Maxillary sinus presentation

surgical anatomy of maxillary sinus.

1. SURGICAL ANATOMY OF MAXILLARY SINUS PRESENTED BY:- SIDDHARTH VERMA FIRST YEAR P.G. ORAL AND MAXILLOFACIAL SURGERY DEPARTMENT

2. CONTENTs Introduction Development and Anatomy Blood supply, Nerve supply& Lymphatic drainage Histology Functions of the Maxillary sinuses Diagnostic evaluation of sinus disease Developmental anomalies & Pathologic conditions of maxillary sinus Clinical significance Conclusion References

3. INRODUCTION Paranasal air sinus Paranasal air sinuses are the air filled mucosa lined cavities which develops in the cranial and facial bones. These are the spaces which communicates with the nasal airway. These forms the various boundaries of the nasal cavity. The sinuses are named for the bones in which they are located. Paranasal sinuses are present in a variety of animals (including most mammals, birds, and crocodile).

4. MAXILLARY SINUS Definition of maxillary sinus :- “Maxillary sinus is the pneumatic space that is lodged inside the body of maxilla and that communicates with the environment by way of the middle meatus and nasal vestibule.” Anatomy of the maxillary sinus was 1 st described by Nathenial Highmore in 1651. Also known as Antrum of Highmore . 2 in number. Largest paranasal sinus. Volume:15-30 ml. Dimensions (Turner, 1902) :- ANTEROPOSTERIOR: 3.5cm HEIGHT: 3.2cm WIDTH: 2.5cm

5. DEVELOPMENT Maxillary sinus is first of the PNS to develop. It starts as a shallow groove on the medial surface of maxilla during the 4th month of intrauterine life. Early stages it is high in maxilla ,later gradually grows downwards by process of Pneumatization. 1.Primary-(10 th week) 2.Secondary –(5 th month) Expansion occurs more rapidly until all the permanent teeth have erupted. It reaches to maximum size around 18years of age.

6. The maxillary sinus development increases in size during the growth of the midface of the maxilla and is also related to the eruption of the deciduous teeth, followed by the permanent dentition .

7. AGE CHANGES

8. AGE CHANGES

9. Anatomy Largest of PNS,communicate with other sinuses through lateral nasal wall. Horizontal Pyramidal shaped. Consists of – 1.Apex 2.Base 3. Walls – A) Superior B) Inferior C) Lateral D) Anterior Wall thickness varies with individual .

10. Base - lateral wall of nose. Apex - zygomatic process of maxilla. Roof - floor of orbit traversed by the infraorbital canal. Floor –lateral hard palate maxillary alveolar process.

11. Anteror wall-facial surface of maxilla Posterior wall- separates sinus from infratemporal and pterygopalatine fossa. MEDIAL WALL:- Formed by lateral nasal wall ◦ Below-inferior nasal conchae ◦ Behind-palatine bone ◦ Above- Uncinate process of ethmoid bone and lacrimal bone Contains double layer of mucous membrane (pars membranacea)

12. MEDIAL WALL:- Important structures Sinus ostium Hiatus semilunaris- The  hiatus semilunaris   (or semilunar  hiatus ) is a crescent-shaped groove in the lateral wall of the nasal cavity just inferior to the ethmoidal bulla. It is the location of the openings for the frontal sinus, maxillary sinus, and anterior ethmoidal sinus. Ethmoidal bulla- The  ethmoid bulla  forms the posterior and superior walls of the  ethmoid  infundibulum and hiatus semilunaris. The  ethmoid bulla  is the largest anterior  ethmoid  air cell. Uncinate process Infundibulum

13. Ostium Opening of the maxillary sinus is called ostium. It opens in middle meatus at the lower part of the hiatus semilunaris. Lies above the level of nasal floor. The ostium lies approximately 2/3rds up the medial wall of the sinus, making drainage of the sinus inherently difficult. In 15% to 40% of cases, a very small, accessory ostium is also found. Blockage of the ostium can easily occur when there is inflammation of the mucosal lining of the ostium.

14. Superior wall:- Forms roof of sinus and floor of orbit. IMPORTANT STRUCTURES Infraorbital canal Infraorbital foramen Infraorbital nerve and vessels Applied aspect 1.Vulnerable to trauma 2.Erosion of this wall by tumor. Posterolateral wall:- Made of zygomatic and greater wing of sphenoid bone. Thick laterally,thin medially IMPORTANT STRUCTURES PSA nerve Maxillary artery and Nerve Pterygopalatine ganglion Applied aspect 1. Involvement of PSA-- 2. Surgical access by careful removal of segment of wall.

15. Anterior wall:- Extends from pyriform aperture anteriorly to ZM suture & Inferior orbital rim superiorly to alveolar process inferiorly. Convexity towards sinus Thinnest in canine fossa IMPORTANT STRUCTURES Infraorbital foramen ASA, MSA nerves Levator labii, orbicularis oculi muscles 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.

16. BLOOD SUPPLY Arterial blood supply:- Greater palatine arteries Infraorbital artery Posterior superior artery Maxillary artery

17. Venous drainage :- Pterygoid venous plexus Sphenopalatine vein Facial vein Anteriorly - sphenopalatine vein Posteriorly - pterygoid venous plexus drain into facial vein Pterygoid plexus communicates with the cavernous sinus by emissary veins.

18. Anterior superior alveolar nerve (ASA) Middle superior alveolar nerve (MSA) Posterior superior alveolar nerve (PSA) Infra-orbital nerve Greater palatine. NERVE SUPPLY

19. Surgical Importance of Nerve supply • As there is chance of damage of nerve during surgical procedure ASA- given off from infraorbital nerve about 15mm from infraorbital foramen,courses down on anteriror wall. MSA- seen in 50 % cases arise from lateral aspect of infraorbital nerve . PSA- superior branch runs at level of malar tuberosity, inferior branch-runs parallel to transverse facial part of anterior nerve.

20. LYMPHATIC DRAINAGE Submandibular lymph nodes Deep cervical lymph node Retro pharyngeal lymph node The lymphatic drainage reaches the specialized cells in the maxillary sinus via infra orbital foramen or through the anterosuperior wall and then to the submandibular lymph nodes.

21. HISTOLOGY Lined by respiratory epithelium Mucous secreting Pseudo stratified ciliated columnar epithelium SCHNEIDERIAN MEMBRANE -is the membranous lining of the maxillary sinus cavity. Microscopically there is a bilaminar membrane with pseudostratified ciliated columnar epithelial cells on the internal side and periosteum on the osseous side. It has mucociliary mechanism. Cilia moves the mucus and debris towards ostium and discharged in middle meatus.

22. Abstract Kalyvas et al. International Journal of Implant Dentistry (2018) 4:32

23. Maxillary Sinus Mucous Clearance The mucus of the maxillary sinuses is produced from serous and goblet cells, which produce 1 L of mucus each day in healthy conditions. The cilia in the maxillary sinus beat toward the ostium. A blanket of mucus is propelled toward the ostium by the beating motion of the ciliated lining cells. The mucous material of the sinus in health has two layers: (1) a top mucoid layer and (2) a bottom serous layer . The top layer is sticky and collects bacteria and other debris, whereas the serous layer is thin and acts as a lubricant.

24. FUNCTIONS OF MAXILLARY SINUS Warming of inspired air. Humidification of dry air. Lightening of skull weight. Resonance of voice. Filters debris. Accessory olfactory organ. Protects skull from mechanical shock. Production of bactericidal lysozyme. Gives air padding to provide thermal insulation to adjacent important tissues. Assisting in regulating intranasal pressure.

25. DIAGNOSTIC EVALUATION Detailed medical & dental history. Clinical examination:- 1) Inspection 2) Palpation 3) Percussion 4) Transillumination Radiographs . Ultrasound, CT scan, MRI. Endoscopy.

26. CLINICAL EXAMINATION INSPECTION : Middle third of the face should be inspected for the presence of asymmetry, deformity, swelling, erythema , ecchymosis or hematoma. EXTRAORAL PALPATION : Tapping of lateral wall of sinus over prominence of cheek bone and palpation intra-orally on lateral surface of maxilla between canine fossa and zygomatic buttress.

27. TRANSILLUMINATION It is done by placing a bright flash light or fiber optic light against the mucosa on the palatal or facial surface of the sinus and observing the transmission of light through the sinus in the darkroom. Good transillumination indicates presence of air in the sinus while the failure of transillumination indicates presence of pus, fluid , solid lesion or mucosal thickening. PRINCIPLE:-In the setting of inflammation, the maxillary sinus becomes fluid filled and will not allow this transillumination.

28. RADIOLOGY OF MAXILLARY SINUS EXTRAORAL VIEWS :- OCCIPITOMENTAL/WATERS LATERAL SKULL SUBMENTOVERTEX ORTHOPANTOMOGRAPHY OTHERS - CT SCAN MRI ULTRASOUND ENDOSCOPY INTRAORAL VIEWS :- OCCLUSAL LATERAL OCCLUSAL PERIAPICAL

29. OCCIPITOMENTAL VIEW (WATER’s VIEW) LATERAL SKULL VIEW

30. SUBMENTOVERTEX VIEW

31. ORTHOPENTOMOGRAPHY(OPG) OPG showing Maxillary Sinus and Molar Roots Relationship

32. CT SCAN OF MAXILLARY SINUS MRI OF MAXILLARY SINUS

33. Occlusal view Lateral occlusal view The roots of maxillary molars usually lie in close apposition to the maxillary sinus and may project into the floor of the sinus, causing small elevations or prominences.

34. Periapical View Borders of the maxillary sinus appear as a thin, delicate radiopaque line . In the absence of disease it appears continuous, but on close examination it has small interruptions in its smoothness or density. Maxillary sinus septum

35. Ultrasound Ultrasound is becoming the diagnostic tool of choice for more physicians in detecting sinusitis. It offers a fast ,reliable and radiation free method for diagnosing sinusitis Ultrasound waves sent out by the sinus when waves are reflected from the posterior wall of the sinus the sinus contains fluid and from the anterior wall when the sinus contains air. Ultrasound waves are generated by probe.

36. Ultrasound image of maxillary sinus Ultrasound Examination

37. ENDOSCOPY It is an optimal method especially for the assessment of foreign bodies (such as root filling materials and root tips) that have penetrated into the maxillary sinus. Direct optical evaluation of the antral floor region.. Path of access used:- 1.Transoral via canine fossa 2.Transalveolar via connection between oral cavity & antrum 3.Trans nasal approach

38. DEVELOPMENTAL ANOMALIES AND PATHOLOGIC CONDITIONS OF MAXILLARY SINUS Developmental anomalies 1.Aplasia 2. Agenesis 3. Hypoplasia Along with Cleft palate, choanal atresia, high palate, septal deformity, mandibular dysostosis, malformation of external nose. Supernumery- two completely separated sinus on same side

39. Pathologic conditions of maxillary sinus Maxillary Sinusitis Oro-antral fistula. Odontogenic cystic lesions of maxillary sinus Tumors of maxillary sinus.

40. Maxillary sinusitis When the inflammation develops in the sinus either due to infection or allergy it is termed as sinusitis. It may be clinically defined as an inflammatory response involving mucous membranes of the nasal cavity and paranasal sinus. Most common involving the maxillary sinus.

41. Maxillary sinusitis

42. Maxillary sinusitis Anatomical variations influencing the development of sinusitis a) Variations of uncinate process b) Variations in bulla ethmoidalis c) Variations of middle turbinate d) Accessory ostium e) Deviated nasal septum f) Nasal masses g) Haller cell Preexisting skeletal and bony abnormalities of the osteomeatal complex may compromise the unit, leading to maxillary sinusitis.

43. Etiology Extrinsic causes 1. Infectious causes a) Bacterial b) Viral c) Fungal d) Parasitic 2. Non infectious causes a) Allergic b) Non allergic c) Pharmocologic d) Irritants 3. Disruption of mucociliary drainage a) Surgery b) Infection c) Trauma In trinsic causes 1. Genetic a) Structural b) Immunodeficiency c) Mucociliary abnormality (cystic fibrosis, dismotility) 2. Acquired a) Aspirin hypersensitivity b) Autonomic dysregulation c) Hormonal d) Structural (Tumors, cysts) e)Idiopathic/ autoimmune f) Immunodeficiency

44. Maxillary sinus Diagnosis 1. History 2. Physical examination Inspection Palpation Percussion Diagnostic techniques a. Rhinoscopy b. Endoscopy c. Nasal valve examination d. Culture and sensitivity

45. Maxillary sinus 3. Radiological examination a) Water’s view b) Caldwell view c) Lateral view d) CT scan e) MRI 4. Tests for mucociliary functions a) Nasomucociliary clearance b) Ciliary beat frequency c) Rhinomanometry 5. Test for olfaction

46. Major & Minor sign and symptoms Associated with the Diagnosis of Chronic Rhinosinusitis Major signs and symptoms Minor signs and symptoms Facial pain/pressure Headache Facial congestion/fullness Fever (non-acute cases) Nasal obstruction/blockage Halitosis Nasal discharge/ purgulence /discolored postnasal discharge Fatigue Hyposmia/ anosmia Dental pain Purulence in nasal cavity on examination Cough Fever (in acute rhinosinusitis only) Ear pain/pressure/fullness

47. Clinical features (Acute Maxillary sinusitis) Can occur at any age. Pt. complains of pain, pressure and heaviness at the affected side. Headache is the most common. Facial erythema, swelling, fever. Drainage of foul smelling mucopurulant material into the nasal cavity and nasopharynx. Pain is exacerbated on bending position. Dull pain may be present on premolar and molar region. Clinical features (Chronic Maxillary Sinusitis) Repeated attacks. Pain and tenderness. Foul unilateral discharge. Cacosmia i.e. Fetid odour with bad taste in mouth.

48. Maxillary sinusitis of Dental Origin 1.Dental abscess (periodontal and periapical abscess) 2.Infected dental cyst 3.Dental material 4.Oro-antral communication

49. Overextension of dental material like sealers, cements ,GP or silver cones A root tip of the maxillary first molar accidentally pushed into the sinus at the time of tooth extraction.

50. Maxillary sinusitis Management MEDICAL 1. Antibiotics 2.Mucolytics(guaifenesin,KI) 3. Decongestants 4. Analgesics 5. Antihistamines 6. Nasal spray & saline irrigation 7.Hydration 8.Steroids SURGICAL 1. Sinus aspiration and lavage 2. Maxillary needle sinusotomy 3. Caldwell luc 4. FESS (Functional endoscopic sinus surgery )

51. Nasal decongestants: Decongestants Systemic (phenylpropanolamine, pseudoephidrine): Contraindications: hypertension, hyperthyroidism, asthma Topical: phenylepinephrine HCl, oxymetazoline HCl Adverse Effects- rhinitis medicamentosa Mucolytic agents: 1. Benzoin compound 2. Camphor 3. Methanol in boiling water

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53. Steroids Corticosteroids work to reduce inflammation and swelling in your sinuses. This makes it easier for nasal mucus to drain into your stomach like it usually does. 1st line of therapy: Topical intranasal (betamethasone, dexamethasone, triamcinolone) Systemic steroids: Prednisolone:0.5-1mg/kg x3-4 days

54. Analgesics & antihistamine Analgesics: for pain relief Opoid : Codeine NSAIDS: Acetaminophen Antihistamines: Mequitazine, terfenad Contraindicated in Bacterial sinusitis Adverse effect: sedation

55. Nasal lavage & sprays Removes debris & dead tissue Washes inflammatory secretions Methods of Nasal lavage Lavage pot Syringe Irrigating bulb Techniques of nasal sprays 1. Moffet position 2. Mygind technique Lavage pot

56. Surgical management Indications Bilateral chronic sinusitis with polyps Fungal sinusitis Presence of complications Tumor of PNS CSF rhinorrhea Contraindication Presence of extensive polyps • Patient with complaint of headache and midfacial pain • Medically compromised • Hypoplastic sinuses

57. Sinus aspiration & lavage Direct removal of bacteria laden secretions Indication: No response to medical therapy

58. Maxillary needle sinusotomy Requires force to enter anterior wall Alternatives : Mallet Steinmann pin Complications: Bleeding Infection Dental injury Sensory nerve disturbance Instrument breakage Preparation of site Infiltration of LA Transcutaneous puncture anterior & posterior to canine eminence

59. Caldwell luc sinusotomy By George Caldwell (1893) & Henry Luc (1897) I ndications Chronic intractable maxillary sinusitis that fail to respond to medical / FESS management (Kartagener’s syndrome / Young’s syndrome) Fungal sinusitis Multiple antral lesions Antrochoanal polyp Excision of tumor Closure of OAF Removal of antral foreign body Antral revision procedures surgical approach for transantral sphenoethmoidectomy, orbital decompression

60. Caldwell Luc procedure steps 1. Under LA with sedation or under GA 2. A semilunar incision is planned in the buccal vestibule from canine to 2nd molar,just above the gingival attachment. 3. A mucoperiosteal flap is elevated 4.An opening or window is created in the anterior wall of maxillary sinus. 5. It is then enlarged in all directions with Rongeur forceps, to permit the inspection of sinus cavity. 6. Pus should be sucked away and thorough irrigation of maxillary sinus is carried out with saline wash.

61. The thickened, infected lining of the sinus can be elevated with Howarths periosteal elevator and removed and sent for histopathology . In case of profuse bleeding- sinus is packed with ribbon gauze soaked in adrenaline 1:1000 for 1 or 2 minutes • The antral cavity is irrigated again and can be packed with iodoform ribbon gauze. • The incison is closed with 3-0 silk

62. Complications:- 1.Bleeding 6.Cheek Edema 2.Dental sensitivity 7. Oroantral fistula 3.Infraorbital neuralgia 4.Osseous defect in anterolateral wall 5.Entrapment of inferior rectus muscle

63. Functional endoscopic sinus surgery(FESS) A minimally invasive surgical treatment which uses nasal endoscopes to enlarge the nasal drainage pathways of the paranasal sinuses to improve sinus ventilation. Intranasal endoscopic technique that allows establishment of adequate sinus drainage without negative impact on sinus mucosa physiology and function.

64. The most suitable candidates for this procedure have recurrent acute or chronic infective sinusitis, and an improvement in symptoms of up to 90 percent may be expected following the procedure. Fiberoptic telescopes are used for diagnosis and during the procedure, and computed tomography is used to assess the anatomy and identify diseased areas. Functional endoscopic sinus surgery(FESS)

65. Functional endoscopic sinus surgery(FESS) Functional endoscopic sinus surgery should be reserved for use in patients in whom medical treatment has failed. The procedure can be performed under general or local anesthesia on an outpatient basis, and patients usually experience minimal discomfort. The complication rate for this procedure is lower than that for conventional sinus surgery.

66. COMPLICATION of Untreated Maxillary Sinusitis Facial cellulitis Orbital extension Intracranial extension

67. Oroantral fistula Oroantral fistula is a pathological communication between oral cavity and maxillary sinus. It develops when the  oro - antral  communication fails to close spontaneously, remains patent and gets epithelialized. Maxillary sinus perforation occurs occasionally during the extraction of a maxillary tooth, and it may be a cause of maxillary sinusitis or oro-antral fistula.

68. Oroantral fistula

69. Oroantral fistula Predisposing factors • Proximity of sinus floor / tuberosity • Thickened tooth cement ( Hypercementosis) / tooth fused to jaw bone • Infected teeth / long-standing decay • Marked periodontitis / gum disease • Previous history of OAC’s.

70. Diagnosis History of previous extraction Mouth mirror test Cotton wisp test Inspection Transillumination test positive Radiological • IOPA • OPG • Water’s View CT Scan

71. SYMPTOMS OF OAF IN FRESH OROANTRAL FISTULA : 5 Es: 1. Escape of fluids 2. Epistaxis(unilateral) 3. Escape of air 4. Enhanced column of air 5. Excruciating pain IN LATE STAGE, ESTABLISHED OROANTRAL FISTULA : 5 Ps: 1. Pain 2. Persistent, purulent or mucopurulent, . foul, unilateral nasal discharge 3. Postnasal drip 4.Possible sequelae of general systemic . . toxemic condition. 5.Popping of Antral polyps

72. Management 3mm-5mm heals spontaneously Ideal treatment :Immediate surgery followed by Antibiotic prophylaxis Acute OAF: closure by simple reduction of buccal and palatal socket walls, followed by acrylic splint. Larger than 5 mm requires surgical closure. Precausion Do not probe the sinus with sharp instruments Do not curette the socket Do not ask the patient to blow the nose

73. Oroantral fistula Management 1) Antibiotics 2) Nasal decongestants: Ephedrine drops Inhalations( steam , benzoin ,menthol) 3) Analgesics: Aspirin 500mg Paracetamol 500mg Ibuprofen 400 mg 4) Antral lavage 5) Denture(Acrylic) plate : It is indicated when surgical repair of fistula is to be deferred. It provides barrier to prevent entry of food particles in antrum.

74. ANTRAL LAVAGE Whitehead’s Varnish   applied to ribbon gauze and used as a dressing in the treatment .

75. Treatment Strategies for OAF Closure

76. Oroantral fistula Management Surgical closure Factors determining flap selection Size of communication Timeline of diagnosis Presence of infection Immediate closure Mucoperiosteal flap, obtained by reducing the height of the bony socket, are loosely sutured over the defect.

77. Buccal flap

78. Rehrmann Buccal Advancement flap Broad based trapezoidal mucoperiosteal flap is created and sutured over the defect. Broad base assure adequate blood supply(93%) Disadvantage Reduction of buccal sulcus depth. Post operative pain & swelling.

79. Rehrmann Buccal Advancement flap

80. Rehrmann Buccal Advancement flap

81. PALATAL FLAP

82. ASHLEY’S ROTATIONAL ADVANCEMENT Flap design Palpation of bony edge PALATAL FLAP

83. ASHLEY’S ROTATIONAL ADVANCEMENT Excising the fistula and reflect the flap

84. Post-op follow-up ASHLEY’S ROTATIONAL ADVANCEMENT

85. COMBINED FLAP

86. Moczair flap Recommended for edentulous patients,. • Buccal sulcus depth is minimally influenced. Disadvantage • Greater amount of dentogingival detachment • May give rise to periodental disease in dentate patient.

87. BUCCAL FAT PAD Grafting of the pedicled  buccal fat pad  is highly considered as an efficient, safe and alternative closure solution in case of a large  oroantral fistula .

88. Tongue flap Distant full thickness pedicle flap Used to close large OAF Rich blood supply Disadvantage Requirement of GA Requirement of 2 stage and 3 stage procedure

89. Tongue flap Posteriorly based Full thickness Lateral tongue flap Anteriorly based Partial thickness Dorsal tongue flap

90. INTRANASAL ANTROSTOMY It is performed to facilitate the drainage at the conclusion of an operation performed: i. To close an oroantral fistula ii. To remove a tooth or a root from sinus.

91. GRAFTS Bone Press fit closure of Oro antral Fistula Indications If OAC is > 10 mm OAF and planned sinus floor elevation. OAF along the neighboring root surface extending into maxillary sinus. Chronic OAF with multiple successful attempts of closure. Bone graft for closure are often harvested from iliac crest, chin retromolar area and zygoma, lateral wall of maxillary sinus.

92. Maxillary sinus Pneumatization : The expansion of the sinus is larger following extraction of several adjacent posterior teeth, if dental implant placement is planned in these cases, immediate implantation and/or immediate bone grafting should be considered to assist in preserving the 3-dimensional bony architecture of the sinus floor at the extraction site.

93. SINUS LIFT PROCEDURES A sinus augmentation, or sinus membrane lift, involves adding bone to fill in the bottom of that air space, essentially raising the floor of the sinus cavity. Done in resorbed maxillary posterior ridges. Done for placement of Dental Implant.

94. ODONTOGENIC CYSTIC LESIONS AFFECTING THE MAXILLARY SINUS - Radicular cyst - Dentigerous cyst - Mucous retention cyst Maxillary sinusitis caused by an apical inflammatory lesion ( radicular cyst) at the root apices of the 2nd molar - NOTICE the cloudiness (Radioopacity) of the sinus Radicular cyst

95. ODONTOGENIC CYSTIC LESIONS AFFECTING THE MAXILLARY SINUS Dentigerous cyst Also known as follicular cyst,2 nd most common cyst , it usually appear on the impacted maxillary 3rd molar

96. TUMORS OF MAXILLARY SINUS Benign tumor of Maxillary Sinus:- Ameloblastoma: is the most common benign tumor affecting maxillary sinus.

97. TUMORS OF MAXILLARY SINUS Malignant tumors of Maxillary Sinus They are Invasive and destructive lesions For Examples :Squamous cell carcinoma

98. Clinical features Signs of chronic sinusitis Foul smelling nasal discharge Nasal stuffiness Epistaxis Loss of Transillumination TUMORS OF MAXILLARY SINUS

99. TUMORS OF MAXILLARY SINUS

100. Surgical treatment • Segmental maxillectomy Lower level of maxilla or only the involved segment is excised. • Partial maxillectomy Excision of maxilla sparing the infra orbial floor • Total maxillectomy Excision of maxilla with orbital floor but sparing the orbital content. • Radical or extended maxillectomy Unilateral maxilla is excised along with the eyeball or including ethmoidectomy and sphenoidectomy in the procedure TUMORS OF MAXILLARY SINUS

101. TRAUMATIC DISEASE Haematoma in Maxillary Sinus A fracture involving infraorbital artery or superior alveolar vessels frequently result in a haematoma formation in the maxillary sinus.

102. Clinical Significance Relation of Root Apices with the floor of the sinus The chances of creating oroantral fistula in patient less than 15yrs are comparatively lesser than in adult. In adult, distance between apical end of maxillary posterior teeth with floor of sinus is approximately 1 to 1.5 cm. Second molar(palatal root) is in closest proximity to antral floor followed by first molar, third molar , second premolar & first premolar.

103. Clinical Significance Ohngrens Line Ohngrens line is an imaginary line extending from medial canthus of the eye to the angle of mandible which divide the sinus into the antero-inferior & postero-superior. It is significant in determining the stage of antral tumour. In general,the tumour below this line have a better prognosis than tumour above it.

104. Revision endoscopic sinus surgery (RESS) Why would I need sinus surgery revision? Revision endoscopic sinus surgery (RESS) is performed when the initial surgery didn’t relieve your symptoms or when the surgery causes a new problem.:- Nasal polyps may develop after sinus surgery. Deviated nasal septum may also require revision sinus surgery. RESS is an endoscopic procedure, during which surgeon insert a small, flexible tube with an attached camera into your nostril. As come across abnormalities, will use a variety of surgical instruments to remove excess tissue, shave nasal polyps, or otherwise enlarge narrowed sinus openings.

105. CONCLUSION Due to close proximity of maxillary sinus to orbit, alveolar ridge, maxillary teeth, diseases involving these structures may produce confusing symptoms. Hence a precise information about the surgical anatomy is essential to surgeons. Knowledge of the anatomical relationship between the maxillary sinus floor and the maxillary posterior teeth is important for the preoperative treatment planning of maxillary posterior teeth. Clinicians must be particularly cautious when performing dental procedures involving the maxillary posterior teeth.

106. REFERENCES Textbook of oral and maxillofacialsurgery, Neelima malik Maxillary sinus and its implication Killey and Kay Orban’s, Oral histology and embryology, 11th edition. Fonseca text book of oral and maxillofacial surgery II edition Textbook of general anatomy, B.D. Chaurasia

107. THANK YOU