17. Maxillary sinus, antrum of highmore, surgical anatomy

surgical anatomy, clinical considerations, importance of sinus

1. MAXILLARY SINUS ( ANTRUM OF HIGHMORE ) Dr. Nadella Koteswara Rao Professor & HOD Dept of OMFS Drs. Sudha & Nageswara Rao Siddhartha Institute of Dental Sciences

2. INTRODUCTION EMBRYOLOGY & ANATOMY FUNCTIONS DISEASES MAXILLARY SINUSITIS ORO-ANTRAL COMMUNICATION CYSTS & TUMOURS OF THE SINUS CALDWELL-LUC PROCEDURE MAXILLARY SINUS

3. INTRODUCTION The maxillary sinus first discovered & illustrated by L eonardo da vinci Detailed description of the sinus/antrum has been given by highmore in the 17 th centuary. maxillary sinus is also called as “ Antrum of Highmore ” Maxillary sinus is a pneumatic space that is lodged inside the body of maxilla & that communicates with environment by way of the middle meatus & nasal vestibule. Maxillary sinus is Pyramidal in shape.

4. C on t … John Hunter gave details about dental infections spreading to maxillary sinus. There are group of sinuses in the facial region which are inter related .

5. GROUP OF SINUSES FRONTAL SINUS ETHMOIDAL SINUSES SPHENOIDAL SINUSES MAXILLARY SINUSES

6. C on t …. All the sinuses are inter related and infection involving all sinuses is called Pansinusitis . Sinuses are empty cavities filled with air & has mucosal lining. The size of sinuses varies in different skulls & even on two sides of the same skull.

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

8. DEVELOPMENT OF THE MAXILLA / SINUS Tubular – birth Ovoid- childhood Pyramidal- adult

9. Growth of the maxillary sinus

10. C on t …. The pyramidal shaped Maxillary sinus is located within the body of the maxilla. Lining of the sinus is with PSEUDOSTRATIFIED CILIATED COLUMNAR epithelium( SCHNEIDERIAN MEMBRANE). The adult sinus can accommodate about 20 to 30ml of solution .

11. ANATOMY DIMENSIONS OF THE SINUS: Antero - posteriorly, it is 35mm Medio - laterally, it is 26mm Height, it is 32mm Thickness of bony wall average is 2-5mm

12. BOUNDARIES OF THE SINUS Roof: By the floor of the orbit -Medially: By the lateral wall of nose Floor: By the alveolar process -Laterally: Zygomatic process of maxilla Anteriorly: Facial aspect of maxilla Posteriorly: By maxillary tuberosity.

13. A N A T O M Y DRAINAGE OF SINUS : Sinus opens into middle meatus on the lateral wall of the nose. The opening is called OSTIUM . The mucosal secretion of the sinus are drained into the nose through ostium with the help of cilia.

14. OPENING OF SINUS

15. Air entry into the sinus

16. FUNCTIONS OF THE SINUS REDUCTION OF SKULL WEIGHT VOICE RESONANCE HUMIDIFICATION & WARMING OF AIR SHOCK ABSORPTION TO THE FACE / SKULL SINUS MUCOUS ABSORBS POLLUTES & TRAPS BACTERIA

17. ANATOMY BLOOD SUPPLY : Facial artery, Infraorbital artery & Greater palatine artery. VENOUS DRAINAGE : Facial & Pterygoid plexus of veins.

18. C on t …. NERVOUS SUPPLY : - Branches of Maxillary nerve Infraorbital, Anterior, Middle & Posterior superior alveolar Nerve. LYMPHATIC DRAINAGE : Submandibular lymph nodes.

19. A PP L I E D A N A T O M Y AGE : Less chances of creating oro-antral communication below 14 years of age. In adults the bone thickness between the apical end of the roots of the upper posterior teeth & floor of the maxillary sinus is about 1 to 1.2 cm. Sometimes even lesser. PROXIMITY : Second molar roots are in close approximation to the sinus followed by first & third.

20. C on t …. SWELLINGS : Any swelling in the sinus erode the thin walls of the sinus & present as a swelling on the cheek, buccal & palate. TUMORS : Tumors extending towards the orbit may lead to exopthalmus, diplopia & loss of sight in advanced stages. FRACTURES : In case of middle third # of face, sinus wall # easily.

21. C on t …. ROOT LENGTH : In some cases, floor of the sinus lies in between the roots of the same tooth or the adjacent teeth. INFECTION : Periapical infections of the tooth close to the sinus can cause oro-antral communication on extracting the tooth.

22. Applied Aspect OHNGREN’s line/Plane: From the medial canthus of the eye to the angle of the mandible. The tumors present anterior to this line have better prognosis .

23. DRAPING With the greater pneumatization of the alveolar process, the floor of the maxillary sinus may appear to undulate around the roots of the teeth, giving the appearance that the tooth roots have penetrated the sinus floor. SHILOUETTE EFFECT This allows the surface contour of soft tissue structures to become visible by contrasting them against air-filled spaces.

24. DISEASES - MAXILLARY SINUSITIS SINUSITIS - Inflammation of the mucous membrane of the sinus. Infection to the sinus mainly occurs through the nose , oral cavity & rarely from the orbit. Infection may spread to other sinuses & when all the sinuses are involved it is called PANSINUSITIS.

25. MAXILLARY SINUSITIS ETIOLOGY - ALLERGY & IMMUNITY INFECTION (Periapical abscess, Infected cysts…etc ) TRAUMA SURGERY ANATOMIC ABNORMALITIES FOREIGN BODIES GENETIC FACTORS

26. MAXILLARY SINUSITIS MICROBIAL FLORA Aerobic bacteria - Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus Anaerobic bacteria - Streptococci & Peptococci are also seen. Viruses - Rhinovirus , Influenza virus A & B, Adenovirus. Fungi - generally rare but seen in immunocompromised pts. Aspergillus , Zygomycosis, Phaeohyphomycosis.

27. CLASSIFICATION 1 Acute s i nus i t i s Less than 4 weeks 2 Suba c ute sinusitis 4-12 weeks 3 Ch r on i c sinusitis More than 12 weeks

28. MAXILLARY SINUSITIS CLINICAL FEATURES : ACUTE Head ache / heaviness Facial pain increases on changing head position Mild fever / chills Nasal obstruction / blockage Difficulty in breathing Fatigue Cough Teeth in the area of sinusitis may be painful Lymphadenopathy

29. CHRONIC Continuous dull pain Pain on percussion of the involved teeth Mild fever Lymphadenopathy Heaviness of head Purulent discharge from nose Oro-antral fistula may be present Halitosis Ear pain may be associated M AX I LLA R Y SI NU SI T I S CLINICAL FEATURES :

30. DIAGNOSTIC FEATURES Pain, pressure,swelling -- anterior sinus wall Nasal obstruction, Epistaxis,discharge-medial wall Diplopia, proptosis-superior wall Trismus-lateral wall PHYSICAL EXAMINATION INSPECTION PALPATION & PERCUSSION

31. RHINOSCOPY Vestibule of nose Nasal mucosa Nasal septum Lateral wall of nose NASAL ENDOSCOPY: 4mm diameter 30 degree telescope SINUS ENDOSCOPY Intra-sinus pathologic condition Therapeutic procedure ASPIRATION Diagnosis

32. 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.

33. INVESTIGATIONS Radiography : EXTRAORAL VIEWS :Occipitomental/waters view Lateral skull Submentovertex Linear tomography Or t hop a n t o m ogr a phy Computed axial tomography INTRAORAL VIEWS: Occlusal Lateral occlusal Periapical Culture & Sensitivity test : - To know the causative organism

34. MAXILLARY SINUSITIS - TREATMENT ACUTE PHASE Broad spectrum antibiotics which cover both aerobic & anaerobic bacteria. Ex - CEFADROXYL & ORNIDAZOLE. Nasal decongestants (drops) Anti histamines Steam inhalation - camphor, menthol, etc Anti inflammatory drugs.

35. C H R ONIC P H ASE Underlying cause dental infection, foreign body, p o l y p s , n a s al in f e cti o n s e t c a r e id e nti f i ed & t rea t ed accordingly. Antral wash is done with antiseptic solution. Nasal antrostomy is performed. C al d w ell o pera ti o n d o n e t o re m o v e p o l y ps & f o re i gn bodies. Medicines - Antibiotics & Antinflammatories. F E S S – Functional Endoscopy Sinus Surgery

36. ORO-ANTRAL COMMUNICATION/ FISTULA The term communication is used when the openning just happened between oral cavity & the antrum. If the openning persists for long then it is called fistula where epithelial linning is formed between the antrum & oral cavity.

37. OCCURRENCE Frequency of Oro-Antral communication related to the location

38. ETIOLOGY ~ Extraction of posterior teeth(specially 1 st & 2 nd molar) ~ While removing broken root piece from the socket. ~ Sometimes root piece enters the sinus. ~ Periapical lesions of upper posterior teeth. ~ Mid facial trauma. ~ Osteomyelitis of the maxilla. ~ Severe infections ~ Malignancy involving the maxilla.

39. ORO-ANTRAL COMMUNICATION / FISTULA CONFIRMATION OF THE COMMUNICATION Probe can be used to detect & confirm the communication. BUBBLE TEST NOSE BLOWING TEST Rinse the mouth with large volume of water, water droplets seen escaping through the nose in case of communication. Inject normal saline into the suspected socket, & ask the pt. to bend his head, communication confirms if water comes through the nose.

40. SEQUELAE OF ORO-ANTRAL COMMUNICATION Infection of the sinus & its spread Fistula formation Voice incompetence Food particles enter into sinus

41. Clinical & Radiological Confirmation

42. O R O- A NT RAL C O MM U N I C A T ION MANAGEMENT CONSERVATIVE MANAGEMENT If the communication is less than 0.5mm, the just suture the marginal gingiva on either sides of the socket. Partial denture covering the communication.

43. SURGICAL PROCEDURES FOR CLOSURE OF O-A COMMUNITION Buccal advancement flap (REHRMANN’S FLAP) Palatal flap (ASHLEY’S FLAP) Buccal pad of fat Combination of both buccal & palatal flap Tongue flap Foreign material (GOLD FOIL, ACRYLIC PLUG)

44. O R O- A NT RAL C O MM U N I C A T ION MANAGEMENT GENERAL PRINCIPLES - Blood supply should be adequate so that flap necrosis is avoided Incision line should be on the sound bone. Wound is not sutured under tension. The flap design should give adequate visibility & accessibility.

45. COMMON PROCEDURES TO CLOSE THE COMMUNICATION Buccal advancement flap ( Rehrmann’s flap ) Palatal pedicle flap ( Ashlay’s flap ) Combination procedure.

46. BUCCAL FLAPS Advancement Flap Sliding Flap

47. PALATAL FLAPS Ashley’s Pedicled Flap Rotational Advancement Flap Submucosal Connective Tissue Flap Hinged Flap

48. COMBINATION OF BOTH Bipedicled flap

49. Distant flaps The limited size of local flaps makes it difficult to close large fistulas. Therefore distant flaps have been are used. They are Flap from extremities Flap from forehead Tongue flap Temporalis flap Buccal fat pad flap

50. ALLOPLASTIC GRAFTS A variety of alloplastic and allogenic materials have been used. § Gold foil § Tantalum § Polymethyl methacrylate § Lyophilized porcine collagen § Hydroxyapatite block § Fibrin glue

51. WHITE HEAD VARNISH Benzoin 10 parts (44g) Storax 7.5 parts (33g) Balsam of tolu 5 parts (22g) Iodoform 10 parts (44g) Solvent- ether to 1 fl oz or 100 parts

52. POST - OP INSTRUCTIONS ~ Advised not to blow the nose, as it creates pressure at the site of the closure of the communication. ~ Advised not to open mouth wide, as it stretches the flap. ~ No rinsing / gargling of mouth. ~ No smoking. ~ Advised slow sneezing & limited mouth opening. ~ Advised nasal decongestants. ~ Sutures to be removed after 7 days. ~ Advised antibiotics & anti - inflammatories.

53. ROOT IN THE SINUS ON CLINICAL & RADIOLOGICAL ( IOPA ) CONFIRMATION ROOT IN THE SINUS IS REMOVED BY VARIOUS METHODS. Socket apices is widened twice the size of the root piece. Lot of saline is pushed into the socket & in turn into the sinus, as the root piece gets flushed out. A thin long ribbon gauze is pushed into the sinus through the socket & removed in single jerk motion. High vacuum suction is used. Sinus opened buccally at the site of the root piece & removed. IF EVERY THING FAILS THEN CALDWEL-LUC OPERATION IS PERFORMED

54. CALDWEL - LUC OPERATION

55. CALDWELL-LUC OPERATION INDICATIONS: For removal of the tooth/root in the sinus, this approach eliminates the blind procedures. For removal of any foreign body in the sinus. In case of trauma of mid facial region, when the roof of the sinus is fractured & the floor of the orbit is dropped, injury is best corrected by this procedure. In case of chronic sinusitis, to remove the sinus lining. In case of removal of any cysts in the sinus. To remove the polyps in the sinus. Management of hematomas of sinus, mainly occurring from the nose bleed. Small neoplasm's of the sinus, best removed by this procedure .

56. CALDWELL - LUC OPERATION PROCEDURE: Procedure can be done under L A & Sedation or G A Upper li p i s e l eva t ed, ver ti cal i nc isi ons d ist al t o l a t eral i nc is or & distal to 1 st molar are made. E it her g i ng i val crev i cu l ar hor i zon t al i nc isi on or hor i zon t al i nc isi on made few mm above the attached gingiva is given. Mucoperiosteal flap raised till infraorbital margin superiorly. Care taken to prevent the damage of the infraorbital nerve. On the facial wall of the sinus with the help of bur & hand piece, an opening of about 1.5 cm in diameter is made. Through the opening purpose of the operation is accomplished Sinus is irrigated with antiseptic solution, flap placed back & sutured over the bone.

57. FUNCTIONAL ENDOSCOPY SINUS SURGERY (FESS TECHNIQUE) FESS is classically described as an intranasal endoscopic technique that allows the establishment of adequate sinus drainge without a negative impact on sinus mucosal physiology and function. The ideas of FESS is to stop the sinusitis cycle, which begins with ostium blockage that leads to chronic sinusitis via stagnated secretions, tissue inflammation, and bacterial infection. FESS concentrates on opening the OMC, thereby allowing adequate ventilation and drainge of the maxillary, anterior & middle ethmoidal and in most cases, the frontal sinuses. Kennedy coined the term FESS for surgical procedure that involves precise resection of inflamed mucosa in the anterior ehtmoidal cells combined with widening of the natural middle meatal ostium of the maxillary sinus, the hiatus semilunaris.

58. Rigid endoscopes with various angled lenses of 0o, 30o & 70o-are used. Once adequate intranasal vasoconstriction has been achieved, the procedure is begun by removing the unicinate process. The anterior ethmoid cells including ethmoid bulla, are then opened to intranasal space using sharp dissection with rongeur under endoscopic vision. Microdebriders, which are powered rotary shaving devices, also can be used to resect tissue precisely during such dissection. Medial wall of the orbit is then identified and this serves as the lateral limit of the surgical dissection. This area is opened caudally by removing the anterior ethmoidal cells, including the natural ostium of the maxillary sinus. The frontal recess may then be approached by proceeding along the ethmoidal roof from a posterior to anterior direction.

59. Such endoscopically assisted surgery allows vision and surgical access to areas that were previously only approached externally with procedures such as the external ethmoidectomy, frontal sinus external sinusotomy, transnasal radical sphenoidectomy and the Cadwell-Luc maxillary sinustomy. Minor Complications: Ø H e m o rr h a ge Ø Scarring Ø H ypo s mi a Ø Epiphoria Ø Orbital ecchymosis or emphysema Ø Dental hypesthesia Major Complications: Ø Cerebrospinal fluid rhinorrhea & meningitis Ø Intracranial injury Ø Orbital trauma with possible diploplia or visual loss Ø Even death from carotid artery injury (the internal carotid artery can be found in the lateral wall of sphenoid sinus)

60. COMPLICATIONS Pain Hemorrhage Infection of wound Parasthesia Relapse of illness Blindness Cavernous sinus thrombosis

61. TUMORS OF MAXILLARY SINUS

62. COMMON TUMORS OF MAX.SINUS BENIGN Osteoma Fibrous Dysplasia Ossifying Fibroma INTERMEDIATE Inverted Papiloma Haemangiopericytoma MALIGNANT Basal cell carcinoma Verrucous carcinoma Squamous cell carcinoma

63. ESSAY Discuss maxillary sinus pathology and management.-20marks (November -2007,April-2012) Write the surgical anatomy of maxillary sinus. Describe the indications & surgical procedure of sinus lift procedure - (April-2010) Management of carcinoma of maxillary sinus. Describe the surgical anatomy of maxillary sinus & explain the management of chronic oroantral fistula Discuss various maxillary sinus lift procedures and add a note on materials used in socket grafting. Classify the tumors arising from the maxillary sinus.Write in detail about the surgical management of malignant tumors inside the maxillary sinus.

64. SHORT NOTES Caldwell luc procedures (April-2012,April -2015,June -2017) Give the development ,growth &surgical anatomy of maxillary antrum. How will you trear a case of oroantral fistula and causes for the same. (April-1997,December – 2002) Maxillary sinus & its applied aspects 4.Maxillary sinusitis 5. Management of odontogenic infections of maxillary sinus 6.Cysts of maxillary sinus Endoscopic sinus procedures Sinus lift & its indications Management of displaced palatal root in the maxillary sinus