Prof. Ragab Shaaban Outlines: 1) Applied anatomy. 2) Diseases. 3) Oro-Antral fistula. Text book Contemporary Oral and Maxillofacial surgery Peterson-Hupp Largest paranasal sinuses Child-------------Adult Pneumatization Pseudo stratified ciliated columnar epithelium • It is a pyramidal-shaped air space which occupies the body of the Maxilla. The base is formed by lateral wall of nasal cavity. Upward (roof) by the orbital floor and downward (base) by the alveolar process of the posterior maxillary teeth. It is bounded anteriorly by the outer wall of maxilla. • The outlet of the sinus is present in the middle meatus and called hiatus semilunaris or ostium maxillary. • The function of the sinuses is to improve resonance to warm inspired air and to decrease the weight of the skull. • The teeth related to the maxillary antrum are first molar, second molar, second premolar, third molar and first premolar in that order, sinus problems can be mixed up with maxillary dental problems. Obstruction of natural flow of drainage from the sinuses due to: 1. Inadequate and higher position of the anatomic openings, 2. Septal deviations, 3. Hyperplasia of the lining and inadequate ciliary action. Diagnosis of the maxillary sinus diseases • I ) History • II ) Clinical Examination • III ) Radiographic Examination • IV ) Sinoscopy I ) History II ) Clinical Examination -Percussion -Palpation -Transillumination III ) Radiographic Examination 1- Intraoral periapical films  Detect approximation of the teeth to the sinus .  Detect root tips or foreign bodies in the sinus . 2- Panoramic view Give an overview of the maxillary sinuses bilaterally 3- Water’s view ( 15 degree Occipitomental view ) Produce a very clear unobstructed view of both sinuses . III ) Radiographic Examination 4- Tomogram 5- Computerized Tomography Scanning ( C.T ) IV ) Sinoscopy • It is a recent investigation method which have an important role in the diagnosis of the malignancy and other pathological conditions of the maxillary ant rum . • May be either acute, subactue or chronic depending on the virulance of the organism, the local condition and resistance of the individuals. Etiology • Inflammation of the sinus and its lining is caused by bacteria from the following sources. A. Nasal origin: common cold and influenza. B. Dental origin: a. Infection from dental abscess. b. Infection from cystic lesion of related teeth. c. Dental material pushed into the sinus “gutta percha”. d. Tooth or root pushed in the sinus. e. Oro-Antral fistula. f. Facial fracture involving the sinus. g. Sever periodontal pocketing. Clinical features 1. Headache and sever pain increasing by bending of the bending head downwards. 2. Pain and tenderness in the upper teeth. 3. Unilateral fetid nasal discharge. 4. Nasal obstruction with unpleasent smell. 5. General sympoms of toxamia as fever, malaise and dizzines. Treatment 1. Ab from 5-7 days. 2. Decongestive nasal drops to shrink the mucous lining and help drainage. 3. Analgesics to relieve pain. 4. If an oror-antral fistula is present, daily irrigation of the sinus by warm normal saline. 5. Removal of the cause, e.g., closure of O.A.F. Clinical features 1. Continous dull pain and Intermittant headache. 2. Periodic or persistant unilateral nasal discharge. 3. Fetid breath. 4. Posterior nasal discharge. 5. Transillumination reveals opacity of the affected side. 6. X-ray show opacity of the sinus with marked thickening of its lining. Treatment 1. Extraction of infected tooth. 2. Repair of O.A communications. 3. The thickened lining should be removed through a Coldwell-Luc operation. Trauma of the sinus Prolapse of the sinus Occur with fracture of middle third of the face, fracture tuberosity or floor of the sinus during extraction, also may occur from nasal operations This rare condition which may follow perforation of the floor of the maxillary sinus as from dental extraction. • This formed in case of fracture of the middle third of the face and cause continuous nasal bleeding. Treatment: 1. 2. 3. Cold application to stop bleeding and decrease swelling. Drainage of the sinus through inferior turbinate puncture. Continuous bleeding needing interference by cold well-luc operation and inserting a pressure pack inside the sinus or by tying the bleeding vessel. • There are hard calcific bodies with rough irrigular surface, it is asymptomatic and discovered on routine radiography as radio-opaque mass, it may become secondarily infected causing maxillary sinusitis. Treatment: • Removal through Coldwell-Luc operation • Usually all the cysts affecting the sinus are asymptomatic. They are discovered by routine radiographic examination. 1. Cysts occurring in the sinus: a. Benign mucosal cyst. b. Mucocele. 2. Cyst encroaching on the sinus: a. Periodontal cysts b. Dentigerous cyst. c. Odontogenic keratocyst. • Most common cyst occurs in the sinus as a result of obstruction of the glandular ducts. Small cysts are formed in the lining, or these cysts may ruptured and coalesce to form one large cyst. Clinical features: 1. 2. 3. 4. 5. Discomfort in the cheek or maxilla. Buccal expansion of the antrum. Nasal obstruction. Post nasal discharge. External deformity of the face. • Radiographic picture: appear as rounded lightly opaque shadow in the floor of the sinus. • Aspiration: through inferior turbinate will reveal straw or “cholesterol crystals”. amber-coloured fluid Treatment: 1. Can be left untreated if found in routine xray. 2. Cannulation through inferior turbinate puncture. 3. Marsupialization 4. Enculeation through cold well. operation with nasal antrostomy. Luc a. Ameloblestoma. b. Adenoameloblastoma c. Odontoma. a. b. c. d. Osteoma. Fibro-osteoma. Ossifying fibroma. Fibroma. By surgical excision. Benign odontogenic tumors: 1- Ameloblastoma: • Ameloblastoma (adamantinoma) is a benign neoplasm deriving from the enamel organ. --Its etiology has not been ultimately determined. • It constitutes about 1% of all head and neck tumours, and about 11% of teeth-originating tumours . -Ameloblastoma,Diagnosis: 1 -in upper jaw, molar area is the commonest site . 2-no deformity results as the tumor grows into the sinus. 3-slowly growing, locally invasive . 4-asymptomatic condition usually. 5-egg shell crackling sensation due to thinning of bone 6-malocclusion due to tooth movement. Radiographics: 1-Multilocular radilucency: -soap bubble appearance. -honey combed appearance. 2-unilocular radiolucency: Resembling cystic lesions with irregular scalloping margins. • Ameloblastoma involving the left maxilla. Axial CT image (soft tissue algorithm). Note the extension beyond the posterior maxilla. Treatment: Surgical excision is the treatment of choice to reduce the recurrence possibility. 2-adenoameloblastoma: It is an adenomatoid odontogenic tumor with no glandular elements. Most common site is maxillary canine region. -slowly enlarging swelling or rarely occurs peripherally as a small sessile mass in the anterior upper gigiva. X-ray: Well defined unilocular area with faint[snow flakes] radioopacities. Treatment: Enucleation is the treatment of choice with no recurrence Adenomatoid odontogenic tumor of maxilla in an edentulous patient. Radiographically, a dentigerous cyst is suggested 3-odontomes: They are mixed lesions containing fully formatted dental tissues, both epithelial and mesenchymal, and are usually found during a routine radiographic examination . Radiographic picture: In early stage, it is well defined radiolucent and radiopaque foci usually associated with an impacted tooth and radiopaue rim. Mature lesion appears radiopaque with radiolucent rim. Compound odontomes appear as a bag of teeth Complex odontomes appear as a radiopaque mass(as osteoma ) with radiating structure and a radiolucent rim. Clinical picture: 1-odontomas occur in children and young adults[second decade]. 2-there is usually a retained deciduous tooth. 3- it is usually asymptomatic as they are a small lesion . 4- large lesions result in jaw expansion. Treatment: Enucleation or local excision with excellent prognosis. Benign non odontogenic tumors : 1-Osteoma It is mesenchyme non odontogenic benign tumor composed of mature or cancellous bone. Osteoma of the paranasal sinuses is a benign, slow growing and well-defined bony tumor arising mostly from the frontal sinus, and less frequently from the ethmoid, the maxillary and the sphenoid sinus. Osteoma clinically: -small asymptomtic lesion. -commener in the mandible premolar lingual area or the condyle region. -types: A] periosteal osteoma; may arise on the surface of the bone as polypoid or sessile mass. B] endosteal osteoma; Arise in the medullary bone. Radiography: well circumscribed sclerotic radiopaque mass Differential diagnosis: -osteoblastoma -focal sclerosing osteomyelitis. Treatment: Conservative surgical excision