Differential diagnosis of haziness of maxillary sinus

Differential diagnosis of haziness of maxillary sinus fromTextbook of Dental and Maxillofacial Radiology, Freny R Karjodkar,3rd edition
Principles and interpretion of oral radiology,white and pharoah

1. Seminar topic - pigmentations 1.Why melanosis is seen in HIV patients Drug - zidovudine

2. Differential diagnosis of haziness of maxillary sinus Seminar -11 Presented by N. Narmatha II year PG

3. contents Introduction Anatomy Classification Imaging modality Clinical features

4. Introduction P aranasal sinuses are air filled cavities of the craniofacial complex comprising the maxillary, frontal, sphenoidal sinuses and the ethmoidal air cells M axillary sinuses because of their close proximity to the dental structures are of importance to the dental surgeon

5. Anatomy of the Maxillary Sinus

6. CLASSIFICATION Traumatic Infection/inflammatory Cysts Neoplasms Metabolic and Endocrinal Calcifications Syndromes (Developmental)

7. General Clinical Features • Feeling of pressure • Altered voice characteristics • Pain on movement of head • Percussion sensitivity of teeth or cheek region • Regional paresthesia or anesthesia • Swelling of the facial structures adjacent to the maxilla

8. Applied Diagnostic Imaging Intra oral periapical radiograph Floor Relationship with upper posterior teeth

9. P anoramic radiograph Depicts both maxillary sinuses

10. Standard Occipitomental Projection (0° OM)

11. Water's view optimal for visualization to compare internal radiopacities roof, medial walls allows the comparison of both the maxillary sinuses.

12. LATERAL SKULL to view the sphenoidal and maxillary sinuses; the anterior and superior walls all four pairs of paranasal sinuses

13. SUBMENTOVERTEX evaluating the lateral and posterior borders of the maxillary sinus as well as the ethmoid air cells

14. Computed tomography determine the extent of the disease in patients who have chronic or recurrent sinusitis . H ounsefield unit for Air − 1000

15. Coronal CT provides superior visualization of the osteomeatal complex, nasal cavities for demonstrating any reaction in the surrounding bone

16. SCINTIGRAPHY to demonstrate physiological changes In case of extension of the antral carcinoma to involve bone, the osteoblastic response produced is clearly evident in the delayed phase of a radionuclide bone scan.

17. Ultrasound is effective in distinguishing normal sinuses , chronically inflammed sinus lining , sinus filled with fluid, tumor or scar

18. MAGNETIC RESONANCE IMAGING extremely sensitive in demonstrating maxillary antrum pathology to delineate soft tissues in the sinus, very clear comparative view of the two sinuses differentiate retained fluid secretions from soft tissue masses in the sinuses .

19. CALDWELL’S POSTEROANTERIOR VIEW Good visualization of the frontal sinus, ethmoidal air cells , nasal cavity and superior portion of the maxillary antrum

20. Developmental Crouzon's syndrome Treacher Collin's syndrome Binder's syndrome

21. CROUZON'S SYNDROME Early synostosis of the sutures – hypoplasia of the maxilla and maxillary sinus, high arched palate

22. TREACHER COLLIN'S SYNDROME Grossly and symmetrically underdeveloped maxillary sinuses and malar bones

23. BINDER'S SYNDROME Maxillonasal dysplasia Hypoplasia of the middle third of the face Maxillary retrognathism Maxillary sinus hypoplasia Diagnosed at 24 weeks of gestation using two and three-dimensional ultrasound, amniocentesis

24. Mucositis (thickened mucous membrane) Etiology Infectious or allergic process - mucosa becomes inflamed - thickness 10 to 15 times - mucositis Any thickening > 3 mm - pathological. Clinical features Asymptomatic Discovered on a routine radiograph.

25. Radiographic features Non-corticated band Mucosal thickening seen distinctly on denta scan Management : R emoval of the cause

26. Maxillary Sinusitis Generalized inflammation of the paranasal mucosa Etiologic agent Allergen, bacterial or viral. Blockage of drainage from the ostiomeatal complex. Inflammatory changes – ciliary dysfunction and retention of sinus secretions

27. Maxillary sinusitis • Acute sinusitis —less than two weeks • Subacute sinusitis —two weeks to three months • Chronic sinusitis —more than three months

28. Radiographic Features • R adiopaque • M ost common radiopaque patterns on the Water's view are: – Localized mucosal thickening along the sinus floor – Generalized thickening of the mucosal lining

29. – In allergic reaction mucosa tends to become lobulated. – In infection- thickened mucosal outline tends to be smoother, with its contour following the sinus floor.

30. Air fluid level resulting from the accumulation of secretions may be present Fluid appears radiopaque

31. Chronic sinusitis Persistent radiopacification of the sinus with sclerosis and or thickening of the sinus wall . The resolution of acute sinusitis becomes apparent till the sinus appears normal.

32. Additional Imaging CT T1-weighted MRI images T2-weighted MRI T1- weighted post Gd Management: to control the infection, promote drainage and relieve pain.

33. Empyema Cavity filled with pus Result as a possible sequela of sinus ostium blockage Variant of a mucocele or pyocele Radiographic features Sinus appears completely radiopaque Decalcification of the surrounding bony walls and haziness of trabecular bone next to the sinus wall is seen Extend into the adjacent bone - osteomyelitis

34. Cyst - not lined by epithelium - pseudocysts Blockage of secretory ducts / cystic degeneration Clinical features Most common - maxillary sinus Not related to extractions nor associated with periapical disease Asymptomatic Localized pain and feeling of fullness or numbness nasal obstruction and postnasal discharge Copious discharge of yellow fluid from the nostrils

35. Radiographic Features non-corticated , smooth domeshaped radiopaque masses no osseous border surrounds it The sinus floor is intact, with a persistent thin radiopaque line of the antral cortex

36. Additional Imaging

37. Differential Diagnosis • Inflammatory lesions • Odontogenic cyst , Apical radicular cyst , dentigerous cyst, odontogenic keratocysts and cyst of the globulomaxillary area are the most common • Antral polyps • Benign Neoplasms • Malignant neoplasms Management : N o treatment

38. Mucocele - expanding, destructive lesion Etiology B locked sinus ostium If the mucocele becomes infected - pyocele , mucopyocele . Clinical Features Thinning , displacement and in some cases destruction of the sinus walls Radiating pain with a swelling and fullness of the cheek.

39. If the lesion expands inferiorly - loosening of the posterior teeth. medially - lateral wall of the nasal cavity will deform , nasal airway obstruction into the orbit – diplopia or proptosis

40. Radiographic Features Maxillary sinus - circular shape as the mucocele enlarges Septa and bony walls may be thinned / destroyed . Teeth may be displaced and/or roots resorbed . uniformly radiopaque Additional Imaging CT T1 and T2 weighted MRI images

41. Differential Diagnosis: • Cyst • Benign tumor • Malignancy • Any suggestion of a lesion associated with occluded ostium should be a mucocele odontogenic cyst Management: Surgical removal by the Caldwell-Luc operation.

42. Surgical Ciliated Cyst of the Maxilla delayed complication arising years after surgery Clinical Features 4th -5th decade pain , discomfort or swelling of the face intra oral swelling of the palate or alveolus, with pus disharge

43. Radiographic Features well-defined radiolucency closely related to the maxillary sinus sclerosis of the surrounding bone thinning of the sinus walls resorption of the maxillary alveolar process Management : Enucleation

44. RHINOLITH AND ANTROLITH Hard calcified bodies or stones that occur in the nose – rhinoliths or antrum - antroliths In rhinolith the nidus is exogenous foreign body (coin, beads) T he nidus for an antrolith is endogenous ( root tip , bone fragment, masses of stagnated mucus, etc )

45. CLINICAL FEATURES • asymptomatic initially. • With increase in size - pain,congestion and ulceration. • M ay develop unilateral purulent rhinorrhea , sinusitis, headache, epistaxis, nasal obstruction , anosmia, fetor, fever and facial pain

46. RADIOGRAPHIC FEATURES • well-defined smooth or irregular borders . • homogeneous or heterogeneous radiopacities – density may exceed the surrounding bone. • Antroliths seen on the periapical , occlusal and panoramic radiographs .

47. DIFFERENTIAL DIAGNOSIS • Osteoma • Healing odontogenic cyst • Root fragments MANAGEMENT: R eferred to an otorhinolaryngologist for the removal of the stone .

48. BENIGN NEOPLASMS Benign Neoplasms – rare Radiographic images - nonspecific Appears radiopaque - displacement of the adjacent sinus borders

49. POLYPS Thickened mucous membrane of a chronically inflamed sinus frequently forms into irregular folds called polyps Clinical Features arise from any part of the sinus wall pass through the opening to appear in the nose as antrochoaneal polyp cause bony displacement or destruction of bone

50. Radiographic Features H omogeneous radiopaque mass of soft tissue density in the nose or sinus • Bone destruction

51. Differential Diagnosis Retention pseudocyst Benign tumor malignancy Bone destruction with radiopacification is an indication for biopsy.

52. EPITHELIAL PAPILLOMA Rare neoplasm of respiratory epithelium Clinical Features more common in ethmoidal and maxillary sinus appear as an isolated polyp in the nose unilateral nasal obstruction, nasal discharge , pain and epistaxis history of recurring sinusitis

53. Radiographic Features homogeneous radiopaque mass of soft tissue density bone destruction r adiographic features are not specific and diagnosis is based only on histological examination

54. OSTEOMA Most common of the mesenchymal neoplasms Clinical Features S low growing, asymptomatic nasal obstruction Swelling of the cheek or hard palate proptosis may produce an external fistula occur in the maxillary sinus after a Caldwell-Luc operation

55. Radiographic Features lobulated or rounded homogeneous radiopacity with sharply defined margins Hounsefield unit for bone - + 400 to + 1000 Differential Diagnosis • Anthroliths • Teeth • Odontogenic neoplasms( odontomas )

56. MALIGNANT NEOPLASMS Squamous Cell Carcinoma originates from metaplastic epithelium of the sinus mucosal lining Clinical Features facial pain or swelling, nasal obstruction and lesion in oral cavity lymph nodes involvement

57. Radiographic Features irregular radiolucent areas in the surrounding bone b one destruction around the teeth or irregular widening of the periodontal ligament space

58. Additional Imaging • Caldwell and Water’s projections • panoramic film • CT • MRI

59. Differential Diagnosis • Sinusitis • Large retention psuedocysts • Odontogenic cysts Neoplasm should be suspected in any older patient in whom chronic sinusitis develops for the first time without obvious cause Management : surgery and radiation therapy

60. Pseudo tumour occurs after a series of recurrent infections recurring pain, proptosis , a ltered nerve function R/F - erosion of the bony walls of the involved sinuses Differential Diagnosis Benign and malignant neoplasms Management: debridement of the sinuses and administration of antifungal medication (amphotericin B and rifampin ) Caldwell-Luc approach and therapy

61. EXTRINSIC DISEASES INVOLVING THE MAXILLARY SINUS Periostitis - inflammation of the periosteum Radiographic Features centered directly above inflammatory lesion single thin radiopaque line very thick radiopaque line, or has a laminated (onion skin) appearance

62. Benign Odontogenic Cysts and TumoRs M ost common - dentigerous cysts, radicular cysts

63. DENTIGEROUS CYST Most commonly related to the third molar - radiolucency elevating the floor of the sinus If it is small it appears - dome shaped opacity in base of the antrum, with well-defined radiopaque corticated margins

64. Radiographic Features curved or oval shape defined by a corticated border homogeneous and radiopaque relative to the sinus displace the floor of the sinus Hounsefield unit - 0 Differential Diagnosis Retention pseudocyst Odontogenic cysts Maxillary sinusitis Antral loculation

65. Radicular cyst

66. ODONTOGENIC TUMORS Nature of bony barriers in this region of the face, relatively good blood supply - responsible for the efficient local spread

67. Radiographic Features curved , oval or multilocular shape with thin cortical border border may be absent - aggressive tumors may displace the floor of the antrum thinning of the peripheral cortex .

68. MALIGNANT TUMORS Invasion of the maxillary sinus by local malignant disease Malignant tumors of the upper jaw spread easily into the sinus . Pleomorphic adenoma A denocystic carcinoma Metastatic Carcinoma of the Maxillary Sinus Maxillary sinus is a rare site for metastasis

69. CRANIOFACIAL FIBROUS DYSPLASIA Clinical Features More common in children and young adults and tends to stop growing when skeletal growth ceases posterior maxilla - most common location It results in facial asymmetry, nasal obstruction, proptosis , pituitary gland compression, impingement on the cranial nerves or sinus obliteration

70. • The sinus obliteration results due to the expansion and encroachment of the dysplastic bone lesion. • displace the roots of the teeth and cause the teeth to separate or migrate does not cause root resorption

71. Radiographic features Not well-defined, and tends to blend with the surrounding bone Radiopaque areas - ground glass appearance on extraoral radiographs or an orange peel appearance on the intraoral views

72. Differential Diagnosis Paget's disease Complex odontoma Ossifying fibroma

73. TRAUMATIC INJURIES TO MAXILLARY SINUSES Dental Structures Displaced into the Sinus Root in the Antrum/Foreign Bodies No visible signs and symptoms if the root is displaced recently Sinusitis

74. Radiographic Features The dislodged fragments are usually found near the floor of the sinus because of gravity F loor of the sinus may break due to the displacement of the tooth fragment into the sinus

75. Additional Imaging Lateral maxillary occlusal views Water's projection: along with the occlusal view Differential Diagnosis Exostoses of the sinus wall or floor and septa within the sinus, may mimic dental root fragments or even whole teeth Antroliths Root tip remains in the socket Management: Surgical removal using the Caldwell-Luc procedure

76. SINUS CONTUSION Occurs due to a blow to the face that damages the lining of the paranasal sinuses without fracturing the facial bone Clinical features • Bloody nasal discharge, tenderness , rapid resolution of the soft tissue changes

77. Radiographic features • Haziness of the sinus due to edema • An opaque sinus or fluid level resulting from hemorrhage from the mucosal tear Differential diagnosis • Sinusitis

78. BLOW-OUT FRACTURE Sudden increase in the intra orbital pressure - direct blow to the eye Clinical Features diplopia enophthalmus

79. Radiographic Features Opacification of the sinus with or without a fluid level S hadow of soft tissue mass and depressed bone fragments Tear drop shaped radiopacity Fracture of the antrum wall of the maxillary sinus

80. ISOLATED FRACTURE Involves a single wall - appear as a bright line on the radiograph M ost common sites - anterolateral wall, floor, during extraction of the upper posterior teeth

81. ZYGOMATIC COMPLEX FRACTURE Occurs at the line of weakness and passes through the orbital floor, usually medial to the zygomatico maxillary suture Clinical Features • F ractured zygoma is forced into the sinus • T earing of the lining membrane with subsequent bleeding into the antrum Radiographic Features - cloudy or will show a fluid level

82. FRACTURED TUBEROSITY Most frequently while extracting a lone standing upper third molar

83. OROANTRAL FISTULA Pathological pathway connecting the oral cavity and the maxillary sinus Etiology : Extraction of teeth having chronic periapical infections, solitary tooth ,teeth having apices very close to antral floor, Blind instrumentation, Surgical removal of large lesions in the upper jaws, malignant tumours, osteomyelitis, malignant granulomatous lesions, facial trauma and inadequate blood clot formation

84. Diagnosis asked to blow air into the pinched nose with the mouth open Radiographic Features break in the continuity of the floor- disalignment of a small portion of the cortical layer of bone acute or chronic sinusitis evidence of the displaced root or tooth

85. Additional Imaging • Confirmation of the presence of the fistula • CT with denta scan Management : repair and surgical closure under antibiotic therapy .

86. Thank you

87. References: Textbook of Dental and Maxillofacial Radiology, Freny R Karjodkar,3 rd edition Principles and interpretion of oral radiology,white and pharoah . 3. Goaz PW, White SC. Principles and Interpretation, In Oral radiology , 3rd ed. St. Louis, Mosby Year Book 1994. 4 . McGowan DA, Baxter PW, James J. The maxillary sinus and its dental implications. Butterworth- Heineman 1993 Oxford .