The document discusses the anatomy, physiology, and clinical aspects of the maxillary sinus. Key points include: - The maxillary sinus is the largest paranasal sinus located within the maxilla. It communicates with the nasal cavity and has a volume of 15-30ml in adults. - Infections of the maxillary sinus can be odontogenic (caused by dental infections), acute or chronic maxillary sinusitis. Symptoms include pain, nasal congestion, and purulent drainage. - Oroantral communications and fistulas can form between the oral cavity and maxillary sinus due to tooth extractions or other trauma/surgery. They may cause pain, nasal discharge,

1. Maxillary
sinus
Instructor:- Dr. Jesus George
1

2. Anatomy
2
 1st
- described by Nathaniel high more also
known as Antrum of high more.
 They are 2 in No. one on either side of
maxilla.
 Largest paranasal sinus.
 Communicate with other sinuses through
the lateral wall of nose.
 Ostium opens into middle meatus
 Volume 15-30ml

3. Cont.
3
 Diamension: Anteroposterior 3.5
Height 3.2
Width 2.5
 Pyramidal in shape.
 Base- lateral wall at the nose.
 Apex- zygomatic process of maxilla.

4. Cont.
4
Four walls- Floor of orbit or roof of
antrum, Alveolar process of maxilla-
floor, infratemporal surface of maxilla
anterior.
 Blood supply
Facial, maxillary, infraorbital and
greater palatine arteries.
Anterior facial vein, pterigoid plexus

5. Cont.
5
 Lymphatic drainage
 Submandibular and deep cervical
lymph nodes.
 Nerve supply
 Superior dental nerve, anterior, middle
and posterior greater palatine nerve.
 Branches of maxillary division of
trigeminal nerve.

6. Cont.
6
 Embryology:
3/12 weeks IUL - Out pouching in
middle meatus
Birth - Tubular 2x 1 x 1 cmm growth.
9 years - 60% of adult size.
12 years - Antral floor parallels nasal
floor
18 years - Adult size

7. Cont.
7
 Physiology:
Lined by respiratory epithelium
 Functions:
Impart resonance to the voice.
Increase the surface area & lighten skull
Moisten and warm inspired air.
Filter debris from inspired air.
They provide thermal insulation to the
tissue above.

8. Applied surgical anatomy
8
 Relation of the root apices with
floor of sinus
 In adults 1-1.5cm between floor of
sinus and root apices of maxillary
posterior teeth.
 Low incidence of oroantral fistula in
children-under fifteen years.
Sinus reaches its normal size by the
age of 18 years.

9. Cont.
9
Circumstances with increased
likelihood of oroantral fistula
Large Sinuses:
Floor is thinned out
Risk of # when force is applied during
maxillary posterior teeth extraction.
Floor is descending down between
adjacent teeth and also in between
roots of individual tooth.

10. Cont.
10
 Tooth lies in close proximity to sinus
heading to inadvertent displacement to
sinus.
 Tooth has conical roots.
 Unerupted III molar in tuberosity forms a
line of weakness, if adjacent II molar is
extracted it result in # of tuberosity.

11. Cont.
11
Lining of maxillary sinus
 Breach in continuity is obtained by
occipitomental radiograph- showing
radioopacity in sinus persist for 10
days to 2 weeks.

12. Cont.
12
 Unilateral epistaxis
 Cracks and fractures in bony floor of
maxillary sinus.
 If there is tear in sinus lining it will heal its
own.
 If clot breaks down> oroantral
communication with in 10 days> oroantral
fistula> foul smelling discharge of pus

13. Cont.
13
 Periapical involvement:
 A/c or C/c periapical abcess in relation
to teeth close proximity with sinus may
secondarily involve sinus.
 Pus may discharge into sinus causing a
fluid level extraction of such tooth cause
infection of blood clot> oroantral fistula.

14. Cont.
14
 Pressure on nerves with in antrum
 Occurs in A/c sinusitis.
 Pus is not able to escape through Ostium
in to nose because of its occlusion by
inflammation of adjoining mucosal lining.
 Tumours in maxillary antrum
 Seen as swelling in cheek, palate,
buccal sulcus.

15. Cont.
15
Teeth maxillary get loosened due to
bone destruction interference in
blood supply causing pulp necrosis
& A/c apical abscess.
Pressure on posterior valve causes
destruction of posterior superior
alveolar nerve & anaesthesia of
gingival & teeth in maxillary molar
area

16. Cont.
16
 Involvement of roof causes
anaesthesia of inferior orbital nerve.
 Encroachment on orbit causes
alteration of papillary level eye is lifted
up proptosis.

17. Cont.
17
 Paraesthesia in maxillary teeth following
surgical procedures
Mainly in the lateral wall of antrum most
cases return to normal.
 Antral puncture
Is done in middle meatus in children.
Inferior meatus in adult.
Floor of sinus is 1.5 cm below floor of
nose.

18. Cont.
18
 Canine fossa
 Used for- Diagnostic aspiration
 Cald well-LUC operation
 Fractures of middle third of face
 Usually involve maxillary sinus

19. Transillumination
19
 Placing a strong light in center of mouth
with lips closed.
Normal sinus: Definite infraorbital
crescent of light, brightly lit eye glossy
pupil.
If antral cavity contains pus, mucus,
polyps, blood thickened linig, fibrosseous
lesions, tumour will not lit as in normal.

20. Radiographs
20
Extra oral:
Occipitomental
Lateral skull
Submento vertex
Orthopantemography
CT
Intra Oral:
Occlusal
Periapical

21. Infections of maxillary sinuses
21
 Odontogenic sinusitis
 A/C maxillary sinusitis
 C/C maxillary sinusitis

22. Odontogenic sinusitis
22
 Definition:
 It is the inflammation of mucosa of any of
paranasal sinuses.
 Inflammation of most or all paranasal
sinuses pansinusitis.
 Maxillary sinusitis in usually Odontogenic
in origin.

23. Cont.
23
 Clinical Features
 Teeth involved, IPM, IM, IIM
 Severe throbbing pain
 Slight swelling of check
 Mobile tooth -if involved periodontally
 Diagnosis:
 Total radiopacity or fluid level in radiography

24. Cont.
24
 Management:
 Extraction of offending tooth
 Antibiotics
 Decongestants: Nasal inhalation or drops

25. A/C maxillary sinusitis
25
 May be suppurative or non suppurative
inflammation of antral mucosa
 Etiology:
Infection: common cold, Upper resp. Tract
infection
Trauma: Fracture of antral floor and walls
 Allergy
Neoplasm

26. Cont.
26
 Oroantral communication & fistula.
 Displaced tooth or root
Clinical features
 Signs
 Tenderness over check
 Anesthesia of check
 Mild swelling in severe cases
 Percussion pain of maxillary teeth

27. 27
 Extrusion of oroantral fistula with or in to
socket
 Fetor oris
 Discharge of pus to mouth from fistula.
 Symptoms:
 H/o cold
 Nasal blocking

28. Cont.
28
 Thick, mucopurulant, foul smelling, discolored
nasal discharge
 Heavy feeling in head.
 Constant throbbing pain in cheek or face more
severe in morning and evening.
 Max. teeth of affected side painful.
 Generalized symptoms:
 Chills
 Fever

29. Cont.
29
 Sweating
 Nausea
 Difficulty in breathing
 Anorexia
 Rhinoscopy
 Edema & erythema of mucosa pus discharge
on to inferior turbinate bone.

30. Cont.
30
 Tran illumination:
Do not transmit high
 Radiograph: Water's view- occipitomental
15o
.
Uniform opacity or fluid level.
 Management:
Bed rest
Plenty of fluids
Oral hygiene
Antral regime for 5-7 days

31. Antral Regime
31
 Antimicrobials
Macrolides: erythromycin 250kg 6th
hrly for 5
days.
Broad spectrum: amoxicillin 250-500mg 8th
hrly
for 5 days.
 Decongestants
 Nasal drop or spay. Ephedrine sulphate
0.5-1% in Normal saline 6th
hrly.
Xylomethozoline hydrochloride 0.1%

32. Cont.
32
 Mucolytic agents
 Tincture benzoin
 Camphor
 Menthol
 Steam inhalation
 Nsaids
 Aspirin
 Paracetamol
 Ibuprofen

33. C/C maxillary sinusitis
33
Causes
 Dental infection
C/C rhinitis
C/C Infection in frontal & Ethmoid sinus.
Allergy
Pathophysiology
Due to C/C infection the mucous membrane of
sinus may develop hyperplasia or atrophy.
Multiple polyps
Degeneration of epithelium

34. Cont.
34
 Diagnosis:
 H/o: Repeated attacks of A/c mucopurulent
rhinitis.
 Long- standing nasal or postnasal discharge.
 Anterior rhinos copy: shows nasal congestion
& mucopurulent material in middle meatus.
 Oro pharynx shows descending pharyngeal
exudates.

35. Cont.
35
Oral antral fistula may me there.
Prolapse of polypoidal mass into mouth.
Radiography
Radiopacity on affected side.
Presence of fluid level
Thickened lining membrane

36. Cont.
36
 Management:
 If the cause is tooth or root in sinus remove the
cause prior to any other treatment.
 Antral polyp is removed
 Antibiotics
 Decongestants
 Analgesics
 C/C sinusitis due to oro antral fistula require closure
of Oro antral fistula
 Surgical Drainage:
Topical anaesthesia is applied to cotton wool
and inserted along the nasal floor near inferior
turbinate.

37. Cont.
37
Sharp trocar and cannula is
introduced inferior to inferior
turbinate.
Antrum wall is punctured.
Trocar with drawn
Pus is drained using suction
Warm saliva irrigation daily till
symptoms are settled down

38. Oro Antral Communication &
Fistula38
 Oro antral per formation:
 It is an unnatural communication B/w
oral cavity & maxillary sinus.
 Oro antral fistula
 It is an epithelized, pathological,
unnatural communication b/w oral cavity
and maxillary sinus.

39. Cont.
39
Etiology:
Extraction of teeth
Palatal root of I molar when broken most
frequently causes oroantral communication
Conical maxillary III molar-during extraction
there will be # of tuberosity oro antral
communication.
Isolated posterior teeth in edentulous arch
more risk of causing destruction of floor of
sinus.
Surgical removal of impacted teeth also have
high risk.

40. Cont.
40
Periapical lesions
Abcess, granuloma, cyst
Apicoectomy
Blind instrumentation
Injudicious use of instruments.
Forcing a tooth or root into sinus during
removal
Trauma of face.
Trauma of middle 1/3 of face. Due to
missiles or sharp objects gunshot
injuries

41. Cont.
41
Surgery of sinus
Partial maxillectomy
Surgical treatment of large abscess or
cyst. Improper incision in Caldwell luc
operation.
zygomatic complex #
Osteomyelitis:
Gumma involving palate
Infected implants in maxilla
Malignant diseases

42. Cont.
42
Symptoms
Fresh Oro antral communication 5 ES
Escape of fluids- from mouth to nose when
patient rinse or gargle.
Epistaxis (unilateral) - Bleeding from nose.
Escape of air - From mouth to nose on
sucking, inhaling.
Enhanced column of air- Change in voice.
Excruciating pain- Around the region of
involved sinus.

43. Cont.
43
 Symptoms- in late stage - OAF 5ps.
 Pain.
 Persistence purulent or mucopurulent
discharge
 Post nasal drip.
 Possible Sequelae of general, systemic
toxemic condition:
 Fever
 Malaise
 Anonexia


44. Cont.
44
 Popping out of an antral polyp.
 Confirmation of presence of oro antral
communication fistula
 If large; Assessed by inspection
 If small: nose blowing test
Compression of anterior nares & gently
blow nose produces a whistling sound,
escape of air bubble blood or pus. At the
oral orifice.

45. Ont.
45
Management:
A fistulous tract persist for more than 14
days is considered as C/c fistula.
 Treatment of early cases
Immediate surgery repair for primary
closure.
 Reduction of buccal & palatal socket for
adaptation of buccal and palatal flap to
close the defect.
Protective acrylic denture.

46. Cont.
46
Antibiotics
Penicillin: initially 1/V than oral penicillin V
250-500ng 6th
hrly
 Nasal decongestants
Ephedrine nasal drop
Steam inhalation.
Tincture benzoin
Menthol inhalation

47. Cont.
47
Analgesics.
Aspirin 500mg 4 times/day
Paracetamol 500mg 3 times/day
Ibuprofen 400 mg 3 times/day
Temporary measures
White head's varnish pack: packed over the
socket and secured with sutures.

48. Cont.
48
 White head's varnish
Benzoin- 10%
Storaly-7.5%
Balsam of tolu- 5%
Lodoform - 10%
Solvent - Ether- 67.5%
 Denture plate: Socket is covered with gauzes
a plate is placed.

49. Cont.
49
 Treatment of delayed cases
 OAF with in 24 HRS
 If the edges of wounds are clean close
immediately.
 Postoperative antibiotics, decongestants can
be closed by buccal flap
 OAF after24 HRS
 Tissue margins often get infected, so defer
surgical closure until gingival edges show
healing- 3 weeks.

50. Cont,
50
 Antibiotics, analgesics, decongestants.
 If purulent discharge or c/c sinusitis irrigate
sinus with warm normal saliva.
 OAF more than 1 month
 Fistula is well epithelized surgical closure
 Surgical drainage:
Established by enlarging fistula
Sinus in irrigated with normal saline until it is
clear.

51. Cont.
51
Supportive care
When symptoms subside surgical closures.
 Surgical closure of OAF 3 types
 Buccal flap
 Palatal flap
 Combination of both

52. Cont.
52
 Essential features of flap
 Free end of flap should have adequate blood
supply
 Base should be wider than apex for buccal
flap
 palatal flap is designed in such a way that
greater palatine vessels are incorporated in
the transposed tissue enclose the fistula.
 Suture line is supported by sound bone
 There should not be any tension along the

53. Buccal flap advancement
operation-rehrmann53
 Inject LA in to mucobuccal fold
 Excision of fistulous tract: incision is made
around fistulous tract 3-4mm marginal to
orifice. Epithelial zed tract with associated
antral polyps dissected gum margins
freshened with blade no: 11
 Two divergent incision are done with blade
No. 15 from each side of orifice into buccal
sulcus (2.5cm). Till bone flap is reflected.
 Reduction & smoothening of alveolar bone is
done.

54. Cont.
54
 Advancement of buccal flap:
 If flap is not covering fistula, flap is advanced
horizontal incision is made in preventing it’s
advancement.
 Inspection of maxillary sinus for infection.
 If any polypoidal mass or other diseased tissue
removed.
 Irrigate with warm normal saline.
 If any pathology - cald well Luc procedure done.
 Arrest of hemorrhage
 Closure of wound with interrupted sutures

55. Cont.
55
 Postoperative medication: Antibiolgics
 Analgesics
 Decongestants
 Inhalation
 Soft diet
 Instruction to patient: Avoid sneezing
 Not to explore wound with tongue
 Avoid sucking of fluid and air
 Removal of suture 7-10 days postoperatively

56. Modified rehrmann's buccal
advancement flap56
 After mobilization of buccal flap & releasing
incision in free end of flap.
 A step is created by removing 1-2mm mucosal
layer.
 The denuded margin is sutured below palatal
flap by vertical mattress suture
 Mucosa is sutured with palatal flap by
interrupted suture, provides double layer
closure.

57. Intranasal antrostomy
57
 It is done to close an OAF & to remove tooth
or root from sinus.
 Surgical procedure:
 A small osteotome or gouge is pushed through
the inferior meatus to max-sinus.
 Iodoform gauze pack is grasped into beaks of
big curved artery forceps and is passed
through the opening is pulled out into nostril.
 A single knot at one end of guaze will keep it
in nostril other end is used to pack sinus,
after achieving hemostasis.

58. Cont.
58
 Remove 1cm of medical wall of antrum, that
bulges into sinus below inferior turbinate this is
extended to floor of nose.

59. Palatal pedicle flap: Rotational
Advancement flap ashley's
operation.59
 LA
 Excision of fistulous tract
 Marking of proposed palatal flap
 Raising palatal mucoperiosteum
 Inspection of sinus and irrigate with betadine
and normal saline.
 Trimming of buccal mucoperiosteum
 Rotational advancement of palatal pedicle flap
to approximate buccal margin.

60. Cont.
60
 Suturing- Interrupted suture.
 Denuded bone in palate is covered by guaze
pack soaked white head's varnish and secured
with suture.

61. Combination of buccal & palatal
flap61
 Used to close large defect.
 Used when there is H/o earlier repair with failure.
 It is the combination of inversion and rotational
advancement flap
 We will get a double layer closure.
 There is mobilization of both palatal flaps.

62. Cald well LUC operation
62
 By George Cald Well
 Indication:
 For removal of root fragments, teeth foragin body stone
from maxillary sinus.
 To treat c/c sinusitis with hyper plastic lining & polypoid
degeneration of mucosa
 Removal of cyst and benign growth in sinus.
 Mangement of hematoma in sinus to control post
traumatic hemorrhage.
 Zygomatic complex # involving floor of orbit and anterior
wall of sinus.
 OAF with c/c sinusitis

63. Cont.
63
 Surgical procedure:
 Performed under LA or GA
 Semilunar incision in buccal vestibule from canine to II
molar above gingival attachment.
 Mucoperiosteal flap is elevated till the infra orbital
ridge.
 An opening is created in anterior wall of sinus with
gouges, drill or chisel.
 Opening is enlarged in an directions with roungeur up
to the size of index finger.
 Opening should be away from roots of maxillary teeth.

64. Cont.
64
 Pus is sucked a ways irrigated with copious saliva
wash
 Inspection of sinus
 Removal of tooth, root, guaze, cotton, stone,
bone.
 Thickened infected lining of sinus is elevated,
removed and sent for histopathologic examination.
 If profuse bleeding in sinus, it is packed with
ribbon guaze soaked in adrenaline 1:1000 for l or
2 min.
 Antral cavity is again irrigated and packed with l0
doforun ribbon guaze.


65. Cont.
65
 Post operative management:
 Antibiotics
 Analgesics
 Anti inflammatory drugs for 5 days
 Pack removed on 5th
day
 Tincture benzoic inhalation 3 times/day
 Soft diet.