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Maxillary sinus new

  1. 1. GUIDED BY: Dr. Manish Sharma Dr. Nida Gaba MADE BY: Abhinav Mudaliar (BATCH 2010-2011)
  2. 2. MAXILLARY AIR SINUS: Introduction Embryology Function of air sinus Clinical importance of maxillary air sinus Disease of the maxillary sinus Inflammatory Disease Benign Neoplasm Malignant Neoplasm Inflammatory Disease Odontogenic Cysts Odontogenic Tumors Oroantral Fistula
  3. 3. AIR 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.
  4. 4. EMBRYLOGY:  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 paranasal sinus.  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 cancellous bone.
  5. 5. 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.
  6. 6. 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
  7. 7. 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 molar.
  8. 8. ANTERIOR WALL: -Formed by the facial surface of the maxilla. - Canine fossa is an important structure of this wall. POSTERIOR WALL: - Formed by sphenomaxillary wall. - A thin plate of bone separate the antral cavity from the infratemporal fossa. 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.
  9. 9. Lymphatic Drainage : - submandibular lymph node. Nerve supply: - Infraorbital nerve - Anterior superior alveolar nerve - Middle superior alveolar nerve - posterior superior alveolar nerve
  10. 10. 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.
  15. 15. MAXILLRY SINUSITIS maxillary sinusitis: It is the inflammation of the maxillary sinus. Maxillary sinusits Acute Subacute Chronic ACUTE SINUSITIS:  It may be supurrative or non supurrative inflammation of the antral mucosa.  It is the most freqently infected of the paranasal sinus.
  16. 16. ETIOLOGY: (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. (4) Trauma: Fracture of the maxilla or zygoma, gun shot wound or penetrating injuries can lead to sinusits.
  17. 17. PATHOGENESIS: 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 antrum.
  18. 18. CLINICAL FEATURES:  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.
  19. 19. DIAGNOSIS; (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. MANAGEMENT: MEDICACAL SURGICAL MANAGEMENT MANAGEMENT
  21. 21. RADIOGRAPHIC FEATURES Waters' view of the sinuses showing partial opacification of the right maxillary sinus, with an air-fluid level.
  22. 22. MEDICAL MANAGEMENT: 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 inflamed sinus.
  23. 23. SURGICAL MANAGEMENT: Antral levage: 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. COMPLICATION - Chronic sinusitis - Osteomylelitis of the maxilla - Orbital cellulites - Middle ear infection - Spread to the other sinus.
  24. 24. SUBACUTE MAXILLARY SINUSITIS: It is the intermediate stage between acute and chronic sinusitis. 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 cough. Patient can not sleep well. The disease may take a long course over week or months.
  25. 25. CHRONIC SINUSITIS Infection of the that last for months or year is called chronic sinusitis. It is most commonly is an extension of an acute sinusitis which failed to resolve completely. CAUSATIVE ORGANISM: - Aerobic organism - Anaerobic organism.
  26. 26. PATHOPHISIOLOGY: After infection Ciliated epithelium gets destroyed Prevent drainage of secretion from the maxilla Pooling and stagnation of mucopurulent in sinus Progression of infection Mucosa changes Cilliary damaged and edema Mucosa may become thick and polypoidal.
  27. 27. Clinical Features: 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. Insomnia. INVESTIGATION Water’s view radiograph. Culture of the discharge from the sinus. Transillumination test.
  28. 28. MANAGEMENT: Medical management: 1) Antibiotics: Broad spectrum antibiotics. 2) Analgesics: Paracetamol providing relief. 3) Decongestant . 4) Steam inhalation. 5) Hot fomentatiom.
  29. 29. SURGICAL MANAGEMENT: 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 nasal antrostomy. Henri Luc in 1897 also reported the same procedure . Later on the procedure was accepted as Caldwell-Luc operation worldwide.
  30. 30. CALDWELL LUC OPERATION: This is the procedure by which the antrum is entered intraorlly through the anterior wall and all irreversible disease is removed. This is followed by an antrostomy to promote permanent cure. INDICATION: • 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, ethmoidal sinus.
  31. 31. POLYPS It is the thickened mucous membrane of a chronically inflamed sinus frequently forms into irregular folds called Polyps. CLINICAL FEATURES: • 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.
  32. 32. RADIOGRAPHIC FEATURES: • 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.
  33. 33. RETENTION PSEUDOCYST 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 epithelium. Arrows pointing to domeshaped radiopaque mass on floor of the maxillary sinus
  34. 34. 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 days.
  35. 35. MUCOSITIS 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. CLINICAL FEATURES: • 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 a radiograph. RADIOGRAPHIC FEATURES: • 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.
  36. 36. Arrows pointing to localized thickening of the mucosa of the maxillary sinus
  37. 37. ANTROLITH 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 (or) A calcification in the maxillary sinus. This calcification may be of long standing mucous or foreign bodies, including tooth fragments. CLINICAL FEATURES: • 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. RADIOGRAPHIC FEATURES: • Occur within the maxillary sinus and are positioned above the floor of the maxillary antrum • 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.
  38. 38. arrow pointing to well-defined radiopaque area not attached to the border of the maxillary sinus superior to the maxillary right first molar
  39. 39. MUCOCELE A Mucocele is an expanding, destructive lesion that results from a blocked sinus ostium. CLINICAL FEATURE: • 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 the area. • 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.
  40. 40. RADIOGRAPHIC FEATURES • 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. MANAGEMENT: Treatment of the mucocele is usually surgical, using a caldwell-lue operation to allow excision of the lesion
  41. 41. BENIGN NEOPLASM: EPITHILEAL PAPILLOMA The epithelial papilloma is a rare neoplasm of respiratory epithelium that occurs in the nasal cavity and paranasal sinuses. CLINICAL FATURES Unilateral nasal obstruction, nasal discharge, pain and epistaxis may occur. RADIOGRAPHIC FEATURE • It is usually in the ethmoidal or maxillary sinus. • Appears as a homogenous radiopaque mass of soft tissue density
  42. 42. OSTEOMA The osteoma is the most common of the mesenchymal neoplasm in the paranasal sinuses. CLINICAL FEATURES • 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
  43. 43. RADIOGRAPHIC FEATURES: • 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. DIFFERENTIAL DIAGNOSIS 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.
  44. 44. 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. CLINICAL FEATURES: • 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 commonly effected. • The medial wall is the first to get eroded, leading to nasal signs and symptoms as obstruction,discharge,pain.
  45. 45. • 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 teeth. RADIOGRAPHIC ASPECTS: • 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 surrounding bone. • The medial wall of maxillary sinus is thinned or destroyed.
  46. 46. 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 sinuses.
  47. 47. Squamous cell carcinoma of the left maxillary. Notice the destruction(disappearance) of the walls and floor of the sinus.
  48. 48. PSEUDOTUMOUR 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. CLINICAL FEATURES • 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 involved. • Mostly occurs in immunocompromised or those who have systemic diseases like diabetes mellitus etc. RADIOGRAPHIC FEATURES: • It involves masses simulating neoplasms that cause erosion of bony walls of involved sinus.
  49. 49. INFLAMMATORY DISEASES PERIOSTITIS 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. RADIOGRAPHIC FEATURES •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.
  50. 50. ODONTOGENIC CYSTS •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 RADIOGRAPHIC FEATURES •The invaginating cyst has a curved or oval shaped. •The internal of the cyst is homogenous and radopaque relative to the sinus cavity.
  51. 51. • 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.
  52. 52. 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 sinus. A radicular cyst at the apices of the first molar and extending into the maxillary sinus.
  54. 54. FIBROUS DYSPLASIA Fibrous dysplasia arises adjacent to any of paranasal sinuses and cause displacement of sinus borders and results in a smaller sinus on the effected side. CLINICAL ASPECTS: • 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 migrate.
  55. 55. RADIOGRAPHIC ASPECT: • 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.
  56. 56. OROANTRAL FISTULA: 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. OROANTRAL FISTULA ACUTE CHRONIC
  57. 57. ETIOLOGY: 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 extraction. - In advert curettage of maxillary tooth socket. 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.
  58. 58. ACUTE OROANTRAL FISTULA: Clinical features: Symptoms- History of recurrent surgery in the vicinity of maxillary sinus. Escape of air and fluids through the nose and mouth. Unilateral epsitaxis. 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.
  59. 59. 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 oral cavity. • - 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 antral polyp.
  60. 60. MANAGEMENT: Aim: - To prevent nasal regurgitation of fluides. - To prevent infection of the maxillary antrum from the oral cavity. CLOUSURE OF OROANTRAL COMMUNICATION: Aim: - Primary repair to close the communication. - Antibiotics to cure the sinus infection PROCEDURE: 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 maxillary antrum. VI. Supportive measure are required for treatment of the
  61. 61. CHRONIC OROANTRAL FISTULA: This occur due to the persistence of the communication between the oral cavity and the maxillary antrum. CLINICAL FEATURES: - Persistent unilatral foul discharge. - Post nasal drip with the discharge trickle down the phrynx from the posterior nares resulting in foul smell and unpleasent test. - Systemic sequeles due to swallowed pus in the form of - -Pyrexia, malaise, Headache, Ansomnia,Anroxia. - Pain is diminish consiberabely. - Polyp projecting form the antrum into the oral cavity prevents the fistulous tract to heal spontaneosly.
  62. 62. INVESTIGATION: - 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. MANAGEMENT SURGICAL SUPPORTIVE METHOD METHOD
  63. 63. SURGICAL METHOD If fistulous persist for more than 2 to 3 months the fistula tract would have been epithelized. METHOD OF CLOSURE TECHQUINE; LOCAL FLAP 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 DISTANT FLAP GRAFT- Buccal fat pad - Bone graft.
  64. 64. RADIOGRAPHIC VIEW 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.
  65. 65. 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