This document discusses pathology of the maxillary sinus, including classification, etiology, pathogenesis, clinical features, radiological features, diagnosis, and treatment of various conditions. It covers inflammatory diseases like acute and chronic sinusitis, mucositis, and antral polyps. It also discusses cysts, neoplasms, developmental disorders, traumatic injuries, and complications of maxillary sinus pathology. Differential diagnosis of maxillary sinus conditions is based on clinical history and examination findings, as well as radiological imaging like radiographs, CT scans.

1. Department of oral medicine and
radiology
Differential diagnosis of
maxillary sinus pathology
Submitted by,
Shiji Margaret
Final BDS

2. CONTENTS
1. INTRODUCTION
2. CLASSIFICATION
3. ETIOLOGY
4. PATHOGENESIS
5. CLINICAL FEATURES
6. RADIOLOGICAL FEATURES
7. DIAGNOSIS
8. TREATMENT
9. COMPLICATION
10. REFERENCE
1

3. INTRODUCTION
The paranasal sinuses are air filled cavities present with some bone around the
nasal cavities. The sinuses are frontal,maxillary,sphenoid and ethmoidal.
Because of the close proximity of maxillary teeth with the maxillary sinuses,
these are the most important paranasal sinuses in dental point of view. They are
the largest air filled sinuses surrounding the nose.
Embryology
It is the first among the paranasal sinuses to develop.
It starts as a groove on the medial surface of the maxilla during the 4th
month of
intrauterine life
At birth,it is a small cavity which is usually fluid-filled. Growth is usually
biphasic with growth occurring during the age of 0-3 years and again between
7-12 years. It attains its maximum size at adulthood at around 18years of age.
During the later phase pneumatisation proceeds more inferiorly as the
permanent teeth develop completely
Anatomy of maxillary sinus
Maxillary sinus is also called “antrum of highmore” This structure is closely
related to oral cavity and lesions/infections of the maxillary antrum may present
in the oral cavity and vice versa.
2

4. Arterial supply
Facial artery,infraorbital artery. Greater palatine artery.
Nerve supply
Infraorbital nerve;anterior,middle and posterior superior alveolar nerve
Venous drainage
Facial vein which then drains into pterygoid venous plexus.
Lymphatic drainage
Submandibular lymph nodes and then to deep cervical lymph nodes.

5. Classification
1. Inflammatory
Acute and chronic sinusitis
Mucositis
Antral polyp
Osteomyelitis
2.cyst
 Intrinsic
Mucus retention cyst(mucocele)
Pseudo cyst
Surgical ciliated cyst
 Extrinsic
 Odontogenic
Radicular
Primordial
3.Neoplasm
 Non-odontogenic
Exostosis
Enostosis
 Malignant
Squamous cell carcinoma
Midline lethal granuloma
4. Developemental
Crouzon syndrome
Treacher Collin‟s syndrome
Binder syndrome
5. Calcification
Anthroliths

6. 6. Traumatic
Fracture of maxilla, tuberosity, nasal bone,
zygoma and orbital floor
– Blow out fracture
– Isolated injury
– Complex fracture
Hematoma due to traumatic injury
Foreign bodies displace into the sinus- fractured
tooth/root
Oral antral fistula
Sinus contusion

7. Inflammatory disease
Acute and chronic sinusitis
Inflammation of the mucosa of the paranasal sinuses is referred to as
sinusitis.when maxillary sinus is involved, it is called as maxillary
sinusitis.when all the sinuses are involved it is called as pansinusitis.
Etiology
Dental causes
Periapical infection from the teeth: it may follow dental infection
particularly from upper molars and premolars teeth
Oroantral fistula: the accidental opening in the floor of the maxillary
sinus during dental extraction is called as oroantral opening.
Periodontitis: it may spread from a deep pocket of marginal
periodontitis.
Traumatic: injury of facial bones especially nasal bones and malar
bones
Dental material in the antrum: perforation of endodontic filling
substance. If root canal is overfilled then there are more changes of gutta
purcha points to be inserted into the maxillary sinus.
Implant: implants are used in upper edentulous jaw to aid the retention
of dentures or bridges or replace missing teeth.implants are also used
when there is insufficiency of bone to support the denture.in these cases
as bone is thin,implant can penetrate the nose or sinus.

8. Infected dental cyst: cyst which have become infected and involve the
maxillary sinus can also cause sinusitis
Non-dental causes
Mechanical obstruction of ostium
 Common cold
 Allergic rhinitis
 Other condition
Direct bacterial contamination: infected material may also be
introduced directlyby jumping or hydrosliding feet first into
contaminated water without holding the nose or during diving,when
pressure changes in the nose force nasal secretion into sinus.
Immune deficiency: sinusitis can occur in immune deficiency, state like
leukemia,lymphoma and AIDS
Influenza: it can also occur in influenza when bacteria invade as
secondary microorganisms.
Blood brone infection: it can also occur in some cases of blood brone
infection
Disease of maxillary sinus: benign mucosal cyst or tumors of maxillary
sinus can also lead to maxillary sinusitis.
Clinical features
 Acute sinusitis:
this is a complication of common cold and is accompanied by clear nasal
discharge or pharyngeal drainage,which may eventually become green or
greenish-yellow colored.
After a few days the stuffiness increases and the patient complaints of pain
and tenderness to pressure or swelling over the involved sinus
There will be signs of sepsis;fever,chills,malaise and an elevated
leukocyte count.
Pain may be referred to the premolars and molar teeth on the affected side
and these teeth may also be sensitive to percussion

9.  Chronic sinusitis
This is a sequel of the former two,which has failed to resolve by 3
months.
There are no external signs, except in case of an acute exaceberation
when increased pain and discomfort is apparent.
This type is usually associated with anatomical derangements that inhibit
the outflow of mucous,like;deviation of the nasal septam and presence of
concha bullosa.
It is also associated with allergic rhinitis,asthma,cystic fibrosis and dental
infection.
Radiographic features
Radiodensity: radiographically,the thickening of the mucous membrane
and the accumulation of secreations that accompany sinusitis reduce the
air content and it will appear as radiopaque.
Allergic sinusitis: in the case of allergy,mucosa will be more lobulated in
contrast to that in infection where it is straighter and parallel to the sinus
wall.
Chronic sinusitis: chronic sinusitis may result in persistent opacification
of the sinus and sclerosis or thickening of surrounding bone.
Antral halo appearance: sometimes if infected teeth are involved then
inflammatory changes may lead to resorption of the antral floor and
remodelling to produce the appearance described as an antral halo.
Resolution of sinusitis: resolution of acute sinusitis will appear as small
clear areas appear in the interior of the sinus as the thickened mucosa
gradually shrinks.
Diagnosis
Transillumination test: affected sinus will be found opaque.
Radiograph: water‟s view and OPG can be taken

10. Waters view showing maxillary sinus
Laboratory diagnosis: there is elevated leukocyte count.lining of
maxillary sinus may show a typical acute inflammatory infiltrate with
edema of the connective tissue and often hemorrhege. In chronic
cases,cellular proliferation is present.
CT.scan:
Management
 Acute sinusitis
Anti-histamines for allergy
Pseudoephedrine 30-60 mg
Phenylephrine 2-4 times/day
Amoxicillin 500 mg tid for 10-14 days
 Topical nasal spray (unlimited daily use)
Ipatropium
 Chorinic sinusitis
Nasal steroid spray

11. Guafenesin
Decongestants
Steam inhalation
Nasal irrigation
Antibiotics with exacerbations
Complication
 Acute sinusitis
Maxillary: usually uncomplicated
Ethmoid: cavernous sinus thrombosis-serious
Frontal: osteomyelitis of frontal bone; cavernous sinus thrombosis;
epidural, subdural, or intracerebral abscess; orbital extension
Sphenoid: Rare; extension to internal carotid artery, cavernous sinuses,
pituitary, optic nerves.
Mucositis (Thickened mucous membrane)
The normal mucosal lining of the para nasal sinus is composed of respiratory
epithelium and is approximately 1mm thick, and is not visualized on the
radiograph. When the mucosa becomes inflamed from either an infectious or
allergic process, it may increase in thickness 10mto 15 times and is then seen on
the radiograph. This thickening is called mucositis. Any thickening greater than
3mm is most likely to pathological.
Clinical features
It is usually asymptomatic and is discovered on a routine radiograph.
Radiographic features
It is seen as a non-corticated band noticeably more radiopaque than the
air filled sinus, paralleling the bony wall of sinus.
Mucosal thickening seen distinctly on denta scan images.

12. Perforation of the floor of the maxillary sinus
Management
Removal of the cause.
Antral polyp
The thickened mucosa of chronically inflamed sinus frequently form
irregular folds called as „polyps’.polypoid atrophy of mucosa may
develop into an isolated area or number of ares throughout the sinus.
Antrochoanal polyps, are solitary polyps arising from the maxillary
antrum. They were first described by Killian in 1906. Although their
etiology remains unknown, allergy has been implicated.
Clinical features
Age: it usually occurs in young persons.

13. Site: maxillary sinus is more involved as compared to other sinus.in
maxillary sinus they may arise from any part of the sinus wall and
occasionally pass through the ostium to appear in the nose as
antrochoanal polyps.
Picture showing antral polyp
Symptoms: patients present with nasal obstruction,pain is very mild on
pressure as mass present inside the nose.
Saints triad: it is associated with “saints triad”, ie.nasal and antral
polyposis, aspirin sensitivity and asthma.
Exacerbation of asthma: polyps may exaceberate the asthma by
causing obstruction of the nose. It is the most commonly pedunculated,
or sessile mass which grows slowly.after the polyps grows to occupy
most of the antrum it frequently hernites into the nasal cavity. this may
be brought about by repeated sneezing or nose blowing in about 4-6%
cases.
Radiological features
Appearance: it appear as homogenous soft mass with smooth,outwardly
convex borders.single or multiple lesions may be present.if polyp occurs
in the roof of the maxillary sinus in a patient with a history of trauma,the
plain film examination may simulate a blow out fracture.
Destruction of walls of sinus: polyps may cause destruction or
displacement of bone. They can displace or destroy medial or lateral wall.

14. CT features: have mucoid attenuation with mucosal enhancement seen at
polyps surface. It appears as smooth homogenous mass.
MRI features: mucosa adjacent to polyps will enhance as compared to
polyps

15. CT scan showing maxillary sinus
Management
 Non surgical
Oral and topical nasal steroid
Corticosteroids
 Surgical
polypectomy
Endoscopic sinus surgery
Osteomyelitis
Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone,
myelo- meaning marrow, and -itis meaning inflammation) simply means an
infection of the bone or bone marrow. It can be usefully subclassified on the
basis of the causative organism (pyogenic bacteria or mycobacteria), the route,
duration and anatomic location of the infection.
Types
 Infantile osteomyelitis
 Tuberculous osteomyelitis
Infentile osteomyelitis
It is a rare type of osteomyelitis seen in infants in few weeks after birth.it
usually involves maxilla.

16. Clinical features
Site: it is more common in maxilla due to hematogenous route.
Symptoms: fever, anorexia, dehydration in some cases, convulsants, and
vomiting may occur.
Signs: redness and edema of eyelids, alveolar bone and palate of the
effected side.
Radiographic features
Radiodensity: about 10 days after acute infection, the density of
trabeculae will be decreased, with blurred and fuzzy.
Trabecular pattern: the earliest radiographic change is that trabeculae in
involved area are thin,of poor density and slightly unsharp or blurred.the
trabeculae soon loose their continuity as well as the little density
present.individual trabeculae become fuzzy and indistinct.
Multiple radiolucency: subsequently, multiple radiolucencies appear
which become apparent on radiograph.
Lamina dura: there is loss of continuity of lamina dura,which is seen in
more than one tooth.
Diagnosis
Clinical diagnosis: fever, pain with maxillary involvement in the infant will
give clue to the diagnosis
Management
Bacterial sampling and culture
Vigorous (empirical) antibiotic treatment
Drainage
Give specific antibiotics based on culture and sensitivities
Give analgesics
Debridement
Remove source of infection, if possible

17. Tuberculous osteomyelitis
Bone and joint tuberculosis is always hematogenous in origin.
Primary focus is related to lung when disease is acquired by inhalation of
human strain or to gastrointestinal tract if it is acquired by ingestion of bovine
tubercle. The disease starts within the synovial membrane or in intra articular
bone.the disease may develop in synovial joint especially the knee and hip joint.
Tuberculosis osteomyelitis of maxilla or mandible or TMJ are rare entities
Cyst involving maxillary sinus
Mucous retention cyst (mucocele)
A mucocele is an expanding,destructive lesion that results from a blocked sinus
ostium. The blockage may result from intra-antral or intra nasal
inflammation,polyp or neoplasm.the entire sinus thus becomes the pathologic
cavity. As mucous secritions accumulate and the sinus cavity fills, the increase
in intra-antral pressure results in thinning,displacement,and in some cases
destruction of sinus walls. When the cavity is filled with pus,it is termed an
empyema,pyocele or mucopyocele.
Clinical features
90% of mucoceles occur in the ethmoidal and the frontal sinus and are
rare in the maxillary sphenoidal sinus
In the maxillary sinus it may exert pressurenon the superior alveolar
nerves causing radiating pain, with a swelling and fullness of the
cheek.the swelling may first observed over the anterioinferior aspect of
the antrum where the wall may be thinned or destroyed.
If the lesion expands inferiorly,it may cause loosening of the posterior
teeth.
If the medial wall of the sinus is expanded the lateral wall of the nasal
cavity will deform and the nasal airway may be observed.
If it expands into the orbit,it cause diplopia or proptosis.

18. Radiographic features
The normal shape of the maxillary sinus is changed into a more circular
shape as the mucocele enlarges.
The scalloped border of the frontal sinus is usually smoothed by
expansion, and the intersinus septum may be displaced.
In the ethmoidal air cells, displacement of the lamina papyracea may
occur, displacing the contents of the orbit.
In the sphenoid sinus the expansion may be in the superioe direction,
suggesting a pituitary neoplasm.
The sinus cavities appear uniformly radiopaque.
Differential diagnosis
Cyst
Benign tumor
Malignancy
Any suggestion of a lesion associated with occluded ostium should be a
mucocele. A large odontogenic cyst displacing the maxillary antral floor
may mimic a mucocele.
Treatment
Surgical removal.
Complications
There are usually no complications.
Surgical ciliated cyst
It is a delayed complication arising years after surgery involving maxilla.
Clinical features

19. It is usually occurs in the 4th
and 5th
decades of life
Mostly seen in males
The patient may complain of pain,discomfort or swelling of face or intra
oral swelling of the palate or alveolus, with pus discharge
Radiological features
it is seen as a well defined radiolucency closely related to maxillary sinus.
There is sclerosis of the surrounding bone.
As the cyst enlarges it produces pressure effects, with thinning of the
sinus walls which may eventually perforate
There may be resorption of mallxillary alveolar process.
There is no communication between the cyst and maxillary sinus which
may be demonstated by injecting the sinus with radiopaque material.
Treatment
Enucleation
Pseudo cyst
Pseudocysts are like cysts, but lack epithelial or endothelial cells.
Initial management consists of general supportive care. Symptoms and
complications caused by pseudocysts require surgery. Computed tomography
(CT) scans are used for initial imaging of cysts, and endoscopic ultrasounds are
used in differentiating between cysts and pseudocysts. Endoscopic drainage is a
popular and effective method of treating pseudocysts.
This has not to be confused with the so-called 'pseudocystic appearance',
mainly radiographically, of other lesions, such as Stafne static bone cyst and
aneurysmal bone cyst of the jaws.
Symptoms

20. Pseudocysts are often asymptomatic. Symptoms are more common in larger
pseudocysts, though the size and time present usually are poor indicators of
potential complications.
Clinical features
it is mainly seen in 2nd
and 3rd
decades of life.
Males are most commonly effected than female.
Mostly involved sites are the antral floor and lateral wall of maxillary
sinus.
There may be localized dull pain in the antral region or fullness and
numbness of cheek.
There may be pain in the teeth and over the face over or near the sinus.
Sometimes antral swelling may also occur.
Radiographic features
it is homogenous mass that is more radiopaque than the surrounding sinus
cavity.
It appears as a soft tissue mass rather than a calcified area so that medial
and lateral landmarks can generally be visualized through the lesion.
It is found projecting from the floor of the sinus, although some may form
on the lateral walls.
The cyst appers as spherical ,ovoid,or dome shaped
It has a uniform and a smooth outline.
They may have narrow or broad base
They vary in size from minute to very large.
There is no resorption of adjacent bone.
Mucous type will associated with thickened mucosa while serous type is
appears normal.

21. Dome shaped radiolucency seen in left maxillary sinus
Suggestive of antral pseudocyst
Treatment.
.Surgical drainage.
Endoscopic drainage
laproscopy
Radicular cyst
A radicular cyst is a cyst that most likely results when rests of epithelial cells
(Malassez) in the periodontal ligament are stimulated to proliferate and undergo
cystic degeneration by inflammatory products from a non-vital tooth.
Clinical features
Most common type of cyst of the jaws.
Rarely seen before the age of 10.
Most frequent between 20 and 60 years.
More common in males than females 3 to 2.
Maxilla affected more than 3 times the mandible.
Cause slowly progressive painless swelling.

22. No symptoms until they become large enough or infected.
If infection enters, the swelling becomes painful and may rapidly expand,
partly due to inflammatory edema.
The swelling is rounded and at the first hard
Later, when the bone has been reduced to egg-shell thickness, a crackling
sensation (crepitant) may be felt on pressure
Finally, part of the wall is resorbed entirely away, leaving soft fluctuant
(rubbery and fluctuant) swelling, bluish in color, beneath the mucous
membrane.
The dead tooth from which the cyst has originated is present, and its
relationship to the cyst will be apparent in a radiograph
Pathogenesis
The main factors in the pathogenesis of cyst formation are:
Proliferation of epithelial lining and fibrous capsule
Hydrostatic pressure of cyst fluid
Resorption of Surrounding bone
Infection from the pulp chamber induces inflammation and proliferation
of the epithelial rest of Malassez.
If infection can be eliminated from the root canal, small radicular cysts
(up to 1 or 2 cm diameter) may regress without surgery.
Radicular cyst expand in balloon-like fashion, wherever the local
anatomy permits, indicates that internal pressure is a factor in their
growth.
The hydrostatic pressure within cysts is about 70 cm of water and
therefore higher than the capillary blood pressure.
Cystic fluid is largely inflammatory exudate and contains high
concentration of proteins, some of high molecular weight which can
exert osmotic pressure.

23. Pathogenesis of radicular cyst
Consistent with the inflammation usually present in cyst walls, cyst fluid
may contain cholesterol, breakdown products of blood cells, exfoliated
epithelial cells, and fibrin.
Collagenases are present in the walls of keratocysts, but their
contribution to cyst growth is also unclear.
All stages can be seen from a periapical granuloma containing a few
strands of proliferation epithelium derived from the epithelial rest of
Malassez, to an enlarging cyst with a hyperplastic epithelial lining and
dense inflammatory infiltrate.
Epithelial proliferation results from irritant products leaking from an
infected root canal to cause periapical inflammation.
The epithelial lining consists of stratified squamous epithelium of
variable thickness.
It lack a well-defined basal cell layer and is sometimes incomplete.
Hyaline bodies may be seen in the epithelium and mucous cells are often
present as a result of metaplasia.
Long-standing cysts typically have a thin flattened epithelial lining, a
thick fibrous wall and minimal inflammatory infiltrate
Radiological features
In most cases the epicenter of a radicular cyst is located approximately at
the apex of a nonvital tooth
Occasionally it appears on the mesial or distal surface of a tooth root, at
the opening of an accessory canal or infrequently in a deep periodontal
pocket

24. RADICALAR CYST INVOLVING THE MAXILLA
Most radicular cysts (60%) are found in the Maxilla, especially around
incisors and canines.
Because of the distal inclination of the root, cysts that arise from the
maxillary lateral incisor may invaginate the antrum.
Radicular cysts may also form in relation to a nonvital deciduous molar
and be positioned buccal to the developing bicuspid.
CT scan showing maxillary sinus

25. Diagnosis
Is based on the combination of:
Adequate History
Clinical Examination
Selected Investigation:
Pulp vitality testing of associated teeth
Radiographs (intra/extra oral)
Aspiration and analysis of cyst fluids
Histopathology
Management
Treatment of a tooth with a radicular cyst may include:
Extraction,
Endodontic therapy,
Apical surgery (Enucleation/Marsupilisation)
Neoplasm
Adenoameloblastoma (AOT)
Adenoameloblastoma is a lesion that is often found in the upper
jaw. Some consider it a non-cancerous tumor, others a hamartoma (tumor-like
growth) or cyst. Often, an early sign of the lesion is painless swelling. These
tumors are rarely found outside of the jaw.
It is mostly seen in the maxilla
Symptoms:
Some of the symptoms of Adenoameloblastoma incude:
Jaw cyst
Jaw tumor
Sinus cyst
Sinus tumor
Dental cyst

26. Etiology
It is fairly uncommon, but It is seen more in young people. Two thirds of the
cases are found in females
Presentation and diagnosis
Two thirds of cases are located in the anterior maxilla, and one third are
present in the anterior mandible.
Two thirds of the cases are associated with an impacted tooth (usually
being the canine).
On radiographs, the adenomatoid odontogenic tumor presents as a
radiolucency (dark area) around an unerupted tooth extending past the
cementoenamel junction.
It should be differentially diagnosed from a dentigerous cyst and the main
difference is that the radiolucency in case of AOT extends apically
beyond the cementoenamel junction.
Radiographs will exhibit faint flecks of radiopacities surrounded by a
radiolucent zone.
It is sometimes misdiagnosed as a cyst.
Clinical features
Clinical features generally focus on complaints regarding a missing tooth. The
lesion usually present as asymptomatic swelling which is slowly growing and
often associated with an unerupted tooth. However, the rare peripheral variant
occurs primarily in the gingival tissue of tooth-bearing areas. Unerupted
permanent canine are the theeth most often involved in adenoameloblastoma.
Radiological features
The radiographic findings of AOT frequently resemble other odontogenic
lesions such as dentigerous cysts, calcifying odontogenic cysts, calcifying
odontogenic tumors, globule-maxillary cysts, ameloblastomas, odontogenic
keratocysts and periapical disease . Whereas the follicular variant shows a well-
circumscribed unilocular radiolucency associated with the crown and often part
of the root of an unerupted tooth, the radiolucency of the extrafollicular type is
located between, above or superimposed upon the roots of erupted permanent
teeth. Displacement of neighbouring teeth due to tumor expansion is much more
common than root resorptions. The peripheral lesions may show some erosions

27. of the adjacent cortical bone. Comparing diagnostic arruracy between intraoral
periapical and panoramic radiographs Dare et al. found that intraoral periapical
radiographs allow perception of the radiopacities in AOT as discrete foci having
a flocculent pattern within radiolucency even with minimal calcifies deposits
while panoramic often do not. Those calcified deposits are seen in
approximately 78% of AOT . In addition, in one recently reported case MRI
was useful to distinguish AOT from other lesions, even if it is difficult on
periapical ordinal radiographies
IOPA showing canine in maxillary sinus
Treatment
Conservative surgical enucleation is the treatment modality of choice. For
periodontal intrabony defects caused by AOT guided tissue regeneration with
membrane technique is suggested after complete removal of the tumor.
Recurrence of AOT is exceptionally rare. Only three cases in Japanese patients
are reported in which the recurrence of this tumor occurred. Therefore, the
prognosis is excellent.
Exostosis
An exostosis (plural: exostoses) is the formation of new bone on
the surface of a bone. Exostoses can cause chronic pain ranging from mild to
debilitatingly severe, depending on the shape, size, and location of the lesion.
If an exostosis is thought to be present your podiatrist will most likely have an
x-ray taken of your foot to evaluate it. The underlying cause of forming the

28. exostosis needs to be addressed. An exostosis can be treated conservatively or
surgically depending on location and symptoms. If a surgery is performed
where the exostosis is removed this is termed an exostectomy.
Clinical features
The clinical features of osteochondromata are:
swelling - usually, at the metaphysis of a long bone
lesions may be single or multiple
rarely painful
the lump is bony hard, although sometimes covered by a bursa which
may be tender
Radiographic features:
Radiologically, the osteochondroma is well-defined. Often the lesion may look
smaller than it feels because the cartilage cap is invisible.
There are two main varieties that are seen:
conical
cauliflower shaped
There may be partial calcification of the osteochondroma.
Pathology:
On cut surface the torus and exostosis show dense bone with a lamellar or
laminated pattern. They are usually comprised of dense, mature, lamellar bone
with scattered osteocytes and small marrow spaces filled with fatty marrow or a
loose fibrovascular stroma. Some lesions have a thin rim of cortical bone
overlying inactive cancellous bone with considerable fatty or hematopoietic
marrow present. Minimal osteoblastic activity is usually seen, but occasional
lesions will show abundant periosteal activity. Large areas of bone may show
enlarged lacunae with missing or pyknotic osteocytes, indicative of ischemic
damage to the bone.
Treatment & Prognosis:
Surgical excision

29. Enostosis
A hyperplasia of bone within the jaws. Also referred to as a dense
bony island.
Clinical features
The lesions were all at least 1.5 cm. in diameter.
Pain, drainage, or localized expansion of the jaw was present
Womens are mostely effected
Causes
genetics
stress
infection
metabolism,.
Symptoms:
The humerus is most commonly affected. Males are more commonly affected
than females. The dog normally limps on the affected limb and only rarely holds
the limb to prevent any weight from being placed on it.
Pathology
Enostoses are likely congenital or developmental, and are thought to represent
either hamartomatous lesions or failure of osteoclastic activity during bone
remodelling
Radiographic Features
Location: Anywhere throughout the maxilla and mandible.
Edge: Well-defined to Well-localized, continuous with the surrounding
bone trabeculae.
Shape: Does not always have a given shape, but may appear round, ovoid
or irregular in shape.
Internal: Radiopaque, radiopacity of cancellous bone.
Other: None.
Number: May be single or multiple. If there are multiple sites throughout
the maxilla and/or mandible, an underlying systemic condition such as
Gardner‟s Syndrome should be considered.

30. Diagnosis
Diagnosis is made by pain on palpation of the long bones of the limbs. X-rays
may show an increased density in the medullary cavity of the affected bones,
often near the nutrient foramen (where the blood vessels enter the bone). This
evidence may not be present for up to ten days after lameness begins.
Differential diagnosis
In the vast majority of cases, bone islands have a pathognomonic appearance.
Larger lesions may sometimes pose a diagnostic dillema, particularly in the
setting of known malignancy.
Differential considerations include:
osteoblastic metastasis
osteoma
osteoid osteoma
low grade osteosarcoma
Squamous cell carcinoma
This originates from metaplastic epithelium of the sinus
mucosal lining
Clinical features
The males are commonly effected.
The most common symptom is facial pain or swelling, nasal obstruction
and lesion in the oral cavity.
Lymphnodes are involved in most of the case.
Erosion of the medial wall causes nasal obstruction, nasal discharge,
bleeding and pain.
Expansion of the alveolar process in the maxillary sinus

31. Sinus root and floor of the orbit causes symptoms related to eye diplopia
and proptosis, pain and hyperesthesia or anesthesia and pain over the
cheek and upper teeth.
Radiographic features
The medial wall of the sinus is best seen on the waters projections
Waters view showing maxillary sinus
As the lesion enlarges it may destroy the sinus walls and in general cause
irregular radiolucent areas in the surrounding bone
Adjacent alveolar process may show bone destruction around the teeth or
irregular widening of periodontal ligame t space.
The medial wall of the sinus maynbe thinned or destroyed and it may also
extend into the nasal cavity.
Destruction of the floor and anterior and posterior walls may be
dectected.
Differential diagnosis
Sinusitis
odontogenic cyst
Large retention cyst
Treatment
Debridement of sinus
Antifungal

32. – Amphotericin b
– Rifampin
Syndromes associated with maxillary sinus
Crouzon’s syndrome
Crouzon syndrome is a genetic disorder known as a branchial arch syndrome.
Specifically, this syndrome affects the first branchial (or pharyngeal) arch,
which is the precursor of the maxilla and mandible. Since the branchial arches
are important developmental features in a growing embryo, disturbances in their
development create lasting and widespread effects.
Causes
Associations with mutations in the genes of FGFR2 and FGFR3 have been
identified.
Heredity
Crouzon syndrome is autosomal dominant; children of a patient have a 50%
chance of being affected
Symptoms
As a result of the changes to the developing embryo, the symptoms are very
pronounced features, especially in the face. Low-set ears are a typical
characteristic, as in all of the disorders which are called branchial arch
syndromes. The reason for this abnormality is that ears on a fetus are much
lower than those on an adult. During normal development, the ears "travel"
upward on the head; however, in Crouzon patients, this pattern of development
is disrupted. Ear canal malformations are extremely common, generally
resulting in some hearing loss. In particularly severe cases, Ménière's disease
may occur.
Diagnosis
Diagnosis of Crouzon syndrome usually can occur at birth by assessing the
signs and symptoms of the baby. Further analysis, including radiographs,

33. magnetic resonance imaging (MRI) scans, genetic testing, X-rays and CT scans
can be used to confirm the diagnosis of Crouzon syndrome.
Treatment
Surgery
Dental significance
For dentists, this disorder is important to understand since many of the physical
abnormalities are present in the head, and particularly the oral cavity. Common
features are a narrow/high-arched palate, posterior bilateral crossbite,
hypodontia (missing some teeth), and crowding of teeth. Due to maxillary
hypoplasia, Crouzon patients generally have a considerable permanent
underbite and subsequently cannot chew using their incisors. For this reason,
Crouzon patients sometimes eat in an unusual way--eating fried chicken with a
fork, for example, or breaking off pieces of a sandwich rather than taking a bite
into it.
Binder syndrome (maxilla nasal dysplasia)
Binder's Syndrome/Binder Syndrome (Maxillo-Nasal Dysplasia) is a
developmental disorder primarily affecting the anterior part of the maxilla and
nasal complex (nose and jaw). It is a rare disorder and the causes are unclear.
Hereditary and vitamin D deficiency during embryonic growth have been
researched as possible causes.
clinical Characteristics
arhinoid face,
intermaxillary hypoplasia,
abnormal position of nasal bones,
atrophy of nasal mucosa, reduced
absent anterior nasal spine,
absence of frontal sinus (not obligatory).
Synonyms:

34. Maxillo-nasal dysplasia.
Maxillo-nasal dysostosis.
Naso-maxillo-vertebral syndrome (Binder syndrome).
Prognosis:
The prognosis is good if there is no other problem associated.
Management:
Orthodontic therapy
osteotomy when the children were older
.
Anthroliths.
An antrolith is a calcified mass within the maxillary sinus. The origin of the
nidus of calcification may be extrinsic (foreign body in sinus) or intrinsic
(stagnant mucus, fungal ball).
Most antroliths are small and asympotomatic. Larger ones may present as
sinusitis with symptoms like pain and discharge.
Radiographic features
Location: Maxillary sinuses.
Edge: Well-defined, smooth or irregular outline.
Shape: Round, ovoid.
Internal: Radiopaque, may have a „laminated‟ appearance with
radiopaque and radiolucent bands evident due to continued laying down
of calcium salts. (This looks similar to layers of an onion.)
Number: May be single of multiple.

35. IOPA SHOWING AN IMAPACTED TEETH
IN THE MAXILLARY REGION
They appearas solitary or multiple, faintly to extremely radio-opaque masses
embedded within the mucoperiosteum. The sinus wall is intact.
Treatment
surgical removel
endoscopic sinus surgery
Differential diagnosis
Aspergillosis infection
Traumatic injuries of maxillary sinuses
Tooth roots may be fractured as a result of various forms, including iatrogenic
reasons. fractured roots may be forced into the sinus during extraction or
subsequent attemps to retrieve them.
Excess root canal filling material may be forced through the apex of an upper
posterior tooth during endodontic therapy. Foreign materials may be pushed
into the antrum via an existing oro antral fistula. Metallic objects such as
pellets, bullets and fragments of shells or bombs may be found if patients has
been exposed to the same.

36. Clinical features
no visible signs and symptoms if the roots is displaced recently.
Ask the patient to hold the nose while attempting to breathe out through,
similar to a valsalva maneuver, it will cause bubbles to appear within the
blood contained within the fresh extraction.
If the patient has the root or tooth in the sinus for a number of days, he
may present with sinusitis
The associated roots are usually of molars and premolars as the sinus is in
close proximity to these teeth.
Radiographic features
The dislodged fragments are usually found near the floor of the sinus
because of the gravity. Sometimes the displaced structure may be
mucosal, between the osseous wall of the sinus and the periosteum. The
floor of the sinus and periosteum.
The foor of the sinus may break due to the displacement of the tooth
fragment into the sinus.
THERE IS A ROOT FRAGMENT LOCATED OBLIQUELY AND APICAL TO THE APEX LINE

37. CT finding which showed that the tooth was located close to mesial wall of the sinus and roots
Differential diagnosis
Exostoses of the sinus wall or the floor and the septa within the sinus,
may mimic dental root fragments or even whole teeth.
Anthroliths
Treatment
Surgical removal
Sinus contusion
This occurs due to a blow to the face that damages the lining of the paranasal
sinuses without fracturing the facial bone. There may be green stick fracture of
the sinus with a resultant tearing injury to the mucosal lining.
Clinical features
There is a bloody nasal discharge, extreme tenderness of the involved
sinus on pressure.
There is rapid resolution of the soft tissue changes.

38. 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
Blow-out fracture
This results from sudden increase in the intraorbital pressure, due to may be a
direct blow to the eye.
Clinical features
The pressure of the blow forces the inferior orbital content through the
fracture.
It results in diplopia when the victim look upward and enophthalmus
following reduction of edema and fat atropy.
Radiographic features
Opacification of the sinus with or without a fluid level.
There will be shadow of soft tissue mass in the upper portion of the sinus
and shadows of the depressed bone fragments into the sinus.
A tear drop shaped radiopacity is produced in the upper part of the sinus,
due to the herniation of the orbital content downward into the sinus
following the collapse of the antral roof.
The depression fracture of the orbit may be accompanied by the fracture
of the antrum wall of the maxillary sinus.

39. CORONAL SECTION TOMOGRAPH OF PATIENT WITH BLOW OUT FRACTURE OF RIGHT ORBITAL
FLOOR
Isolated fracture
This involves a single wall which may appear as a bright line on the radiograph.
The most common sites are the anterolateral wall of the antrum and the floor of
the antrum, during extraction of the upper posterior teeth whose roots are in
close proximity to the antrall floor.
Zygomatic complex fracture
This fractures occurs at the line of weakness and passes through the orbital
floor, usually medial to the zygomaticomaxillary suture.
Clinical features
The fractured zygoma is forced into sinus.
There may be tearing of the lining membrane with subsequent bleeding
into antrum.

40. Radiographic features
the antrum appers cloudy or will show a fluid level.
Standard occipitomental showing fracture of the right zygomatic complex with a break of antral roof
Oroantral fistula
This is a pathological pathway connecting the oral cavity and the maxillary
sinus. It may be caused due to extraction of teeth having chronic periapical
infection, extraction of solitary tooth. Extraction of teeth having apices very
close to the antral floor, blind instrumentation, surgical removal of large lesions
in the upper jaws, malignant tumors,osteomyelitis, syphilis, malignant
granulomatous lesion, facial trauma and inadequate blood clot formation.

41. Clinical features
immediate history of recent traumatic extraction or disappearance of the
roots during extraction.
Passage of fluid into the nose from the oral cavity
Inability to blow the cheek or smoke.
Unilateral epitaxis, due to blood in the antrum escaping through the nasal
ostium.
Alteration in vocal resonance.
Radiographic features
There will be a break in the continuity of the floor of the maxillary sinus,
which may be seen as a disalignment of a small portion of cortical layer
of bone
Radiographic features of acute or chronic sinusitis are present.

42. Periapical showing a discontinuity of the antral foor
There may be evidence of the displaced root or tooth,and a second view
of the sinus with the head in a different position may be required to
asceration the the exact location of the displace object,
Treatment
It consist of repair and surgical closure under antibiotic therapy.

43. Reference
Dental and maxillofacial radiology: freny r kajodkar ,2nd
edition, jaypee
2009 ; page 751 to 773
Text book of oral medicine: anil govidharao editors, ghom,2nd
edition,
jaypee 2010 , page 677 to696
Text book of oral and maxillo facial surgery: chitra chakravarthy
editor,2nd
edition, paras publishers 2011 ,page 246 to 263
Oral & Maxillofacial Pathology: Neville, B, et al. editors,3rd
Ed.
Saunders 2002 ,page 219 to 226
Text book of medicine; pramod john r editor,2nd
edition,jaypee 2005,page
284 to 288