Diseases of maxillary sinus

2. DISEASES OF
MAXILLARY SINUS
PRESENTER
DR. MODHA VISHAL D.
POSTGRADUATE STUDENT
DEPT OF ORAL AND
MAXILLOFACIAL SURGERY
OXFORD DENTAL COLLEGE
GUIDED BY
DR. RAMAKRISHNA T

3. INTRODUCTION
 Paranasal sinuses
 Air containing bony spaces present
around the nasal cavity
 Usually lined by respiratory
mucus membrane
 Four paired

4. MAXILLARY SINUS
 Pneumatic space lodged in the
body of maxilla that
communicates with the external
environment by way of middle
meatus and nasal vestibule -
by Orban’s
 Also known as antrum of
Highmore (1651)

5. EMBRYOLOGY
 First sinus to develop
 Initial development of sinus follows number of morphogenic
events in differentiation of nasal cavity

6. EMBRYOLOGY
 Development of sinus begins
as evagination of mucus
membrane in lateral wall of
middle meatus when nasal
epithelium invades maxillary
mesenchyme ( Kitamura,
1989)
 Growth of sinus takes place by
pneumatization
 Primary (10th weeks)
 Secondary (5th month)

7. EMBRYOLOGY
 Maxillary sinus has biphasic growth 0-3 years and
7-12 years
 Post natally grows @ 2 mm vertically and 3 mm AP
 Radiographically; triangular area medial to IOF (5th
month)
 3 growth spurts
a) 0-2.5 years
b) 7.5-10 years
c) 12-14 years

8. ANATOMY
 Largest of PNS,communicate
with other sinuses through
lateral nasal wall.
 Horizontal Pyramidal shaped
 Base
 Apex
 4 walls
 Wall thickness varies with
individual
superior
inferior
lateral
anterior

9. ANATOMY
 Various shapes
 Hyperbolic-47%
 Paraboloid-30%
 Semi-ellipsoid-15%
 Cone shaped-8%
 Dimensions (Therner, 1902)
 H: 3.5cm
 W: 2.5cm
 L: 3.25cm
 Vol:15-30 ml

10. ANATOMY
 Receses-
 Alveolar
 Zygomatic
 Palatal
 Frontal
 Teeth in proximity
2nd, 1st , molar>3rd molar>2nd pm>1st pm>canine

11. MEDIAL WALL
 Formed by lat nasal wall
 Below-inf nasal conchae
 Behind-palatine bone
 Above-uncinate process
of ethmoid,lacrimal bone
 Contains double layer of
mucous membrane(pars
membranacea)

12. MEDIAL WALL
 Imp structures
 Sinus ostium
 Hiatus semilunaris
 Ethmoidal bulla
 Uncinate process
 Infundibulum
 Applied aspect

13. SUPERIOR WALL
 Forms roof of sinus and floor of orbit
 Imp structures
 Infraorbital canal
 Infraorbital foramen
 ASA nerve
 Applied aspect
 Vulnerable to trauma
 Erosion of this wall by tumor

14. POSTEROLATERAL WALL
 Made of zygomatic and greater wing of sphenoid
bone(maxillary tuberosity)
 Thick laterally,thin medially
 Imp structures
 PSA nerve
 Maxillary artery
 Maxillary nerve
 Pterygopalatine ganglion
 Nerve of pterygoid canal
 Applied aspect
 Involvement of PSA-pain in post teeth
 Surgical access by careful removal of segment of wall

15. ANTERIOR WALL
 Extends from pyriform aperture anteriorly to ZM
suture
& IO rim superiorly to alveolar process inferiorly.
 Convexity towards sinus
 Thinnest in canine fossa
 Imp structures
Infraorbital foramen
ASA, MSA nerves
Levator labii, obicularis oculi muscles
 Applied aspect

16. FLOOR OF SINUS
 Formed by junction of anterior
sinus wall and lateral nasal wall
 1-1.2 cm below nasal floor
 Close relationship between sinus
and teeth facilitate spread of
pathology
 Inner surface is rough by bony
septa
 Retrieval of root fragment
 Interferes with sinus drainage

17. VASCULARIZATION & INNERVATION
Arterial Supply
a) Nasal Mucosal Vasculature
SP, Ethmoid
b) Osseous Vasculature
IO, PSA, ASA, GP, Facial
Venous Drainage
a) Medial wall - SP
b) Other walls – Pterygomaxillary Plexus
Lymphatic Drainage Collecting vessels in middle meatus
Nerve Innervation ION, GP, PSA, MSA, ASA

18. MICROSCOPIC ANATOMY
 3 layers
 Epithelium
 Basal lamina
 Sub epithelium

19. EPITHELIUM
 Pseudostratified columnar ciliated epithelium
 Cells
 Columnar ciliated
 Goblet
 Basal
 Non – ciliated

20. CILIATED EPITHELIUM

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

22. DRAINAGE OF SINUS
 Mucus transported from nose and PNS to
nasopharynx, ingested and presented to GIT
(Messerklinger)
 Forms basis of fess

23. DRAINAGE OF SINUS
Mucociliary flow from anterior sinuses converge at OMC, carried to
posterior nasopharynx & inferiorly to eustachian tube orifice
Mucus coursing along lateral wall, carried medially along roof to reach
ostrium
Drainage into ethmoidal infumdibulum
Upward course along walls of entire cavity and then towards natural
ostium in superomedial wall
Flow of mucus superiorly against gravity
By Donald et al & Antunes et al

24. DRAINAGE OF SINUS

25. FUNCTIONS OF SINUS
1. Decrease skull weight
2. Impart resonance to voice
3. Mucus production and storage
4. Humidify and warm inhaled air
5. Define facial contour
6. Immunodefensive action
7. Conserve heat from nasal fossae
8. Moisturize air
9. Filters debris
10. Dampen pressure differential during inspiration
11. Limit extent of facial injury from trauma
12. Serves as accessory olfactory organ

26. CLASSIFICATION
 Inlammatory
 Cystic
 Neoplasm
 Calcification
 Traumatic
Acute and chronic sinusitis
Mucositis
Antral polyp
Osteomyelitis
Intrinsic
Mucus retention cyst(mucocele)
Pseudo cyst
Surgical ciliated cyst
Extrinsic
Odontogenic
Radicular
Primordial
Non-odontogenic
Exostosis
Enostosis
Malignant
Squamous cell carcinoma
Midline lethal granuloma
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

27. MAXILLARY SINUSITIS
 Group of diseases
mainly inflammation &
infection which affect
the nasal mucosa and
PNS

28. MAXILLARY SINUSITIS

29. 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.
 Infected dental cyst: cyst which have become infected and
involve the maxillary sinus can also cause sinusitis

30.  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.

31.  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

32.  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.

33.  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.

34.  Diagnosis
 Transillumination test: affected sinus will be found
opaque.
 Radiograph: water’s view and OPG can be taken

35.  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:

36. ANTIBIOTICS
Antibiotic Micro factors Pediatric dosage
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/trimethopr
im
6-12 mg/kg/day divided (based on
trimethoprim)
800-160 mg BID

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

38. DECONGESTANTS
 Systemic (phenylpropanolamine, pseudoephidrine):
 Contraindications: hypertension, hyperthyroidism, asthma
 Topical: phenylepinephrine HCl, oxymetazoline HCl
 Adv. Effects- rhinitis medicamentosa

39. ANALGESICS & ANTIHISTAMINES
 Analgesics:
 Opoid: acetaminophen, codeine
 NSAIDS:
 Antihistamines:
 Mequitazine, terfenad
 Contraindicated in bacterial sinusitis
 Adv effect: sedation

40. NASAL LAVAGE & SPRAYS
 m/a:
 Removes debris & dead tissue
 Washes inflammatory secretions
 Eliminates nutrient source
 Methods:
 Lavage pot
 Syringe
 Irrigating bulb

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

42. SINUS ASPIRATION & LAVAGE
 Direct removal of bacteria laden secretions
 Indication: no response to medical therapy
 D/A

43. MAXILLARY NEEDLE SINUSOTOMY
 d/a
 Requires force to enter anterior wall
 Alternatives:
 Mallet
 Steinmann pin
 Complications:
 Bleeding
 Infection
 Dental injury
 Sensory nerve disturbance
 Instrument breakage
Infiltration of LA
Preparation of
site
Transcutaneous
puncture ant & post to
canine eminence

44. SINUSITIS
 Complications:
Facial cellulitis
Orbital extension
Intracranial
extension

45. SURGERY FOR ACUTE SINUSITIS
 Several techniques have been described for
drainage of the maxillary sinus. The inferior meatus
and canine fossae are optimal drainage sites
because of their ease of accessibility and relatively
thin, well-vascularized bone.
 Place conscious patients in the sitting position to
allow for drainage of the sinus contents into a
provided basin. Protect the airway and suction the
oropharynx during sinus puncture performed on
unconscious patients. In patients in the intensive
care unit, catheterization of the sinus may be
undertaken with puncture to ensure continued
adequate drainage.

46.  INFERIOR MEATAL PUNCTURE
 CANINE FOSSA PUNCTURE
 ENDOSCOPIC TECHNIQUE

47. SURGERY FOR CHRONIC SINUSITIS
 History of surgical therapy for chronic maxillary sinusitis
 Open approaches to the maxillary sinus were first described in
the early 1700s. The well-known Caldwell-Luc operation was
first described in the United States by George Walter Caldwell
in 1893 and then by Henri Luc of France in 1897. Subsequent
advances in the understanding of the physiologic drainage
pattern of the maxillary sinus led to intranasal middle meatus
antrostomy in the late 1960s and the early 1970s.
 Functional endoscopic sinus surgery (FESS) is based on the
surgical approach performed by Messerklinger and Wigand in
Europe via the ostiomeatal complex.[1, 2] FESS has become
the standard surgical treatment for chronic maxillary sinusitis,
with external approaches being used as an adjunct in more
complicated cases or in tumor management.

48. CONFORMATORY CT SCANS
 Computed tomography (CT) scanning should be
obtained to confirm clinical suspicion of chronic sinusitis.
Findings may include significant mucosal thickening, air-
fluid levels, ostiomeatal complex obstruction, polyposis,
or calcification suggestive of fungal sinusitis.
 A thorough review of preoperative CT scanning is
required to check for the following:
 Position of the lamina papyracea in relation to the
uncinate process
 Position of the skull base and the nasolacrimal duct
 Presence of a hypoplastic maxillary sinus with or without
an atelectatic uncinate process (see image below)
 Dehiscence of the lamina papyracea or the skull base

49. A study by Joshua et al suggested that the
severity of chronic maxillary sinusitis can
be determined by CT-scan evaluation of
sinus wall thickness. The study, which
included 38 patients with unilateral chronic
maxillary sinusitis, found that the degree of
inflammation corresponded to wall
thickness, although not to wall density.

50.  The main functional component of the maxillary sinus outflow tract is the
ostiomeatal complex, which is collectively constituted by the uncinate process, the
maxillary ostium, the infundibulum, and the ethmoid bulla. These structures form a
functional complex through which the maxillary sinus contents egress. Obstruction
of the ostiomeatal complex and its relief with surgery form the basis for FESS.
 The uncinate process is a sickle- or L-shaped bone that starts anterosuperiorly and
then slopes posteroinferiorly, running horizontally from anterior to posterior. It has a
free edge along its superior surface, which is taken down during uncinectomy.
Superiorly, the uncinate process may attach to the lamina papyracea (most
common configuration), the middle turbinate, or the skull base. At its most posterior
point, it attaches to the inferior turbinate at the ethmoidal process.
 Once the uncinate process is taken down, the natural maxillary sinus ostium can
be visualized. The cilia of the maxillary sinus beat uphill toward the natural
maxillary sinus ostium. Therefore, the natural ostium of the maxillary sinus must be
included with maxillary antrostomy for maximal functional benefit.
 If the natural ostium is missed, mucus recirculation may be a problem. The
ethmoid bulla lies just posterior to the uncinate process and may be visible along
with the uncinate process on routine nasal endoscopy. The ethmoid bulla, which is
one of the features depicted in the image below, is the most constant anterior
ethmoid air cell.

54.  Surgical Options
 Surgery is reserved for patients with confirmed chronic sinusitis—
as documented by findings on history, physical examination, and
CT scan—who have not responded to medical therapy.
 Three main surgical options are available: (1) endoscopic
uncinectomy with or without maxillary antrostomy, (2) the
Caldwell-Luc procedure, and (3) inferior antrostomy (nasoantral
window).
 Today, endoscopic maxillary antrostomy and uncinectomy are the
standard for treatment for refractory chronic maxillary sinusitis.
The Caldwell-Luc and inferior antrostomy approaches are
reserved for rare circumstances, such as a case of severe
allergic fungal sinusitis in which standard antrostomy alone does
not allow complete extirpation of fungal concretions or complete
drainage.
 Additionally, further FESS with mucosal-sparing techniques may
be performed if additional disease is present within the ethmoid,
sphenoid, and frontal sinuses.

55. FESS
 Coined by Kennedy
 Intranasal endoscopic
technique that allows
establishment of adequate
sinus drainage without
negative impact on sinus
mucosa physiology and
function.
 Principle: stop the cycle that
begins with ostium blockage
that leads to chronic sinusitis
via stagnated secretions,
tissue inflammation and
bacterial infections.

56. FESS

57. FESS

58. FESS
Minor hemorrhage
Hyposmia
Adhesions
Periorbital emphysema
Intracranial hemorrhage
Brain injury
CSF leak
Diplopia
Blindness
Anosmia
Epistaxis
NL duct injury
Meningitis
Complications

59. FESS WITH VIDEO

60. CALDWELL LUC SINUSOTOMY
 By George Caldwell (1893) & Henry Luc (1897)
 Indications
 Fungal sinusitis
 Multiple antral lesions
 Antrochoanal polyp
 Excision of tumor
 Closure of OAF
 Removal of antral foreign body
 Antral revision procedures
 surgical approach for transantral sphenoethmoidectomy, orbital
decompression

61. CALDWELL LUC WITH VIDEO

62. 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.

63.  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.

64. 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.

65.  Clinical features
 Age: it usually occurs in young persons.
 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.


66.  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.

67.  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.
 CT features: have mucoid attenuation with
mucosal enhancement seen at polyps surface. It
appears as smooth homogenous mass.

68. Management
•Non surgical
•Oral and topical nasal steroid
•Corticosteroids
•Surgical
•polypectomy
•Endoscopic sinus surgery

69. 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

70.  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.

71.  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.

72.  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.

73.  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.

74.  ciliated cyst
 It is a delayed complication arising years after surgery involving maxilla.

 Clinical features
 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

75.  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
 Pseudocysts are often asymptomatic. Symptoms are more
common in larger pseudocysts, though the size and time present
usually are poor indicators of potential complications.

76.  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.

77.  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.

79. NEOPLASMS

83. STAGING
 T1 means the tumour is only in the innermost most
tissues lining the sinus. It has not grown into the
bone.

84.  T2 means the tumour has begun to grow into the
bone surrounding the maxillary sinus. (If the tumour
is in the bone in the back part of the sinus - the
posterior wall - it is T3.)

85.  T3 means the tumour has begun to grow into the
back (posterior) wall or into bones of any of the
other sinuses. If the cancer grows right through
these bones it may reach the tissues under the
skin, the skin of the cheek, the eye socket or the
ethmoid sinus in front of the maxillary sinus.

86.  T4 means the tumour has grown into any other nearby
structures such as the eye, skull, skin of the cheek, the tissues
below the temple, the area connecting the back of the nose to
the back of the mouth (nasopharynx) , sphenoid or frontal
sinuses or up into the brain.

89. OROANTRAL FISTULA
 Fistular canal between oral cavity and sinal
mucous membrane covered with epithelium
which may or may not be filled with
granulation tissue or polyposis.
 Duration and width of lumen contributes to
infection of sinus.
 OAC OAF(incidence: 0.3-3.8
%)

90. OROANTRAL FISTULA
 OAC OAF
 Defect > 5mm diameter
 No approximation of gingival tissues
 Post op regime not followed
 Loss of clot or wound dehiscence
 Cyst enucleation
 Smoking, drinking

91. OROANTRAL FISTULA
 Etiology
• Iatrogenic (50%)
• Presence of periapical lesions
• Injudicious use of instruments
• During attempted extraction
• Trauma(7.5%)
• Chronic infections(11%)
• Malignant diseases(18.5%)
• Infected maxillary dentures(3.7%)
• h/o sinus surgery(7.5%)

92. OROANTRAL FISTULA
 Predisposing factors
• Proximity of sinus floor / tuberosity
• Thickened tooth cement / tooth fused to jaw bone
• Infected teeth / long-standing decay
• Marked periodontitis / gum disease
• Lone-standing
• Previous history of OAC’s.

93. OROANTRAL FISTULA
Acute Chronic
1. Escape of air and fluids through nose
& mouth
1.Pain, tenderness over cheeks
2. Epistaxis 2. Purulent discharge
3. Excruciating pain 3. Post nasal drip
4. Altered voice 4. Presence of polyps
5. h/o surgery in vicinity of sinus 5. Generalized constitutional symptoms
 Common in males,2nd-3rd decade
 Immediate sign:
 Displaced root /tooth
 Tuberosity #

94. OROANTRAL FISTULA
 Diagnosis
h/o previous extraction
Valsavin test
Mouth mirror test
Cotton wisp test
Inspection
Radiological
 IOPA
 OPG
 OM

95. OROANTRAL FISTULA
 Management
• 3mm-5mm heals spontaneously(HANAZANE)
• Ideal treatment :immediate surgery followed by
Ab prophylaxis
• Acute OAF: closure by simple reduction of
buccal and palatal socket walls, followed by
acrylic splint.
• Treatment for small opening

96. OROANTRAL FISTULA
1) antibiotics : Pn & derivatives
2) nasal decongestants:
Ephedrine drops
Inhalations(steam,benzoin ,menthol)
3) Analgesics:
Aspirin 500mg
Paracetamol 500mg
Ibuprofen 400 mg
4)Antral lavage

97. OROANTRAL FISTULA
 Antral lavage

98. OROANTRAL FISTULA
 Whitehead’s varnish

99. OROANTRAL FISTULA
• Acrylic plates

100. SURGICAL CLOSURE
Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J Oral Maxillofac
Surg68:1384-1391, 2010
•Temporalis
flap
•Forehead
flap
Overview of the treatment modalities of Oro-Antral Communications

101. SURGICAL CLOSURE
 Factors determining flap selection
 Size of communication
 Timeline of diagnosing
 Presence of infection

102. BUCCAL FLAP

103. PALATAL FLAP

104. DISTANT FLAPS
BUCCAL FAT PAD

105. TONGUE FLAP
Introduced by lexer,1909
Technique
Advantages
Disadvantages

106. GRAFTS

107. Grafts
GRAFTS
AUTOGENOUS
Iliac crest
Chin
Retromolar area
Zygoma
ALLOGENOUS
Collagen sheet
Fibrin glue
Gold foil
Tantalum
PMMA
Hydroxyapatite
XENOGRAFTS
Porcine dermis
Bio guide & Bio
oss

108. OTHER TECHNIQUES
 Third molar transplantation(kitagawa et al)
 Interseptal alveolotomy(hori et al)
 GTR(Waldrop & Semba)
 Prolamine gel(Gotzfried & Kaduk)
 Laser light(Janas)
 Splints for immunocompromised pts(llogan and
coates)

109. CONCLUSION
 Due to close proximity of maxillary sinus to orbit, alveolar ridge,
maxillary teeth, diseases involving these structures may produce
confusing symptoms. Hence a precise information about the surgical
anatomy is essential to surgeons.
 The oroantral fistula is a problem that requires detailed attention to
the management of a flap in the mouth. For the sake of obtaining the
best results and to give the patient the benefit , proper knowledge
about the different types of modalities and their limitations is
necessary.

110. REFERENCES
• ECAB: Clinical update-otorhinolaryngology-Paranasal sinuses and
rhinosinusitis-V.P Sood
• OMFSClinics of North America-Diagnosis & treatment of disorders of
maxillary sinus-Laskin
• Principles of oral and maxillofacial surgery-Peterson
• Textbook of oral and maxillofacial surgery-Killey and kay
• Maxillary sinus and its dental implications:dental practice handbook-Killey
and Kay
• Review of oral and maxillofacial surgery-Ghosh

111. REFERENCES
• OTOLARYNGOLOGY CLINICS OF NORTH AMERICA 37(2004), 347-364
• Open access atlas of otolaryngology, head & neck operative surgery -johan
fagan
• Otolaryngology Online Textbookwww.utmb.edu/otoref/
• CANCER RESEARCH - UK
• Treatment of Oroantral Fistula-Klara Sokler et al, Acta Stomatol Croat, Vol.
36, br. 1, 2002
• Oronasal fistula closure by tongue flap-Manimaran K et al, JIADS,Jan-mar
2011
• A New Surgical Management for Oro-antral Communication,The
Resorbable Guided Tissue Regeneration Membrane – Bone Substitute
Sandwich Technique-C Ogunsalu, West Indian Med J 2005; 54 (4): 261
• EMEDICINE
• Dental and maxillofacial radiology: freny r kajodkar ,2nd edition, jaypee 2009
; page 751 to 773
• Oral & Maxillofacial Pathology: Neville, B, et al. editors,3rd Ed. Saunders
2002 ,page 219 to 226

112. THANK YOU