Paranasal sinuses are air-filled spaces located around the nose. This document discusses the anatomy, physiology, development, and pathologies of the paranasal sinuses. It describes the examination and investigations used to evaluate sinus diseases. The major classifications of sinus pathologies discussed are developmental variations, inflammatory/infectious diseases, cysts, tumors, and other surgically relevant conditions. Specific conditions like polyps, sinusitis, and granulomatous diseases are described in more detail.

1. PARANASAL SINUS PATHOLOGIES
Presented by
Dr. Cathrine Diana PG-III

2. contents
 Paranasal sinuses
 Introduction
 Development
 Anatomy
 Physiology
 Examination and investigations
 Paranasal sinus pathologies
 Classification
 Description
 Complications
 Treatment

3. INTRODUCTION
 Sinus (Latin) - fold or pocket.
 Paranasal sinuses - four paired,
hollow air filled spaces in various
cranio-facial bones
 Named after the bones in which
they are located

4. INTRODUCTION Clinically, Divided into two groups:
1. Anterior group: maxillary, frontal, anterior and middle ethmoidal air
cells. They all open in the middle meatus.
2. Posterior group: Posterior ethmoidal and the sphenoid sinus

5. DEVELOPMENT
 Excavation of bone by air-filled sacs (pneumatic diverticula) from
the nasal cavity.
 Begins prenatally - continues through lifetime.

7. ANATOMY– MAXILLARYSINUS
 MAXILLARY ANTRECHEA / ANTRUM
OF HIGHMORE
 Largest
 Maxilla - under the eyes, on either
side of the nose.
 Pyramidal - base toward the lateral
wall of nose and apex directed
laterally into the zygomatic process.
 Capacity of 15 ml (average).

8. FRONTAL SINUS
 Situated deep to the inner and outer table of
frontal bone
 Drain- frontal recess to the middle meatus
 Absent on one (15 %) or both sides (5 %)
 Drainage pathway – naso- frontal duct-
frontal recess - situated at its floor – drains
into middle meatus (62%) or ethmoid
infundibulum (38%).

9. Ethmoid sinus
Thin-walled air cavities in the lateral masses
of ethmoid bone, between nose and the
eyes.
1. Anterior ethmoidal air cells –3- 11 drain
into either the ethmoidal infundibulum
or the frontonasal duct.
2. Bullar cells (middle ethmoidal air cells)
- usually <3 - open in ethmoidal
infundibulum.
3. Posterior group :- Up to 7 - usually drain
by a single orifice into the superior
meatus.

10. Agar nasi cells
 They are the most anterior ethmoidal air
cells. .
 Its size influence the patency of the frontal
recess and the anterior middle meatus.
 Haller cells:
 Also called infraorbital ethmoid cells.
 Present in approx. 20 % pateints.
Clinical significance –
 Become infected , with potential extension
into orbit.
 Narrows the maxillary ostium.

11. Onodi cells
 These are posterior ethmoidal cells
extending into the sphenoid
bone ,either adjacent to or impinging
upon the optic nerve.
 When these Onodi cells abut or
surround the optic nerve, the nerve is
at risk when surgical excision of these
cells is performed.
 It is also a potential cause of
incomplete sphenoidectomy.

12. SPHENOID SINUS
 Body of sphenoid - behind the nose, in the
center of the skull.
 Rarely symmetrical and separated by a
thin bony septum.
 Ostium of the sphenoid sinus is situated
in the upper part of its anterior wall and
drains into sphenoethmoidal recess.
 Average size – 2 x 2 x 2 cm.
 According to Congdon sphenoid
pneumatization can be as follows
 Conchal – 5 %
 Presellar – 23 %
 Post-sellar – 67%

13. ANATOMY- LATERAL NASALWALL
 3 projections - superior, middle
and inferior concha.
 Meatus - space below each
concha.
 Inferior meatus: nasolacrimal
duct
 Middle meatus:
 Maxillary sinus
 Frontal sinus
 Anterior ethmoid sinuses
 Superior meatus: posterior
ethmoid sinuses
 Sphenoethmoidal recess:
sphenoid sinus

14. OSTEOMEATAL COMPLEX
 It is a common channel that links
the frontal sinus, anterior and
middle ethmoid sinuses and the maxillary
sinus to the middle meatus. It is composed
of five structures:
 Maxillary ostium
 Infundibilum
 Ethmoidal bulla
 Uncinate process
 Hiatus semilunaris

15. PHYSIOLOGY– SINUS EPITHELIUM
 Respiratory epithelium - ciliated pseudostratified columnar epithelium,
goblet cells, and submucosal glands
 Produce a protective mucous blanket - traps bacteria and noxious
materials, which are carried by ciliary motion to the ostium and into the
nose for elimination

16.  Ciliary movements: 50- 300 cilia/ cell; 8-20
beat/ second.
 For maximum ciliary activity:
Humidity: >85%, Temperature: 18- 40 degree
C, pH: 7- 8.
 The orientation of the cilia within a given
sinus is specific as secretions are propelled
towards the natural sinus ostia and from
there to the nasopharynx and oropharynx
where they are subsequently cleared by
swallowing.

17. SINUS HEALTH
 Composition of gas content in the maxillary sinus is similar to venous
blood, with high CO2 and lower O2 level compared to breathing air.
 Sinus health depends on:
1. Mucous secretion of normal viscosity, volume, and composition
2. Normal muco-ciliary flow to prevent mucous stasis and subsequent
infection
3. Open sinus ostia to allow adequate drainage and aeration.
 Negative factors:
 Dryness of air, Cigarette, Temperature variations, hypoxia, hypercapnia,
Hypertonic/ hypotonic fluids, Dehydration, pH changes, diseases (like
Cystic fibrosis and Primary ciliary dyskinesia), Drugs (phenylephrine,
adrenaline, lidocaine, atropine, antihistaminic), Infections, Anatomic
obstruction (septal deviation, enlarged or irregular turbinate), Foreign
bodies and Nasal polyps.

18. PATHOPHYSIOLOGICALSTAGES OF
SINUS DISEASES
Initial phase: - reversible
Ostium obstruction phase
Bacterial phase
Chronic phase

19. Osteomeatal complex obstruction
↓
Decreased ventilation of the sinuses
↓
Decreased drainage of the sinuses
↓
pO2 decrease, pCO2 increase, mucous stasis
↓
Inflammation and viscous mucous, ciliary movement slowing
↓
Stasis and proteolytic enzymes
↓
Ciliary damage
↓
Anaerobic microorganisms
↓
More damage

20. FUNCTIONS OF SINUS
1. Reduction of weight of skull
2. Increasing resonance of the voice
3. Providing a buffer against blows to the face.
4. Insulating sensitive structures like dental roots and eyes from rapid
temperature fluctuations in the nasal cavity.
5. Humidifying and heating of inhaled air because of slow air turnover in this
region.
6. Regulation of intranasal and serum gas pressures
7. Increasing surface area for olfaction
8. Contribute to facial growth

21. EXAMINATION
 History and systemic clinical examination:
 Check general signs of health
 Systemic medical history, history of
allergies, drug use and abuse
 Occupation history
 Examination of and neck for lumps or
swollen lymph nodes

22. Examination
 Local examination of the nose,
face, and neck:
1. Anterior Rhinoscopy:
Examination of nose with a
nasal speculum to check
for abnormal areas, useful in
evaluation of nasal
obstruction.
2. Posterior rhinoscopy: With a
mouth mirror in the
nasopharynx

23. Examination - transillumination
 Normal transillumination decreases chance of pus in the sinus.
 No light reflex suggests mucopurulent material or thickening of
nasal mucosa.
 Inexpensive screening tool

24. Transillumination of Frontal Sinus
Transillumination of Maxillary Sinus
24

25. Examination - endoscopy
 Endoscopic examination/ Rhinoscopy:
 nasoscope/rhinoscope is a thin, tube-like instrument with a light and
a lens for viewing. A special tool on the nasoscope may be used to
remove samples of tissue. The tissues samples are viewed under a
microscope by a pathologist.

26. EXAMINATION – PLAIN RADIOGRAPHS
 Plain radiographs:
 to check for Sinus opacifications, Air-fluid level, Mass, Fractures
 Caldwell view: PA view/ “forehead-nose” view to evaluate maxilla, maxillary
and frontal sinus, ethmoid air cells, lamina papyracea

27.  Water’s view: chin-nose” or “occipito-
mental” view for evaluation of the
paranasal sinuses.
submento-vertical” view to evaluate the
sphenoid, the posterior ethmoids, the
maxillary and frontal sinuses

28. CT SCANS
 CT scans: Excellent views of the sinuses, best for
osteomeatal complex and ethmoidal disease
 “Limited CT Evaluation” – slice 3-4 mm
 CT navigation:
 A computer is used to identify the 3-
dimensional location of a probe tip placed
within the patient's nose or sinuses..
 Improves anatomical identification and avoid
damage to vital neighbouring structures such
as the brain and eyes.

29. AXIAL CT

32. CORONAL CT

35. SAGITTAL CT

36. EXAMINATION
 MRI:
 Excellent soft tissue definition
- evaluation of neoplastic
disease.
 MRI (magnetic resonance
imaging) with gadolinium:
Gadolinium is injected into a
vein. The gadolinium collects
around the cancer cells so
they show up brighter in the
picture.

37.  PET scan (positron emission tomography scan): A small amount
of radioactive glucose is injected into a vein. The PET scanner rotates
around the body and makes a picture of where glucose is being used
in the body. Malignant tumor cells show up brighter in the picture
because they are more active and take up more glucose than normal
cells do.
 Stuckensen and colleagues found a sensitivity of 70%, 84%, and 66%
and a specificity of 82%, 68%, and 74% for PET, ultrasound, and CT
scan in terms of nodal metastasis

38. 9. Histological examination:
 Fine-needle aspiration (FNA) biopsy,
Incisional biopsy and excisional biopsy are
done from pathologic tissues.
10. Culture examination: Correlation of
routine nasal culture and sinus culture is
poor. Endoscopically guided aspiration of
cultures from medial meatus do correlate
with sinus culture.
Silver stained section showing invasive
fungal sinusitis (aspergillus)
Allergic mucin of allergic fungal
sinusitis

39. Classification
 DEVELOPMENTAL VARIATIONS AND ANOMALIES
 INFLAMMATORY/INFECTIOUS DISEASES
 CYSTS
 TUMORS
 OTHER SURGICALLY RELEVANT CONDITIONS

40. Developmental variations and anomalies
 Paradoxical curvature of middle turbinate
 Concha bullosa in middle turbinate
 Lateralization and pneumatisation of uncinate process
 Variations of ethmoidal roof anatomy
 Bulla ethmoidalis – torus ethmoidalis and giant bulla
 Others: Agenesis of sphenoid sinus, pneumatisation of greater wings
of sphenoid and crista galli.

41. DEVELOPMENTALVARIATIONSAND
ANOMALIES
Paradoxical curvature:
Normally the convexity of the middle
turbinate is directed medially toward
the nasal septum.
When the convexity is directed
laterally, it is termed a paradoxical
middle turbinate .
Most authors agree that the
paradoxical middle turbinate can be a
contributing factor to sinusitis.

42. DEVELOPMENTALVARIATIONS
ANDANOMALIES
Concha bullosa:
When pneumatization involves the
bulbous portion of the middle turbinate
it is termed concha bullosa.
If only the attachment portion of the
middle turbinate is pneumatized, it is
termed lamellar concha .
A concha bullosa may obstruct the
ethmoid infundibulum.

43. Variations of uncinate process
The uncinate process may be medialized,
lateralized, or pneumatized/bent.
Medialization occurs with giant bulla
ethmoidalis.
Lateralization of the uncinate process
may obstruct the infundibulum.
Pneumatization (uncinate bulla) can
rarely cause obstruction of the
infundibulum.

44. Variation of the ethmoidal roof anatomy
The ethmoid roof is of critical importance for two
reasons.
 most vulnerable to iatrogenic cerebrospinal
fluid leaks.
 anterior ethmoid artery is vulnerable to injury.
The depth of the olfactory fossa is determined by
the height of the lateral lamella of the
cribriform plate.
In 1962, Keros classified the depth of the olfactory
fossa into three types, that is,
Keros type I: <3 mm
Keros type II: 4-7 mm
Keros type III: 8-16 mm - most vulnerable to
iatrogenic injury.

45. Variations of sphenoid sinus … Agenesis of sphenoid sinus
 Pneumatisation of other bones
 The crista galli is normally bony.
When aerated, it may communicate with
the frontal recess, causing obstruction of
the ostium and thus lead to chronic
sinusitis and mucocele formation

46. Bullae ethmoidalis
 The bulla ethmoidalis is a
prominent anterior ethmoid air
cell.
 Failure to pneumatise - torus
ethmoidalis.
 A 'giant bulla' may fill the entire
middle meatus and force its way
between the uncinate process and
the middle turbinate.

47. INFLAMMATORY/ INFECTIOUS
CONDITIONS
 POLYPS
 SINUSITIS
 GRANULOMATOUS DISEASES

48. POLYPS
 They are fleshy outgrowths of the nasal
mucosa that form at the site of dependent
edema in the lamina propria of the mucous
membrane, usually around the ostia of the
maxillary sinuses.
 usually start near the ethmoid sinuses and
grow into the open areas.
 Large polyps can block the sinuses or nasal
airway.
 Risk factors: Aspirin sensitivity (wheezing),
Asthma, Acute and Chronic sinus infections,
Cystic fibrosis, Hay fever (allergic rhinitis).

49.  Clinical features:
 Nasal obstruction and mouth breathing
 Nasal congestion and postnasal drainage
 Anosmia, hyposmia
 Sneezing, rhinorrhea
 Facial pain
 Ocular itching
 Bleeding polyps occur in rhinosporidiosis
 Unilateral polyps occasionally occur in association with or represent
benign or malignant tumors of the nose or paranasal sinuses, or in
response to a foreign body.
 Diagnosis:
 physical examination - A developing polyp is teardrop-shaped; when
mature, it resembles a peeled seedless grape.
 CT scans

50.  Treatment
1. Steroids –may shrink or eliminate polyps
 Topical corticosteroid spray - mometasone [30
mcg/spray], beclomethasone [42 mcg/spray], flunisolide -
given as 1 or 2 sprays bid in each nasal cavity
 1-wk tapered course of oral corticosteroids.
2. Surgery :
 FESS
 Steroid therapy after surgery - to retard recurrence.
 In severe recurrent cases- maxillary sinusotomy or
ethmoidectomy, usually done endoscopically.
3. Removal of etiology – control of underlying allergy or infection.

51. SINUSITIS
 Definition: Sinusitis is the
inflammatory condition of the
mucous membrane lining of the
sinuses
 RHINOSINUSITIS is a better term
because:
 Allergic or non-allergic rhinitis
nearly always precedes sinusitis
 Sinusitis without rhinitis is rare
 Nasal discharge and congestion
are prominent symptoms of
sinusitis
 Nasal mucosa and sinus mucosa
are similar and are contiguous

52. Classifications
ACCORDING TO DURATION:
1. Acute :infection lasting 4 weeks, symptoms resolve completely resolved
in < 30 days.
2. Subacute :infection lasting between 4 to 12 weeks, yet resolves
completely.
3. Recurrent: ≥ 4 discrete acute episodes per year, each completely resolved
in < 30 days but recurring in cycles, with at least 10 days between complete
resolution of symptoms and initiation of a new episode
4. Chronic: symptoms lasting more than 12 weeks.

53.  ACCORDING TO PATHOGEN:
1. Bacterial: Hospital-acquired acute infections are more often
bacterial, typically involving Staphylococcus aureus, Klebsiella
pneumoniae, Pseudomonas aeruginosa
2. Viral: In immunocompetent patients - in the community is almost
always viral (eg, rhinovirus, influenza, parainfluenza).
antibiotics given for:
 Mild to moderate sinus symptoms persisting for ≥ 10 days
 Severe symptoms (eg, fever ≥ 39°, severe pain) for ≥ 3 to 4 days
 Worsening sinus symptoms after initially improving from a typical
viral URI ("double sickening" or biphasic illness)

54. 3. Fungal: Usually seen in immunocompromised patients because
of poorly controlled diabetes, neutropenia, or HIV infection. It is
clinically of 2 types:
 Non-invasive fungal sinusitis:
 Saprophytic fungal infestation/colonization
 Allergic fungal rhinosinusitis (AFRS)
 Saprophytic fungus balls (mycetoma)
 Invasive fungal sinusitis –
 Chronic invasive fungal sinusitis
 Granulomatous invasive fungal sinusitis
 Acute (fulminant) invasive fungal sinusitis

55. sinusitis
 According to source:
 Primary
 Secondary
 According to number of sinuses
involved:
 Hemisinusitis –all sinuses on one side
 Polisinusitis – several sinuses, but
not all, are involved
 Pansinusitis
 According to source of infection:
 Rhinogenous
 Odontogenic
 Traumatic
 Hematogenic
 Allergic

56. Risk factors:
1. Obstruction to drainage: most important
2. Defect of self-cleaning mechanism of the mucous membrane of sinus –
infections causing immobility of the cilia, Increased viscosity of
secretions, Immotile cilia syndrome, Prolonged exposure to cigarette
smoke
3. Medications
 First generation antihistamines (non sedating do not affect)
 Anticholinergics, Aspirin, Anesthetic agents, Benzodiazepines
4. Immunodeficiency: Immunoglobulin deficiency (IgA, IgG), diabetes, HIV
infection
5. Other factors: prolonged ICU stays, severe burns, cystic fibrosis, and
ciliary dyskinesia.

57. Clinical Features:
1. Nasal congestion and discharge
2. Sore throat and postnasal drip
3. Pain or pressure.
4. Oedema of facial tissues.
5. Bad breath or loss of smell (hyposmia/anosmia).
6. Systemic symptoms: Malaise may be present. Fever and chills suggest an
extension of the infection beyond the sinuses, rise in temperature, bad
appetite, sleep disturbances, changes of the blood (leukocytosis),
Productive cough (especially at night)
7. Complications – ocular, neurological, local

58. Diagnosis
1. Diagnosis is clinical;
2. CT and cultures - mainly for chronic, refractory, or atypical cases.
3. X-rays of the apices of the teeth
Clinical diagnostic criteria include 2major factors, I major and 2 minor
factors or presence of pus in nasal cavity.
Major Factors Minor Factors
Facial pain/pressure Headache
Facial congestion/fullness Maxillary dental pain
Nasal drainage/discharge Cough
Postnasal drip Halitosis
Nasal obstruction/blockage Fatigue
Hyposmia/anosmia Ear pain/ pressure/ fullness
Fever (acute sinusitis only) Fever
Purulence in nasal cavity on examination
(diagnostic by itself)

59. TREATMENT OPTIONS
MEASURES TO ENHANCE DRAINAGE:
1. Heat therapy: Steam inhalation; hot, wet towels over the affected
sinuses; and hot beverages
2. Topical vasoconstrictors/ Nasal decongestants:
 Topical nasal sprays (limit use to 3-7 days) - Phenylephrine,
Oxymetazoline, Naphthazoline, Tetrahydrozoline, Zylometazoline.
Phenylephrine(0.25%) spray q 3 h or oxymetazoline q 8 to 12 h, are
effective but should be used for a maximum of 5 days or for a
repeating cycle of 3 days on and 3 days off until the sinusitis is
resolved
 CORTICOSTEROIDS: Corticosteroid nasal sprays can help relieve
symptoms but typically take at least 10 days to be effective
3. Systemic vasoconstrictors: Systemic vasoconstrictors, such
as pseudoephedrine 30 mg po (for adults) q 4 to 6 h, are less effective.

60. 4. Nasal irrigation:
 Commercial buffered sprays, Bulb syringe, waterpik and ceramic
irrigators with lavage tip or disposable enema bucket
 Washes away irritants and moistens the dry nose.
 cumbersome and uncomfortable - better for patients with recurrent
sinusitis.
 ANTIHISTAMINICS: recommended if allergy present. They can be oral or
topical
 HYDRATION

61. 5. Mucoactive drugs:
 main purpose - increase the ability to expectorate sputum and/or
decrease mucus hypersecretion.
1. Expectorants: hypertonic saline, iodine containing compounds,
guaifenesin (glyceryl guaiacolate), ion channel modifiers (tricyclic
nucleotides)
2. Mucoregulators: carbocysteine, anticholinergic drugs,
glucocorticoids, macrolide antibiotics
3. Mucolytics: classic mucolytic (N-Acetyl Cysteine), peptide mucolytic,
non destructive mucolytics
4. Mucokinetics: bronchodialators, ambroxol

62. a) Nebulization: best form of physiotherapy. Can be done using
compressors or ultrasonic nebulisers. Normal saline solutions
are nebulized which has a hydrating effect on the mucous
lining. Ultrasonic nebulisers can set the rate according to need.
b) Laser therapy: used directly over the sinuses to reduce
inflammation
c) Ultrasound therapy: sound waves are conducted through a
hypoallergenic gel to reduce inflammation and loosen the
accumulated mucous.
d) Short-wave diathermy
e) Rinoflow therapy: new option, basically micronized
endotracheal wash. Used in sinusitis, rhinitis, pharyngitis,
laryngitis and secretory otitis media.

63. Antibiotics and antifungal drugs:
 Amoxicillin 500 mg tid for 10-14 days - First line
 Beta-lactanase resistance - Amoxicillin/clavulanate, Cefuroxime,
Cefpodoxime, Cefprozil

65. Surgery
 Indications:
 Sinusitis unresponsive to antibiotic therapy
 Necrotic sinusitis
 Orbital complications (abscess and phlegmon of orbit)
 Intracranial complications (meningitis, brain abscess)
 Rhinogenic sepsis
 Odontogenic sinusitis combined with maxillary osteomyelitis.
 Approaches:
1. Removal of etiology
2. Fess
3. Caldwell-luc procedure
4. Intranasal antrostomy
5. Radical surgeries

66. Removal of etiology:
 Treatment of affected tooth.
 Caldwell luc approach may be used.
 Intra-nasal antrostomy may be needed.

67. Caldwell - luc
 Caldwell-Luc is the fenestration of the anterior wall
of the maxillary sinus and the surgical drainage of
this sinus into the nose via an antrostomy.
 a middle meatus antrostomy is being utilized as a
more physiologic antrostomy..

68. Denkers procedure

69. FESS:
 Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical
treatment of sinusitis and nasal polyps, including bacterial, fungal,
recurrent acute, and chronic sinus problems.
 Nasal endoscopes through the nostrils to avoid cutting the skin.
 Telescope diameters - 4mm (adult use) and 2.7mm (pediatric use)
 Viewing angles - 0 degrees to 30, 45, 70, 90, and 120 degrees
 Carry: High definition cameras attached to monitors, tiny articulating
instruments - cutting, suction, biopsy, curettage
 All the sinuses can be accessed at least to some degree by means of FESS.

70.  Extended approaches: Paranasal sinuses are found to a relatively low-
morbidity approach to selected tumors even inside the skull or brain. This
can be divided into approaches to: anterior cranial fossa, mid cranial fossa,
posterior cranial fossa, infratemporal fossa (incl. pterygopalatine fissure),
sella turcica, orbital access, and optic nerve access.
 Complications:
 Proximity of the sinuses to the eyes, optic nerves, brain and internal
carotid arteries
 Serious risks are rare occurrences

71. Before FESS 2 months after FESS

72.  Principal element - granuloma formation - a conglomerate of
macrophages, epithelioid cells, and multinucleated giant cells.
1. Infectious:
 spirochetes (syphilis, yaws)
 mycobacteria [tuberculosis, leprosy]
 bacterial [rhinoscleroma]
 fungus [aspergillus]
2. Inflammatory
 Wegener granulomatosis
 sarcoidosis,
 Churg-Strauss syndrome
 cocaine induced midline destructive lesions
Granulomatous diseases

73. Cysts
 Mucocele and Pyocele
 Retention cyst
 Pseudocyst
 Post-operative maxillary cyst

74. Mucocele and pyocele
 Mucocele:
 formed when drainage of mucus from one of the paranasal sinuses
becomes blocked by obstruction of its ostium.
 Contents: clear serous fluid, thick mucoid material, or, if hemorrhage has
occurred, thick brown material
 Pyocele/mucopyocele:
 Infected mucocele
 Contents: mixture of mucus and pus from which a causative organism
may or may not be seen on smear or subsequently cultured.

75. Pathogenesis:
 Blockage of the ostium pressure develops within sinus
 expansion of the sinus space erosion, and displacement of bone.
 Encroachment of the mucocele upon contiguous structure
 Sinus lining – remains normal or becomes attenuated to undergo
metaplasia to low cuboidal or squamous cells.

76.  Most commonly: frontal and anterior ethmoid sinuses
 Etiology: chronic inflammation, osteomas, fractures, tumors, polyps,
scarring, and congenital abnormalities.
Management
 Decompression by complete removal and curettage
 Marsupialisation via endoscopic approach through the middle meatus
 Prophylactic Nasofrontal duct obstruction

77.  Retention cyst and Pseudocyst: Together called antral cyst or mucosal
cyst
 Indistinguishable on radiological or clinical examination.
 Quite common.
 Mostly - single cysts, but in a few instances - they may be multiple
and bilateral.
 Clinical features:
 Usually asymptomatic – discovered during radiographic
examination
 Symptoms – similar to chronic sinusitis
 Sometimes an antral cyst may produce a swelling

78.  Diagnosis :CT based
 Spherical, ovoid or dome-shaped radiopacities that have a
smooth and uniform outline
 narrow or broad base.
 Size from minute to very large
 Usually remain static
 Many regress spontaneously

79. POST-OPERATIVE MAXILLARYCYST
(SURGICALCILIATEDCYSTOFMAXILLA)
 Delayed complication arising years after surgery of maxillary sinus.
 Causes:
 Caldwell–Luc procedure including a nasal antrostomy
 Gun- shot injuries
 Fractures of the malar–maxillary complex
 Mid-face osteotomies.
 Clinical features:
 Pain, discomfort or swelling in the cheek or face, or intra-orally in the
palate or alveolus.
 Pus discharge.
 Radiographs - well-defined radiolucent area closely related to the
maxillary sinus.
 Treatment: enucleation.

80. TUMORS
 0.2% of all malignancies
 80% - maxillary sinus.
 Men>> women.
 40 and 70 years.
 Carcinomas >> sarcomas
 Metastases are relatively rare.
 Tumours of the sphenoid and frontal sinuses are extremely rare - no
standard staging system
 Most common - squamous cell carcinoma

81. WHO HISTOLOGICAL CLASSIFICATION OF NASAL
AND PNS TUMORS

82. TNM CLASSIFICATION OF CARCINOMAS OF
NOSE AND PARANASAL SINUSES
.

83. Risk factors:
1. Woodworking (carpentry), Shoemaking, Metal-plating, Flour mill or bakery
work.
2. Human papillomavirus (HPV) infection
3. Male
4. Older than 40 years.
5. Smoking.

84. Clinical features
 No signs or symptoms in the early stages.
 later:
 Blocked sinuses that do not clear, or sinus pressure.
 Headaches or pain in the sinus areas.
 Rhinitis and epistaxis
 A lump or sore inside the nose that does not heal.
 A lump on the face or roof of the mouth.
 Numbness or tingling in the face.
 Swelling or other trouble with the eyes, such as double vision or the
eyes pointing in different directions.
 Pain in the upper teeth, loose teeth, or dentures that no longer fit
well.
 Pain or pressure in the ear.

85. Treatment
1. Surgery: For all stages of paranasal sinus and
nasal cavity cancer.
 Transfacial approaches
 1. lateral rhinotomy/ weberfergussen incision
 2. diffenbech extension
 3. Lynch extension with the modification
 External ethmoidectomy/frontoehtmoidectomy
 Bicoronal with Mid face degloving
 Subcranial approach
 Acess osteotomies

86.  Trans oral approach:
 Caldwell lue
 Denker
 Janson – horgan approach
 Trans nasal:
 Transseptal approach
 Endoscopic approaches

87. Draw backs of endoscopic
approach
 -Not indicated in case of extensive involvement
 Trans orbital extension
 Scar tissue due to previous surgery
 in case to reduce the bony fracture

88.  TRANSORAL ROBOTIC SURGERY
 New advances in technology facilitate minimal access
 To avoid large transcervical or face-splitting incisions.
 Transoral robotic surgery allows access to tumors within the posterior oral
cavity and oropharynx via multiple robotic arms and a high-definition/
magnification camera.
 The operator sits at a separate console and via remote control can operate
the various instruments.
 Electrocautery, laser, and standard dissection instruments can be used with
the robot.
 Advantages include surgical access via minimal approaches, resulting in
definitive pathologic assessment while minimizing transection and resection
of critical swallowing musculature
Oral Maxillofacial Surg Clin N Am 24 (2012) 307–316

89. Trans oral Robotic surgery
 more-precise movements in narrow spaces and the capability to work
around corners.
 This result in preservation of maximum amount of healthy muscular
and neurovascular tissue which helps the patient swallow on their
own sooner and discharged home earlier.

90. 1. Radiation therapy: External radiation therapy, Internal radiation
therapy - depending on the type and stage of the cancer being treated.
 IMRT:
 Intensity-modulated radiation therapy (IMRT) can deliver high doses of
radiation with precision while minimizing damage to surrounding
tissues.
 IMRT can conform to the irregular shape of a tumor, delivering higher
doses directly to the tumor cells and potentially destroying more tumor
cells.
 The technique requires more precise planning due to the sharp dose
falloff gradient between the gross tumor and the surrounding normal
tissue.
 IMRT provides locoregional control (90%) and is well tolerated by
patients.
Oral Maxillofacial Surg Clin N Am 24 (2012) 307–316

91. Chemotherapy:
 Systemic chemotherapy: When chemotherapy drug is given PO, IV or
IM the drugs enter the bloodstream and can reach cancer cells
throughout the body
 Regional chemotherapy: When chemotherapy is placed directly into
the cerebrospinal fluid, an organ, or a body cavity, the drugs mainly
affect cancer cells in those areas.
 Combination chemotherapy is treatment using more than one
anticancer drug.
 The way the chemotherapy is given depends on the type and stage of
the cancer being treated.
 Intra arterial cisplastin therapy: As a primary therapy, the complete
response rate was 83.3%, The 2-year local control rate was 63.0%, and
the 2-year overall survival rate was 75.5%. The 2-year preservation
rate of the hard palate was 97.1%, that of the eyeball was 97.2%, and
that of visual function was 94.4%. This treatment regimen can
contribute to improving the quality of life of patients without reducing
the curability of the therapy.
Int. J. Oral Maxillofac. Surg. 2015; 44: 697–704.

92. Other surgically relevant conditions
 Oro-antral communication/fistula
 Antral foreign bodies
 Hypertrophied maxillary sinus

93. Oro-Antral Fistula (oaf)
 Oro-antral communication: it is an abnormal connection between oral
and Antral cavities.
 Oro-antral fistula: long standing oro-antral communication when left
open, epithelializes to form a patent fistula between the two cavities.
 Types:
 ALVEOLOSINUSAL
 PALATO-SINUSAL
 VESTIBULO-SINUSAL
Oro-Antral Communications

94. CAUSES:
 Extraction – maxillary posterior teeth
 Cysts, tumors
 Osteomyelitis
 Radiation therapy
 Trauma
 Implant denture
CLINICAL FEATURES:
 Some patients are asymptomatic
 Unpleasant tasting discharge and odor
 Reflux of fluids and foods into the nose from mouth
 Leakage of air
 Difficulty in smoking and blowing air
 Development of chronic sinusitis in infected cases

95. Diagnosis:
 Valsalva maneauver
 Mirror fog test
 Cotton wisp test
 Nasal regurgitation of fluid
 Radiographs: Sinus floor discontinuity, Sinus opacity, Focal alveolar
atrophy, Associated periodontal disease
Oro-Antral Communications (UL7)

96. Treatment:
 Immediate treatment: Primary purpose is closure of defect and
prevention of sinusitis through:
 Suturing across the defect with/without periodontal pack, warm
saline rinses, antibiotic and antihistaminic therapy with
decongestants.
 Size < 5mm: non-invasive intervention (spontaneous closure by
blood clot)
 Size > 5mm, and > 48 hours - : surgical closure : small defects –
local flaps; large defects – regional/distant flaps.

97.  Obturators
 Buccal Advancement Flap most common.
 Described by Rehrmann & made popular by Berger.
 Trapezoidal sliding flap – Moczair
 buccal osteoperiosteal flapOro-Antral Communications

98.  Palatal flaps
1. Palatal rotational advancement flap most common
2. V-shaped palatal flap (kruger) &
3. Split-thickness palatal flap (ito & hara).Oro-Antral Communications

99.  Combination flaps
 Inverted periosteal flap
 Tongue flap, temporalis flap
 BFP closure
 PRF membrane coverage
 Autologous bone grafts: press-fit
technique
 Autologous cartilage grafts: auricular
cartilage, auricular cartilage
 Alloplastic materials
 Transplantation of a mature wisdom
tooth (followed by root canal treatment of
the tooth 5 - 6 weeks later)
 Laser bio-stimulation (over 5 days)
Oro-Antral Communication

100. ANTRAL FOREIGN BODIES:
 Gutta-percha points, tooth roots,
impression materials, dental
burs, bone pieces , implants etc..
Treatment has been direct
explored by Caldwell-Luc
approach, with or without nasal
antrostomy. FESS may be done
for sinusitis.
HYPERTROPHIED MAXILLARY SINUS:
 Not pathology but causes
difficulty in implant supported
rehabilitation of posterior
maxilla, with the risk of
subsequent development of sinus
pathologies. The management
includes direct and indirect sinus
lifting.
Oro-Antral Communications (UL8)

101. Complications
 Because of the proximity of the paranasal sinuses to the eyes and
brain, complications of sinusitis are divided into
 orbital,
 neurological and
 local complications.

102. Orbital complications
 highest frequency - in children under 6 years of age.
 Infection usually originates from the ethmoids and occurs through:
(1) direct extension through the orbital wall
(2) retrograde spread through veins between the sinuses and the orbit.
 Lymphatic spread – not significant

103. Orbital complications
1. Preseptal cellulitis, or periorbital cellulitis
2. Orbital cellulitis and edema
3. Subperiosteal abscess
4. orbital abscess
5. Cavernous sinus thrombosis: direct extension or retrograde
thrombophlebitis (via the ophthalmic vein) of ethmoid or sphenoid
infections.
 restriction of extra ocular mobility, proptosis, chemosis, and visual loss
 cranial neuropathies and signs of meningitis

104. Neurological complications
 Less frequently than orbital
 Most commonly related to the
frontal or sphenoid sinuses.
 Via - direct spread or retrograde
thrombophlebitis.
A – osteomyelitis
B - periorbital abscess
C – epidural abscess
D – subdural abscess
E – brain abscess
F – meningitis
G - septic thrombosis of superior sagittal
sinus

105. Local complications
 Osteomyelitis - complication of frontal sinusitis.
 Tender, doughy, erythematous swelling over the forehead.
 Treatment of choice - surgical eradication of the affected bone under
antibiotic coverage.

106. REFERENCES
1. References:
2. Peterson’s principles of oral and maxillofacial surgery
 DISEASES of the SINUSES Diagnosis and Management- DAVIDW. KENNEDY, MD, FACS
1. WHO classification of head and neck tumors
2. PL Dhingra - Disease of ear, nose & throat 4th edition
3. Rosai and Ackerman’s Surgical Pathology (9th edition)
4. David L. Daniels et.al. The Frontal Sinus Drainage Pathway and Related Structures, AJNR: 24,
August 2003.
5. Interactive Atlas. http://uwmsk.org/sinusanatomy2/axial/axial.html
6. (Adapted from Chow AW, Benninger MS, Brook I, et al: IDSA clinical practice guideline for acute
bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases 54 (8):1041–5 (2012).)
7. Thompson and Patterson: Fungal disease of the nose and paranasal sinuses:J Allergy Clin
Immunol 2012;129:321-6.
8. Multiplanar Sinus CT: A Systematic Approach to Imaging Before Functional Endoscopic Sinus
Surgery Jenny K. Hoang, James D. Eastwood, Christopher L. Tebbit, and Christine M. Glastonbury
American Journal of Roentgenology 2010 194:6, W527-W536

107.  Raef S. Ahmed, Roger Ove, Jun Duan, Richard Popple, Glenn B. Cobb Intensity-modulated
radiotherapy (IMRT) for carcinoma of the maxillary sinus: A comparison of IMRT planning systems
Medical Dosimetry, Volume 31, Issue 3, Autumn 2006, Pages 224-232
 Management of rhinomaxillary mucormycosis with Posaconazole in immunocompetent patients
Sachin Rai *, Shikha Yadav, Dinesh

 Kumar, Vijay Kumar, Vidya Rattan Journal of Oral Biology and Craniofacial Research xxx (2016) xxx
 Modified transnanal endoscopic maxillectomy: a novel surgery style of maxillary malignant tumor
Yonghua Bi1,2, Shuangba He1, Tao Guo1, Jingwu Sun Int J Clin Exp Med 2016;9(6):11361-11366
 Modified double-layered flap technique for closure of anoroantral fistula: Surgical procedure and
case reportAlberto Merlinia, Joseph Garibaldia, Matteo Piazzaia, Luca Giorgisb, British Journal of
Oral and Maxillofacial Surgery 54 (2016) 959–961
 Repair of Oroantral Communication by Use of a Combined Surgical Approach Functional
Endoscopic Surgery and Buccal Advancement Flap/Buccal Fat Pad Graft Timothy Adams, DDS,*
Daniel Taub, DDS, MD,y and Marc Rosen, MD. J Oral Maxillofac Surg 73:1452-1456, 2015


 An Update on Squamous Carcinoma of the Oral Cavity,Oropharynx, and Maxillary SinusJoshua E.
Lubek, DDS, MDa,*, Lewis Clayman, DMD, MD Oral Maxillofacial Surg Clin N Am 24 (2012) 307–316

108. Thank you