Surgical anatomy of maxillary sinus

SURGICAL ANATOMY OF MAXILLARY SINUS

1. SURGICAL ANATOMY oF maxillary sinus -by DR. FIRDOUS MULLA (PG OMFS)

2. Contents Introduction Embryology of maxillary sinus Anatomy of maxillary sinus Vascularization & innervation ` Drainage of sinus Functions of sinus Maxillary sinusitis Oroantral fistula Conclusion References

3. Introduction Paranasal sinuses Air containing bony spaces present around the nasal cavity Usually lined by respiratory mucus membrane Four paired

4. Maxillary sinus Pneumatic space lodged in the body of maxilla that communicates with the external environment by way of middle meatus and nasal vestibule Also known as antrum o f Highmore

5. First sinus to develop Initial development of sinus follows number of morphogenic events in differentiation of nasal cavity Embryology

6. Horizontal shift of palatal shelves and fusion with one another Nasal septum separates Oral cavity from nasal chambers Influence expansion of lateral nasal wall and 3 walls begin to fold 3 conchae & meatus Superior & inferior - Shallow depression for half of IU Life Middle - Expansion in lateral wall and in inferior direction Embryology

7. Development of sinus begins as evagination of mucus membrane in lateral wall of middle meatus when nasal epithelium invades maxillary mesenchyme Growth of sinus takes place by pneumatization Primary (10 th weeks) Secondary (5 th month) Embryology

8. Maxillary sinus has biphasic growth 0-3 years and 7-12 years Post natally grows @ 2 mm vertically and 3 mm AP Radiographically; triangular area ( 5 th month) 3 growth spurts 0-2.5 years 7.5-10 years 12-14 years Embryology

9. Embryology

10. Embryology

11. Embryology

12. Embryology Developmental anomalies Agenesis Aplasia Hypoplasia Supernumary maxillary sinus

13. Largest of PNS,communicate with other sinuses through lateral nasal wall. Horizontal Pyramidal shaped Base Apex 4 walls supe r i o r i n f e r i o r lateral A nterior Wall thickness varies with individual Anatomy

14. Various shapes Hyperbolic-47% Paraboloid-30% Semi-ellipsoid-15% Cone shaped-8% Dimensions (Therner, 1902) H : 3.5cm W : 2.5cm L : 3.25cm Vol:15-30 ml Anatomy

15. Anatomy Receses- Alveolar Zygomatic Palatal Frontal Teeth in proximity 2 nd, 1 st , molar>3 rd molar>2 nd pm>1 st pm>canine

16. Formed by lat nasal wall Below- inf erior nasal conchae Behind-palatine bone Above-uncinate process of ethmoid,lacrimal bone Contains double layer of mucous membrane(pars membranacea) Medial wall

17. Medial wall Imp structures Sinus ostium Hiatus semilunaris Ethmoidal bulla Uncinate process Infundibulum

18. Natural ostium Located in posterior ½ of infundibulum or behind lower1/3 of uncinate process. Tunnel shaped, length: 1- 22mm;3-6mm diameter Not detected endoscopically Unfavorable position for gravity dependent drainage Post edge-continuous with lamina papyracea(imp for surgical dissection)

19. Accessory ostium 2-3 in no.(30-40%) Bony dehiscences covered by mucosa(ant/post frontanelles)

20. Superior wall Forms roof of sinus and floor of orbit Imp structures Infraorbital canal Infraorbital foramen ASA nerve Applied aspect Vulnerable to trauma Erosion of this wall by tumor

21. Posterolateral wall Made of zygomatic and greater wing of sphenoid bone(maxillary tuberosity) Thick laterally,thin medially Imp structures PSA nerve Maxillary artery Maxillary nerve Pterygopalatine ganglion Nerve of pterygoid canal Applied aspect Involvement of PSA-pain in post teeth Surgical access by careful removal of segment of wall

22. Anterior wall Extends from pyriform aperture anteriorly to ZM suture & IO rim superiorly to alveolar process inferiorly. Convexity towards sinus Thinnest in canine fossa Imp structures Infraorbital foramen ASA, MSA nerves Levator labii, o r bicularis oculi muscles

23. 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 Inner surface is rough by bony septa Retrieval of root fragment Interferes with sinus drainage

24. a) Nasal Mucosal Vasculature Arterial Supply S pheno palatine , Ethmoid b) Osseous Vasculature Venous Drainage IO, PSA, ASA, GP, Facial Medial wall - Spheno palatine Other walls – Pterygomaxillary Plexus Lymphatic Drainage Collecting vessels in middle meatus Nerve Innervation ION, GP, PSA, MSA, ASA Clinical significance PO2 of sinus = 116 mm Hg Vascularization & innervation

25. Surgical Importance of Nerve supply As there is chance of damage of nerve during surgical procedure Asa-given off from infraorbital n erve about 15mm fr o m infraorbital foramen,courses down on anteriror Wall Msa-seen in 50 % cases arise from lateral aspect of infraorbital nerve Psa -sup erior branch runs at level of malar tuberosity,inf branch-runs parallel to tranverse facial part of ante r ior nerve

26. Vascularization & innervation

27. IMPORTANCE OF THIS SINUS...?? Largest sinus. Most frequent PNS involved in malignancies. Very difficult to treat: Close anatomical proximity to the vital structures. Complete surgical resection is challenging. Remain asymptomatic for a long time.

28. Microscopic anatomy 3 layers Epithelium Basal lamina Sub epithelium

29. Epithelium Pseudostratified columnar ciliated epithelium Cells Columnar ciliated Goblet Basal Non – ciliated

30. 100 motile and no. of immotile microvilli present along apical surface Function: mucus clearance along with entrapped debris from nose and PNS All cilia beat together to form metachronous wave Each cilia has power stroke followed by recovery stroke Ciliated epithelium

31. Microvilli Hair like projection of actin filament Length 1-2 mm Function: Increase surface area of cell Prevent drying of surface

32. Sino nasal epithelium covered by mucus blanket Traps particles>0.5-1 um Composition Water (95%) Others (5 %) Peptides Salts Debris Ph = 5.5-6.5 Physiologic nature of mucus layer

33. Physiologic nature of mucus layer 2 layers Inner sol - Continuous - Low viscosity - Surrounds shafts of cilia Outer gel -Discontinuous - High viscosity -Along ciliary tips

34. Mucus transported from nose and PNS to nasopharynx, ingested and presented to GIT Forms basis of Functional endoscopic sinus surgery ( FESS) Drainage of sinus

35. Flow of mucus superiorly against gravity Upward course along walls of entire cavity and then towards natural ostium in superomedial wall Drainage into ethmoidal infumdibulum Mucus coursing along lateral wall, carried medially along roof to reach ostium Mucociliary flow from anterior sinuses converge at O steo M eatal C omplex , carried to posterior nasopharynx & inferiorly to eustachian tube orifice By Donald et al & Antunes et al Drainage of sinus

36. Drainage of sinus

37. Drainage of sinus Mucociliary flow Smooth:0.85 cm/minute Jerky: 0.3 cm/minute Mucostasis: <0.3 cm/minute

38. Basal lamina & sub epithelium Contains serous glands and blood vessels Subepithelium – 1 serous Mucosa removal – 73% decrease in serous glands and 30% in goblet cells

39. Functions of sinus Decrease skull weight Impart resonance to voice Mucus production and storage Humidify and warm inhaled air Define facial contour Immunodefensive action Conserve heat from nasal fossae Moisturize air Filters debris Dampen pressure differential during inspiration Limit extent of facial injury from trauma Serves as accessory olfactory organ

40. Group of diseases mainly inflammation & infection which affect the nasal mucosa and PNS Maxillary sinusitis

41. Maxillary sinusitis

42. Anatomical variations influencing the development of sinusitis Variations in bulla ethmoidalis Variations of middle turbinate Accessory ostium Deviated nasal septum Nasal masses Haller cell Maxillary sinusitis

43. Maxillary sinusitis 1. Infectious causes Bacterial Viral Fungal Parasitic 2. Non infectious causes Allergic Non allergic Pharmocologic Irritants 3. Disruption of mucociliary drainage Surgery Infection Trauma Extr i nsic causes 1. Genetic Structural Immunodeficiency Mucociliary A bnormality (cystic fibrosis, dismotility) 2 . Acquired Aspirin h y p erse n s i t i v i t y A u t o n o m ic dysregulation Hormonal Structural (Tumors, cysts) Idiopathic/ autoimmune Immunodeficiency Intr i nsic causes

44. Maxillary sinusitis Diagnosis History Physical examination Inspection Palpation Percussion Diagnostic techniques Rhinoscopy Endoscopy Nasal valve examination Culture and sensitivity

45. Maxillary sinusitis Major & Minor Factor Associated with the Diagnosis of Chronic Rhinosinusitis Major Factors Minor Factors Facial pain/pressure Headache Facial congestion/fullness Fever (non-acute cases) Nasal obstruction/blockage Halitosis Nasal discharge/ pu r ulence /discol ored postnasal discharge Fatigue Hyposmia/anosmia Dental pain Purulence in nasal cavity on examination Cough Fever (in acute rhinosinusitis only) Ear pain/pressure/fullness

46. Maxillary sinusitis Radiological examination O ccipito M ental view Caldwell view Lateral view CT scan MRI Tests for mucociliary functions Nasomucociliary clearance Ciliary beat frequency Rhinomanometry Test for olfaction

47. Maxillary sinusitis M an a g ement M ed i c al Antibiotics Steroids Decongestants Analgesics Antihistamines Nasal spray & saline irrigation Hydration Mucolytics(guaifenesin,KI) S u r g i c al sinus aspiration and lavage Maxillary needle sinusotomy Caldwell luc FESS

48. Antibiotics Antibiotic Micro factors Pediatric dosage First line therapy Amoxicillin 45 mg/kg/day or 90 mg/kg/day divided 500 g BID Second line therapy Amoxicillin/potassium calvulanate 22.5-45 mg/kg/day divided (dose based on amoxicillin component) 500-875 mg BID Azithromycin 10 mg/kg/day on day 1, then 5 mg/kg/day on days 2-5 500 mg QID on day 1, then 250 mg QID on days 2-5 Cefdinir 14 mg/kg/day 300 mg BID Cefpodoxime 10 mg/kg/QID 200 mg BID Cefprozil 15 mg/kg/QID 250-500 mg BID Cefuroxime 15 mg/kg/QID 250 mg BID Ciprofloxacin 500 mg BID Clarithromycin 7.5 mg/kg/day 500 mg BID Cindamycin 8-20 mg/kg/day divided QID 150-450 mg BID Doxycycline 100-200 mg QID Garifloxacin 400 mg QID Levofloxacin 500 mg QID Sulfamethoxazole/trimethop rim 6-12 mg/kg/day divided (based on trimethoprim) 800-160 mg BID

49. Steroids 1 st line of therapy: topical intranasal (betamethasone, dexamethasone, triamcinolone) Systemic steroids: Prednisolone:0.5-1mg/kg x3-4 days

50. Decongestants Systemic (phenylpropanolamine, pseudoephidrine): Contraindications: hypertension, hyperthyroidism, asthma Topical: phenylepinephrine HCl, oxymetazoline HCl Adv. Effects- rhinitis medicamentosa

51. Analgesics & antihistamines Analgesics: Opoid: acetaminophen, codeine NSAIDS: Antihistamines: Mequitazine, terfenad Contraindicated in bacterial sinusitis Adv effect: sedation

52. Nasal lavage & sprays Mechanism of a ction : Removes debris & dead tissue Washes inflammatory secretions Eliminates nutrient source Methods: Lavage pot Syringe Irrigating bulb

53. Nasal lavage & sprays Techniques of nasal sprays Moffet position Mygind technique

54. Surgical management Indications Bilateral chronic sinusitis with polyps Fungal sinusitis Presence of c o m pli c at i ons Tumor of PNS Csf rhinorrhea Contraindications Presence of extensive polyps Pt withc/c of headache and midfacial pain Medically c o m p r o m i s ed Hypoplastic sinuses

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

56. Maxillary needle sinusotomy Mallet Steinmann pin Complications: Bleeding Infection Dental injury Sensory nerve disturbance Instrument breakage Infiltration of LA Preparation of site Alternatives: Transcutaneous puncture ant & post to canine eminence

57. Caldwell luc sinusotomy By George Caldwell (1893) & Henry Luc (1897) Indications 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

58. Caldwell luc sinusotomy

59. Caldwell luc sinusotomy Complications Bleeding Dental sensitivity Infraorbital neuralgia Osseous defect in anterolateral wall Entrapment of inferior rectus muscle

60. Functional endoscopic sinus surgery Coined by Kennedy Intranasal endoscopic technique that allows establishment of adequate sinus drainage without negative impact on sinus mucosa physiology and function. Principle: stop the cycle that begins with ostium blockage that leads to chronic sinusitis via stagnated secretions, tissue inflammation and bacterial

61. FESS

62. FESS

63. Minor hemorrhage Hyposmia Adhesions Periorbital emphysema Intracranial hemorrhage Brain injury CSF leak Diplopia Blindness Anosmia Epistaxis NL duct injury Meningitis Complications FESS

64. Sinusitis Complications: Facial cellulitis Orbital extension Intracranial extension

65. Oroantral fistula Fistular canal between oral cavity and sinal mucous membrane covered with epithelium which may or may not be filled with granulation tissue or polyposis. Duration and width of lumen contributes to infection of sinus. OAC OAF(incidence: 0.3-3.8 %)

66. OAC OAF Defect > 5mm diameter No approximation of gingival tissues Post op regime not followed Loss of clot or wound dehiscence Cyst enucleation Smoking, drinking Oroantral fistula

67. Etiology Iatrogenic (50%) Presence of periapical lesions Injudicious use of instruments During attempted extraction Trauma(7.5%) Chronic infections(11%) Malignant diseases(18.5%) Infected maxillary dentures(3.7%) h/o sinus surgery(7.5%) Oroantral fistula

68. Acute Chronic 1. Escape of air and fluids through nose & mouth 1.Pain, tenderness over cheeks 2. Epistaxis 2. Purulent discharge 3. Excruciating pain 3. Post nasal drip 4. Altered voice 4. Presence of polyps 5. h/o surgery in vicinity of sinus 5. Generalized constitutional symptoms Oroantral fistula

69. Diagnosis h/o previous extraction Valsavin test Mouth mirror test Cotton wisp test Inspection Radiological IOPA OPG OM Oroantral fistula

70. Management 3mm-5mm heals spontaneously(HANAZANE) Ideal treatment :immediate surgery followed by Ab prophylaxis Acute OAF: closure by simple reduction of buccal and palatal socket walls, followed by acrylic splint . Oroantral fistula

71. Treatment for small openings: antibiotics : Pn & derivatives nasal decongestants: Ephedrine drops Inhalations(steam,benzoin ,menthol) Analgesics: Diclofenac 50mg Paracetamol 500mg Ibuprofen 400 mg Antral lavage Oroantral fistula

72. Oroantral fistula Antral lavage

73. Oroantral fistula Whitehead’s varnish

74. Acrylic plates Oroantral fistula

75. Surgical closure Te mp or alis flap F or ehe ad flap Overview of the treatment modalities of Oro-Antral Communications Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J Oral Maxillofac Surg68:1384-1391, 2010

76. Surgical closure Factors determining flap selection Size of communication Timeline of diagnosing Presence of infection

77. Buccal flap Modifications Moczaic Laskin & Robinson

78. Palatal flap

79. Palatal pedicle flap Ito & Hara m o di f icat i on Island flap Gullane & Arene modification

80. Combined flap

81. Distant flaps BUCCAL FAT PAD

82. Tongue flap

83. Grafts

84. G R A F TS AUTOGENOUS Iliac crest Chin Retromolar area Zygoma AL L OG E N O US Collagen sheet Fibrin glue Gold foil Tantalum PMMA Hydroxyapatite XENOGRAFTS Porcine dermis Bio guide & Bio oss Grafts

85. A case in sri mookambika dental college kulasekaram

86. Other techniques Third molar transplantation Interseptal alveolotomy GTR Prolamine gel Laser light Splints for immunocompromised pts

87. CA MAXILLARY SINUS Arises from lining of Maxillary sinus. Middle aged males(40- 60yrs). Remain silent for a long time or showing only symptoms of sinusitis. Destroys bony walls and invades the surrounding structures.

88. CA MAXILLARY SINUS Clinical Features: Nasal stuffiness. Blood-stained nasal discharge. Facial paraesthesia or pain. Epiphora. These are early C/F Often misdiagnosed and treated as Sinusitis.

89. Patterns of tumour spread. Anteriorly Posteriorly Medially Superiorly Inferiorly Intracranial Lymphatic Systemic

90. Patterns of tumour spread. Anteriorly Posteriorly Medially Superiorly Inferiorly Intracranial Lymphatic Systemic

91. Ohngrens Line D ivide s the sinus into the antero-inferior & postero -superior .

92. TREATMENT Stage 1 & 2 SCC Surgery or Radiation. Stage 3 & 4 SCC Combined modalities. Inoperable tumours Chemoradiation. intra arterial infusion of 5-Fluorouracil or Cisplatin.

93. WEBER-FERGUSSON’S INCISION

94. P R O G NOSIS Survival diminishes with stage of tumour. 5 y r su r vi v a l 40 - 50% Advances are being made in multimodal therapy with improved Radiation delivery with a hope to improve results.

95. 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. The oroantral fistula is a problem that requires detailed attention to the management of a flap in the mouth. For the sake of obtaining the best results and to give the patient the benefit , proper knowledge about the different types of modalities and their limitations is necessary.

96. References ECAB: Clinical update-otorhinolaryngology-Paranasal sinuses and rhinosinusitis-V.P Sood OMFSClinics of North America-Diagnosis & treatment of disorders of maxillary sinus-Laskin Principles of oral and maxillofacial surgery-Peterson Textbook of oral and maxillofacial surgery-Killey and kay Maxillary sinus and its dental implications:dental practice handbook-Killey and Kay Review of oral and maxillofacial surgery-Ghosh Open access atlas of otolaryngology, head & neck operative surgery - johan fagan Treatment of Oroantral Fistula-Klara Sokler et al, Acta Stomatol Croat, Vol. 36, br. 1, 2002

97. References Oronasal fistula closure by tongue flap-Manimaran K et al, JIADS,Jan-mar 2011 A New Surgical Management for Oro-antral Communication,The Resorbable Guided Tissue Regeneration Membrane – Bone Substitute Sandwich Technique-C Ogunsalu, West Indian Med J 2005; 54 (4): 261

98. Thank You