PATHOLOGIES OF MAXILLARY SINUS- Part III / oral surgery courses

PATHOLOGIES OF MAXILLARY
SINUS- Part III
A Seminar On
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Pathologies of maxillary sinus
1. Developmental anomaliesDevelopmental anomalies
-Agenesis
-Aplasia
-Hypoplasia
-Supernumerary maxillary sinus
2. Inflammatory diseasesInflammatory diseases
-Mucositis
-Maxillary sinusitis
-Empyema
-Antral polyps
-Antroliths

3. Cysts of the maxillary sinusCysts of the maxillary sinus
- Odontogenic cysts
- Non odontogenic cysts
4. Traumatic diseasesTraumatic diseases
-Oro-antral fistula
-Root in the antrum or foreign body in antrum
-Fractures
-Pneumocele and cheek emphysema

5. TumorsTumors of the maxillary sinus
-Benign tumors -Antral Papilloma, Osteoma,
Odontomes, Odontogenic
tumors, Cholesteatoma
-Malignant tumors- Squamous cell carcinoma,
adenocarcinoma, metastatic
carcinoma
6. Other diseasesOther diseases involving the maxillary sinus
-Fibro-osseous diseases,
-Granulomatous diseases

TRAUMATIC DISEASES OF THE
MAXILLARY SINUS
ORO ANTRALORO ANTRAL FISTULAFISTULA
 Oroantral fistula is an abnormal
communication between the oral cavity and
the maxillary sinus.
It can result due to several causes such
as extraction of teeth, massive trauma,
surgery to maxillary sinus, osteomyelitis of
maxilla, malignant tumor, infected upper
implant denture, Malignant granuloma

Clinical features
Immediate symptomsImmediate symptoms:
 Regurgitation of liquids from the mouth into the
nose.
 Unilateral epistaxis due to blood in maxillary sinus
escaping through the nasal ostium.
 Escape of air from the mouth into the nose and an
alteration in vocal resonance.
 An inability to blow out the cheeks and smoke
cigarettes

Delayed symptomsDelayed symptoms:
 Unilateral mal odorous nasal discharge (Purulent or
mucopurulent).
 Postnasal mucus drip will often lead to an unpleasant
taste accompanied by nocturnal cough, horseness,
earache, facial pain or headache
 Sometimes patient experiences painless lump at the
extraction socket.
 Inability to 'draw' on a cigarette or pipe, or inability
blow a wind instrument.

Signs of Recently created OAFSigns of Recently created OAF-
 After forceful extraction, floor of sinus seen with root of
the teeth
 Sudden disappearance of upper molar root while
extraction
 There may be water running out of the nose while rinsing

Test to establish the presence of
recently created OAF
 If the fistula is large it will be obvious on simple
inspection but if patency of OAF remains in doubt,
nose blowing testnose blowing test may be confirmatory.
 Compression of anterior nares followed by gently
blowing down the nose (with mouth open) causes a
rise in intra-oral pressure, exhibited by whistling
sound, escaping air bubbles, blood or pus may appear
at the oral orifice.
 There may be alterations in resonance of the patients
voice immediately after the extraction

Established fistulaEstablished fistula:
 A simple dimple on the alveolar ridge
 Invasion of antral polyp through fistula resulting in sudden
appearance of exophytic mass on alveolar crest
 Aspiration of air into mouth through tooth socket
 Tenderness positive over maxillary sinus

Differential diagnosis
 Sinus tract from a chronic alveolar abscessSinus tract from a chronic alveolar abscess- A
radiograph taken with a gutta percha cone placed in
the tract will yield differential information
 OsteomyelitisOsteomyelitis in the area
 MalignancyMalignancy - Openings in the maxillary antral floor
that have been produced by malignant disease are
often accompanied by irregular bony margins due to
erosion by tumor

Radiograph may
show break in
continuity of floor
of maxillary sinus

Management of OAF
 Repair as soon as possible- Closure within the first 48
hours reduces the chances of infection and the
development of chronic changes in the antral mucosa and
is associated with faster healing and a higher success rate.

 Treatment of OAF, seen within 24 hours of accidentwithin 24 hours of accident
– Edges of the wound should be closed immediately
after which the nasal drops, inhalation and antibiotics
are given.
 If opening is small, great care is to be exercised such
as avoidance of use of irrigation, vigorous mouth
washing and forceful nose blowing
 In majority of cases good clot will form and normal
healing will occur

Treatment of OAF Seen more than 24 hours:more than 24 hours:
 soft tissue margins of fistula are infected.
 Allow the edges of wound to heal soundly for 3 weeks.
 First antibiotics, analgesics and decongestants should be
prescribed and then after healing surgical repair is done

 Treatment of OAF which has been present for moremore
than one monththan one month-
 In this fistulous tract is well epithelized so healing is
difficult. Drainage of maxillary sinus should be
established through fistula by enlarging it surgically
and sinus should be gently irrigated daily with normal
saline until the washings are clear.
 In some cases antral lavage and antrostomy can be
done to help drainage

Surgical proceduresSurgical procedures used for the closure of OAF –
 Rehrmann’s buccal flap operation
 Intranasal antrostomy
 Ashley’s palatal flap operation

ROOT OR FOREIGN BODY IN THE
ANTRUM
 The inadvertent displacement of a root, even a whole
tooth into the maxillary sinus may cause an oro
antral fistula.
 Following incomplete extraction of a tooth the apical
segment remaining in the socket may be dislodged by
injudicious use of elevators into the sinus.
 Various foreign bodies have been reported in the
maxillary sinus. Most of them gain entry via OAF and
others gain entry through a tooth-socket, during an
operation in proximity to the antrum

Foreign bodies can be
 Burs,
 Dental impression material,
 RC filling material,
 Implants.
 Matchsticks, Bullets, missile fragments
etc.

Clinical features:
 Some of these objects may remains
asymptomatic, others may result in chronic
sinusitis.

Investigations and Diagnosis
 Careful examination of Periapical or occlusal radiographs
- show a root within the sinus or
 Break in continuity of floor of antrum shows point of
entry.
 A panoramic radiograph & water's view are also
important.

A root tip in
the sinus does
not have
lamina dura
around it

The root tip may change its position in the sinus
which changes with patient’s head position. It will
not change its position when it is trapped
between the mucosa and floor of the sinus.

ECTOPIC
ERUPTION OF
MAXILLARY
3RD
MOLAR

Management
 Remove the root promptly to reduce chance of
producing chronic maxillary sinusitis.
 There is also the possibility of discharge of a root
through the antronasal duct into the nose and its
inhalation.
 Roots displaced into the antrum can be expelled
from the nose during sneezing and coughing attacks.
Surgical removal of root or foreign body in the
antrum is done by two methods
- Removal through the tooth socket
- Caldwell Luc Approach

FRACTURES
Fractures of the maxillary sinus includes
 Fractured tuberosity
 Zygomatic Complex fracture
 Le Fort I fracture
 Le Fort II fracture
 Le Fort III fracture
 Orbital floor blowout fracture.

 Fractures that involve maxillary sinus may be classified as
a singlesingle (isolated) wallwall fracture, as a part of a complexcomplex
fracture or as a component of a trans facial fracture .

Fractured Tuberosity
 This occurs most frequently when extracting a lone
standing upper third molar
 Fracture should be immobilized to promote healing
by splint, if the teeth are present in opposing arch.
 Fractures are allowed to heal and then tooth is
removed in sections by bur.
 The tuberosity should be retained as it helps in
denture retention.
 Antibiotics, nasal drops and inhalation are prescribed
to prevent chronic OAF.

Midface Fractures
 The radiographs may show separated nasofrontal,
maxillofrontal, zygomaticofrontal and
zygomaticotemporal sutures.
 The nasal bones, frontal processes of the maxilla,
orbital floors and pterygoid plates may show
radiolucent lines and discontinuity.
 Associated fracture of the walls of the maxillary
sinuses result in a radiopaque radiographic
appearance due to filling of blood.

 Complications of fractures -
chronic inflammatory mucosal changes can occur in the
maxillary sinus following fractures

Orbital floor blow out Fractures
 Due to impact of external object, the rapid increase in
intraorbital pressure is transmitted to the orbital walls
and fracture occurs at the thinnest parts of the orbital
floor called orbital blow out fracture.

Radiographic features
 “Hanging drop appearanceHanging drop appearance” due to
herniation of periorbital fat and
extravasated blood from ruptured
periosteum into the maxillary sinus
 Radioopacity in the antrum
 Maxillary sinus Endoscopy - may be used
for diagnosis of orbital floor fractures

A and B, Drawings in lateral (A) and frontal (B) projections
show Le Fort I fracture runs horizontally above maxillary alveolar
process. Pterygoid plates are broken, as is true in all types of Le Fort
fracture. Walls of maxillary sinuses in this plane are broken, including
point at anterolateral margin of nasal fossa. Maxillary teeth would be
movable on physical examination relative to remainder of face.
A B

A and B, Drawings show plane of Le Fort II fracture in
lateral (A) and frontal (B) projections. Le Fort II fracture
is pyramidal in shape with teeth at base of pyramid and nasofrontal suture at
apex of pyramid. Pterygoid plates are broken, as is true in all types of Le Fort
fracture. Posterior and lateral walls of maxillary sinus are broken as fracture
skirts inferior in relation to body of zygoma. Fracture then crosses inferior orbital
rim, orbital floor, and medial wall of orbit before crossing midline near
nasofrontal suture. Maxillary teeth and nose as a unit would be movable
relative to zygomata and rest of skull.
A B

A and B, Drawings show plane of Le Fort III fracture in
lateral (A) and frontal (B) projections. Le Fort III fracture separates bones of face
from rest of skull. Pterygoid plates are broken, as is true in all types of Le Fort
fracture. Upper posterior margins of maxillary sinuses
fracture, as does zygomatic arch, lateral orbital wall, and lateral orbital rim. There is
fracture near junction of frontal bone and greater wing of sphenoid in posterior
aspect of orbit, fracture along medial orbital wall,
and fracture across nasofrontal suture. Maxillary teeth, nose, and zygomata as a
unit would be movable on physical examination relative to rest of skull.
A B

A B C
A - In Le Fort I fracture, anterolateral margin of nasal fossa
(arrow) is broken. This structure is intact in both Le Fort II and III
fractures.
B - In Le Fort II fracture, inferior orbital rim (arrow) is broken. This
structure is intact in both Le Fort I and III fractures.
C - In Le Fort III fracture, zygomatic arch (arrow) is broken. This
structure is intact in both Le Fort I and II fractures.

PNEUMOCELE AND CHEEK
EMPHYSEMA
 A pneumocelepneumocele of the orbit occurs following forceful blowing
of the nose when there is a small bony defect in the roof of
the sinus.
 Onset of sluggish pupillary reaction to light and
accommodations are signs of optic nerve edema,
 Air emphysemaAir emphysema of the cheek also may follow fracture of the
facial wall of the sinus which can be associated with trauma to
the inferior orbital rim.
 Treatment
 Patient should be given antibiotics and observed for
developing orbital cellulitis.

BENIGN TUMOURS
 ANTRAL PAPILLOMA
The epithelial papilloma is a rare neoplasm, may occur in
areas of squamous metaplasia in the sinus.
Clinical Features –
 M > F
 Unilateral nasal obstruction
 Pain
 Epistaxis
 H/o recurring sinusitis for years.

 Radiographic features are not specific.
 On CT scan it appears as a homogeneous radiopaque
mass of soft tissue density.
 Rarely bone destruction or erosion due to pressure of
lesion.
 Treatment - Surgical exicision of the lesion
 Tendency to recur after removal

OSTEOMA
 The osteoma is the most common of the mesenchymal
neoplasms of the paranasal sinuses.
 It does not arise from the sinus cavity but from one of
the bones of sinus and invades antral space later.
 Multiple Osteomas of the facial bones is the feature of
Gardners syndrome.

Clinical Features
 M > F
 Occurs in 2nd, 3rd and 4th decades
 Slow growing and asymptomatic
 Swelling of cheek or hard palate due to expansion of
the sinus.
 Osteomas growing in maxillary sinus may extend into
the nose and cause nasal obstruction or a swelling of
the side of the nose.
 In case expanding to the orbit – proptosis, diplopia
and decreased visual acuity.

Radiographic Features
 The osteoma is usually lobulated or rounded
homogeneous, extremely radiopaque lesion with a
sharply defined margins.
PRESENCE OF
TRABECULAE IN THE
LESION HELPS TO
DISTINGUISH IT FROM
MUCOUS RETENTION
CYST

 Differential Diagnosis –
 Antroliths, teeth or odontogenic neoplasm like
odontoma.
 Treatment –
 Small osteomas do not require treatment. Symptomatic
large osteomas need surgical excision by Cald-Well-Luc
approach.

 Other rare benign tumors include pleomorphic adenoma,
hemangioma, ameloblastoma, benign osteoblastoma,
desmoplastic fibroma etc.

MALIGNANT TUMORS
 The most common malignancy affecting the maxillary
sinus is squamous cell carcinomasquamous cell carcinoma (80%)
 Incidence : 2 – 8%
 It is more common in patients over 40 years of age
and twice in males than females.
 Other less common malignancies include
Adenocarcinoma, Melanoma, neuroblastoma,
sarcoma, fibrosarcoma, Lymphoma, secondary tumor
deposits.

 Etiology-
 Chronic sinusitisChronic sinusitis may be a predisposing factor for antral
carcinoma
 Squamous cell carcinoma are more common in boot andboot and
shoe workersshoe workers and
 The use of snuffsnuff and the smoky atmospheresmoky atmosphere may be
casual factors for carcinoma of the paranasal sinuses

Signs and Symptoms
 ORAL – Swelling, ulceration, mobility of teeth,
exfoliation of teeth, heaviness in teeth, oroantral
communication, Fungation through upper alveolus, ill
fitting denture.
 NASAL– Obstruction, bloody discharge, pain
 ORBITAL – proptosis, diplopia, eye pain, visual loss,
epiphora, neurological deficit in infraorbital nerve
 FACIAL – Infraorbital parasthetia, swelling, pain,
hyperesthesia of maxillary teeth.

 Radiographically, sinus neoplasia appears as a ‘cloudy’
antrum.
 In advanced cases, bony erosion and irregular
destruction of sinus walls may be evident.
 Panoramic View – defines the alveolar & sinus
interface.
 Water’s View – It shows loss of the fine linear
outline of the walls of the sinus.
 CT & MRI - permit precise anatomical localization of
tumor, enlarged involved retropharyngeal lymph
nodes and more detailed preoperative planning of
surgery or radiotherapy

BiopsyBiopsy
 Via a Cald-well-Luc type approach
 By sinus endoscopy via Intranasal antrostomy
 Intraorally, if lesion extends in oral cavity

Classification and Staging system
 The Ohngren line which connects the inner canthus of
eye and mandibular angle divides the maxillary sinus into
suprastructure, mesiostructure, and infrastructure

 SuprastructureSuprastructure includes ethmoidal labyrinth, frontal
sinus, sphenoid sinus, olfactory part of nasal fossa.
 MesiostructureMesiostructure includes maxillary sinus , respiratory
part of nasal fossa-vestibule and septum, lateral wall,
inferior turbinate.
 Infra structureInfra structure includes floor of maxillary sinus , floor
of nose, odontogenic tumours, tumours of antrum
and hard palate or palate and floor of nasal fossa.

TNM classification for maxillary
carcinoma ( AJCC 1976)
 T1-tumour confined to the antral mucosa of the
infrastructure.
 T2-tumour confined to the suprastructure or
infrastructure.
 T3-more extensive tumour involving the skin of the
cheek,anterior ethmoid sinus or pterygoid muscle.
 T4-massive tumour with invasion of cribriform plate
,posterior ethmoid,sphenoid, nasopharinx, pterygoid
plates, base of skull

 N0-no nodes
 N1-single palpable homolateral node,less than 3cm in
diameter.
 N2-
o N2a-single clinically positive homolateral node 3-6cm in
diameter .
o N2b-multiple clinically positive homolateral nodes not
above 6cm in size.

 N3-
o N3a-clinically positive homolateral nodes, one over
6cm in diameter.
o N3b-bilateral clinically positive nodes.
o N3c- contralateral clinically positive nodes only.
 M0- no distant metastasis.
 M1-with distant metastasis.

Prognosis
 Prognosis depends upon direction and extent of spread
and not related to age at presentation, histological type
of malignancy or to the treatment given.
 100% for T1, 80% for T2, 50% for T3, 5% for T4.

PSEUDO TUMOR
 Pseudo tumor is descriptive name for a group of
apparently related disease of fungal origin that occur in
the paranasal sinuses, as well as other parts of the head
and neck.
 It occurs after a series of recurrent infections.

Clinical features
 Recurring pain
 Common in immunocompromised patients and patient
having systemic diseases like – diabetes mellitus.
 Symptoms depending upon severity .

 Radiograph shows masses simulating malignant neoplasms
that cause erosion of bony walls of the involved sinuses.
Differential diagnosis
 Benign and malignant neoplasms.

Treatment –
 Debridement of sinus
 Antifungal medication.
 Surgery if necessary.

FIBROOSSEOUS DISEASES OF
THE MAXILLARY SINUS
FIBROUS DYSPLASIAFIBROUS DYSPLASIA :
 Craniofacial fibrous dysplasia may arise in the maxillary,
sphenoid, frontal, ethmoid and temporal bones, causing
displacement of the sinus borders and resulting in a
smaller sinus on the affected side.

Etiology –
 Fibrous dysplasia results from a localized change in
normal bone metabolism that leads to the replacement of
all components of cancellous bone by fibrous tissue
containing varying amounts of abnormal appearing bone.

Clinical Features
 Facial asymmetry, nasal obstruction, proptosis, pitutory
gland compression, impingement on cranial nerves and
sinus obliteration.
 The sinus obliteration results when the expanding lesion
of dysplastic bone enchroaches on it.

 The lesion may displace the roots of teeth and cause
teeth to separate or migrate, but it usually does not
cause root resorption.
 Fibrous dysplasia is more common in children and young
adult and tends to stop growing when skeletal growth
ceases.

 The lesion is not well definednot well defined tending to blend into
the surrounding bone.
 External cortex of the bone is intact.
 The normal radiolucent sinus may be partly or totally
replaced by the increased radiopaque lesion.
 Usually the radiopaque areas have characteristic
ground glass appearanceground glass appearance
 The roots of the involved teeth may be separated.
 There may be displacement of antral walls, orbital
floor or obliteration of nasal fossa.

Differential Diagnosis
 Paget’s Disease- does not usually obliterate the sinus
 Complex odontome- surrounded by radiolucent line
 Ossifying fibroma- well defined

Ossifying fibroma
 Ossifying fibroma can occur in the maxilla and
encroaches on the sinus.
 It can grow into maxilla and occupying the entire
maxillary sinus, expanding its walls outward however,
a bony partition always exists between the internal
aspect of the remaining sinus and the tumor.
 Radiographic Features: Ossifying fibroma tends
to be well demarcated from surrounding bone.

 CHERUBISM and PAGETS DISEASE –
lesions can enlarge into the maxillary sinuses

REFERENCES
 B.D. CHAURASIA’S HUMAN ANATOMY, VOL. 3: FOURTH
EDITION
 GRAY’S ANATOMY, 39TH EDITION
 ORBAN’S ORAL HISTOLOY & EMBRYOLOGY, 9TH
EDITION
 MAXILLARY SINUS & IT’S DENTAL APPLICATIONS-
McGowan .D
 TEXTBOOK OF ORAL MEDICINE: GHOM
 TEXTBOOK OF ORAL SURGERY- NILIMA MALIK

 TOOTH IN THE MAXILLARY SINUS: A CASE REPORT. J CONTEMP
DENT PRACT 2005 AUGUST;(6)3:104-110.
 PN LISTON, RF WALTERS.FOREIGN BODIES IN THE MAXILLARY
ANTRUM: A CASE REPORT, AUSTRALIAN DENTAL JOURNAL
2002;47:(4):344-346
 Fang-Cheng Liuand Marshall strome.
Staging in the treatment
of maxillary carcinoma. The Journal of Laryngology & Otology
(1988), 102:224-226

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