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1:MAXILLARY AIR SINUS

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MAXILLARY AIR SINUS: Introduction Function of air sinus Anatomy & Histology of maxillary air sinus Clinical importance of maxillary air sinus Disease of the maxillary sinusInfection- 1. Acute maxillary sinusitis 2. subacute maxillary sinusitis 3. Chronic maxillarysinusiti communication- 1. Acute oroantral fistula 2. Chronic oroantral fistula - Etiology -clinical features - Investigation - management

Slide 3:AIR SINUS These are air filled hollow space present within the bone around the nasal cavitycalled as paranasal air sinuses. The sinuses are (1) Frontal air sinus (2) Maxillary air sinus (3)Sphenoidal air sinus (4) Ethmoidal air sinus These sinus forms various boundaries of the nasal

cavity & all these sinus communicate with each other and open into the lateral wall of the nasalcavity.

Slide 4:FUNCTION OF AIR SINUS : The function of air sinus are Humidification of inspired air It

provides resonance to voice. It lightens the bone. It act as thermal insulator to protect organ suchas the eye and cranium from variation in intranasal temperature. Sinus increase the surface areaof the skull.

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MAXILLARY AIR SINUS : Definition: An antrum is a hallow cavity within the bone calledmaxillary air sinus. Maxillary air sinus known as antrum of Highmore, named after an englishantomist Nathaniel Highmore who was described it. It is one of the largest paranasal sinus.ANATOMY OF THE MAXILLARY AIR SINUS : It is basically pyramidal in shape with the

base of the pyramid forming the lateral nasal wall and apex at the root of the zygoma. Capacity :10-15 ml (in adult antrum) Size : Dimension of sinus are Height 3.5 cm Width 2.5 cmAnteroposterior Depth 3.2 cm

Slide 6:ROOF OF THE ANTRUM : - Formed by floor of the orbit. - Thin plate of orbital plate of maxilla. - It lodges the infraorbital canal and groove which lodges the infraorbital nerve. FLOOR OF THE SINUS: - Alveolar process of the maxilla. - its level is lower than the level of the floor of the nose. - Closely related to root apices of the maxillary premolar and molar.

Slide 7:ANTERIOR WALL: -Formed by the facial surface of the maxilla. - Canine fossa is an importantstructure of this wall. POSTERIOR WALL: - Formed by sphenomaxillary wall. - A thin plate of

bone separate the antral cavity from the infratemporal fossa. MEDIAL WALL : - Lateral wall of


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the nasal cavity. - the opening of the antrum in the middle meatus at the lower part of the hitussemilunaris. - The opening of the sinus is closer to the roof and thus at a highr level than thefloor.

Slide 8:HISTOLOGY OF THE MAXILLARY AIR SINUS: - the sinus is lined by respiratory mucosawhich is lined by ciliated columnar epithelium. The ciliated movement help in removal of mucussecretion towards the osteum. BLOOD AND NERVE SUPPLY: Arterial supply : - Facial artery- Infraorbital artery - Greater palatine artery Venous drainage: - Facial vein - pterygoid venous

plexus

Slide 9:Lymphatic Drainage : - sumbmandibular lymph node. Nerve supply: - Infraorbital nerve -Anterior superior alveolar nerve - Middle superior alveolar nerve - posterior superior alveolar nerve

Slide 10:EMBRYLOGY: The sinus are rudimentary or even absent at birth. They enlarge rapidly at theage of 6 to 7 months. The maxillary air sinus formed first among the other paranasal sinus. Itstart as a shallow groove on the medial surface of the maxilla during the fourth month of intrauterian life. Present as small cavity at birth. From birth to adult life the growth of sinus dueto enlargment of bone. It reach maximum size by around 18 years of age. In old age it enlargedue to resorption of the surrounding cancellous bone.

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CLINICAL IMPOTANCE ; Dental infection: Infection from the maxillary premolar and molarscan easily communicate and infect the maxillary antrum. Oroantral Communication: Traumaticextraction of maxillaryteeth can cause oroantral communication. Root Pieces: Root pieces of maxillary teeth may sometimes be accidentally forced into the maxillary antrum. MaxillarySinusitis : Because of the thickned and inflammed sinus lining compresses the nerve supply of the maxillary posterior teeth causing tenderness of the maxillary teeth. The Maxillary Artery can

be approached through the posterior wall of the maxillry antrum for ligation. The infraorbital andsuperior alveolar vessels are freqently ruptured in maxillary fracture causing the hemotomaformation in the antrum.

Slide 12:MAXILLRY SINUSITIS maxillary sinusitis: It is the inflammation of the maxillary sinus.Maxillary sinusits Acute Subacute Chronic ACUTE SINUSITIS: It may be supurrative or nonsupurrative inflammation of the antral mucosa. It is the most freqently infected of the paranasalsinus.

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ETIOLOGY: (1)Nasal Infection (most common) : Viral rhinitis and influenza are the commoninfection. (2) Dental Infection: Infection from the maxillary posterior teeth can easily spread tothe maxillary sinus as the plate of bone dividing the root apices from the sinus . (3)ContaminatedSwimming water : Diving in such water forcibly directs water into the nasal cavity and then intothe sinus. (4) Trauma: Fracture of the maxilla or zygoma, gun shot wound or penitrsting injuriescan lead to sinusits.

Slide 14:PATHOGENESIE: During early phase of inflammation, intial vasodilation leads to increases

production of mucosa from the mucosa gland. The mucosa concequently exert pressure withinthe lumen of the antrum.

Slide 15:CLINICAL FEATURES: The patient gives history of `catching cold 3 to 4 days earlier. Nasal

block secondary to rhinitis. Increase in purulent, thick, discoloured and foul smelling nasal

discharge is prominenant features. A sense of fullness and pain on cheek on bending forward.Patient producing cough secondary to the nasal discharge with onset of pharyngitis. The relatedmaxillary teeth are tender on percussion. Nasal resonance- change in the voice due to blocking of sinus. Constitutional symptoms Fever, Headache, Malaise, Difficulty in breathing.

Slide 16:DIAGNOSIS; (1) Water view radiograph. (2) Transillumination test: Shows opacity involvedsinus. (3) Culture: Nasal secretion may be for culture sensitivity test to see the organisaminvolved. MANAGEMENT: MEDICACAL SURGICAL MANAGEMENT MANAGEMENT

Slide 17:MEDICAL MANAGEMENT: Antibiotics: Broad spectrum antibiotics. Decongestant: Decreasesthe congestion and edema of the nasal sinus. Help in the drainage of the sinus. Analgesics:Paracetamol provide symptomatic relief. Steam inhalation: Steam+ Menthol+ Tincture. After Decongestion for 15 to 20 minutes. Helps in drainage. Hot Fomentation: Local heat applicationis soothing to the inflamed sinus.

Slide 18:SURGICAL MANAGEMENT: Antral levage: Acute maxillary sinusitis usually responds well tomedication. It is basically involves inserting a canula into the maxillary sinus trough the inferior meat us. Luke warm water is irrigated through the sinus and this drains out through the osteumalong with the sinus exudates. COMPLICATION - Chronic sinusitis - Osteomylelitis of themaxilla - Orbital cellulites - Middle ear infection - Spread to the other sinus.

Slide 19:SUBACUTE MAXILLARY SINUSITIS: It is the intermediate stage between acute and chronicsinusitis. There is pain only in the form of the local discomfort. patient has persistent discharge.


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The voice is nasal, throat is sore with constant irritating cough. Patient can not sleep well. Thedisease may take a long course over week or months.

Slide 20:CHRONIC SINUSITIS Infection of the that last for months or year is called chronic sinusitis. Itis most commonly is an extension of an acute sinusitis which failed to resolve completely.CAUSATIVE ORGANISM: - Aerobic organism - Anaerobic organism.

Slide 21:PATHOPHISIOLOGY: After infection Ciliated epithelium gets destroyed Prevent drainage of secretion from the maxilla pooling and stangnation of mucopurulent in sinus Progression of infection Mucosa changes Cilliary damaged and edema Mucosa may become thick and

polypoidal.

Slide 22:Clinical Features: Symptoms are non specific unlike acute sinusitis. patient not having pain or tenderness. Purulent nasal discharge may be foul smelling. Block of nasal and change in voicedue to loss of resonance. Ansomia. INVESTIGATION Waters view radiograph. Culture of thedischarge from the sinus. Transillumination test.

Slide 23:MANAGEMENT: Medical management: Antibiotics: Broad spectrum antibiotics. Analgesics:Paracetamol providing relief. Decongestant . Steam inhalation. Hot fomentatiom.

Slide 24:SURGICAL MANAGEMENT: Treat any dental infection if present. Antral leavage: If morethan three successive punture have purulent fluid than the treatment should be more radical. Intranasal Antrostomy : A window or opening is created in the inferior meatus of facilltates drainageof the sinus. Cold Well luck Operation.

Slide 25:CALDWELL LUC OPERATION: This is the procedure by which the antrum is enteredintraorlly through the anterior wall and all irreversible disease is removed. This is followed by anantrostomy to promote permanent cure. INDICATION: Chronic maxillary sinusitis. Removal of foreign bodies in the antrum such as root pieces. Treatment of oroantral fistula that fails to heal.treatment of benign dental cyst tumor. Biopsy procedure for a suspected malignancy in theantrum. Recurrent antrachoanal polyp. Approach to pterygopalatine fossa, sphenoidal sinus,ethmoidal sinus.

Slide 26:CONTRAINDICATION: Age- Not performed in patient below 17 years as there may be damageto devloping tooth bud in that region. Acute infecion. Other systemic cause contraindicating


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surgery. PROCEDURE: procedure is usually under general anesthesia. Patient is placed supinewith head end of the table raised. Head is turned slightly to the opposite side. Incision: Asemilunar incision is placed in the mucobuccal fold.

Slide 27:Exposure: A full thickness mucoperiostel flap is reflected upto the infraorbital nerve. Care istaken to protect the infraorbital nerve. Approach to the antrum: A micromotor with the largeround burr is used to create a window about 1.5 to 2 cm in the anteroir wall of the antrum. Thesinus mucosa is seen below the bone. Antral lesion: The lesion may be delt with. A biopsy may

be done or sinus mucosa is removed with the help of the curette as the case demand. Antrostomy:A opening is made in the medial wall in the lower most and anterior aspect of the inferior meatus.

Slide 28:(8) Packing: The sinus cavity may be packed with the ribbon gauze impregnated with vaseline.

The gauze is packed in layer and the free end is brought out through the created antrostomyopening. (9)Sutures: The bone margin is smoothened and the flap is replaced. The flap may besutured using resorbable suture material.

Slide 29:POST OPERATIVE CARE: Ice pack over the cheek for first few hour after surgery. Sinus pack is removed after 24 to 48 hours. Avoid blowing of the nose for at least 2 week after surgery.COMPLICATION: Intraoperative complication: Bleeding Damaged to infraorbital nerve.Damaged to orbital content- Due to perforation into the thin orbital floor during curettage of thesuperior wall of the trauma. Postoperative complication; Reactionary Heamorrhage. Infection.

Numbness in the infraorbital region. Recurrence of the lesion. Antrstomy opening. OroantralFistula (rarely)

Slide 30:OROANTRAL FISTULA: Definition: It is the pathological communication between oral cavityand maxillary antrum. Fresh communication will lake the epithelium lining while long standingones known as chronic oroantral fistula have epithelized fistulous tract. OROANTRALFISTULA ACUTE CHRONIC

Slide 31:ETIOLOGY: Extraction of teeth: - Occurs as a result of a traumatic extraction of maxillary

posterior teeth whose root may be inclose proximity to the floor of the maxillary antrum. -Tuberosity fracture as a result of upper third molar extraction. - In advert curettage of maxillarytooth socket. Facial Trauma: Maxillofacial trauma and penitrating injury. Surgical removal of thecyst and tumor associated with the maxillary alveolar region extending into the antrum.Osteomylities of the maxilla or following irradication. palatal gumma (syphilis) Malignant tumor such as wegeneres granulomatosis wich may perforate the palate. Implant surgery in themaxillary posterior region.


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Slide 32:ACUTE OROANTRAL FISTULA: Clinical features: Symptoms- History of recurrent surgery inthe vicinity of maxillary sinus. Escape of air and fluids through the nose and mouth. Unilateralepsitaxis. pain may be severe throbbing ordull aching pain. Enhanced column of air causingchange in the vocal resonance and consequently change in the voice. IMIDIATED SIGN- The

part of the bony part of the sinus may be adhearent to the root tip on extraction. Maxillarytuberosity fracture. Root tip in the maxillary antrum.

Slide 33:DELAYED SIGN OF OROANTRAL FISTULA: Discharging of foul smelling pus from thefistula. Maxillary sinusitis. Infraobital region is tender on palpation. Infraorbital edema. Teeth anaffected side will be tender on percussion. Nasal congestation around the osteum. Pus in the

posterior wall of the pharynx. Antral polyp in the oral cavity.

Slide 34:

DIAGNOSIS OF OROANTRAL FISTULA: - A large fistula is easily seen on inspection. - Nose blowing test: The patient is placed to close his nostril and blow gently down the nose with noseopen. Whistling sound as air passes down the fistula in the oral cavity. - cotton wisp test: Theescape of air through the nose can be tested by placing a wisp of cotton near the orrifice. - Mouthmirror fogging test: A mouth mirror placed at the oroantral fistula causing the fogging of themirror. - Unilateral epistaxis may sometimes be seen - some time the oroantral fistula can

blocked by the an antral polyp.

Slide 35:MANAGEMENT: Aim: - To prevent nasal regurgitation of fluides. - To prevent infection of the

maxillary antrum from the oral cavity. CLOUSURE OF OROANTRAL COMMUNICATION:Aim: - Primary repair to close the communication. - Antibiotics to cure the sinus infectionPROCEDURE: Irrigation of the antrum with saline. Simple suturing of the socket. A well fittingdenture base may be constructed with a flenge extention to cover the oppening completely. This

prevent contamination of the oral cavity and antral cavity and thus enabled healing. Once acommunicate is formed between the oral and antral cavity, ther are the chance of infection of themaxillary antrum. Supportive measure are required for treatment of the maxillary antruminfection.

Slide 36:SUPPORTIVE MEASURE: Antibiotics: -For prevent the sinusitis. - For preventing the

infection. Steam inhalation: Steam inhalation with benzoin compound helps to thin down theantral section and helps in the easy drainage of these fluids through the nose.. NasalDecongestant: - for reduce nasal secretion. - Decrease the nasal inflammation of the nasalmucosa. Analgesics and Antihistaminics: -For reduction of the pain - Decrease the secretion.Antral leavage:- When an accumulation of pus is suspected in the antrum it may be necessary towash out the antrum with either warm normal saline or antibiotic rinse. Procedure is done at theregular interval till a clear fluid is obtained from the antrum.


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Slide 37:CHRONIC OROANTRAL FISTULA: This occur due to the persistence of the communication

between the oral cavity and the maxillary antrum. CLINICAL FEATURES: Persistent unilatralfoul discharge. Post nasal drip with the discharge trickle down the phrynx from the posterior nares resulting in foul smell and unpleasent test. Systemic sequeles due to swallowed pus in the

form of -Pyrexia, malaise, Headache, Ansomnia,Anroxia. Pain is diminish consiberabely. Polyp projecting form the antrum into the oral cavity prevents the fistulous tract to heal spontaneosly.

Slide 38:INVESTIGATION: - Intra oral periapical radiograph is taken with the silver probe placed intothe fistula tract to determine the frequency of the tract. - Maxillary sinus radiograph of the skull.- Routine evalution. MANAGEMENT SURGICAL SUPPORTIVE METHOD METHOD

Slide 39:SURGICAL METHOD If fistulous persist for more than 2 to 3 months the fistula tract wouldhave been epithelized. METHOD OF CLOSURE TECHQUINE; LACAL FLAP 1. Buccal flap Buccal advancement flap - Buccal sliding trepezoid flap - Bipedic flap 2. Palatal Flap- Palataladvancement flap - Palatal rotational advancement flap Submucosal connective tissue pedicle -Pedicle island flap - Anterior based flap 3. Combination of buccal and palatal flap DISTANTFLAP GRAFT- Buccal fat pad - Bone graft.

Slide 40:PRINCIPLE : 1. Blood supply should be adequate so that the flap does not necrose. 2. Sutureline is well supported by normal bone. 3. Wound is sutured in tension. 4. All basic requirementshould be fullfilled. BUCCAL ADVANCEMENT FLAP: (VON REHRMANN FLAP)

Described by Von Rehrmann in 1936. Mostly is used method. TECHQUINE: Excise the tissuelining the oroantral fitula. Two vertical divergent incision are made on either side of the fistulaon the buccal gingiva. A broad based mucoperiosteum flap then elevated from the under lying

bone and flap is mobilized to cover the oroantral communication.

Slide 41:4. If the extent of the flap is inadequate the periosteum and the inner side of the flap may beincised horizontaly. the flap now be sutured more easiley. 5. The flap is made to cover theopening and is sutured to the palatal tissue. ADVANTAGE: 1. Simple and easily to perform. 2.Flap is usually has a good blood supply due to broad base. 3. Well tolerated by the most patient.4. Denture may be placed immediately DISADVANTAGES: Reduction in the buccal vestibular

depth.

Slide 42:PALATAL ADVANCEMENT FLAP: Procedure: The palatal tissue surrounding the oroantaralcommunication may be advanced and sutured to the buccal tissue o cover the defect. The surfacemarking is midway between the free gingival margin and midline of the palate. The palatalmucoperiosteal flap with greater palatine vessles is raised its bed and roteted across the fistula


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with greater palatine foramen as the center of rotation Incision is made with the B.P. blade no.11, the fistulous tract at least 2mm away from the epithelized surface. It is desected and removedout. Surface line rest on the normal bone. Flap design and length of the flap are determined.Depending on the length of the flap is raised carefully since the survival of the flap entirelydepends on the vuscularitiey. The flap is rotated buccaly with greater palatine foramen as thecentre of rotation to the extent needd to cover the fistula.

Slide 43:DISADVANTAGE: - Palatal tissue is not very elastic and cannot be streached to cover thedefect completely.

Slide 44:ROTATIONAL ADVANCEMENT FLAP: This is posteriorly based flap which gets its bloodsupply from greater palatine artery. It has the advantage greater mobility and bulk. The flap isreflected and rotated to fit the defect. Chance of bending of the tissue when it is truned to cover

the oroantral opening. This may be damaged due to venous congestion. To prevent the bending aV- shaped excision of the tissue at the bend may be done. This prevent the folding of the tissue atthe junction. Then sutured to the buccal side with minimal tension.

Slide 45:SUBMUCOSAL CONNECTIVE TISSUE PEDICLE: The submucosa on the palatal is used tocover the oroantral communication. The mucosa layer or the epithelial layeris then packed back on the donor site. Therefore there is no row surface on the palatal unlike the previous procedure.The dissection of the submucosa is however is difficulty procedure and required great care.

Slide 46:COMBINATION PROCEDURE: A combination has been described where in alveolar bone

based buccal flap is reversed and sutured with palatal margin. This replace the living part of thewound. The palatal flap is rotated and palaced in the usual manner. Thus the row surface of boththe flaps are placed against each other. this is two layerd closure.

Slide 47:DISTANT FLAP : Tongue Flap: Highly vascular and provide adequate bulk for the closure of large defects without tension. Disadvantages: Mobility of the tongue which can result in failureof flap.

Slide 48:GRAFT PROCEDURE : 1. Buccal fat pad- small to medium sized defect can be closed with a

buccal fat pad graft. It is simple surgical technique with the donor site being closed to area of closure. 2. Bone graft Allopalstic material : - Gold foil / gold plate : Gold foil can be used to

bridge between the buccal and palatal flap till the defect heals. - soft polymethylmethacrylate -Hydroxyapatite blocks


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Slide 49:References Textbook of oral and maxillofacial surgery - chitra chakravarty Text book of oral andmaxillofacial surgery - B.shrinivasan Text book of oral medicine - Anil govindrao Ghom

deepaknarayan

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