Paranasal sinuses

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Presented By:- Jasmohan S Sidana
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Learning Objectives
• By the end of the presentation a learner should be able to :-
1. Enlist the Paranasal Sinuses.
2. Describe the Development of PNS.
3. Enumerate the Functions of Paranasal Sinuses.
4. Illustrate the Blood supply, Nerve Supply & Lymphatic
drainage.
5. Enumerate the Diagnostic Methods in the Diseases of the
Sinuses.
6. Describe the Developmental Anomalies, infections, Cysts &
Tumors associated with Paranasal Sinuses along with the
treatment.

Contents:

Introduction:
Sinus - cavity or a channel such as a
cavity within a bone- a dilated channel
for venous blood or one permitting the
escape of purulent material.
Paranasal sinus - air filled extension
of the respiratory part of the nasal
cavity into the frontal, ethmoidal,
sphenoidal & maxillary cranial bone.

History:
Galen (130-301 AD) made the first
known description about the
adult maxillary sinus
Nathaniel Highmore in 1651 was
the first to describe in detail the
morphology of the maxillary
sinus and advance the idea of
pneumatization of the sinuses.
Therefore maxillary sinus is also
called as antrum of Highmore.

Development
Sinuses begin their
development at the
third month of IUL
as outpouchings of
the mucous
membrane of the
nasal meatuses
and the
sphenoethmoidal
recesses.
The early paranasal
sinuses expand
into the walls and
roof of the nasal
fossae by growth of
mucous membrane
sacs into the
maxillary,
sphenoid, frontal
and ethmoid bones.
The sinuses
enlarge variably
and greatly from
their initial small
outpocketings but
always retain their
original
communication
with the nasal
fossa through
ostia.

Functions:
Resonance of voice
Lightening of the skull weight
Production of bactericidal lysosome to the nasal cavity.
Humidification and warming of inspired air and
contribution to olfaction – controversial .It is possible
that if air is arrested in the sinus for a certain time it
quickly reaches body temperature and thus protects the
internal structures particularly the brain against exposure
to cold air.

There are four sets of paranasal sinuses namely;
• Frontal sinus
• Sphenoidal sinus
• Ethmoidal sinus
• Maxillary sinus
Which are present in the respective bones.

Frontal Sinus :
• These are two irregular cavities situated deep
to glabella and superciliary arches between
outer and inner tables of the bone.
• Seen as furrows in frontal recess of middle
meatus of nasal fossa at 3-4 months IU
Height- 3.15cms
Breadth- 2.5cms
Depth- 1.8cms

Invades the bone at 2nd year of life.
More developed in males.
Radiographically visible at 6 years of age.
They grow upward at an extremely variable rate
until puberty. Even after puberty all the sinuses
appear to increase slowly in size into old age.
Two sinuses are separated from each other by a
thin bony septum which is often deflected to one
or the other side. www.indiandentalacademy.com

Each sinus communicates with the
middle meatus of the nose by a
passage called the frontonasal
canal.
Subsequent enlargement is the
result of atrophic changes in the
bone

Blood supply:
Supra orbital artery and Anterior ethmoidal arteries
Venous Drainage:
Into the anastomotic vein between supraorbital
and superior ophthalmic veins
Lymphatics:
To the submandibular nodes

Sphenoidal Sinus :
Height- 2cms
Breadth- 1.8cms
Depth- 2cms
• Two large irregular cavities enclosed in the
body of sphenoid bone.
• Right and left sinuses are separated from each
other by a deflected bony septum.

• The two sinuses therefore are usually asymmetrical and often
partially subdivided by additional bony septa.
• Commence at 4th month of IUL by invading posterior part of
nasal capsule into the body of the sphenoidal bone.
• It continues growing into early adulthood and may invade the
wings and rarely the pterygoid plates of the sphenoid bone
• Sinus may extend into the lingual and basilar part of occipital
bone. www.indiandentalacademy.com

• Sinus opens into the sphenoethmoidal recess of the
lateral wall of the nose.
• Radiographically visible at four years of age only.
• By 8th year it extends to the hypophyseal fossa.
Relations:
• Above - optic chiasma and hypophysis cerebri.
• Each side – Internal Carotid Artery and
Cavernous sinus.www.indiandentalacademy.com

• Blood supply:
Posterior ethmoidal arteries
• Lymphatics:
To the retropharyngeal nodes.
• Nerve supply:
Posterior ethmoidal nerve and orbital branches
of the pterygoid ganglion.

Ethmoidal sinus:
• Occupy the labrynth of
ethmoidal bone.
• Ethmoidal labyrinths are
two very light cubical
masses which enclose a large number of
air cells arranged in three groups,
Anterior, middle and posterior ethmoidal sinuses.

• Many of these cells are incomplete and are closed by
the related bones (frontal, maxillary, lacrimal,
sphenoid and palatal).
• Invade the ethmoid bone from the 5th month of IUL
and may also be of a clinically significant size at birth.
• Grow variably into irregular contour until puberty.
• The most anterior of the ethmoidal cells grow upward
into the frontal bone and may form the frontal sinuses
retaining their origin from the middle meatus of the
nose as the fronto-nasal duct.www.indiandentalacademy.com

• Anterior sinus:
Consists of around 11-12 air cells.
Opens into the middle meatus at the anterior part of hiatus
semilunaris.
• Middle sinus:
Opens to middle meatus by 1 or more opening
above ethmoidal bulla.
• Posterior sinus:
Opens to superior meatus of nasal cavity.www.indiandentalacademy.com

Lymphatic drainage and blood
and nerve supply
• Anterior :
Anterior ethmoidal nerve and vessels.
Submandibular nodes.
• Middle : Posterior ethmoidal nerve and vessels and the orbital
branches of the pterygopalatine ganglion.
Submandibular nodes.
• Posterior : Posterior ethmoidal nerve and vessels and the orbital
branches of the pterygopalatine ganglion.
Retropharyngeal nodes.www.indiandentalacademy.com

Maxillary Sinus:
Height - 3.5cms
Breadth – 2.5cms
Depth – 3.2cms
• First sinus to develop.
• The maxillary sinus is the pneumatic space that is
lodged inside the body of maxilla and that
communicates with the environment by way of middle
nasal meatus.

• Four sides related to surface of maxilla in the following
manner
Anterior: Facial surface of body
Posterior: Infratemporal surface
Superior: Orbital surface
Inferior: Alveolar and zygomatic processes
• Pyramidal in shape with the base directed medially
towards the lateral wall of nose and the apex directed
laterally into the zygomatic process of maxilla.

Maxillary Sinus contd:
• The base of the sinus,
which is thinnest of all
walls presents a perforation, the ostium, at the level of middle
nasal meatus.
• In majority of the cases the ostium presents at the posterior
one third of hiatus semilunaris
• 23% accessory ostia seen in the middle meatus.

• Pneumatisation of the maxillary sinus is the earliest to start, at
3 months of IUL.
• The rapid and continuous growth of the sinus after birth brings
its walls in close proximity to the roots of maxillary molars
and its floor below its osteal opening.
• It expands and modifies until the eruption of all permanent
teeth.

Radiographically
• Identified in most newborns (caldwell’s view).
• At the latest it is seen at 5 months (water’s view).

• Blood supply:
Facial, maxillary, infraorbital and greater palatine
arteries
• Venous Drainage:
Into the facial vein and the pterygoid plexus of
veins
• Lymphatics:
To the submandibular nodes
• Nerve supply:
Infraorbital, anterior, middle and posterior
superior alveolar nerves

Histology:
• Microscopically in a sinus 3 layers can be seen
The epithelial layer
Basal lamina
Subepithelial layer including periosteum

• Epithelium is pseudostratified columnar ciliated which is
derived from the olfactory epithelium of the middle nasal
meatus and therefore undergoes the same pattern of
differentiation as does the respiratory segment of the nasal
epithelium.
• Most cells are columnar ciliated cells.
• In addition there are columnar non-ciliated cells, mucous
producing, secretory goblet cells.

DIAGNOSTIC
METHODS IN DISEASES
OF THE SINUSES.

1.ELICITING SINUS TENDERNESS
2. TRANSILLUMINATION: In maxillary and frontal
sinusitis.
3. RADIOLOGICAL EXAMINATION.
4. DIAGNOSTIC PROOF PUNCTURE.
5. SINOSCOPY
6. ECHOSINOGRAPHY: detecting sinus pathology by
ultra sound
7. CT SCAN www.indiandentalacademy.com

Eliciting Sinus Tenderness:
• Maxillary sinus is palpated in the small area of the
anterior wall of the maxillary sinus just lateral to the
ala naris.
• Frontal sinuses are palpated by pressing the finger
superiorly at the medial end of the superior orbital
margin.
• Ethmoidal sinuses are palpated with the thumb in the
inner canthus of one eye and the index finger in the
other and pushing posteriorly, posterior to the lacrimal
bone and squeezing.

Transillumination
Purpose
To detect obstruction of the sinuses or openings to the sinuses
How it works
Since light is able to pass through the delicate skin covering
the hollow sinus cavities, a light source held against the
upper cheek will produce a red dot on the palate if the
sinuses are normal (filled with air rather than obstructed).

• Test procedure
The examiner presses the light source against the patient’s
upper cheek, close to the nose, asks him to open his mouth
widely, and looks at palate to see if the light passes
through.

Advantages
It's simple, quick, and noninvasive.
It's inexpensive.
• Disadvantages
It detects obstruction of the sinuses but not its cause.
Factors affecting results
The presence of fluids, pus, or other debris in the sinus cavities.
Interpretation
If the sinus cavities are obstructed (by a tumor, infection, or
inflammation due to an allergic reaction), no red dot will be
seen. X-rays or other tests must be performed to establish the
cause.

Radiological examination
Caldwell Water’s
view
lateral submento
vertex
OPG

Computed Tomography
• Great details of sinus structure
• Demonstraton of solid masses like
 osteoma
 Antroliths
 malignancy

Sinoscopy
• endoscopic examination of the maxillary sinus
• Using a fibre optic sinoscope. Detects early pathology, particularly
malignancy. Done through intranasal antrostomy

Applied anatomy
Developmental
anomalies
Sinusitis Referred pain
Infections of
dental origin
Cysts and
tumors
Trauma
(Fractures)
Accidental
opening
Oro-antral
fistula

Developmental anomalies
Agenesis:
• Complete absence or aplasia or hypoplasia - Altered
development or under development of the maxillary
sinus occurs either alone or in association with other
anomalies.
• Eg.Cleft palate, high palate, septal deformity, absence
of concha, mandibulofacial dysostosis, malformation
of external nose, and pathologic conditions of the
nasal cavity as a whole.
.

Absence of frontal and spenoidal
sinus
• Seen in Down's syndrome(trisomy 21).
• Diminution or absence of sinuses  seen in
Apert's syndrome.

Supernumerary maxillary sinus:
• Occurrence of two completely separated sinuses on the same
side.
• Most likely initiated by outpocketing of the nasal mucosa into
the primordium of the maxillary body from two points either in
the middle nasal meatus or in the middle and superior, or middle
and inferior nasal meatuses respectively.
• Consequently the result is two permanently separated ostia of the
sinus

Pituitary gigantism:
All sinuses assume a much larger volume than in healthy
individuals.
Pituitary dwarfism:
The sinus size is much smaller.
Congenital syphilis:
Pneumatic process is greatly suppressed resulting in small
sinus.

Sinusitis
• Inflammation of the mucosal lining of the sinus.
• Inflammation of most or all of paranasal sinuses
simultaneously is called Pansinusitis.
• Classified as:
Acute
Subacute
Chronic

Acute
• Causative organism : Streptococcus pneumoniae and
hemophilus influenza.
Main signs
• Tenderness over the cheek .
• Teeth may become sore and painful. TOP positive.
• Anaesthesia of of cheek

• Patient gives history of cold 3-4 days prior to the attack
• Nasal discharge may be initially thin, watery and serous but
soon it becomes mucopurulent in form, dripping into the
nasopharynx and causing a constant irritation.
• sinusitis that develops from infected teeth the secretion has foul
odour.
• General toxemia develops with the disease, producing chills,
sweats, elevation of temperature, dizziness and nausea.
• Difficulty in breathing.

Diagnosis:
• mainly by the signs and symptoms.
• Radiographs
• Transillumination
Treatment :
• Bed rest ,fluids and maintainance of oral hygiene.
• Antibiotics & Analgesics
• Nasal decongestants
• Mucolytic agents

Chronic sinusitis
• Causative organism - Anaerobic bacteria - Branhamella
catarrhalis and -lactum producing strains of
H.influenzae.
Causes :
• Repeated attack of acute sinusitis
• Single attack of long duration
• Persistent dental focus
• Chronic rhinitis

• Chronic infection in frontal or ethmoidal sinuses
• Fatigue
• Overindulgence, worries, dietary deficiency, lack of sleep
• Allergies
• Endocrine imbalance and debilitating diseases
Symptoms :
Pain and tendernesss
Unilateral foul discharge through posterior nares
cacosmia www.indiandentalacademy.com

Diagnosis :
• History
• Symptoms
• X-ray - waters view –hyperplasia and multiple polyps
Treatment
• Removal of cause
• Antral regime
• Establish adequate drainage - by intranasal antrostomy.
• Endoscopic nasal surgery/caldwell luc.
Complications of Maxillary Sinusitis :
• Acute cellulitis
• Osteitis
• Rarely infection may spread to the orbit.

Fronto Ethmoidal Sinusitis
• Symptoms : Same as maxillary sinusitis.
Diagnosis :
• Nasal endoscopy
• CT scan
• X-ray - Water's view
Treatment :
• Mainly antibiotics and nasal decongestants
• Small incision made below the medial end of the
eyebrow  Sialastic tube is left in it for drainage.
• In chronic sinusitis - Osteoplastic flap procedure

Complications :
• Rare, but if occurs are serious
• May spread to other sinus
• Orbital cellulitis - may extend to form extraperiosteal
abscess & may lead to blindness
• Intracranial spread of infection-CST,meningitis,
subdural empyema, brain abscess
Treatment :
• I.V. broad spectrum antibiotics and decompression by
external approach.

Referred Pain:
• Tooth ache may be a symptom of sinusitis
• Superior alveolar nerve runs for a considerable distance in the walls
of the antrum.
• Progressive expansion of the sinus in older persons cause resorption
of bone and thus the connective tissue covering the structures of the
canal are brought in direct contact with the muco-periosteum of the
sinus. This will cause involvement of dental nerves if inflammation
of sinus occurs.
• Examination of teeth by cold stimulation reveals that not one tooth
but an entire group of teeth are hypersensitive.www.indiandentalacademy.com

Infections of Dental Origin:
• 10 - 15% of all the pathological conditions involving maxillary
sinus are of dental origin. It includes :
• Accidental opening during extraction
• Displacement of roots or whole teeth during extraction.
• Infections introduced through the abscessed tooth through the antral
floor

• Granuloma, cyst or a tumor may invade the sinus
• Empyema of the sinus may also occur as a result of too
active curettage of the root sockets after extraction.

Cysts and Tumors
• Dentigerous cyst
• Cyst of mucosa of sinus lining
• Benign and malignant neoplasms
• Antral rhinoliths
• Polyps
• Angiomas, myomas, fibromas and central giant cell
granulomas seldom invade the sinus.
• Cystic odontomas
• Osteoma. www.indiandentalacademy.com

Cysts and Tumors
• Ameloblastoma
• Epidermoid carcinoma
Symptoms
• Initially asymptomatic
• Teeth may become loose and pain if extraction is done which fails to
heal
• Metastasis to vital organs may cause death
• Often swelling of the face
Treatment - surgical

Trauma
• Fracture of maxilla with associated crushing of sinus
region may occur.
• Zygoma may be forced into the sinus
• An acute infection may follow because of retention of
an accumulation of blood in the sinus
Treatment
• Most of the time treatment is symptomatic.

Accidental Opening
• Mostly occurs during extraction of maxillary second premolar
and molars.
Symptoms:
5 E’s
• Escape of fluids
• Epistaxis (unilateral)
• Escape of air
• Enhanced column of air
• Excruciating pain

Diagnosis :
• Ask the patient to compress the nostrils and blow the
nose gently.
• If an opening has occurred through the membrane lining
the sinus, the blood in the tooth socket will bubble.
Treatment :
• If the opening is small , avoid irrigation, vigorous mouth
washing, frequent blowing of the nose, majority of cases
a good clot will form and organize and normal healing
will occur.
• Ideal is primary closure + Antibiotic prophylaxis.

• Probing of the socket must be avoided to prevent infection.
• If floor of the antrum is completely disrupted then immediately
closure is done  This prevents infection at the sinus.
• If the tip of the root is pushed into the anturm try to remove it
through the socket. If unsuccessful then stop the procedure,
encourage healing.
• Take a radiograph
• Remove it through Cald Well Luc procedure

Oroantral Fistula
• Fistula :
Communication between two organs / structures which is lined by
epithelium. Both the ends are opened.
Oro-Antral Fistula :
• Communication between the oral cavity and antrum.
• To call it as a fistula it has to be chronic.

Causes:
Untreated accidental opening during extraction
Perforation due to any tumour, cyst
Injudicious use of instruments
Extensive trauma to face
Surgery
Osteomylitis of sinus
Gumma involving palate
Infected implants

Symptoms
5 p’s
• Pain – but minimal
• Persistent, purulent or mucopurulent unilateral nasal
discharge
• Post nasal drip
• Possible sequelae of general systemic toxemic condition
• Popping out of an antral polyp

Treatment
• There will be chronic sinusitis, it should be treated first
• An acrylic plate should be given
• Irrigate the sinus
• Antral regime
• Once the sinusitis subsides then only treat the fistula
• Surgical closure of fistula

Surgical closure
Types of Flaps :
• Palatal flap
• Buccal flap
• Combinaion of both
Causes for Failure of Closure :
• Poor flap technique
• Asepsis not maintained
• Removal of sutures
• Sinusitis not treated www.indiandentalacademy.com

Cald Well Luc Operation
• By George Walter Caldwell, USA(1983) & Henri Luc, France(1889)
• It is a technique to gain access to the maxillary sinus through the canine
fossa region.
Indications :
• Removal of teeth, root fragments, cysts, neoplasms, chronic maxillary
sinusitis.
• Management of hematomas of the antrum with active bleeding through the
nose.
• Trauma to the maxilla or when the floor of the orbit has dropped.

Procedure
• Done under LA with sedation or GA
• Semilunar incision in buccal vestibule from canine to 2nd
molar just above gingival attachment
• Mucoperiosteal flap elevated till infraorbital
ridge.window in anterior wall of maxillary
sinus
• Opening enlarged with Rongeur forceps

• Pus sucked away, irrigation,
inspection, removal
• Iodoform ribbon gauze pack
& Suture
• Antibiotics, analgesics,
nasal drops
• Pack removal on the 5th day

Antrostomy :
• It is a technique of making an artificial ostium to the maxillary
sinus in the inferior meatus of the nose.
• uses a combination of 300&700 rigid endoscopes.

• The principle behind it is that the ostium of the sinus is at
as higher level than the floor of the sinus. Therefore
making an opening at a lower level improves the drainage.
• But the recent concept is even though the opening is made
at a lower level the cilia of the cells tend to beat the
secretions towards the direction of original ostium.
Therefore now a days antrostomy is rarely done

CONCLUSION :
• There is a great importance of paranasal sinuses especially
maxillary sinus in dentistry.
• Extensive vascular and neural connections between maxillary
sinus and oral structures.
• Close proximity of premolar and molar roots to the sinus.

• To differentiate whether the disease is of dental origin or
from the sinus and treatment of the diseases of the sinus if
it is of dental origin.
• Referral of the patients with diseases of sinus origin to
ENT.

REFERENCES :
• Human Anatomy - By B.D. Chaurasia, 3rd Volume, 4th
edition, Pg.168-173.
• Oral Histology and Embryology - By Orban,
12th edition, Pg.313-321.
• Short Practices of Surgery - By Bailey and Love, 24th
edition, Pg.674-686.
• Text book of Oral and Maxillofacial Surgery - By
Neelima Anil Malik, 1st edition, Pg.525-545.
• Text book of Oral and Maxillofacial Surgery – By
Gustav o Kruger, 6th edition, Pg. 281-295
• David A Gowan.The Maxillary sinus and its dental
implications,1 st edition
• Peterson ,Ellis,Hupp,Tucker.Oral and maxillofacial
surgery,4th edition
• Brand,Issel Hard.Anatomy of orofacial structures,3rd
edition.

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