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The maxillary sinus

  1. 1. P
  2. 2. The Maxillary Sinus "Antrum of Higmore"
  3. 3. <ul><li>It is a pyramidal-shaped air space which occupies the body of the Maxilla. The base is formed by lateral wall of nasal cavity. Upward (roof) by the orbital floor and downward (base) by the alveolar process of the posterior maxillary teeth. It is bounded anteriorly by the outer wall of maxilla. </li></ul><ul><li>The outlet of the sinus is present in the middle meatus and called hiatus semilunaris or ostium maxillar. </li></ul>General Considerations
  4. 7. <ul><li>The function of the sinuses is to improve resonance to warm inspired air and to decrease the weight of the skull. </li></ul><ul><li>The teeth related to the maxillary antrum are first molar, second molar, second premolar, third molar and first premolar in that order, sinus problems can be mixed up with maxillary dental problems. </li></ul>
  5. 8. <ul><li>Obstruction of natural flow of drainage from the sinuses due to: </li></ul><ul><ul><li>Inadequate and higher position of the anatomic openings, </li></ul></ul><ul><ul><li>Septal deviations, </li></ul></ul><ul><ul><li>Hyperplasia of the lining and inadequate ciliary action. </li></ul></ul>
  6. 9. <ul><li>May be either acute, subactue or chronic depending on the virulance of the organism, the local condition and resistance of the individuals. </li></ul><ul><li>Etiology </li></ul><ul><li>Inflammation of the sinus and its lining is caused by bacteria from the following sources. </li></ul><ul><li>Nasal origin: common cold and influenza. </li></ul>Maxillary Sinustis Affection of the Maxillary Sinus
  7. 10. <ul><li>Dental origin: </li></ul><ul><li>Infection from dental abscess. </li></ul><ul><li>Infection from cystic lesion of related teeth. </li></ul><ul><li>Dental material pushed into the sinus “gutta percha”. </li></ul><ul><li>Tooth or root pushed in the sinus. </li></ul><ul><li>Oro-antrol fistula. </li></ul><ul><li>Facial fracture involving the sinus. </li></ul><ul><li>Sever periodontal pocketing. </li></ul>Affection of the Maxillary Sinus
  8. 11. <ul><li>Headache and sever pain increasing by bending of the bending head downwards. </li></ul><ul><li>Pain and tenderness in the upper teeth. </li></ul><ul><li>Unilateral fetid nasal discharge. </li></ul><ul><li>Nasal obstruction with unpleasent smell. </li></ul><ul><li>General sympoms of toxamia as fever, malaise and dizzines. </li></ul>Clinical features Acute Maxillary Sinusitis <ul><li>Ab from 5-7 days. </li></ul><ul><li>Decongestive nasal drops to shrink the mucous lining and help drainage. </li></ul><ul><li>Analgesics to relieve pain. </li></ul><ul><li>If an oror-antral fistula is present, daily irrigation of the sinus by warm normal saline. </li></ul><ul><li>Removal of the cause, e.g., closure of O.A.F. </li></ul>Treatment
  9. 12. <ul><li>Continous dull pain and Intermittant headache. </li></ul><ul><li>Periodic or persistant unilateral nasal discharge. </li></ul><ul><li>Fetid breath. </li></ul><ul><li>Posterior nasal discharge. </li></ul><ul><li>Transillumination reveals opacity of the affected side. </li></ul><ul><li>X-ray show opacity of the sinus with marked thickening of its lining. </li></ul>Clinical features Chronic Maxillary Sinusits <ul><li>Extraction of infected tooth. </li></ul><ul><li>Repair of O.A communications. </li></ul><ul><li>The thickened lining should be removed through a could well luc operation. </li></ul>Treatment
  10. 16. Occur with fracture of middle third of the face, fracture tuberosity or floor of the sinus during extraction, also may occur from nasal operations Trauma of the sinus This rare condition which may follow perforation of the floor of the maxillary sinus as from dental extraction. Prolapse of the sinus
  11. 18. <ul><li>This formed in case of fracture of the middle third of the face and cause continuous nasal bleeding. </li></ul><ul><li>Treatment: </li></ul><ul><li>Cold application to stop bleeding and decrease swelling. </li></ul><ul><li>Drainage of the sinus through inferior turbinate puncture. </li></ul><ul><li>Continuous bleeding needing interference by cold well-luc operation and inserting a pressure pack inside the sinus or by tying the bleeding vessel. </li></ul>Hematoma of the Sinus
  12. 19. <ul><li>There are hard calcific bodies with rough irrigular surface, it is asymptomatic and discovered on routine radiography as radio-opaque mass, it may become secondarily infected causing maxillary sinusitis. </li></ul><ul><li>Treatment: </li></ul><ul><li>Removal through cald well-Luc operation </li></ul>Antral Rhinoliths &quot;Calculi or Stones&quot;
  13. 21. <ul><li>Usually all the cysts affecting the sinus are asymptomatic. They are discovered by routine radiographic examination. </li></ul><ul><li>Cysts occurring in the sinus: </li></ul><ul><ul><li>Benign mucosal cyst. b. Mucocele. </li></ul></ul><ul><li>Cyst encroaching on the sinus: </li></ul><ul><ul><li>Periodontal cysts b. Dentigerous cyst. </li></ul></ul><ul><ul><li>Odontogenic keratocyst. </li></ul></ul>Cysts Affecting the Sinus
  14. 22. <ul><li>Most common cyst occurs in the sinus as a result of obstruction of the glandular ducts. Small cysts are formed in the lining, or these cysts may ruptured and coalesce to form one large cyst. </li></ul><ul><li>Clinical features: </li></ul><ul><li>Discomfort in the cheek or maxilla. </li></ul><ul><li>Buccal expansion of the antrum. </li></ul><ul><li>Nasal obstruction. </li></ul><ul><li>Post nasal discharge. </li></ul><ul><li>External deformity of the face. </li></ul>Benign Mucosal Cyst
  15. 23. <ul><li>Radiographic picture: appear as rounded lightly opaque shadow in the floor of the sinus. </li></ul><ul><li>Aspiration: through inferior turbinate will reveal straw or amber-coloured fluid “cholesterol crystals”. </li></ul>
  16. 24. <ul><li>Treatment: </li></ul><ul><li>Can be left untreated if found in routine x-ray. </li></ul><ul><li>Cannulation through inferior turbinate puncture. </li></ul><ul><li>Marsupialization </li></ul><ul><li>Enculeation through cold well. Luc operation with nasal antrostomy. </li></ul>
  17. 25. Tumors Affecting The Sinus
  18. 26. <ul><li>Ameloblestoma. </li></ul><ul><li>Adenoameloblastoma </li></ul><ul><li>Odontoma. </li></ul>Benign (Non Odonlogenic) <ul><li>Osteoma. </li></ul><ul><li>Fibro-osteoma. </li></ul><ul><li>Ossifying fibroma. </li></ul><ul><li>Fibroma. </li></ul>Benign Odonlogenic Treatment <ul><ul><li>By surgical excision. </li></ul></ul>
  19. 27. <ul><li>Epidermoid carcinoma. </li></ul><ul><li>Adenocarcinoma. </li></ul><ul><li>Malignant lymphoma. </li></ul><ul><li>Metastatic deposits from breast or lung carcinoma. </li></ul><ul><li>Malignant granuloma. </li></ul>Treatment Malignant <ul><li>Radical resection by maxillectomy. </li></ul><ul><li>Irradiation. </li></ul><ul><li>Cytotoxic drugs and corticosteroid may be helpful in malignant granuloma. </li></ul>
  20. 30. <ul><li>History diffuse toothache with history of common cold. </li></ul><ul><li>Clinical examination: </li></ul>Diagnostic Aids Percussion Palpation Transillumination
  21. 31. <ul><li>Radiographic examination: </li></ul><ul><li>Intra-oral periapical and occlusal: may be helpful to detect root tips or foreign bodies in sinus. </li></ul><ul><li>Panoramic view. </li></ul><ul><li>Water view: 15°°  occipito-mental produce a very clear view of both sinuses and permits comparison of both sinuses.° </li></ul><ul><li>Tomogram: it is of high benefit to reveal early errosion of the wall by neoplastic lesions. </li></ul><ul><li>Computerized tomography (C.T. scanning). </li></ul>
  22. 32. <ul><li>Sinoscopy: it is a recent investigation method which will have an important role in the diagnosis of malignancy and other pathological condition in the sinus. </li></ul>
  23. 33. <ul><li>It is the communication between maxillary sinus cavity and oral cavity through a perforation in the sinus wall. </li></ul><ul><li>Etiology: </li></ul><ul><li>Accidental antral opening after extraction. </li></ul><ul><li>Massive trauma to middle third, e.g., gunshot injuries. </li></ul><ul><li>After surgical excision of large cyst. </li></ul>ORO-Antral Fistula
  24. 38. <ul><li>May occur as a result of malignant tumor. </li></ul><ul><li>Osteomyelitis of the maxilla. </li></ul><ul><li>Gumma of the palate. </li></ul><ul><li>After implants. </li></ul><ul><li>Unhealed cold well-luc operation. </li></ul>ORO-Antral Fistula
  25. 39. <ul><li>Clinical features: </li></ul><ul><li>Abnormal deep socket after extraction. </li></ul><ul><li>Regurgitation of liquids, from the mouth into the nose. </li></ul><ul><li>Unilateral epistaxis. </li></ul><ul><li>Alternations in vocal resonance. </li></ul>ORO-Antral Fistula
  26. 40. <ul><li>Inability to blow-out the cheek. </li></ul><ul><li>Difficulty in smoking. </li></ul><ul><li>Foul or salty unpleasant taste (chronic). </li></ul><ul><li>In chronic fistula a painless lump present at the site of extraction. </li></ul><ul><li>The nose blowing test: when the patient blows we found bubbling of blood in the socket. </li></ul><ul><li>In chronic fistula there are signs of sinusitis. </li></ul><ul><li>X-ray (periapical or water’s view) reveals presence of a fistulous tract. </li></ul>ORO-Antral Fistula
  27. 41. <ul><li>Immediate oro-antral communications. </li></ul><ul><li>Chronic oro-Antral fistula. </li></ul>Management of O-A Communications
  28. 42. <ul><li>Stop bleeding. </li></ul><ul><li>Examine the socket carefully and (remove the root). </li></ul><ul><li>Undremining the wound margins and decrease the height of buccal and palatal alveolar plates. </li></ul><ul><li>Approximate the Bu & palatal mucoperiosteum with proper suturing. </li></ul><ul><li>Post-operative care: </li></ul><ul><li>Avoid any positive or negative pressure. </li></ul><ul><li>Ab  sedatives. </li></ul><ul><li>Nasal decongestant drops. </li></ul><ul><li>Soft dite. </li></ul>Management of Immediate O.A Communication
  29. 43. <ul><li>A small fistula may heal spontaneously. </li></ul><ul><li>The fisula persists in case of: </li></ul><ul><ul><li>The orifice is more than 4mm width. </li></ul></ul><ul><ul><li>Infection. </li></ul></ul><ul><ul><li>Laceration of soft tissue. </li></ul></ul><ul><ul><li>Presence of root. </li></ul></ul>Sequelae of Immediate oro-antral fistula
  30. 44. <ul><li>The buccal flap operation. </li></ul><ul><li>The palatal flap operation. </li></ul><ul><li>Combination of buccal and palatal flap. </li></ul><ul><li>Tongue flap. </li></ul><ul><li>Tunneled palatal pedicle flap. </li></ul>Management of Chronic Oro-Antral Fistula
  31. 54. <ul><li>Incomplete elimination of infected tissues. </li></ul><ul><li>Presence of a tooth or a root fragment inside the sinus. </li></ul><ul><li>Placement of the soft tissue flap under tension. </li></ul><ul><li>Inadequate length of the flap. </li></ul><ul><li>Improper approximation of the flap. </li></ul><ul><li>Haematoma formation and its infection. </li></ul><ul><li>Inadequate drainage through a small nasal antrostomy. </li></ul><ul><li>Mechanical interference with sutures by the patients. </li></ul><ul><li>Inadequate post-operative care or instructions. </li></ul>Causes of O.A Fistula Closure Failure
  32. 55. <ul><li>Define the exact location of the tooth or root using x-ray films and careful clinical examination. </li></ul><ul><li>Use of L.A or G.A. </li></ul><ul><li>Remove through cold well-Luc operation. </li></ul><ul><li>Close the O.A communication. </li></ul>Treatment of Accidentally Forced tooth or Root Into the Maxillary Sinus
  33. 56. <ul><li>Removal of tooth and root fragments from the sinus. </li></ul><ul><li>Trauma to the maxilla “orbital floor” fractures. </li></ul><ul><li>Management of hematoma of the sinus. </li></ul><ul><li>Chronic maxillary sinusitis. </li></ul><ul><li>Cysts in the maxillary sinus. </li></ul><ul><li>Neoplasms in the maxillary sinus. </li></ul><ul><li>Resection of maxillary nerve. </li></ul>Indication Cold Well-Luc Operation
  34. 59. <ul><li>Anesthesia of lip, cheek and gum. </li></ul><ul><li>O.A. fistula. </li></ul><ul><li>Heavy Bleeding. </li></ul><ul><li>Devitalization of teeth. </li></ul><ul><li>Osteomyelitis. </li></ul>Cold Well-Luc Operation Complications
  35. 60. <ul><li>Keep biting on the pack for 2 hr. </li></ul><ul><li>Apply cold fomentation for 24 hr. </li></ul><ul><li>Avoid any mouth wash for 24hr. </li></ul><ul><li>Avoid any hot drinks or food for 24hr. </li></ul><ul><li>Ab, analgesics, decongestive nasal draps. </li></ul><ul><li>Avoid any negative or positive pressure as smoking, blowing, sucking and caughing. </li></ul>The Post-Operative Care & Instruction

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