The document provides an extensive overview of the maxillary sinus, covering its embryology, anatomy, drainage, and various diseases, including maxillary sinusitis and fungal infections. It discusses the developmental changes of the maxillary sinus, its anatomical relationships with surrounding structures, and the clinical implications of infections and tumors. Management strategies for sinusitis, tumors, and complications such as oroantral communications are also explored, along with descriptions of diagnostic and surgical interventions.

1. Maxillary sinus
Presenter:-
Dr. Shivani Taank
PG 2nd year
Dept. of Oral and Maxillofacial
Surgery
Guided by:-
Dr. Deepak Thakur
Dr. Manish Pandit
Dr. Sruthi Rao
Dr. Aafreen Aftab

2. CONTENT
• INTRODUCTION
• EMBROYOLOGY
• DVELOPMENT AND AGE CHANGES
• ANATOMY
• DRAINAGE OF MAXILLARY SINUS
• APPLIED ASPECT
• OHNGREN’S LINE
• DISEASES OF SINUS
• MAXILLARY SINUSITIS
• FUNGAL SINUSITIS
• SILENT SINUS SYNDROME
• OROANTRAL COMMUNICATION
• CALDWELL-LUC OPERATION
• FESS
• BIBLIOGRAPHY

3. PARANASAL SINUS
• FRONTAL AIR SINUS
• ETHMOIDAL AIR SINUS
• SPHINOIDAL AIR SINUS
• MAXILLARY AIR SINUS

4. INTRODUCTION
• First illustrated and described by Leonardo da Vinci
in 1489
• Later by the English anatomist Nathaniel Highmore
in 1651.
• Hence also known as “ ANTRUM OF HIGHMORE”.
• Pneumatic space that is lodged within the body of
maxilla
• Opens via osteum into the middle meatus.
• It is pyramidal in shape and largest of all paranasal
sinuses
• Volume of an adult sinus is approximately 15 ml.

5. EMBROYOLOGY
Sinus starts growth &
development from the 17th
week of I.U life.
In the 17th week of fetal life
mucosal evagination occurs in
the middle meatus.
It continues to grow till the
age of second molar eruption (i.e.) 12 to 13 years of age.
Growth direction is mainly towards
Inferiorly & Anteriorly

6. Time Growth Shape
3months IU Out Pouching in middle
Meatus
Birth 7mm x 4mm x 4mm
3mm/year x 2 x 2mm
Tubular
9 years 60% of adult size Ovoid
12 years Antral floor parallels
nasal floor
18 years Adult size ,antral floor is
1-1.25 cm below nasal
floor
Pyramidal

7. DEVELOPMENT & AGE CHANGES
Tubular – birth Ovoid- childhood Pyramidal- adult

8. At birth filled with
deciduous tooth germs
• Size: 7mm x 4mm x
4mm
• Vol 6-8ml
(Sperber,1989)
•20th month- posterior
development (Ennis
1937)
•3rd year : ½ Adult
size (Ennis 1937)
0-3 years
Increase in width
with facial growth
•Position: 2nd
deciduous molars and
crypts of 1st
permanent molars
•More prone to
infections (Sperber
1989)
3-4 years
•Size:
27mmx18mmx17m
m
•Growth
corresponds to
permanent teeth
eruption
•Canine presents
as ridge in
anterior surface
of sinus
(Ennis 1937)
7-9 years

9. Antral floor same
level with nasal floor
•Portion of alveolar
process vacates and
becomes
pneumatised
•It forms pyramidal
shape
9-12 years
Floor of sinus 5-12.5
mm below nasal floor
•Size: 32mm x 35mm
x 25mm (Turner
1902)
•Vol 15-20 ml (Nivert
1930)
•Sinus floor : 1st
molar 2nd molar 2nd
premolar
15-18 years
Resorption of
ridge with
continued sinus
pneumatization
•Antral floor same
level with nasal
floor
•Leaves thin layer
of cortical bone
separating sinus
mucosa from oral
mucosa
OLD

10. ANATOMY
QUADRANGULAR PYRAMIDAL
IN SHAPE
Apex: zygomatic arch
Base: lateral nasal wall
4 walls: Floor of orbit
Buccoalveolar surface
Facial surface
Infratemporal surface
Schneiderian membrane lines it
and is composed of
pseudostratified ciliated
columnar epithelium with
thickness of 0.8mm

11. Superior surface
• Forms ROOF OF THE SINUS by FLOOR OF ORBIT
• Important structures:-
• Infraorbital canal & nerve
• Ophthalmic artery
• ASA nerve
• Zygomatic branch of Maxillary nerve
• Inferior rectus, Inferior oblique
• Periorbital fat

12. Inferior surface
• Forms the 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.

13. Anterior surface
Forms by pyriform aperture anteriorly to ZM suture & IO
rim superiorly to alveolar process inferiorly
Important structures:-
Infraorbital foramen
ASA, MSA nerves
Levator labii, obicularis oculi muscles
THINNEST IN CANINE FOSSA

14. • Made of zygomatic & greater wing of sphenoid
bone (maxillary tuberosity)- infratemporal surface
• Thick laterally, thin medially
• Important structures
• PSA nerve
• Maxillary artery & nerve
• Pterygopalatine ganglion
• Nerve of pterygoid canal
• Pterygomaxillary fissure
Posterolateral surface

15. BLOOD SUPPLY
• Infraorbital artery
• Greater palatine artery
• Sphenopalatine artery
• Posterior Superior Alveolar artery
Anastomoses
• Nasopalatine artery
• Facial artery
• Ophthalmic artery
• Transverse Facial artery

16. Venous Drainage
• Anteriorly via the cavernous plexus that
drains into the facial vein
• Posteriorly via the pterygoid plexus and
to the internal jugular vein
Nervous Supply
• Anterior superior, middle superior, and
posterior superior alveolar nerves.
• General sensory – Maxillary nerve
• Sympathetic – Superior Cervical Ganglion
• Parasympathetic – Sphenopalatine
Ganglion

17. Lymphatic Drainage
• Converge with those of lateral nasal wall
Lymphatic plexus near Eustachian tube
Submandibular nodes
Retropharyngeal nodes
Upper deep cervical nodes
Jugular lymphatic trunk

18. Drainage of Maxillary Sinus
Flow of mucus superiorly againstgravity
Upward course along walls of entire cavity and then towards natural
ostium in superomedialwall
Drainage into ethmoidal infumdibulum
Mucus coursing along lateral wall, carried medially along roof toreach
ostrium
Mucociliary flow from anteriorsinusesconvergeat OMC, carried to
posteriornasopharynx & inferiorlytoeustachian tubeorifice
By Donald etal & Antunesetal

19. Drainage of sinus
 Mucociliary flow Smooth:0.85 cm/minute
Jerky: 0.3 cm/minute
Mucostasis: <0.3 cm/minute

20. APPLIED ASPECT OF MAXILLARY
SINUS
• Floor of sinus: Close relation to root apices
Facilitates spread of infection from teeth
[Endo – antral syndrome, Selden (1974)]
Oroantral Fistula formation.
•Superior wall: vulnerable to trauma, Erosion by
tumor
•Posterolateral wall: borders Pterygopalatine fossa,
Infratemporal fossa

21. • Tumors associated with maxillary sinus:
Thin walls of sinus eroded by tumours - swelling on
cheek, palate, buccal mucosa.
•Sinus wall thin in canine fossa:- Diagnostic aspiration
Caldwell-Luc
•Oro-antral communication: Clearance 1-1.2 cm in
adults, more in children – hence, less chance OAF

22. • Infections of sinus:- may spread to involve
cavernous sinus via any of its draining veins as
pterygoid plexus communicates with cavernous
sinus by EMISSARY VEIN
•Antral puncture - middle meatus in children, inferior
meatus in adults.
•Inner surface is rough by bony septa
Retrieval of root fragment
Implant placement, sinus augmentation
Interferes with sinus drainage

23. OHNGREN’S LINE
Imaginary line from medial canthus
to angle of mandible
Divides sinus antero-inferiorly &
postero-superiorly
Determines stage of antral tumour
Tumours below or anterior this line
have better prognosis
. Ohngren G., Malignant tumors of the maxilloethmoidal region: A clinical study with
special referrence to the treatment with electrosurgery and irradiation. Gelsingfors. 1933

24. • Ohngren’s line may still have important value as a
prognostic factor in patients who are to be treated with
open surgery.
• With the modern capability for endoscopic removal
followed by adjuvant radiation therapy and good
outcomes becoming more popular. Ohngren’s Line,
described in 1933, does not necessarily predict outcomes
for tumors treated using endoscopic approaches that
allow better visualization and access to the skull base.
• Ohngren’s line may no longer be a prognostic factor for
maxillary sinus tumors or sinonasal malignancy,
Turner, Meghan & Geltzeiler, Mathew & Hebert, Andrea & Fernandez-Miranda, Juan
& Gardner, Paul & Wang, Eric & Snyderman, Carl. (2018). Ohngren's Line: A Relic in
the Modern Era.

25. DISEASES OF MAXILLARY SINUS
• A broad spectrum of
disease processes can
involve the maxillary
sinus arising either from
within the lining of the
sinus, the adjacent
paranasal sinuses, nasal
space, dental and oral
tissues, or in the
adjacent bone with
expansion into the sinus
Bell, Garmon & Joshi, B & Macleod, R. (2011). Maxillary sinus disease: diagnosis and
treatment. British dental journal. 210. 113-8. 10.1038/sj.bdj.2011.47.

27. • Orofacial pain without nasal obstruction, nasal discharge or
impaired smell sense is unlikely to be sinogenic

28. DEVELOPMENTAL DEFECTS
• Crouzon syndrome
Early synostosis of sutures - hypoplasia of maxilla & sinus
High arched palate
• Treacher Collins syndrome
Grossly & symmetrically underdeveloped maxillary
sinuses & malar bones
• Binder syndrome
Hypoplasia of middle third of face
Small maxillary length
Maxillary sinus hypoplasia

29. MAXILLARY SINUSITIS
• European Academy of Allergology and Clinical Immunology
defines acute rhinosinusitis as, “Inflammation of the nose
and the paranasal sinuses characterized by two or more of
the following symptoms: blockage/congestion; discharge
(anterior or postnasal drip); facial pain/pressure; reduction
or loss of smell, lasting less than 12 weeks.
• The definition of chronic rhinosinusitis is nasal congestion
or blockage lasting more than 12 weeks and accompanied
by one of the following three sets of symptoms: facial pain
or pressure; discoloured nasal discharge or postnasal drip;
or reduction or loss of smell

30. AETIOLOGY

31. Ah-See Kim W, Evans Andrew S. Sinusitis and its management BMJ 2007; 334 :358

32. Peterson-old
• The precipitating factor in acute sinusitis seems to be
blockage of the sinus ostium, typically the maxillary sinus
ostium.

34. Anon-healing upper right extraction site with
a spindle cell squamous carcinoma arising
from the maxillary sinus
Left sided nasal obstruction with epistaxis in a
patient with an advanced squamous cell carcinoma
of the left maxillary sinus. Examination also showed
lateral expansion of the alveolus

35. Richard H. Haug Microorganisms of nose
ans paranasal sinus Ora Maxillofacial Surg
Clin N Am 24 (2012) 191–196

36. DIAGNOSIS OF SINUSITIS
DIAGNOSTIC FEATURES
• Pain, pressure, swelling -- anterior sinus wall
• Nasal obstruction,
• Epistaxis, discharge-medial wall
• Diplopia, proptosis-superior wall
• Trismus-lateral wall
TESTS DONE:- raised ESR
ultrasonography,
computed tomography,
sinus puncture, and culture of aspirate

37. RHINOSCOPY
NASAL AND SINUS ENDOSCOPY
TRANSILLUMINATION TEST
It is performed in a dark room by inserting an electrically a safe light
into the mouth (with lips closed). Good illumination indicates
presence of air in the sinus ,while the failure of illumination indicates
presence of pus , fluids , soft lesion or mucosal thickening.

38. MANAGEMENT OF SINUSITIS
• MEDICAL MANAGEMENT:-
• SURGICAL MANAGEMENT:-
ANTIBIOTICS
ANTIHISTAMINICS
a-ADRENERGIC DECONGESTANTS
GLUCOCORTICOIDS
SALINE
MUCOLYTICS & EXPECTORANTS
IVIG- INTRAVENOUS IMMUNOGLOBULINS
Caldwell-Luc procedure
Intranasal Antrostomy with Uncinectomy
Extended Middle Meatus Antrostomy
Mega-antrostomy or Modified Medial
Maxillectomy
Maxillary Sinuscopy
Endoscopic Maxillary Sinus Antrostomy
Minimally Invasive Sinus Technique
Balloon sinus procedure

40. • STEROIDS
• DECONGESTANTS
• MUCUS MODULAATION
1st line of therapy: topical intranasal (betamethasone,
dexamethasone, triamcinolone)
Systemicsteroids:
 Prednisolone:0.5-1mg/kg x3-4days
Oral- Phenylephrine, pseudoephedrine
Topical- Oxymetazoline, phenylephrine
Nasal saline Mist spray, irrigation, nebulization
Mucolytics Guaifenesin, acetylcysteine
Anticholinergics Ipratropium bromide

41. Complications of untreated
maxillary sinusitis
• Direct extension to the orbital wall
• Retrograde spread through veins between the sinuses
and the orbit.
• Cellulitis
• Abscess
• Meningitis
• Cavernous sinus thrombosis
• Osteomyelitis
• Oroantral fistula
• Periorbital cellulitis
• Cavernous sinus thrombosis

42. FUNGAL SINUSITIS
• Aspergillus fumigatus as the most frequently
detected fungusis the most common cause of sinus
fungus ball.
Histologic appearance of fungal ball
demonstrating densely packed fungal
hyphae.

43. • Referred to a mycetoma, refers
to a fungal mass that is usually
unilateral and most often
occurs in the maxillary sinus.
• A noninvasive fungal sinusitis
• It is characterized as a
denseconglomeration of fungal
hyphae, usually localized in the
maxillary sinus of
immunocompetent patients.

44. The maxillary antrum is a relatively common site for formation of an aspergilloma
where it forms around a nexus of foreign body.
Dental material containing zinc that has been extruded into the maxillary antrum has
the potential to become infected and form an aspergilloma.
Root canal cements and amalgam contain zinc in large enough quantities to cause this
reaction.

45. MANAGEMENT OF FUNGUS BALL
1) Removal of fungus ball.
2) Treating dental cause
3) Ensuring sufficient ventilation of sinus.
SURGICAL MANAGEMENT:
1) Fess- gold standard
2) Caldwell-luc
3) Bone lid method

46. IATROGENIC DISEASE
Teeth displaced into sinus
• Foreign body, which usually is displaced
into the maxillary sinus is a tooth or a
fragment of a tooth root.
Aetiology:- 1. Absence of intervening bone
in between the tooth root and antrum.
2. Aggressive instrumentation
3. Solitary maxillary molar
around which the bone is dense and
cortical, causing alveolus fracture

47. • Diagnosis:- intraoral periapical radiograph (IOPA),
upper occlusal PNS (posterior nasal spine)
Root fragments do not always penetrate the membrane of the
antrum & can be found between the membrane and the bony
wall.
MANAGEMENT:-
• 1. Powerful suction is kept at the entrance of the fistula and
the root recovered.
• 2. If the tooth is lying loose in the antrum, it can be removed
by packing roller gauze and withdrawing in a jerky motion.
• 3. Surgical approach (Caldwell-Luc operation). Saline is
continuously irrigated into the sinus through the window
created by the Caldwell-Luc procedure.

48. BENIGN AND MALIGNANT
TUMORS
Tumors occasionally represent part of a syndrome:-
Osteoma in Gardner syndrome,
Fibrous dysplasia in McCune–Albright syndrome,
Neurofibromas in type 1 neurofibromatosis

49. MAXILLARY SINUS CANCER
STAGING
• STAGE 0- carcinoma insitu.
Found in the innermost lining of the maxillary sinus
only
• STAGE 1- Cancer is found in the mucous
membranes of the maxillary sinus
• STAGE 2- spread to bone around the maxillary
sinus, including the roof of the mouth and the
nose, but not to bones at the back of the maxillary
sinus or the base of the skull.

50. • STAGE 3- Cancer is found in any of the following places:
Bone at the back of the sinus
Tissues under the skin
The eye socket
The base of the skull
The ethmoid sinuses
STAGE 4- divided into 3 subtypes:-
4A-
OR
one lymph node on the same side of the
neck as the cancer, lymph node is 3
centimeters or smaller., involving:-
The maxillary sinus
Bones around the maxillary sinus
Tissues under the skin
The eye socket
The base of the skull
The ethmoid sinuses
Larger than 3 centimeters but smaller than 6
centimeters or spread to more than one lymphnode
and all are 6 centimeters or smaller
Or

51. • Stage IVB
Cancer has spread to either:
• One or more lymph nodes larger than 6 centimeters; or
• The back of the eye, the brain, the base and middle parts of
the skull, nerves in the head, and/or the upper part of the
throat behind the nose; cancer may also be found in one or
more lymph nodes.
• Stage IVC
Cancer has spread to other parts of the body
Cancer is found in one or more lymph nodes in the neck, none larger
than 6 centimeters, and in any of the following areas:
The front of the eye
The skin of the cheek
The base of the skull
Behind the jaw
The bone between the eyes
The sphenoid or frontal sinuses

52. MANAGEMENT
Surgery is the mainstay of treatment in the majority of
cases.
• ENDOSCOPIC RESECTION- small lesions
• MID FACIAL DEGLOVING- allows direct access to sinus
• LATERAL RHINOTOMY & MEDIAL MAXILLECTOMY-
direct access to the lateral nasal wall and maxillary
sinus.
• Bisphosphonates have been used for the treatment of
fibrous dysplasia

53. SILENT SINUS SYNDROME
First case of maxillary sinus opacification and collapse
was reported by Montgomery.
Term “silent sinus syndrome” (SSS) for this phenomenon
was coined by Soparkar et al. in 1994
Pathogenesis of SSS is based on chronic maxillary sinus
obstruction related to occlusion of the maxillary
infundibulum, which results in a hypoventilated sinus and
negative pressures within the sinus
Choudhary SH, Kale L, Mishra SS, Choudhary AK. Silent sinus syndrome: An
imploding antrum syndrome. J Indian Acad Oral Med Radiol 2016;28:30-3

54. FEATURES:-
“sinking down of the eye” or
“drooping of the upper eyelid”
a) Enophthalmos and hypoglobus of right eye
(black arrow)
b) deepening of left superior orbital sulcus
(black arrow)

55. orbital floor is typically inferiorly displaced and may be associated
with concavity of the medial and posterolateral walls

56. MANAGEMENT
Treatment for SSS is mostly surgical with otolaryngological
intervention.
1) surgical treatment was done by performing a Caldwell–
Luc procedure and transconjunctival repair of the orbital
floor.
2) Blackwell et al. in 1993 endoscopic maxillary antrostomy
in conjunction with a transconjunctival orbital floor repair,
having a greater success rate.

57. OROANTRAL
COMMUNICATION
• Oro-antral communication is an unnatural communication
between the oral cavity and the maxillary sinus.
• Oro-antral fistula (OAF) is an epithelialized pathological
unnatural communication between oral cavity and maxillary
sinus.
• This epithelial fusion of the schneiderian membrane to the
oral epithelium usually occurs when the perforation persists
for at least 48-72 hours

58. • OAF can be further classified as:- alveolo-sinusal
palatal-sinusal
vestibulo-sinusal.
• Szabo found out that 7-8 days is the average time during
which an oro-antral perforation epithelialize and become a
chronic fistulous tract
• Harrison demonstrated that the bone lamella between the
maxillary posterior teeth and the maxillary sinus is
occasionally 0.5mm.
• Thus, the first premolars accounted for 5.3% of OACs
Borgonovo AE, Berardinelli FV, Favale M, Maiorana C. Surgical Options in Oro-antral Fistula Treatment. Open
Dent J 2012;6:94-8.
Haanaes HR, Pederson KN. Treatment of oroantral communication. Int J Oral Surg 1974;3:124-32.
Harrison DF. Oro-antral fistula. Br J Clin Pract. 1961;15:169–74.

59. Parvini P, Obreja K, Begic A, et al. Decision-making in closure of oroantral communication
and fistula. Int J Implant Dent. 2019;5(1):13. Published 2019 Apr 1. doi:10.1186/s40729-
019-0165-7

60. 5E: FRESH OROANTRAL COMMUNICATION
• Escape of fluids: From mouth to nose
• Epistaxis (Unilateral): due to blood in sinus escaping
through ostium into nostril
• Escape of air: From mouth into nose, on sucking, inhaling
or puffing cheeks
• Enhanced column of air: Causes alteration in vocal
resonance
• Excruciating pain: In and around the region of affected
sinus
Chronic cases
• Halitosis/ pus discharge
• Asymptomatic
• Intraoral polyp

61. ACUTEORCHRONICOAF

62. CLINICAL SYMPTOMS & DIAGNOSIS
• Nasal regurgitation of
liquid,
• Altered nasal resonance,
• Difficulty in sucking
through straw,
• Unilateral nasal discharge,
• Bad taste in the mouth and
whistling sound while
speaking.
• Pain may be present at
malar region.
LATER STAGES:-
• Formation of antral
polyp is visible through
the defect intra-orally.
• Large fistula is easily
seen on inspection.
• Air bubbles, blood or
mucoid secretion
around the orifice

63. PROCEDURES PERFORMED
1) Intraoral examination:-
The large OAC is easily seen on the investigation. At a
later stage, the antral polyp is seen through the defect.
2) Valsalva test:-
The patient is instructed to try to exhale through blocked
nasal airway. However, a negative test does not exclude
the possibility of antral perforation. It is worth noting
that the detection of small perforations is not always
possible.
3) Cheek-blowing test:-
The patient is asked to blow air into the cheeks against a
closed mouth. This test is considered a risk of antral
complications due to the spread of microorganisms from
the oral cavity into the maxillary sinus.

64. 4)-Exploration of the perforation with probing:-
Attempt of probing the fistula is likely to result in
sinusitis or widening of the fistula due to pushing of
foreign
5) The escape of air through the nostril can be tested
by placing a cotton wisp near the orifice.
6) A mouth mirror placed at oro-antral fistula causes
fogging of the mirror.
Parvini P, Obreja K, Begic A, et al. Decision-making in closure of oroantral
communication and fistula. Int J Implant Dent. 2019;5(1):13. Published 2019 Apr
1. doi:10.1186/s40729-019-0165-7
Khandelwal P, Hajira N. Management of Oro-antral Communication and Fistula:
Various Surgical Options. World J Plast Surg. 2017 Jan;6(1):3-8. PMID: 28289607;
PMCID: PMC5339603.

65. MANAGEMENT OF OAC/OAF
Parvini P, Obreja K, Sader R, Becker J, Schwarz F, Salti L. Surgical options
in oroantral fistula management: a narrative review. Int J Implant Dent.
2018;4(1):40. Published 2018 Dec 27. doi:10.1186/s40729-018-0152-4

67. BUCCAL ADVANCEMENT FLAP
Rehrmann 1936

68. SLIDING BUCCAL FLAP
Buccal vestibular height
was not affected
following the closure of
the fistula
Moczair flap

69. PALATAL ROTATION FLAP
Ashley 1939
Kruger’s modification: A back cut at the posterior end of the
flap for ease of rotation and avoid kinking.

70. • Bare bony base of the resultant palatal defect may be
covered by apack, composed of Whitehead’s varnish on
ribbon gauze

71. BUCCAL FAT PAD FLAP
Egyedi-1977

72. TONGUE FLAPS
• Tongue flaps can be created from the ventral, dorsal, or
lateral part of the tongue.
• lateral tongue flap has been described as a suitable method
for the closure of large
Dym H., Wolf J.C. Oroantral communications Oral
Maxillofacial Surg Clin N Am 24 (2012) 239–247
Guerrero- santos J plastic & reconstructive
surgery: Tongue flaps for OAF 1966

73. BRIDGE FLAPS
• Commonly employed in edentulous maxilla.
• Incisions are placed transversely across the line of the arch.
• The bridge must be wider than the bony defect.
• Raw area is allowed to epithelized.

74. Bone Press fit closure of OAF
• The basic principle of the surgical procedure lies in press-
fitting monocortical block grafts into the bone defect to
ensure primary stability.
Watzak G, Tepper G, Zechner W, Monov G, Busenlechner D, Watzek G. Bony press-fit closure of oro-antral fistulas:
a technique for pre-sinus lift repair and secondary closure. J Oral Maxillofac Surg. 2005;63(9):1288‐1294.
Indications
•If OAF > 10 mm
•OAF with planned sinus floor elevation
•OAF along neighboring root surface extending into maxillary sinus
•Chronic OAF with multiple unsuccessful attempts of closure
Bone graft
•Iliac crest, chin, retromolar area, zygoma, lateral wall of sinus
•Autografts better option than allograft

76. AUTOGRAFTS FOR CLOSING OAFS
Procedure is indicated in closure of defects larger than 10 mm
or in the case of failure of conservative methods.
• Autografts harvested from:- extraction socket,
retromolar area,
zygomatic process,
chin
auricular & septal cartilage
Distant sites like the iliac crest

77. CALDWELL-LUC PROCEDURE
• George Caldwell of the USA, Scanes Spicer of England, and
Henri Luc of France—described creation of an anterior
antral window for surgical extirpation of diseased sinus
mucosa, to be used in conjunction with an inferior meatal
antrostomy.
• Also known as transbuccal radical antrostomy

78. INDICATIONS
Biopsy or resection of tumours of the nose and paranasal sinuses
Transantral access for tumours in the pterygopalatine fossa
Transantral ligation of internal maxillary artery and its branches for epistaxis
Transantral access for fractures of the midface and orbital floor.
Orbital decompression
As part of medial maxillectomy procedure e.g. to resect juvenile nasopharyngeal
angiofibromas
Removal of foreign bodies e.g. bullets or dental roots, from the antrum
Removing base of antrochoanal polyp
Transantral ethmoidectomy approach to ethmoids and sphenoid e.g. for pituitary
resection
Repairing oroantral fistulae
Dental cysts
Vidian neurectomy
Chronic sinusitis in the absence of endoscopic sinus surgery facilities
JOHAN FAGAN CALDWELL-LUC (RADICAL ANTROSTOMY), INFERIOR MEATAL ANTROSTOMY & CANINE FOSSA AND
INFERIOR MEATUS PUNCTURES ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

79. PROCEDURE

81. (A,B) After entrance into the sinus, the
contents are removed with grasping
instruments. The sinus mucosa is then
elevated and removed with curved Coakley
curettes and grasping forceps.
(A) A small opening into the antrum is
made using a trocar. Placement is
performed in a location just superolateral
to the canine
fossa.
(B) After opening into the maxillary sinus,
the opening is enlarged using a Kerrison
punch.

82. COMPLICATIONS
• Facial edema and pain,
• Bleeding and hematoma,
• Numbness in the infraorbital and anterior superior
alveolar nerve distributions,
• Dacryocystitis and persistent epiphora,
• Devitalized teeth and
• Oroantral fistulae.
• Facial hypoesthesia
• Mucocele or granulation tissue formation causing
blockage in secretions with continued infections.

85. • The two classic endoscopic approaches are those of
Messerklinger (1985) and Wigand (1978).
• The Wigand technique calls for a back-to-front exenteration
of disease from the paranasal sinuses,
• Messerklinger approach deals with the anterior group of
sinuses*
Kaluskar S.K. (1997) FESS Technique. In: Endoscopic Sinus Surgery. Springer, London
FUNCTIONAL ENDOSCOPIC
SINUS SURGERY- FESS

86. • IT aim at re-establishing normal drainage channels, thereby
reversing the diseased mucosa to normalcy.
• Surgical objectives:-
1. Restoration of nasal patency, without excessive exposure.
2. Improved delivery of medications and washes.
3. Improved exposure to olfactory stimuli.
4. Clearance of inflammatory foci (opacified cells and sinuses).
5. Maintenance and restoration of natural mucociliary
pathways
Barnes, Martyn & Surda, Pavol & Douglas, Richard & Shao, Angus. (2016). Functional
Endoscopic Sinus Surgery (FESS) - Part 1. ENT and Audiology News. 25. 104.

87. INDICATIONS FOR FESS
1) Chronic rhinosinusitis unresponsive to medical treatment.
2) Recurrent acute sinusitis
3) Sinunasal polyposis
4) Mucocele
5) Non-invasion fungal ball
6) Invasive fungal rhinosinusitis
7) Csf rhinorrohoea & anterior meningoencephalocele
8) Sinonasal tumor
9) Sever exopthamos
10) Nasolacrimal duct obstruction

88. Panje and Anand have developed a classification system for
FESS:-
• Type I: Uncinatectomy with or without agger nasi
cellexenteration
• Type II: Uncinatectomy, bulla ethmoidectomy, removal of
sinus lateralis mucous membrane, and exposure of the
frontal recess or frontal sinus
• Type III: Type II plus maxillary sinus antrostomy through the
natural ostium
• Type IV: Type III plus complete posterior ethmoidectomy
• Type V: Type IV plus sphenoidectomy and stripping ofthe
mucous membrane
Panje W, Anand V. Endoscopic sinus surgery indications, diagnosis, and technique. In: Anand VK, Panje WR, eds.
Practical Endoscopic Sinus Surgery. New York: McGraw-Hill; 1993:68–86.

89. PROCEDURE

90. • FESS procedure must begin only
after correction of relevant
septal deformities for adequate
access to ostio-meatal complex.
• Patient is placed in the 20°
head-up position with the neck
slightly flexed
• The procedure may be started
using either the 0° or 30°
endoscope
• After suitable vasoconstriction
using cocaine or ephedrine,
middle turbinate is identified

92. 1) UNCINECTOMY:-
On the lateral wall of the nose at
the level of the anterior end of the
middle turbinate lies the uncinate
process
Either by direct visualisation of the
uncinate process or by
medialisation of the middle
turbinate
Performed at the most anterior
portion of the uncinate process in
order to avoid incising the
nasolacrimal duct
Grasped using Blakeseley forceps
and then removed.
Complete uncinectomy is important
otherwise it will lead to failure of
the surgery which is the most
common cause.

93. Gentle medialisation ofthe middle
turbinate is the first step of the operation.
LW, lateral wall; UP, uncinate process; MT,
middleturbinate; 5, septum.
a The incised uncinate process (UP) is grasped by means of an upward-cutting forceps
at its superior and then its inferior ends, and mobilised gently medially, to detach
itfrom the lateral nasal wall. b The intimate relations of the uncinate. LW, lateral wall;
MT, middle turbinate; S, septum; 0, orbit; FP, frontal process of maxilla; IT, inferior
turbinate; MX, maxillary sinus; V, vomer; Me, maxillary crust; N, nasal bone.
a Note the completely separated uncinate
process (UP) from its superior to inferior ends,
an infundibulotomy has been performed
(polyps seen in the infundibulum).
b Excised uncinate process with
pneumatisation of its superior end.
LW, lateral wall; P, polyp; MT, middle turbinate;
S, septum.

94. 2) MAXILLARY ANTROSTOMY:-
Maxillary sinus ostium can be
easily identified and visualised
following uncinectomy.
It is usually at the level of the
inferior edge of the middle
turbinate.
A sharp cutting instrument is
used circumferentially to
enlarge the maxillary ostium to
a diameter of 1 cm so that it
allows adequate outflow.

95. 3) ANTERIOR ETHMOIDECTOMY:-
Next, the ethmoid bulla should be
identified and opened.
A J-shaped curette may be used to
open the bulla at its interior and medial
aspect.
Then the Anterior ethmoid air cells are
opened, allowing better ventilation but
leaving the bone covered with mucosa.
This is sufficient to greatly improve the
function of the ostiomeatal complex
and therefore provide better
ventilation of the maxillary, ethmoidal
and frontal sinuses
J-shaped curette may be used to open
the bulla at its interior and medial
aspect.

96. • If the sinus disease is limited to the anterior ethmoid cells
and the maxillary sinus, the procedure may end with simple
anterior ethmoidectomy and maxillary antrostomy.
• If radiographic interpretation shows disease spread to the
posterior ethmoidal and sphenoidal cells, then dissection
should further continue with posterior ethmoido
frontosphenoidectomy.
• Once the procedure is complete and haemostasis is
achieved, an antibiotic gauze pack is placed into the nostril.

97. COMPLICATIONS
MINOR COMPLICATIONS
periorbital emphysema,
epistaxis,
postoperative nasal
synechiae, and
odontalgia.
Massive hemorrhage
Orbital ecchymosis
Dental hyperesthesia
MAJOR COMPLICATIONS
CSF Rhinorrhea
Meningitis
Intracranial injury
Orbital trauma with
diplopia and vision loss
Injury to internal carotid
artery
Extended uses of FESS
• Endoscopic dacryocystorhinostomy
• Endoscopic orbital decompression

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