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PARANASAL AIR SINUS
Dr. Payal Dash
1ST year post graduate trainee
Department of public health dentistry
1
CONTENTS
• Introduction
• Embryology
• Growth and development
• Histology
• Functions
• Evaluation of sinus
• Maxillary air sinus
• Frontal air sinus
• Ethmoidal air sinus
• Sphenoidal air sinus
• Applied anatomy
• Conclusion
• References
2
INTRODUCTION
• Paranasal sinuses are air filled spaces in certain skull bones.
• Embryologically developed as diverticula of mucous membrane of the nose.
• Bones containing air sinuses are called pneumatic bones.
• Classified as –
Anterior group
Maxillary ,frontal ,anterior ethmoidal air sinuses
Posterior group
Posterior ethmoidal air sinuses, sphenoidal
3
EMBRYOLOGY
• Begins at 3rd month in-utero
• Outpouchings of superior and middle nasal meatus
• Two primary process- primary pneumatisation
secondary pneumatisation
4
SINUS PRIMARY
PNEUMATISATION
SECONDARY
PNEUMATISATION
MAXILLARY 10 weeks I.U. 5th month I.U.
SPHENOIDAL 4th month I.U. 6-7 years
ETHMOIDAL 4th month I.U. 2 years
FRONTAL 4th month I.U. 6 months
GROWTH AND DEVELOPMENT
5
SINUS STATUS AT BIRTH GROWTH FIRST RADIOLOGIC EVIDENCE
MAXILLARY Present
Volume : 6- 8 ml
Rapid growth from birth to 3
years.Adult size-15 years
4-5 months
after birth
ETHMOID Present
Anterior group-5*2*2mm
Posterior group-5*4*2mm
Adult size by 12 years 1 year
FRONTAL Not present Invades frontal bone at 4 years and size
increases till teens
6 year
SPHENOID Not present Sella turcica- 7 years
Dorsum sellae-late teens
Basisphenoid- adult age
Adult 15 years
4 year
Source- Diseases of ear ,nose and throat and head and neck surgery 6th edition-
PL Dhingra ,Shruti Dhingra
HISTOLOGY
• Microscopically 3 layers
• Epithelial layer
• Basal lamina
• Subepithelial layer including periosteum
• They are lined by pseudostratified columnar epithelium studded with mucus and
serous glands
6
FUNCTIONS
• Air conditioning of inspired air
• Lighten the skull bones
• Resonance for voice
• Protection of orbit
• Provide extended surface for olfaction
• Provide local immunologic defence
• Act as buffers against trauma
7
EVALUATION OF SINUS
• Clinical examination- Inspection
Palpation
Percussion
Transillumination
8
Palpation Transillumination
• Radiographs- Periapical,
occlusal,lateral (intra-oral)
Panoramic ,Water’s view,
submentovertex (extra-oral)
9
10
• CT scan and MRI
• Endoscopy
MAXILLARY AIR SINUS
• Also know as
Antrum of highmore
(1651)
• Largest of all
• Pyramidal in shape
• Capacity-15cc (average)
11
Maxillary sinuses
BOUNDARIES
• APEX- zygomatic process of maxilla
• BASE- lateral wall of nasal cavity
• ROOF- floor of orbit
• FLOOR- alveolar process of maxilla situated 1.25cm below the level of
nasal floor.
12
AVERAGE MEASUREMENTS
Vertical - 3.5 cm
Transverse - 2.5 cm
Antero- posterior - 3.2 cm of base
OPENING
In intact skull the size of opening
is reduced to 3-4mm as it is
overlapped
13
RELATIONS
ANTEROLATERALLY POSTERIORLY
Infra-orbital plexus of nerves Infratemporal
Infra –orbital veins Pterygopalatine fossa
Origin of muscles of upper lip Posterior superior alveolar vessels and
nerves
Anterior superior alveolar vessels and nerves
in Canalis Sinusus ( a bony canal )
14
NEUROVASCULAR SUPPLY
15
16
•Facial
•Infraorbital
•Greater palatine
ARTERIAL
SUPPLY
•Facial vein
•Pterygoid plexus of veins
VENOUS
DRAINAGE
•Submandibular lymph nodes
LYMPHATICS
•Infraorbital
•Superior alveolar nerves (anterior,middle
and posterior)
NERVE
SUPPLY
17
FRONTAL AIR SINUS
• Resides in frontal bone.
• 2nd largest
• Asymmetrical (triangular)
• On average vertically- 3cm
antero-posteriorly- 3cm
transversally- 2.5 cm
18
NEUROVASCULAR SUPPLY
ARTERY-
Supra-orbital branch of
opthalmic artery
VEIN-
Junction of supra-orbital and
superior ophthalmic vein
LYMPH NODE
Submanibular lymph nodes
NERVE -
Supra-orbital branch of frontal
nerve
19
ETHMOIDAL SINUS
• Present in ethmoid bone
• Classified as Anterior -1-11 air cells
Middle- 1-5 air cells
Posterior-1-7 air cells
Relations
Superiorly-Cranial Cavity
Inferiorly- Maxillary air sinus
Anteriorly- External nose
Medially- Nasal cavity
Laterally- Optic nerve and nasolacrimal
duct
20
NEUROVASCULAR SUPPLY
21
LYMPHATIC DRAINAGE
Submandibular lymph nodes (anterior sinuses)
Retropharyngeal lymph nodes(posterior sinuses)
NERVE SUPPLY-
22
SPHENOIDAL SINUS
• Present in sphenoid bone
• Pair of sinus
separated by
septum
• Approximately-
2*1.8*2cm
23
24
25
DRAINAGE SITES
26
APPLIED ANATOMY
• Maxillary sinus, frontal sinus
• Developmental anomalies
• Intrinsic diseases (originating from tissues
within sinus)
• Extrinsic diseases (arising from odontogenic
tissues)
27
APPLIED ANATOMY OF MAXILLARY SINUS
Sphenopalatine fossa approached.
Oro-antral fistula
Infraorbital crescent
Antral puncture
APPLIED ANATOMY OF FRONTAL SINUS
Frontal sinusitis
Vacuum frontal headache
Howarth operation
Sinus gallop
28
DEVELOPMENTAL ANOMALIES
• Aplasia
• Agenesis
• Hypoplasia
• Crouzon syndrome
• Treacher collins
syndrome
• Binder
syndrome
29
INTRINSIC
INFLAMMATORY
Mucositis
Sinusitis
Retention
pseudocyst
Polyps
Antrolith
Mucocele
NEOPLASMS
BENIGN
Papilloma
Osteoma
MALIGNANT
Squamous cell
carcinoma
Pseudotumor
30
EXTRINSIC
INFLAMMATORY PERIOSTITIS
BENIGN
ODONTOGENIC
CYSTS
ODONTOGENIC
TUMORS
FIBROUS
DYSPLASIA
31
MUCOSITIS
• Thickened sinus mucosa
• Normal mucosa thickness -1mm thick
not seen in radiograph
• Inflamed (infectious or allergic )-10-15 times
seen radiographically
• Detectable as noncorticated
Band
Radiopaque
32
SINUSITIS
• generalized inflammation of the paranasal sinus mucosa
• Causes blockage of drainage through the osteomeatal complex
• Pansinusitis
• 3 types- ACUTE,SUBACUTE,CHRONIC
33
ACUTE SINUSITIS
• AETIOLOGY
A.EXCITING CAUSES
• Nasal infections
• Swimming and diving
• Trauma
• Dental infections
B.PREDISPOSING CAUSES
LOCAL GENERAL
1.Obstruction to sinus 1. Environment
Ventilation and drainage 2. Poor general health
2.Stasis of secretions
3.Previous attack of
sinusitis
34
PATHOLOGY OF SINUSITIS
Acute inflammation of sinus
Hyperaemia, exudation of fluid,outpouring of PMNs,
increased activity of serous and mucous glands
May be non –supperative or supparative
Intially exudate is serous later becomes mucopurulent or
purulent
Destruction of mucosal lining
Failure of ostium to drain
Empyema
35
ACUTE
MAXILLARY
SINUSITIS
ACUTE
FRONTAL
SINUSITIS
ACUTE
ETHMOID
SINUSITIS
ACUTE
SPHENOID
SINUSITIS
CLINICAL
FEATURES
Headache
Pain
Oedema of
cheek
Nasal
discharge
Frontal
Headache
Tenderness
Oedema of
upper eyelid
Nasal
discharge
Pain
Oedema of lids
Nasal
discharge
Swelling of
middle
turbinate
Pain
Oedema of lids
Nasal
discharge
Swelling of
middle
turbinate
36
37
CHRONIC SINUSITIS
• Infections lasting for months or years
38
39
CALDWELL-LUC(Anterior antrostomy)
operation
40
COMPLICATIONS OF SINUSITIS
41
LOCAL
•Mucocele
•Osteomylitis
ORBITAL
•Inflammatory
oedema of lids
•Subperiosteal
abscess
•Orbital cellulitis
•Orbital abscess
•Superior orbital
fissure
syndrome
•Orbital apex
syndrome
INTRACRANIAL
•Meningitis
•Extradural
abscess
•Subdural
abscess
•Brain abscess
•Cavernous sinus
thrombosis
DESCENDING
INFECTIONS
•Otitis media
•Pharyngitis
•Tonsilitis
•Laryngitis
•tracheobronchit
is
FOCAL
INFECTIONS
•Polyarthritis
•Tenosynovitis
POLYPS
• The thickened mucuous membrane of a
chronically inflamed sinus forms into irregular
folds called polyps.
42
ANTROLITH
• Radiographical features
• Location- maxillary sinus
• Periphery and shape-well defined ,smooth and irregular shape
• Internal structure-radiopaque ,homogenous or heterogenous
43
MUCOCELE
• Synonyms-pyocele ,mucopyocele
44
BENIGN NEOPLASMS
45
PAPILLOMA
46
Present in
ethmoial/maxilla
ry sinus
Appear as
isolated polyp in
sinus
Homogenous
radiopaque
OSTEOMA
47
Most common
mesenchymal neoplasm
Occur in frontal an
ethmoidal sinuses
Lobulated,sharp defined
margin
Homogenous and
radiopaque
MALIGNANT NEOPLASMS
48
SQUAMOUS CELL CARCINOMA
49
Occur in maxillary
sinuses
Radiopaque
Destroy sinus walls,
Bone destruction,
Widening of
periodontal
Ligament space
Floor destroyed
EXTRINSIC
50
PERIOSTITIS
Presence of one or more halo layer of new bone indicates periosteum inflammation.
Radiographic features-
Periosteal new bone formation-
Thin or thick radiopaque line (onion skin)
Centered directly above the inflammatory lesion
51
ODONTOGENIC CYSTS
Radicular cyst Dentigerous cyst Mucus Retention Cyst
52
ODONTOGENIC TUMORS
• Ameloblastoma
• Myxoma
Radiographic features
oval or multilocular shape
,aggressive tumors lack border.
Displace the floor of antrum
Thinning of peripheral cortex
Bony walls of sinus eroded.
Tooth may be embedded
53
FIBROUS DYSPLASIA
Radiographic features
Posterior maxilla ,
not well defined
Radiopaque-
ground glass appearance ,
orange peel appearance
54
CONCLUSION
55
REFERENCES
• Gray’s anatomy 39th edition
• Robbins and cotran 8th edition
• Oral radiology by White and pharaoh 6th edition
• Bailey and love’s short practice of surgery 24 th
edition
• Textbook of oral an maxillofacial surgery by
Kruger 6th edition
• Oral and maxillofacial surgery by Daniel M. Laskin
volume 1
• Orbans oral histology and embryology
56

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