONS HISTORICAL REVIEW FUNCTIONAL IMPORTANCE DEVELOPMENT OF PARANASAL SINUSES HISTOLOGY OF PARANASAL SINUSES TYPES OF PARANASAL SINUSES

3. MAXILLARY SINUS -EMBRYOLOGY -OSTEOLOGY -ANATOMY FRONTAL SINUS -EMBRYOLOGY -OSTEOLOGY -ANATOMY

4. SPHENOIDAL SINUS -EMBRYOLOGY -OSTEOLOGY -ANATOMY ETHMOIDAL SINUS -EMBRYOLOGY -OSTEOLOGY -ANATOMY -TYPES

5. CLICK HERE TO DOWNLOAD THIS PPT https://userupload.net/68y6c1yik0f3

6. APPLIED ANATOMY CONCLUSIONS BIBLIOGRAPHY

7. INTRODUCTION

8. SINUS It can be defined as a cavity or a channel such as a cavity within a bone, a dilated channel for venous blood or one permitting the escape of purulent material. or It can also be defined as an air filled cavity in the dense portion of a skull. DEFINITIONDEFINITION

9. DEFINITIONDEFINITION PARANASAL SINUSES Are air filled spaces lined by respiratory ciliated mucosa which are present within some bones around the nasal cavities, and they communicate with the nasal cavities through small apertures.

10. HISTORICAL REVIEWHISTORICAL REVIEW Hippocrates of Cos (about 400BC )believed that the paranasal sinuses had a function in draining mucus from the brain to the nasal cavity. During 15th century, Leonardo Da Vinci was the first artist to depict the anatomic appearance of the maxillary and frontal sinuses.

11. During 16th century ,Andreus Vesalius a Belgian anatomist was first to describe the maxillary, frontal and sphenoidal sinuses as empty aerated cavities. Maxillary sinus was known before 1651. Galen made the first known description about the adult maxillary sinus.

12. In 17th century ,Nathaniel Highmore an english anatomist was the first to describe in detail the morphology of the maxillary sinus and advance the idea of pneumatization of the sinuses. In 18th century ,John Hunter was the first to observe the dental infection can spread to the neighbouring areas and predicted the possible relationship between dental pathology and antral infection.

13. FUNCTIONAL IMPORTANCE OFFUNCTIONAL IMPORTANCE OF PARANASAL SINUSESPARANASAL SINUSES PHONETICS:PHONETICS: Adds resonance to the voice.Adds resonance to the voice. Protects from bone conduction of own speech.Protects from bone conduction of own speech. RESPIRATORY:RESPIRATORY: Provides humidification.Provides humidification. Buffers pressure changes.Buffers pressure changes.

14. OLFACTORY:OLFACTORY: Supplies olfactory mucosa (animals).Supplies olfactory mucosa (animals). Acts as a air reservoir of stimuliActs as a air reservoir of stimuli.. STATIC: Reduces skull weight and growth.Reduces skull weight and growth.

16. MECHANICAL:MECHANICAL: Protects from trauma.Protects from trauma. THERMAL:THERMAL: Provides heat insulation.Provides heat insulation. BACTERICIDAL:BACTERICIDAL: Production of bactericidal lysosomes to theProduction of bactericidal lysosomes to the nasal cavity.nasal cavity.

17. DEVELOPMENTDEVELOPMENT Sinuses begin their development at the 3rd ,4th and 5th months of intrauterine life as outpouchings of the mucous membrane of the superior ,middle nasal meatuses and the sphenoethmoidal recesses.

18. The early paranasal sinuses expands into the walls and roof of the nasal fossae by growth of mucous membrane sacs into the maxillary, sphenoidal, frontal and ethmoidal bones.

19. The sinuses enlarge variably and greatly from their initial small outpocketings but always retain their original communication with the nasal fossa through ostia.

20. HISTOLOGYHISTOLOGY Microscopically three layers can be seen  The epithelial layer  Basal lamina  Subepithelial layer including periosteum

21. Epithelium is pseudostratified columnar ciliated which is derived from the olfactory epithelium of the nasal cavity. Epithelium of the sinus is similar to that of the nasal cavity but it is thinner and contains less goblet cells.

22. Most of the cells are columnar ciliated cells. In addition there are columnar non-ciliated, mucous producing cells called as goblet cells. GOBLET CELLSGOBLET CELLS Basal cells are the site of cell divisions, daughter cells continuously replace the mucous and ciliated cells.

23. Mucous cells arising from the basement membrane have a thin stem like extension and the apical cytoplasm is filled with varying amounts of mucus. The nucleus is situated between these parts of the cell. When the cell is full of mucus, it looks like goblet glasses hence the term goblet cell is used to describe these cells.

24. TYPES OF PARANASALTYPES OF PARANASAL SINUSESSINUSES Maxillary sinus Frontal sinus Sphenoidal sinus Ethmoidal sinus

26. MAXILLARY SINUS:MAXILLARY SINUS: EMBRYOLOGYEMBRYOLOGY Maxillary sinus is the first paranasal sinus to show pneumatization at the 3rd month of intrauterine life. At birth the sinus is • 2cms in length, • 1cm in height and width, • Expands 2mm vertically,laterally and 3mm antero posteriorly.

27. The rapid and continuous growth of the sinus in later stages brings its walls in close proximity to the roots of maxillary molars and its floor below its osteal opening. In adults the floor of the sinus is approximately 1.0 -1.25cm below the level of the floor of the nasal cavity.

28. PHYSIOLOGY Mucocliliary mechanism - move the mucus and other debris towards the ostium, and subsequently discharges in the middle meatus. Gravity plays no role in draining sinus. Cilia beats at an approximate rate of 1000 strokes/min providing a flow rate of 6mm/min.

29. OSTEOLOGY It is the pneumatic space within the body of the maxilla previously known as maxillary antrum of Highmore. It is largest of all the paranasal sinuses.

30. It is pyramidal in shape, with its apex in the zygomatic process of maxilla and the base at the lateral wall of the nose ,anteriorly it is approximated by the cheecks and posteriorly by the infratemporal surfaces of the body of maxilla.

31. Roof of the sinus is formed by floor of the orbit. Floor of the sinus is formed by the alveolar part of the maxilla. Average size: Height : 3.5cms Width : 2.5cms Antero posteriorly : 3.5cms

32. Volume of the maxillary sinus: 15-30ml The ostium of the sinus is 2-4mm in diameter,6mm in length and it opens at the posterior part of the infundibulum in the middle meatus of the lateral wall of the nose.

33. Arterial supply: Facial artery, Infraorbital artery and Greater palatine artery. Venous drainage: Facial vein and pterygoid plexus of veins. Lymphatic drainage: Submandibular lymph nodes. Nerve supply: Infraorbital nerve, Anterior, Middle and Posterior alveolar nerves.

34. ARTERIAL SUPPLY NERVE SUPPLY

35. FRONTAL SINUS: EMBRYOLOGY These are the only sinuses which are not present at birth.  It appears as excavations into the diploe between the outer and inner tables of the frontal bone during the second year. These are not visible radiographically before 6years of age.

36. OSTEOLOGY Lies most superiorly compared to all the other sinuses. It is marked by a triangular area formed by joining i. Nasion ii. 2.5cms below the Nasion iii.Superior orbital notch

37. It lies in the frontal bone deep to the superciliary arch. Superiorly it extends above the medial end of the eyebrows. Posteriorly into the medial part of the roof of the orbit. Right and left sinuses are usually unequal in size and rarely one or both the sinuses may be absent.

38. Average size: Height :2.5cms Width :2.5cms Antero posteriorly :2.5cms Sinuses are better developed in males than in females. It opens into the middle meatus of the nose through the infundibulum or frontonasal duct.

39. Arterial supply : Supra orbital artery Venous drainage: Into the anastomotic vein between the Supra orbital and Superior Ophthalmic veins in the Supra orbital notch. Lymphatic drainage: Submandibular lymph nodes. Nerve supply: Supra orbital nerve

40. NERVE SUPPLY

41. SPHENOIDAL SINUSES : EMBRYOLOGY Starts developing at 4th month of intrauterine life by invading posterior part of the nasal capsule into the body of the sphenoid bone. It continues growing into early adulthood and may invade the wings and rarely the pterygoid plates of the sphenoid bone.

42. At birth the sinuses are minute and their main development occurs after puberty.

43. OSTEOLOGY Paired sinus occupies the body of the sphenoid bone which are separated by nasal septum. Superiorly it is related to the Pituitary gland and Optic chiasm. Inferiorly it is related to the roof of the nasopharynx.

44. Posteriorly it is related to the posterior cranial fossa and pons. Laterally it is related to the cavernous sinus and internal carotid artery. Each sinus opens into the sphenoethmoidal recess behind the superior concha.

45. Arterial supply: Posterior ethmoidal and internal carotid arteries. Venous drainage: Into pterygoid venous plexus and cavernous sinus. Lymphatic drainage: Into the retropharyngeal nodes. Nerve supply:Posterior ethmoidal nerve and orbital branches of the pterygopalatine ganglion.

46. ARTERIAL SUPPLY NERVE SUPPLY

47. ETHMOIDAL SINUSES: EMBRYOLOGY Invades the ethmoid bone during 5th month of intrauterine life and grows variably into irregular contour until puberty. The anterior most ethmoidal cells grow upward into the frontal bone and may form the frontal sinuses retaining their origin from the middle meatus of the nose as the fronto-nasal duct.

48. OSTEOLOGY These are numerous small intercommunicating spaces which lie within the labyrinth of the ethmoid bone between the orbit and the nose.

49. Its number varies from 3-18 each with their own ostium and they are called anterior, middle and posterior ethmoidal sinuses according to where they drain.

50. They are completed from above by the orbital plate of the frontal bone. Posteriorly by the sphenoidal concha and the orbital process of the palatine bone. Anteriorly by the lacrimal bone and Medial angle articulates with the cribriform plate of the ethmoid bone.

51. Anterior ethmoidal sinus: It occupies the anterior part of the sinus.  It consists of 1-11 air cells. Roof and the bony walls are completed by the frontal bone.

52. The ostia may open either into the infundibulum in the middle meatus or into the frontonasal recess that drains the frontal sinus. Nerves and vessels: Anterior ethmoidal nerves and vessels. Lymphatic drainage: Submandibular lymph nodes.

53. Middle ethmoidal sinus: It consists of 1-7 air cells. It drains into the superior meatus of the nose. Anterior +Middle etmoidal air cells constitute an anterior ethmoidal system.

54. Nerves and vessels: Posterior ethmoidal nerves and vessels ,the orbital branches of the pterygopalatine ganglion. Lymphatic drainage: Submandibular lymph nodes.

55. Posterior ethmoidal sinus: It consists of 1-7 air cells. The posterior most cell may extend far enough back to lie immediately adjacent to the optic nerve in its canal. It drains into the superior meatus of the nose.

56. Nerves and vessels: Posterior ethmoidal nerves and vessels ,orbital branches of pterygopalatine ganglion. Lymphatic drainage: Retropharyngeal lymph nodes.

57. SPECIAL AND ADDITIONAL AIR CELLS Ethmoid bulla Agger Nasi cells Tip cells Nasal cells Onodi cells Bullae frontales Concha bullosa

58. APPLIED ANATOMY Developmental anomalies Sinusitis Referred pain Infections of dental origin Cysts and tumors Trauma Oro-antral fistula Miscellaneous

59. DEVELOPMENTAL ANOMALIES AGENESIS: -Complete absence or aplasia of maxillary sinus occurs either alone or in combination with anomalies like Cleft palate, Mandibulofacial dysostosis, absence of concha, Septal deformity.

60. SUPERNUMERARY MAXILLARY SINUS: Occurrence of two completely separated sinuses on the same side.  It is initiated by outpocketing of the nasal mucosa resulting in two permanently separated ostia of the sinus.

61. ABSENCE OF FRONTAL AND SPHENOIDAL SINUS: Down’s syndrome . Apert’s syndrome. CONGENITAL SYPHILIS: Pneumatic process is greatly suppressed resulting in small sinus.

62. PITUITARY GIGANTISM: All sinuses assume a much larger volume than in healthy individuals. PITUITARY DWARFISM: All sinuses assume a smaller size than in healthy individuals.

63. SINUSITIS:  Inflammation of the mucosal lining of the sinus. CLASSIFIED INTO 3 TYPES  ACUTE  SUBACUTE  CHRONIC

64. STEPS IN SINUSITIS

65. ACUTE SINUSITIS  Caused by Streptococcus pneumoniae and Hemophilus influenza. Symptoms:  Pain :localized and constant (Throbbing type)  Exacerbates by lowering head as in bending.  Difficulty in breathing

66. Signs: Teeth may become sore and painful  Nasal discharge is watery and serous initially but soon becomes mucopurulent causing a constant irritation by dripping into nasopharynx DIAGNOSIS: Mainly by the symptoms Clinical examination

67. TREATMENT: Sinus lavage Nasal decongestants Analgesics  Antibiotics

68. M. Hacarova, J. Hubacek, Department of ENT and Allergology,  Using Low Level LASER(He Ne) Treatment (LLLT) for acute sinusitis. External irradiation with a laser of 830 nm wavelength, enabling the beam to penetrate 4 - 6 cm deep for 3-6 minutes.

69. Laser irradiation works through its - Analgesic, Anti-inflammatory and Bio-stimulative effects . -leading to withdrawal of inflammation ,oedema of the mucosa and restoration of drainage of sinus as well as normalisation of the mucociliary function.

70. LASER THERAPY 74 SINUSITIS

71. SUB ACUTE SINUSITIS It is intermediate stage between acute and chronic sinusitis It is devoid of acute symptoms Sore throat is a common finding Discharge is persistent and associated with nasal voice and stiffness

72. DIAGNOSIS: Signs and symptoms History- from few weeks to months Rhinoscopy Transillumination  X-ray Water’s view

73. TREATMENT: Improvement of drainage(sinus lavage) Nasal decongestants Analgesics and antibiotics rarely required

74. CHRONIC SINUSITIS Caused by β-lactum producing strains of Hemophilus influenzae and Branhamella catarrhalis ETIOLOGY: Repeated attack of acute sinusitis Single attack of sinusitis of long duration

75. Neglected dental infection Chronic infection in frontal or ethmoidal sinuses Allergies

76. Diagnosis:  History  Signs and Symptoms  Transillumination  X-ray by Water’s view –appears hazzy  Endoscopy

77. Treatment: Analgesics and Antibiotics Nasal decongestants Mucolytic agents Establishing adequate drainage by intranasal antrostomy Endoscopic nasal discharge allows a more functional approach than radical antrostomy Caldwell-luc procedure

78. AYURVEDIC MEDICINE GINGER -Ginger extract is very good for curing sinusitis. GARLIC -Take 4-5 garlic seeds and soak in water for some time make its paste and inhale its fragrance this will loosen the mucus and will make breathing easier.

79. FENUGREEK(METHI) -Prepare a mixture by adding 2-3 teaspoon of fenugreek seeds in a glass of water boil till the water content reduces to half drain the mixture, and take in small sips. MUSTARD SEEDS -Take mustard seeds in a glass of water boil ,allow it to cool put 3-4 drops into the nose with the help of a dropper.

80. CINNAMON POWDER -cinnamon powder+water=cinnamon paste apply this paste over the head and nose. FRUITS -Sinusitis patient should eat plenty of fresh juicy fruits like oranges, and other Vitamin C-rich fruits. Mango is also very good for sinusitis patient. Freshly prepared orange juice, sweet grape juice are best for curing sinusitis.

81. SIDDA MEDICINE The Siddha drug, ‘Karpoora Mezhugu’ has a variety of traditional uses. In the clinical therapy the drug is administered orally for the treatment of Peenism (Sinusitis).

82. YOGIC MEDICINE SARVANGASANA (Shoulderstand) ARDHA HALASANA(Supported Half Plow Pose) EKA PADA SAVARGANASANA (plow pose with one leg up and one down) PRANAYAMA NETI

83. SINUS POLYPS Sinus polyps are growths or swollen tissue in the sinuses that may obstruct breathing or make it hard for sinuses to drain. Diagnosis: Endoscopy, C.T. scan Treatment : Nasal sprays that contain corticosteroids like budesonide and fluticasone. 

84. ENDOSCOPY 88 SINUS POLYP

85. COMPLICATIONS OF SINUSITIS ORBITAL CELLULITIS CAVERNOUS SINUS THROMBOSIS MENINGITIS OTOLARYNGITIS INTRACRANIAL ABSCESS DEATH

86. REFERRED PAIN Superior alveolar nerve runs for a considerable distance in the walls of the antrum. Progressive expansion of the sinus in older persons cause resorption of bone and the connective tissue covering the structures of the canal are brought in direct contact with the mucoperiosteum of the sinus.

87. This leads to involvement of dental nerves if inflammation of sinus occurs. Examination of teeth by cold stimulation reveals that entire group of teeth are hypersensitive.

88. INFECTIONS OF DENTAL ORIGIN 10 -15% of all the pathological conditions involving maxillary sinus are of dental origin It includes -Accidental opening during extraction . -Displacement of roots or whole tooth during extraction .

89. Infections introduced through the abscessed tooth by perforating antral floor. Infections of dental origin like granuloma,cyst or a tumour may invade the sinus. Empyema of the sinus may also occur as a result of excess curettage of the tooth sockets after extraction.

90. CYSTS AND TUMORS Dentigerous cyst,Odontomes. Benign and Malignant neoplasms -Angiomas, Myomas, Fibromas and Central giant cell granuloma -Ameloblastoma -Epidermoid carcinoma

91. Symptoms: Asymptomatic in early stages Swelling of face is the chief complaint Involved tooth will be painful and becomes loose After extraction wound of extracted tooth fails to heal Metastasis to vital organ causes death

92. TRAUMA Fracture of maxilla (Lefort 2, Lefort3) Zygomatic fracture Blow out fracture of the orbit -leads to crushing of the sinus region Treatment: Most of the time treatment is symptomatic

93. ORO-ANTRAL FISTULA Fistula: Communication between two organs or structures which is lined by epithelium in which both ends are opened. Oro-Antral Fistula: Communication between the oral cavity and the antrum.

94. CT SCAN VIEW Oro-Antral fistula

95. Causes: Untreated sinusitis Accidental opening during extraction Perforation due to any tumor or cyst Diagnosis: Done by asking the patient to compress the nostrils and blow the nose gently, if an opening has occurred through the membrane lining the sinus then there will be bubbling of blood in the tooth

96. If the opening is small then use of irrigation, vigorous mouth washing, frequent blowing of the nose is to be avoided . In majority of cases a good clot will form and organize leading to normal healing process. Probing of the socket must be avoided to prevent infection.

97. Treatment: Chronic sinusitis should be treated first Curette, clean by irrigating the sinus An acrylic plate should be given Nasal drops

98. TREATMENT: Palatal flap Buccal flap Cartilage Bone disks Gold disks

99. TREATMENT OF ORO-ANTRAL FISTULA USING BUCCAL FLAP

100. CALD WELL -LUC OPERATION  It is a technique to gain access into the maxillary sinus through the canine fossa region.

101. Indications: Removal of teeth, root fragments, cysts, neoplasms,chronic maxillary sinusitis Management of hematomas of the antrum with active bleeding through the nose Trauma to the maxilla or when the floor of the orbit has dropped

102. CALDWELL-LUC PROCEDURE

103. Procedure:  Incision  Cut the bone Purpose of operation is accomplished Suture Antibiotics, analgesics and nasal drops

104. ANTROSTOMY It is a technique of making an artificial ostium to the maxillary sinus in the inferior meatus of the nose The principle behind it is that the ostium of the sinus is at higher level than the floor of the sinus,making an opening at a lower level improves the drainage

105. But the disadvantage is that,eventhough the opening is made at a lower level the cilia of the cells tend to beat the secretions towards the direction of original ostium, therefore antrostomy is rarely done.

106. MISCELLANEOUS As the sinus does not reach its normal size before the age of 15 years risk of creating an oro-antral fistula is less likely in children and teenagers than in adults. Some subjects have very large antra and in such cases the floor is thinner than normal and more likely to fracture as a result of force applied during extraction of any upper tooth from the canine to the third molar.

107. If there is an unerupted third molar in the tuberosity its presence constitutes a potential line of weakness in that area resulting in fracture of tuberosity along with maxillary sinus while extracting third molar. When the adjacent second molar is extracted any undue force with the forceps may result in fracture of the maxillary sinus.

108. The anterior and infratemporal walls of the maxillary sinus are very thin -Tumors developing in the maxillary sinus can readily erode them and presents as swelling on the cheeck extraorally, -And presents as a palatal lump or a swelling in the buccal sulcus intraorally which leads to non vitality of the tooth.

109. The nerve supply of the mucous membrane of the antrum is from the superior dental nerves. There is possibility of superior dental nerve damage during removal of portions of the anterior and lateral antral walls during surgical procedure Leads to paresthesia of that area.

110. ANTROLITHS Hard calcific bodies with a rough, irregular surface also called as antral rhinoliths, antral stones, antral calculi, maxillary antroliths. Minerals like calcium phosphate, calcium carbonate, magnesium on foreign body. (Tomaino and Picchi 1966) DIAGNOSIS: Radiographs, Endoscopy TREATMENT: Caldwell –Luc operation.

111. CONCLUSIONS Studying the embryology, anatomy and histology of paranasal sinus helps us to know -The importance of paranasal sinus especially maxillary sinus in dentistry as it is closely related to roots of premolars and molars. -To differentiate whether the disease is of dental origin or from the paranasal sinus which helps in referral of patients to the respective faculty .

112. For obtaining the best results and to give the patient the benefit of mutual or specialized knowledge a close liaison between the Otolaryngologist and the oral surgeon through unhesitating call for consultation when needed are certainly to be encouraged.

113. BIBLIOGRAPHY  Greoffrey H. Sperber :Craniofacial Embryology 1981 ;3 :Wright publications ,Canada.  Orban :Oral Histology and Embryology 2006 ; 12: Mosby publications ,India.  James K. Avery :Oral Development and Histology 2002 ; 3: Thieme medical publishers.

114.  Antonio Nanci: Tencate’s oral Histology – development, Structure and function 1998 ; 6 : Elsevier publications, India .  B. D. Chaurasia : Human Anatomy 2008 ; 4(3) :CBS publications, India.  Neelima Malik : Oral and Maxillofacial Surgery 2008 ; 2 : Jaypee publications ,India.

115. Neelima Malik :Oral and Maxillofacial Surgery 2008 ; 2 : Jaypee publications ,India.  Peterson :Contemporary Oral and Maxillofacial Surgery 2007 ;4 : Mosby publications, India.  Srinivas B :Oral and Maxillofacial Surgery 2004;2 : Elsevier publishers, India.

116. Chummy. S .Sinnatamby :Lasts’ Anatomy 2006 ;11 ;Elsevier puublications ,China. Killey and Kay :The Maxillary Sinus and its Dental Implications 1975 ;1 : John Wright and sons publishers,London. Thomas Koppe, Hiroshi Nagai, Kurt W. Alt : The Paranasal sinuses of Higher Primates (Development, Function and Evolution) Quintessence publishers ,London.

117.  Thomas Koppe, Hiroshi Nagai, Kurt W. Alt : The Paranasal sinuses of Higher Primates (Development, Function and Evolution) Quintessence publishers ,London.  Rajendra, Shivapatha sundaram :Shafer’s Text book of Oral Pathology 2009;6:Elsevier publications, India .  M. Hacarova, J. Hubacek ,Dept.of ENT and Allergology, Olomouc, CZ :Low Level Laser Therapy of Sinusitis .

118.  Dr. Paul J. Donald: Recent advances in paranasal sinus surgery ;Head and neck surgery ;1980 (Abstract)  Bechara Y. Ghorayeb, :Repair of Oro-Antral Fistula with Buccal Mucosa Advancement Flap ; Otolaryngology Houston, Texas.(Internet source).  Krishnaveni M,Maheswari Dr, Prema S, and Anbu J. :Antimicrobial activity of Karpoora Mezhugu: a Siddha drug. Siddha Papers, 01 (08) RP (Independence Day Special); 2008 ;p (1-5).

Paranasal Sinuses - an overview

Dr Medical

Paranasal Sinuses - an overview