maxillary sinus its anatomy, land marks and clinial consideration

1. M A X ILL ARY S I NUS
D R . A I S WA RYA D I L E E P
1 M D S

2. CONTENTS
• INTRODUCTION
• EMBRYOLOGY
• DEVELOPMENT
• ANATOMY
• VASCULARIZATON AND INNERVATIONS
• CLINICAL EXAMINATION
• RADIOLOGICAL INVESTIGATION
• MICROSCOPIC ANATOMY
• INFECTION OF MAXILLARY SINUS
• MANAGEMENT
• APPLIED SURGICAL ANATOMY
• CONCLUSION
• REFERENCES

3. INTRODUCTION

4. MAXILLARY SINUS
 The maxillary sinus is the pneumatic space that is lodged
inside the body of maxilla and that communicates with the
environment by way of the middle meatus and the nasal
vestibule- Orban’s textbook
 Also known as “antrum of Highmore”, named after an
English anatomist Nathaniel Highmore who first
described it.(1651)
 Size- 3.5 cm x 3.2cm x 2.5 cm
(Therner,1902)
 Volume 15 to 30 ml

5. EMBRYOLOGY

6. Horizontal shift of the
palatal shelves and
subsequent fusion with one
another
Nasal septum separates the
oral cavity from the two nasal
chambers
Influences further expansion of
the lateral nasal wall and 3 walls
begin to fold
3 conchae and meatuses arise
Superior & inferior
- Shallow depression for half of IU Life
Middle
- Expansion in lateral wall and in inferior
direction

10. DEVELOPMENT
 4th month of fetal life: shallow groove between the
oral cavity and the floor of the orbit.
 At birth: slit like out-pouching of the nasal cavity
 Develop as an evagination of the mucous membrane
of the lateral wall of the nasal cavity at the level of the
middle nasal meatus forming a minute space that
expands primarily in an inferior direction into the
primordium of the maxilla.
 Grows rapidly by a process known as ‘Pneumatization’
during the eruption of deciduous teeth
 Reaches half its adult size by 3yrs of age
 Reaches full size after eruption of permanent
dentition

11. PNEUMATIZATION
 Growth of the maxillary sinus is
determined by a process of bone
remodeling referred to as pneumatization
 Carried out by resorption of the internal
walls (except the medial wall) at a rate that
lightly exceeds growth of the maxilla.
At young age, sinus growth by pneumatization α growth of the maxilla
With the advance of age, pneumatization exceeds maxillary growth.
Thus the antrum will expand at the expense of the maxillary process.

12.  In old age pneumatization becomes more pronounced, the floor
of the sinus moves at more downward position particularly when
the maxillary teeth are lost.

13. Recesses-
• Alveolar process
• Zygomatic process
• Palatine process
• Frontal process

14. AVERAGE MEASUREMENTS
•Height (opposite first molar tooth)-3.5cm
•Width-2.5cm
•Antero-posterior depth- 3.25cm
•Average volume -15ml

15. DIMENSION OF SINUS FROM BIRTH TO OLD
• Tubular at birth
• Ovoid in childhood
• Pyramidal in adulthood

16. ANATOMY
• Largest of PNS,communicate with other sinuses through lateral nasal wall.
• Pyramidal shaped
• Base
• Apex
• 4 walls

17. ANATOMICAL RELATIONSHIP
• Mediolaterally
• Central air-filled cavity
• Roof: bounded by the orbit
• Medial wall: bounded by the nasal cavity
• Lateral wall: related to the zygoma and
cheek
• Anteroposteriorly
• Anterior wall: related to the facial surface of
maxilla
• Posterior wall: related to the pterygopalatine
fossa
• Floor: related to the apices of the maxillary
posterior teeth

18. MEDIAL WALL
Formed by nasal cavity
• The opening of the sinus is closer to the roof
and thus at a higher level than the floor.

19. ROOF OF THE ANTRUM
• Formed by floor of the orbit and is transversed
by the infraorbital nerves.It is flat and slopes
slightly anteriorly and laterally.
.

20. LATERAL WALL
• Related to zygoma and cheek.

21. NATURAL OSTEUM
• Ostium of the maxillary sinus is
situated high up in medial wall and
opens into the middle meatus of the
nose in the lower part of the hiatus
semilunaris.
• Poorly placed from the point of view of
free drainage.
• An accessory ostium is also present
behind the main ostium in 30% cases.

22. POSTERIOR WALL
• Formed by sphenomaxillary wall.
• A thin plate of bone separate the antral
cavity from the infratemporal fossa

23. ANTERIOR WALL
• Formed by the facial surface of the maxilla.
• Canine fossa is an important structure of this wall.

24. FLOOR OF THE SINUS
• Formed by junction of anterior sinus wall and lateral nasal
wall
• Curved rather than flat formed by alveolar process of the
maxilla. and lies
about 1cm below the level of the floor of the nose.
• Closely related to root apices of the maxillary premolar
and molar.

25. VASCULARIZATION & INNERVATION
Branch of third part of maxillary artery(pterygopalatine
part)
1. Posterior superior alveolar artery
2. Infra-orbital artery
3. Greater palatine artery.

26. VENOUS DRAINAGE
Infection from the maxillary sinus may spread to involve cavernous sinus via any of
its draining veins as the pterygoid plexus communicates with the cavernous sinus
by EMISSARY VEIN.
Veins accompany artery
Anterior facial vein
Pterygoid venous plexus

27. NERVE SUPPLY
By last (1959)
• Anterior superior alveolar nerve
• Middle superior alveolar nerve
• Posterior superior alveolar nerve
• Greater palatine nerve
Surgical Importance of Nerve supply
• As there is chance of damage of nerve during surgical
procedure
• Asa-given off from infraorbital and about 15mm form
infraorbital foramen,courses down on anterior Wall
• Msa-seen in 50 % cases arise from lateral aspect of
infraorbital nerve
• Psa-sup branch runs at level of malar tuberosity,inf
branch-runs parallel to tranverse facial part of anteior

28. • Submandibular lymph nodes
• Deep cervical lymph node
• Retro pharyngeal lymph nodes
LYMPHATIC DRAINAGE

29. CLINICAL EXAMINATION
Middle third of face should be inspected for
presence of:
Asymmetry
Deformity
Swelling
Erythema
Ecchymosis
Hematoma
Eyes should be looked for proptosis, ptosis, upward displacement of globe
and restriction of the movement producing diplopia

30. PALPATION
• Place index finger and middle fingers on either side of
nose below the rim of the orbit
• If gentle pressure does not produce pain, percussion
can be carried out
• Palpating fingers are placed in the same position and
the sinus is percussed using the tip of the middle finger of
the other hand

31. TRANSILLUMINATION
• Requirements: Dark room, bright light source
• Place the light source in the mouth and press it firmly
against the anterior and lateral aspects of the hard palate
with the patient’s lips closed
• Amount of light passing through each sinus is compared

32. • Intraoral examination should be performed
looking for the following in upper molar and
premolar region:-
– Alveolar ulceration
– Expansion
– Tenderness
– Paresthesia

33. RADIOLOGICAL INVESTIGATIONS
• Water’s view
• Standard occipitomental- 00 OM
• True lateral skull
• Caldwell view
• Submentovertex
• CT
• MRI
• CBCT
Conventional Advanced imaging

35. WATERS VIEW

36. LATERAL SKULL VIEW

37. O R T H O P A N T O M O G R A P H

38. PERI APICAL RADIOGRAPHS

39. MICROSCOPIC ANATOMY
EPITHELIUM SUBEPITHELIUM
BASAL LAMINA

40. EPITHELIUM

41. CILIATED EPITHELIUM

42. GOBLET CELLS
• It is mucous synthesizing and secreting cells.
• It resembles an inverted wine glass with a short stack like basal end containing the
nucleus and a swollen apical end containing mucin.
Basal end
Apical end

43. MICROVILLI
• Hair like projection of actin filament
• Length 1-2 mm
• Function:
• Increase surface area of cell
• Prevent drying of surface

44. BASAL LAMINAAND SUBEPITHELIUM
•It is formed of connective tissue cells, and intercellular substance of
collagen bundles ,blood capillaries,fibroblasts ,fibrocytes .
•The lamina propria contains subepithelial antral glands composed of
mixed glands formed of serous and mucous acini or mixed acini as
well as myoepithelial cells.
•The antral glands are more concentrated in the lamina propria
located around the ostium.
.

45. FUNCTIONS OF MAXILLARY SINUS
1. Decrease skull weight
2. Impart resonance to voice
3. Humidify and warm inhaled air
4. Define facial contour
5. Filters debris
6. Serves as accessory olfactory organ
7. Create Air padding to the important tissues

46. INFECTION OF MAXILLARY SINUS

48. • ACUTE
• SUBACUTE
• CHRONIC
• BACTERIAL
• VIRAL
• FUNGAL
• MYCOBACTERI
A
• PARASITE

49. Anatomical variations influencing the development of sinusitis
a) Variations of uncinate process
b) Variations in bulla ethmoidalis
c) Variations of middle turbinate
d) Accessory ostium
e) Deviated nasal septum
f) Nasal masses
g) Haller cell
MAXILLARY SINUSITIS

50. EXTRINSIC
CAUSES
INFECTIOUS CAUSES
• Bacterial
• Viral
• Fungal
• Parasitic
NON INFECTIOUS
• Allegic
• Non- Allergic
• Pharmacologic
• Irritants
DISRUPTION OF
MUCOCILIARY DRAINAGE
• Surgery
• Infection
INTRINSIC
CAUSES
GENETIC
• Structural
• Immunodeficienc
• Mucociliary
abnormality
ACQUIRED
• Aspirin
hypersensitivity
• Autonomic
dysregulation
• Hormonal
• Structural
[tumors/cyst]
• Idiopathic

51. ACUTE SINUSITIS
Dental cause
• Periapical infection from the teeth
• Oroantral fistula
• Dental material in antrum
• Traumatic injuries
• Implant
• Infected dental cyst
• Periodontitis
Non dental cause
• Mechanical
• obstruction of ostium
• Bacterial contamination
• Immune deficiency

52. Signs
• Tenderness over the cheek.
• Anesthesia of the cheek
• Mild swelling of the cheek.
• Existance of OAF
• Fetor oris
• Discharge of pus into the mouth
Symptoms
History of cold
• Nasal blocking following rhinitis
• Thick mucopurulant, foul smelling
discharge
• Heavy feeling in the head
• throbbing pain, constant
• Area: area of eyeball, cheek, frontal
region.
• Exacerbated by bending or lowering
head.

53. WATER VIEW RADIOGRAPH : (occipitomental) is radiograph of choice.
• TRANSILLUMINATION TEST : Shows opacity of involved sinus.
• CT SCAN : Demonstrate mucosal abnormalities in the nose and sinuses.
• CULTURE : Nasal secretion may be for culture sensitivity test to see the
organism involved.
DIAGNOSIS

54. RADIOGRAPHIC FEATURES
Waters' view of the sinuses showing partial opacification of the right
maxillary sinus, with an air-fluid level

55. .
1) ANTIBIOTICS : Doxycycline hydrochloride( vibramycin) 100 mg daily,
Erythromycin 250-500 mg 6 hourly for 5 days.
Amoxicillin 250-500 mg 8 hourly for 5 days.
2) DECONGESTANT:.
Ephedrine nasal drops(0.5%) 6 hourly
Xylometazoline (0.1%)
TREATMENT

56. 4) STEAM INHALATION : Acts by hydrating the mucous layer, making it
less viscous and encouraging normal ciliary clearance of the sinus. (steam alone
or medicated with menthol or eucalyptus)
5) NSAIDS : Aspirin , Ibuprofen , paracetamol

57. SUBACUTE MAXILLARY SINUSITIS
1) It is the intermediate stage between acute and chronic sinusitis. There
is pain only in the form of the local discomfort
2 ) Persistent discharge
3) Throat is sore with constant irritating cough. Patient cannot sleep well.
4) The disease may take a long course over week or months

58. CHRONIC SINUSITIS
• The term Chronic sinusitis is poorly defined but is best considered as
persistent incompletely resolved acute sinusitis.
• PATHOPHISIOLOGY: The mucous membrane of the sinus due to
chronic inflammation may undergo changes like hyperplasia or atrophy.
Multiple polyps formation or degeneration of epithelium where the cilia
are lost and ostium shows edematous changes causing complete
blockage.

59. • CAUSE : Persistence of external aggravating factors like nasal
polyp,septal deviation ,oroantral fistula.
• CLINICAL FEATURES : Pain and tenderness in the area of antrum
Unilateral foul discharge through posterior
nares
Fetid odour
• DIAGNOSIS : Water’s view radiograph.
Transillumination test.
Anterior rhinoscopy

60. TREATMENT
1. Dental origin : Affected teeth must be removed and the socket closed surgically as there will
be risk of oroantral fistula.
2. Nasal Polyp : Concurrent presences of polyps should be removed followed by routine post
operative antibiotics and analgesics.
3. With presence of Oroantral fistula : Surgical closure of fistula
4. Antrostomy : If above all procedures fails to cure chronic sinusitis the inferior meatal
Antrostomy and middle meatal antrostomy can be done.
5. Transnasal endoscopic surgery : An approach to the middle meatus using rigid instrument
to visualize the infundibulum and the natural openings of the sinus.

61. Management
1. Antibiotics
2. Steroids
3. Decongestants
4. Analgesics
5. Antihistamines
6. Nasal spray & saline irrigation
7. Hydration
8. Mucolytics(guaifenesin
MEDICAL
1. sinus aspiration and lavage
2. Maxillary needle sinusotomy
3. Caldwell luc
4. FESS
SURGICAL

62. First line therapy
Amoxicillin 45 mg/kg/day or 90 mg/kg/day divided 500 g BID
Second line therapy
Amoxicillin/potassium
calvulanate
22.5-45 mg/kg/day divided (dose based
on amoxicillin component)
500-875 mg BID
Azithromycin
10 mg/kg/day on day 1, then 5
mg/kg/day on days 2-5
500 mg QID on day 1, then 250
mg QID on days 2-5
Cefdinir 14 mg/kg/day 300 mg BID
Cefpodoxime 10 mg/kg/QID 200 mg BID
Cefprozil 15 mg/kg/QID 250-500 mg BID
Cefuroxime 15 mg/kg/QID 250 mg BID
Ciprofloxacin 500 mg BID
Clarithromycin 7.5 mg/kg/day 500 mg BID
Cindamycin 8-20 mg/kg/day divided QID 150-450 mg BID
Doxycycline 100-200 mg QID
Garifloxacin 400 mg QID
Levofloxacin 500 mg QID
Sulfamethoxazole/trimethop
rim
6-12 mg/kg/day divided (based on
trimethoprim)
800-160 mg BID
ANTIBIOTICS

63. STEROIDS
1st line of therapy: topical intranasal (betamethasone,
dexamethasone, triamcinolone)
Systemic steroids:
Prednisolone:0.5-1mg/kg x3-4 days

64. DECONGESTANTS
• Systemic (phenylpropanolamine, pseudoephidrine)
• Topical : phenylepinephrine HCl, oxymetazoline HCl

65. ANALGESICS & ANTIHISTAMINES
• Analgesics:
Opioid: acetaminophen, codeine
NSAIDS:
• Antihistamines:
Mequitazine, terfenad

66. NASAL LAVAGE & SPRAY
Function:-
• Removes debris & dead tissue
• Washes inflammatory secretions
• Eliminates nutrient source

67. SURGICAL MANAGEMENT
• Bilateral chronic sinusitis
with polyps
• Fungal sinusitis
• Presence of complications
• Tumor of PNS
• Csf rhinorrhea
INDICATIONS
• Presence of extensive polyps
• Pt with c/c of headache and
midfacial pain
• Medically compromised
• Hypoplastic sinuses
CONTRAINDICATIONS

68. OROANTRAL FISTULA
 Oroantral fistula….
ETIOLOGY
• Presence of periapical lesions
• Injudicious use of instruments
• During attempted extraction
• Trauma
• Chronic infections
• Malignant diseases
• h/o sinus surgery like resections of
cyst and tumors of maxilla

69. FRESH OROANTRAL COMMUNICATION
• ESCAPE OF FLUIDS
• EPISTAXIS
• ESCAPE OF AIR
• ENHANCED COLUMN OF AIR
• EXCRUCIATING PAIN
ESTABLISHED OROANTRAL FISTULA
• PAIN
• PERSISTENT,PURULANT DISCHARGE
• POSTNASAL DRIP
• POSSIBLE SEQUALE OF GENERAL SYSTEMIC
TOXEMIC CONDITION
• POPPING OUT OF AN ANTRAL POLYP
5 Es
5 Ps

70. DIAGNOSIS
 Inspection
 h/o previous extraction
 Nose blowing test
 Cotton wisp test
 Transillumination test
positive
 Radiological
IOPA • OPG • OM

71. IMMEDIATE CLOSURE
MANAGEMENT

72. 1) antibiotics
2) nasal decongestants:
Ephedrine drops
Inhalations(steam,benzoin ,menthol)
3) Analgesics:
Aspirin 500mg
Paracetamol 500mg
Ibuprofen 400 mg
4) Antral lavage
SUPPORTIVE MEASURES

73. WHITE HEADS VARNISH ACRYLIC PLATES
TEMPORARY THERAPEUTIC MEASURES

74. TREATMENT OF DELAYED CASES
When a period of 24 hours has elapsed…
In case there is purulent discharge….
Treatment of OAF of long duration…

75. SURGICAL PROCEDURE
 BUCCAL FLAP
 PALATAL FLAP
 COMBINATION OF BOTH

76. BUCCAL FLAP

77. PALATAL FLAP

78. COMBINED FLAP

80. GRAFTS
Ileac crest
Chin
Reteromolar area
Zygoma
AUTOGENOUS
Collagen sheet
Fibrin Glue
Gold foil
Tantalum
PMMA
Hydroxyapatite
ALLOGENOUS
Porcine Dermis
Bioguide & Bio-oss
XENOGRAFTS

81. CALDWELL LUC OPERATION
• By George Caldwell (1893) & Henry Luc (1897)
• To treat maxillary sinusitis…
• Removal of cyst …
• Zygomaticomaxillary complex fractures…
• Removal of impacted canine or impacted 3rd molar…

83. Functional Endoscopic Sinus Surgery

84. Indications
 Recurrent sinusitis with stenosis.
 Chronic hyperplastic sinusitis with obstructive nasal
polyps.
 Chronic sinusitis with mucocele formation.
 Fungal sinusitis in patient with diabetes or
immunocompromised status.
 Neoplasms
 Orbital cellulitis or abscess
Unresponsiveness to medical treatment

85.  Performed under GA or LA
 Patient is placed in supine position at 15 degree reverse trendelenberg position.
 Nose is additionally anaesthetized with 4% cocaine soaked cotton pledgets placed in
middle meatus.
 Additional injections are given at greater palatine foramen and middle meatus
perimeter.
 Endoscopy of maxillary sinus is performed by canine fossa or through maxillary sinus
antrostomy.
 All diseased mucous membrane and polyps if in case are present is removed.
Overzealous removal of septa and normal appearing mucous membrane is not advocated
SURGICAL TECHNIQUE

86. PATHOLOGIC CONDITIONS OF MAXILLARY SINUS
1. Inflammatory - Maxillary sinusitis
2. Traumatic - Fractured root Sinus contusion
Blow out fracture
Zygomatic complex fracture
3. Calcification - Antroliths
4. Cyst - Radicular cyst Dentigerous cyst
Mucous retention cyst
5. Tumor - Antral Polyps
Squamous cell carcinoma

87. APPLIED SURGICAL ANATOMY
• Relation of root apices with the floor of the sinus
• Lining of maxillary sinus
• Foreign bodies in the sinus
• Infections of sinus
• Oro-antral communication
• Tumors associated with maxillary sinus
• Implant placement

88. Relation of Root Apices with the floor of the sinus

89. OHNGRENS LINE

90. • In the maxilla, 7 millimetres of bone height is sufficient to accommodate short
implants.
• However, the use of 7–10 mm long implants is a greater concern in the maxilla than
the mandible because the implant failure rate is higher in the maxilla.
• Therefore, 13 mm is the recommended minimum occlusocervical bone dimension in
the maxilla.
IMPLANTS
In case we don’t have enough Bone height we go for sinus lift, which is a
surgical procedure which aims to increase the amount of bone in the
posterior maxilla
In these cases bone is thin implant can penetrate the sinus or nose causing
inflammation of the sinus lining

91. • Crouzon syndrome : Early synostosis(fusion) of sutures produces
hypoplasia of the maxilla and therefore the maxillary sinus together with
the high arched palate.
• Treacher Collins syndrome : Associated with grossly and
symmetrically underdeveloped maxillary sinuses and Malar bones
. • Binder syndrome : Hypoplasia of middle third of the face with
smaller maxillary length and maxillary sinus hypoplasia
DEVELOPMENTAL ANOMALIES

92. CONCLUSION

93. REFERNCES
 BD CHAURASIA’S Human anatomy
 Contemprory oral and maxillofacial surgery, Peterson IV edition
 ORABANS Oral histology and embryology
 Essentials of oral histology,& embryology
 NEELIMA MALIK; Textbook of Oral &maxillo facial surgery.
 Oral radiology: white and pharoah
 ORIGINAL ARTICLE the location of maxillary sinus ostium and its clinical application
(l.C.Prasanna•h.Mamatha) [indianjotolaryngol headnecksurg october–december2010)
62(4):335–337