Differential diagnosis of haziness of maxillary sinus fromTextbook of Dental and Maxillofacial Radiology, Freny R Karjodkar,3rd edition Principles and interpretion of oral radiology,white and pharoah

1. SEMINAR TOPIC - PIGMENTATIONS
1.Why melanosis is seen in HIV patients
Drug - zidovudine

2. Differential diagnosis of haziness of
maxillary sinus
Seminar -11
Presented by
N. Narmatha
II year PG

3. CONTENTS
• Introduction
• Anatomy
• Classification
• Imaging modality
• Clinical features

4. INTRODUCTION
• Paranasal sinuses are air filled cavities of the craniofacial
complex comprising the maxillary, frontal, sphenoidal sinuses
and the ethmoidal air cells
• Maxillary sinuses because of their close proximity to the dental
structures are of importance to the dental surgeon

5. Anatomy of the Maxillary Sinus

7. CLASSIFICATION
• Traumatic
• Infection/inflammatory
• Cysts
• Neoplasms
• Metabolic and Endocrinal
• Calcifications
• Syndromes (Developmental)

8. GENERAL CLINICAL FEATURES
• Feeling of pressure
• Altered voice characteristics
• Pain on movement of head
• Percussion sensitivity of teeth or cheek region
• Regional paresthesia or anesthesia
• Swelling of the facial structures adjacent to the maxilla

9. APPLIED DIAGNOSTIC IMAGING
Intra oral periapical radiograph
• Floor
• Relationship with upper posterior teeth

10. Panoramic radiograph
• Depicts both maxillary sinuses

11. Standard Occipitomental Projection (0° OM)

12. WATER'S VIEW
• optimal for visualization
• to compare internal
radiopacities
• roof, medial walls
• allows the comparison of
both the maxillary
sinuses.

13. LATERAL SKULL
• to view the sphenoidal and maxillary sinuses; the anterior and
superior walls
• all four pairs of paranasal sinuses

14. SUBMENTOVERTEX
• evaluating the lateral and posterior borders of the maxillary sinus
as well as the ethmoid air cells

15. Computed tomography
• determine the extent of the disease in patients who have
chronic or recurrent sinusitis.
Hounsefield unit for Air − 1000

16. Coronal CT provides
• superior visualization of the osteomeatal complex, nasal
cavities
• for demonstrating any reaction in the surrounding bone

17. SCINTIGRAPHY
• to demonstrate physiological changes
• In case of extension of the antral carcinoma to involve bone, the
osteoblastic response produced is clearly evident in the delayed
phase of a radionuclide bone scan.

18. Ultrasound is effective in
• distinguishing normal
sinuses, chronically
inflammed sinus lining ,
sinus filled with fluid,
tumor or scar

19. MAGNETIC RESONANCE IMAGING
extremely sensitive in
• demonstrating maxillary antrum pathology
• to delineate soft tissues in the sinus,
• very clear comparative view of the two sinuses
• differentiate retained fluid secretions from soft tissue masses in
the sinuses.

20. CALDWELL’S POSTEROANTERIOR VIEW
• Good visualization of the frontal sinus, ethmoidal air cells,
nasal cavity and superior portion of the maxillary antrum

21. DEVELOPMENTAL
• Crouzon's syndrome
• Treacher Collin's syndrome
• Binder's syndrome

22. CROUZON'S SYNDROME
• Early synostosis of the sutures – hypoplasia of the maxilla
and maxillary sinus, high arched palate

23. TREACHER COLLIN'S SYNDROME
• Grossly and symmetrically underdeveloped maxillary
sinuses and malar bones

24. BINDER'S SYNDROME
• Maxillonasal dysplasia
• Hypoplasia of the middle third of the face
• Maxillary retrognathism
• Maxillary sinus hypoplasia
Diagnosed at 24 weeks of gestation using two and three-
dimensional ultrasound, amniocentesis

25. Mucositis (thickened mucous membrane)
Etiology
• Infectious or allergic process - mucosa becomes inflamed -
thickness 10 to 15 times - mucositis
• Any thickening > 3 mm - pathological.
Clinical features
• Asymptomatic
• Discovered on a routine radiograph.

26. Radiographic features
• Non-corticated band
• Mucosal thickening seen distinctly on denta scan
Management: Removal of the cause

27. MAXILLARY SINUSITIS
• Generalized inflammation of the paranasal mucosa
Etiologic agent
• Allergen, bacterial or viral.
• Blockage of drainage from the
ostiomeatal complex.
• Inflammatory changes – ciliary
dysfunction and retention of sinus secretions

28. Maxillary sinusitis
• Acute sinusitis—less than two weeks
• Subacute sinusitis—two weeks to three months
• Chronic sinusitis—more than three months

29. Radiographic Features
• Radiopaque
• Most common radiopaque patterns on the Water's view are:
– Localized mucosal thickening along the sinus floor
– Generalized thickening of the mucosal lining

30. • – In allergic reaction mucosa tends to become lobulated.
• – In infection- thickened mucosal outline tends to be
smoother, with its contour following the sinus floor.

31. • Air fluid level resulting from the accumulation of secretions may be
present
• Fluid appears radiopaque

32. Chronic sinusitis
• Persistent radiopacification of the sinus with sclerosis and
or thickening of the sinus wall.
• The resolution of acute sinusitis becomes apparent till the sinus
appears normal.

33. Additional Imaging
• CT
• T1-weighted MRI images
• T2-weighted MRI
• T1- weighted post Gd
• Management: to control the infection, promote drainage and
relieve pain.

34. Empyema
• Cavity filled with pus
• Result as a possible sequela of sinus ostium blockage
• Variant of a mucocele or pyocele
Radiographic features
• Sinus appears completely radiopaque
• Decalcification of the surrounding bony walls and haziness
of trabecular bone next to the sinus wall is seen
• Extend into the adjacent bone - osteomyelitis

35. Cyst - not lined by epithelium - pseudocysts
• Blockage of secretory ducts / cystic degeneration
Clinical features
• Most common - maxillary sinus
• Not related to extractions nor associated with periapical
disease
• Asymptomatic
• Localized pain and feeling of fullness or numbness
• nasal obstruction and postnasal discharge
• Copious discharge of yellow fluid from the nostrils

36. Radiographic Features
• non-corticated, smooth domeshaped radiopaque masses
• no osseous border surrounds it
• The sinus floor is intact, with a persistent thin radiopaque line of the
antral cortex

37. Additional Imaging

38. Differential Diagnosis
• Inflammatory lesions
• Odontogenic cyst ,Apical radicular cyst, dentigerous cyst,
odontogenic keratocysts and cyst of the globulomaxillary area are
the most common
• Antral polyps
• Benign Neoplasms
• Malignant neoplasms
Management: No treatment

39. Mucocele - expanding, destructive lesion
Etiology
• Blocked sinus ostium
• If the mucocele becomes infected - pyocele, mucopyocele.
Clinical Features
• Thinning, displacement and in some cases destruction of the
sinus walls
• Radiating pain with a swelling and fullness of the cheek.

40. If the lesion expands
• inferiorly - loosening of the posterior teeth.
• medially - lateral wall of the nasal cavity will deform , nasal
airway obstruction
• into the orbit – diplopia or proptosis

41. Radiographic Features
• Maxillary sinus - circular shape as the mucocele enlarges
• Septa and bony walls may be thinned / destroyed.
• Teeth may be displaced and/or roots resorbed.
• uniformly radiopaque
Additional Imaging
CT
T1 and T2 weighted MRI images

42. Differential Diagnosis:
• Cyst
• Benign tumor
• Malignancy
• Any suggestion of a lesion associated with occluded ostium
should be a mucocele
• odontogenic cyst
Management: Surgical removal by the Caldwell-Luc operation.

43. Surgical Ciliated Cyst of the Maxilla
delayed complication arising years after surgery
Clinical Features
• 4th -5th decade
• pain, discomfort or swelling of the face
• intra oral swelling of the palate or alveolus, with pus disharge

44. Radiographic Features
• well-defined radiolucency closely related to the maxillary sinus
• sclerosis of the surrounding bone
• thinning of the sinus walls
• resorption of the maxillary alveolar process
Management: Enucleation

45. RHINOLITH AND ANTROLITH
• Hard calcified bodies or stones that occur in the nose – rhinoliths
or antrum - antroliths
• In rhinolith the nidus is exogenous foreign body (coin, beads)
• The nidus for an antrolith is endogenous (root tip, bone fragment,
masses of stagnated mucus, etc)

46. CLINICAL FEATURES
• asymptomatic initially.
• With increase in size - pain,congestion and ulceration.
• May develop unilateral purulent rhinorrhea, sinusitis,
headache, epistaxis, nasal obstruction, anosmia, fetor, fever and
facial pain

47. RADIOGRAPHIC FEATURES
• well-defined smooth or irregular borders.
• homogeneous or heterogeneous radiopacities – density may exceed
the surrounding bone.
• Antroliths seen on the periapical, occlusal and panoramic
radiographs.

48. DIFFERENTIAL DIAGNOSIS
• Osteoma
• Healing odontogenic cyst
• Root fragments
MANAGEMENT: Referred to an otorhinolaryngologist for the
removal of the stone.

49. BENIGN NEOPLASMS
• Benign Neoplasms – rare
• Radiographic images - nonspecific
• Appears radiopaque - displacement of the adjacent sinus borders

50. POLYPS
Thickened mucous membrane of a chronically inflamed sinus
frequently forms into irregular folds called polyps
Clinical Features
• arise from any part of the sinus wall
• pass through the opening to appear in the nose as
antrochoaneal polyp
• cause bony displacement or destruction of bone

51. Radiographic Features
• Homogeneous radiopaque mass of soft tissue density in the
nose or sinus
• Bone destruction

52. Differential Diagnosis
• Retention pseudocyst
• Benign tumor malignancy
• Bone destruction with radiopacification is an indication for
biopsy.

53. EPITHELIAL PAPILLOMA
Rare neoplasm of respiratory epithelium
Clinical Features
• more common in ethmoidal and maxillary sinus
• appear as an isolated polyp in the nose
• unilateral nasal obstruction, nasal discharge, pain and epistaxis
• history of recurring sinusitis

54. Radiographic Features
• homogeneous radiopaque mass of soft tissue density
• bone destruction
• radiographic features are not specific and diagnosis is based
only on histological examination

55. OSTEOMA
Most common of the mesenchymal neoplasms
Clinical Features
• Slow growing, asymptomatic
• nasal obstruction
• Swelling of the cheek or hard palate
• proptosis
• may produce an external fistula
• occur in the maxillary sinus after a Caldwell-Luc operation

56. Radiographic Features
• lobulated or rounded
• homogeneous radiopacity with sharply
defined margins
Hounsefield unit for bone - + 400 to + 1000
Differential Diagnosis
• Anthroliths
• Teeth
• Odontogenic neoplasms(odontomas)

57. MALIGNANT NEOPLASMS
Squamous Cell Carcinoma
• originates from metaplastic epithelium of the sinus mucosal lining
Clinical Features
• facial pain or swelling, nasal obstruction and lesion in oral cavity
• lymph nodes involvement

58. Radiographic Features
• irregular radiolucent areas in the surrounding bone
• bone destruction around the teeth or irregular widening of the
periodontal ligament space

59. Additional Imaging
• Caldwell and Water’s projections
• panoramic film
• CT
• MRI

60. Differential Diagnosis
• Sinusitis
• Large retention psuedocysts
• Odontogenic cysts
• Neoplasm should be suspected in any older patient in whom
chronic sinusitis develops for the first time without obvious
cause
Management: surgery and radiation therapy

61. PSEUDO TUMOUR
• occurs after a series of recurrent infections
• recurring pain, proptosis ,altered nerve function
R/F - erosion of the bony walls of the involved sinuses
Differential Diagnosis
• Benign and malignant neoplasms
Management: debridement of the sinuses and administration of
antifungal medication (amphotericin B and rifampin)
• Caldwell-Luc approach and therapy

62. EXTRINSIC DISEASES INVOLVING THE
MAXILLARY SINUS
Periostitis - inflammation of the periosteum
Radiographic Features
• centered directly above inflammatory lesion
• single thin radiopaque line
• very thick radiopaque line, or has a
laminated (onion skin) appearance

63. BENIGN ODONTOGENIC CYSTS AND TUMORS
• Most common - dentigerous cysts, radicular cysts

65. DENTIGEROUS CYST
• Most commonly related to the third molar -
radiolucency elevating the floor of the sinus
• If it is small it appears - dome shaped opacity
in base of the antrum, with well-defined
radiopaque corticated margins

66. Radiographic Features
• curved or oval shape defined by a corticated border
• homogeneous and radiopaque relative to the sinus
• displace the floor of the sinus
• Hounsefield unit - 0
Differential Diagnosis
• Retention pseudocyst
• Odontogenic cysts
• Maxillary sinusitis
• Antral loculation

67. RADICULAR CYST

68. ODONTOGENIC TUMORS
• Nature of bony barriers in this region of the face, relatively
good blood supply - responsible for the efficient local spread

69. Radiographic Features
• curved, oval or multilocular shape with thin cortical border
• border may be absent - aggressive tumors
• may displace the floor of the antrum
• thinning of the peripheral cortex.

70. MALIGNANT TUMORS
Invasion of the maxillary sinus by local malignant disease
• Malignant tumors of the upper jaw spread easily into the sinus.
• Pleomorphic adenoma
• Adenocystic carcinoma
Metastatic Carcinoma of the Maxillary Sinus
• Maxillary sinus is a rare site for metastasis

71. CRANIOFACIAL FIBROUS DYSPLASIA
Clinical Features
• More common in children and young adults and tends to stop
growing when skeletal growth ceases
• posterior maxilla - most common location
• It results in facial asymmetry, nasal obstruction, proptosis,
pituitary gland compression, impingement on the cranial nerves
or sinus obliteration

72. • The sinus obliteration results due to the expansion and encroachment
of the dysplastic bone lesion.
• displace the roots of the teeth and cause the teeth to separate or
migrate
• does not cause root resorption

73. Radiographic features
• Not well-defined, and tends to blend with the surrounding bone
• Radiopaque areas - ground glass appearance on extraoral
radiographs or an orange peel appearance on the intraoral views

74. Differential Diagnosis
• Paget's disease
• Complex odontoma
• Ossifying fibroma

75. TRAUMATIC INJURIES TO MAXILLARY SINUSES
Dental Structures Displaced into the Sinus
Root in the Antrum/Foreign Bodies
• No visible signs and symptoms if the root is displaced recently
• Sinusitis

76. Radiographic Features
• The dislodged fragments are usually found near the floor of the
sinus because of gravity
• Floor of the sinus may break due to the displacement of the
tooth fragment into the sinus

77. Additional Imaging
• Lateral maxillary occlusal views
• Water's projection: along with the occlusal view
Differential Diagnosis
• Exostoses of the sinus wall or floor and septa within the
sinus, may mimic dental root fragments or even whole teeth
• Antroliths
• Root tip remains in the socket
Management: Surgical removal using the Caldwell-Luc procedure

78. SINUS CONTUSION
Occurs due to a blow to the face that damages the lining of the
paranasal sinuses without fracturing the facial bone
Clinical features
• Bloody nasal discharge, tenderness , rapid resolution of the soft
tissue changes

79. Radiographic features
• Haziness of the sinus due to edema
• An opaque sinus or fluid level resulting from hemorrhage from
the mucosal tear
Differential diagnosis
• Sinusitis

80. BLOW-OUT FRACTURE
• Sudden increase in the intra orbital pressure - direct blow to the
eye
Clinical Features
• diplopia
• enophthalmus

81. Radiographic Features
• Opacification of the sinus with or without a fluid level
• Shadow of soft tissue mass and depressed bone fragments
• Tear drop shaped radiopacity
• Fracture of the antrum wall of the maxillary sinus

82. ISOLATED FRACTURE
• Involves a single wall - appear as a bright line on the radiograph
• Most common sites - anterolateral wall, floor, during extraction of
the upper posterior teeth

83. ZYGOMATIC COMPLEX FRACTURE
Occurs at the line of weakness and passes through the orbital floor,
usually medial to the zygomatico maxillary suture
Clinical Features
• Fractured zygoma is forced into the sinus
• Tearing of the lining membrane with subsequent
bleeding into the antrum
Radiographic Features - cloudy or will show a fluid level

84. FRACTURED TUBEROSITY
Most frequently while extracting a lone standing upper third molar

85. OROANTRAL FISTULA
• Pathological pathway connecting the oral cavity and the maxillary
sinus
Etiology:
• Extraction of teeth having chronic periapical infections,
solitary tooth ,teeth having apices very close to antral floor,
• Blind instrumentation,
• Surgical removal of large lesions in the upper jaws, malignant
tumours, osteomyelitis, malignant granulomatous lesions, facial
trauma and inadequate blood clot formation

87. Diagnosis
• asked to blow air into the pinched nose with the mouth open
Radiographic Features
• break in the continuity of the floor- disalignment of a small
portion of the cortical layer of bone
• acute or chronic sinusitis
• evidence of the displaced root or tooth

88. Additional Imaging
• Confirmation of the presence of the fistula
• CT with denta scan
Management: repair and surgical closure under antibiotic therapy.

89. Thank you

90. References:
1. Textbook of Dental and Maxillofacial Radiology, Freny R Karjodkar,3rd edition
2. Principles and interpretion of oral radiology,white and pharoah.
3. Goaz PW, White SC. Principles and Interpretation, In Oral radiology, 3rd ed. St.
Louis, Mosby Year Book 1994.
4. McGowan DA, Baxter PW, James J. The maxillary sinus and its dental
implications. Butterworth-Heineman 1993 Oxford.