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 Index

Sr. Topic Page

No. No.

1. Introduction 1

2. Development 4

x Developmental variations 8

3. Anatomy 11

x Regional 20

x Applied 24

4. Histology of the Maxillary Sinus 29

5 Physiology and Pathophysiology 31

6 Examination and Investigation 35

7 Diseases 71

8 Bibliography 134
 Introduction

Introduction

Paranasal sinuses are air filled spaces present within some bones around the

nasal cavities and are named according to the bone in which they are present. 1 The

four paranasal sinuses are ; frontal ,maxillary , sphenoidal and ethmoidal .All the

paranasal sinuses open into the lateral wall of the nasal cavity by small apertures; that

permit both the equilibration of air between the various air spaces and the clearance of

mucus from the sinuses into the nose via a mucociliary escalator . Respiratory

epithelium extends through the apertures of the paranasal sinuses to line their cavities,

a feature that unfortunately favours the spread of infections.2 The mastoid air cells of

the temporal bones are an interconnected network of small sinus cavities which

1
 Introduction

communicate with the middle ear. Hypopneumatized mastoid system has been found

to be a risk factor for the development of various middle ear diseases.

The maxillary sinuses are of particular importance to the dentist because of

their proximity to the teeth and their associated structures.3 The maxillary sinus or

antrum is the pneumatic space that is lodged inside the body of the maxilla and that

communicates with the environment by way of the middle nasal meatus and the nasal

vestibule.4 Anthropometric measurements have shown that the maxillary second

molar is most often (45.5%) in the immediate vicinity of the antrum (0.5 mm or

nearer ) ,followed by the first molar (30.4%) , third molar (27.2 %) and second

premolar (19.7 %).5

Maxillary sinuses are two in number, one on either side of the maxilla and

they are the largest of the paranasal sinuses.6 Due to close proximity of the maxillary

posterior teeth with the maxillary sinus odontogenic infections may spread to the

sinus. An appreciation of the bacteriology of acute and chronic maxillary sinusitis is

important to guide empiric therapy ,confirm successful treatment and limit the

inappropriate use of antibiotics that can promote the development of resistant strains

,which is possible because the maxillary sinus is relatively easy and safe to access and

is the first site of invasion for the microbiology of sinusitis. The maxillary sinus may

harbour any of a large number of benign lesions with a different array of etiologies.

Being a relatively large cavity within the craniofacial skeleton long period may pass

before any symptoms manifest themselves .Frequently patients only present when

their lesions have filled the cavity, causing pressure symptoms or spread into

surrounding structures. Consequently, abnormalities arising from within the maxillary

2
 Introduction

sinuses can cause symptoms that may mimic diseases of odontogenic origin and

conversely abnormalities that arise in and around the teeth may affect the sinuses or

mimic the symptoms of sinus disease.3

Part or all of the maxillary sinus appears on radiographs made for dental

purpose, thus the dentist should have some familiarity with variations to the normal

appearances of the sinuses and the more common diseases that may affect them. The

antral shadows as in radiographs are a source of difficulty and an abnormal state of

affairs is only possible with a background of sound knowledge of the normal.7

It may possess a challenge in the diagnosis and management of problems

related to maxillary sinus in the orofacial region of both dental and non dental origin.

In order to understand proper diagnosis, treatment modalities of the disorders related

to the maxillary sinus and to treat the complications in this area, the anatomy of this

region as well as the radiology of the maxillary sinus must be well known.

Thus, the following section deals with the development, age changes, regional

and applied anatomy, imaging, pathological aspects and treatment of the disorders

related to the maxillary sinus.

3
 Development

Development

The paranasal sinuses develop as invaginations from the nasal fossa into their

respective bones i.e. maxillary , frontal ,sphenoid and ethmoid.3 Although paranasal

sinus development begins in utero ,only the maxillary and ethmoid sinuses are present

at birth.8 The maxillary sinuses are the first to develop in the second month of

intrauterine life and shows two main growth spurts at 0-3 yrs and second one at the

7-12 yrs of life corresponding with the development of the permanent dentition and

pubertal facial growth.9

As invagination develops in the lateral wall of the nasal fossa in the middle

meatus ,simultaneous resorption of the maxillary bone occurs and the sinus enlarges

laterally into the body of the maxilla. The maxillary sinuses develop in the space

existing between the oral cavity and the floor of the orbit.10

4
 Development

The initial development of the maxillary sinus follows a number of

morphogenic events in the differentiation of the nasal cavity in the early gestation

(about 32mm crown-rump length [CRL] in an embryo). First the horizontal shift of

the palatal shelves and subsequent fusion of the shelves with one another and with the

nasal septum separate the secondary oral cavity from two secondary nasal chambers.

This modification presumably influences further expansion of the lateral nasal wall in

that the wall begins to fold; thus three nasal conchae and three subjacent meatuses

arise. The inferior and superior meatuses remain as shallow depressions along the

lateral nasal wall for approximately the first half of the intrauterine life; the middle

meatus expands immediately into the lateral nasal wall. Because the cartilaginous

skeleton of the lateral nasal capsule is already established, expansion of the middle

meatus proceeds primarily in an inferior direction, occupying progressively more of

the future maxillary body.

The maxillary sinus thus established in the embryo of about 32 mm CRL

expands vertically into the primordium of the maxillary body and reaches a diameter

of 1mm in the 50 mm CRL foetus (at this time the first glandular primordial from the

maxillary sinus epithelium are apparent), 3.5mm in the 160 mm CRL foetus and 7.5

mm in the 250 mm CRL foetus. In the perinatal period the human maxillary sinus

measures about 7 to 16 mm in the anteroposterior direction, 2 to 13 mm in the

superoinferior direction and 1 to 7 mm in the mediolateral direction.4

At birth, these sinuses are approximately the size of a small lima bean and are

situated with their longer dimension directed anteroposteriorly.10 According to

Shaeffer these diameters increase to 15, 6 and 5.5 mm respectively at the age of 1

5
 Development

year to 31.5,19 and 19.5 mm at the age of 15 years and to 34,33 and 23 mm in the

adult. They enlarge with facial growth to occupy the space between the posterior

maxillary teeth and the floor of the orbit.

The maxillary sinus volume is 6-8 mm3 at birth and increases to several

directions such as the infraorbital wall, nasal cavity, zygomatic process and alveolar

process. Until the age of 8 yrs, the maxillary sinus volume increases by 2mm per year

in the vertical and lateral dimensions and by 3mm per year in the anteroposterior

dimension .At the age of 10 yrs, the lower boundary of the maxillary sinus is at the

level of the nasal cavity floor. The following growth is principally in an inferior

direction and after the eruption of the maxillary teeth, the maxillary sinus reaches its

maximum volume at about the late adolescence age. 11

In early stages, maxillary sinus is high in maxilla. Although the exact time at

which the human maxillary sinus attains its definite size is not known, the sinus

appears to expand and modify in form until the time of eruption of all permanent

teeth. The maxillary sinus grows downward by a process of pneumatisation.

In the course of development, the maxillary sinus often pneumatises the

maxilla beyond the boundaries of the maxillary body. Some of the processes of the

maxilla consequently become invaded by the air space forming recesses. These

recesses are found in the alveolar process (50% of all instances), zygomatic process

(41.5 % of all instances) and palatine process of maxilla (1.75 % of all instances).

The growth slows down with the decline of facial growth during puberty but

continues throughout life. The expansion of the sinuses normally ceases after eruption

6
 Development

of permanent teeth. However, occasionally, the sinuses pneumatise further, after

removal of one or more of maxillary posterior teeth and extend into the residual

alveolar process.6

Fig. 2.1: PNEUMATISATION OF THE MAXILLARY SINUS

7
 Development

DEVELOPMENTAL VARIATIONS

Anatomic variants are relatively common in the evaluation of patients with

maxillary sinusitis and may also present in a significant number of persons without

sinus disease. The pathogenic role of each anatomic variation should be evaluated on

an individual basis with consideration to the size, position and presence of

inflammation. Embryogenic developmental abnormalities or acquired reasons such as

infection or trauma leading to arrest of maxillary sinus pneumatisation may lead to the

various developmental variations which includes agenesis (complete absence of the

sinus), aplasia and hypoplasia (altered or underdevelopment of the maxillary sinus).

This variations occurs either alone or in combination with other anomalies like

choanal atresia , cleft palate, high palate, septal deformity ,absence of concha,

mandibulofacial dysostosis, malformation of the external nose and various pathologic

conditions of the nasal cavity.4

1. Supernumerary maxillary sinus: It is the occurrence of two completely

separated sinuses on the same side with two permanently separated ostia of the

sinus which results due to outpocketing of the nasal mucosa into the

primordium of the maxillary body from two points either in the middle nasal

meatus or in the middle and superior or middle and inferior meatuses

respectively.

2. Aplasia: It is the altered development of maxillary sinus cause by failure of

pneumatisation. In this condition the sinus appears radiopaque.

3. Agenesis: It is the complete absence of maxillary sinus.

8
 Development

4. Hyperplasia: It is an excessive development of maxillary sinus .It occurs in

acromegaly. These anomalies occur either alone or in association with other

anomalies like choanal atresia, cleft palate, high palate, septal deformity,

absence of chondra, mandibulofacial dysostosis, malformation of external

nose and pathologic condition of nasal cavity as a whole.

5. Hypoplasia: It describes an anatomic abnormality spectrum ranging from mild

sinus hypoplasia to cleft like sinuses. It is an uncommon clinical entity that has

been reported in 1.73% to 10.4% of patients with sinus symptoms.11 It appears

as radiopacity of sinus.

Uncinate process hypoplasia or aplasia can be associated with maxillary sinus

hypoplasia (MSH) and three severity levels of MSH have been described,

based on CT appearances. MSH type I is characterized by mild to moderate

hypoplasia, normally developed uncinate process and well defined

infundibular passage , with varying degrees of mucosal thickening within the

affected sinus . MSH type II is characterized by a hypoplastic uncinate process

with ill defined or absent infundibular passage, total opacification of the

affected sinus by soft tissue density on CT scan and markedly significant sinus

hypoplasia. MSH type III is characterized by an absent or very hypoplastic

uncinate process and profound sinus hypoplasia or aplasia : the sinus is

represented by only a shallow cleft in the lateral nasal wall. Realizing MSH

preoperatively may prevent complications such as orbital injury, while

performing uncinectomy during endoscopic sinus surgery.12

9
 Development

6. Infraorbital ethmoid air cell (Haller cell): It is the most common anatomic

variation.8 This is an ethmoid cell that pneumatises along the medial roof of

the maxillary sinus and inferomedial portion of the lamina papyracea. These

cells are present in approximately 3-4 % of patients and arise most commonly

from the anterior ethmoid and frequently encroach on the infundibulum.

Bolger et al investigated the role of the infraorbital air cell in sinusitis and

found no statistically significant difference between its prevalence in patients

presenting with recurrent maxillary sinusitis and that of asymptomatic

patients.8

10
 Anatomy

Anatomy

The maxillary sinus is the largest of all the paranasal sinuses. The maxillary

sinus is subject to a great extent of variation in shape, size and mode of developmental

pattern. It is inconceivable therefore to propose any structural description that would

satisfy the human maxillary sinuses. Usually, however, the sinus is described as a four

sided pyramid, the base of which is facing medially towards the nasal cavity and the

apex of which is pointed laterally toward the body of the zygomatic bone. It lies

primarily in the maxilla but may extend into the palatine and zygomatic bones.

The maxillary sinuses on either side may be identical or asymmetrical in size

and shape. The average dimensions of the maxillary sinus are approximately 3.5 cm

(anteroposteriorly) x 3.2 cm (height) x 2.5 cm (width) – (Turner 1902). The transverse

and anteroposterior width of the maxillary sinus on axial CT are convenient indices

11
 Anatomy

for its size. The height of the sinus floor altered with changes in sinus volume but was

not directly influenced by the status of the dentition. The maxillary sinus has a

horizontal pyramidal shape that consists of a base, an apex and 4 sides. The base is

formed by lateral wall of nasal cavity, whereas apex is at the junction of the maxillary

and zygomatic bones. It may extend into the zygomatic bone when the sinus is very

large and thus in such case it forms zygomatic recess and projects as V shaped

shadow over the antrum.

The four walls are:

1) Superior wall or roof of sinus

2) Anterior wall

3) Posterior and lateral wall ( posterolateral wall)

4) Floor of sinus

Fig. 3.1: ANATOMY OF THE MAXILLARY SINUS

The four sides of the sinus, which are usually distant from one another

medially converge laterally and meet at an obtuse angle. The identity of each of the

four sides is somewhat difficult to discern and the transition of the surface from one

12
 Anatomy

side to the other is usually poorly defined. Thus it is apparent that the comparison of

the sinus space to a geometrically well defined body is of pedagogic value only.

The thickness of the bony wall of the sinus varies and it depends on the

amount of bone resorption that occurred in these walls during growth. The volume of

the sinus is 15 to 30 ml. The base of the sinus i.e. the lateral wall of the nose, which is

the thinnest of all the walls presents a perforation, the ostium, at the level of the

middle meatus.

The ostium is a large opening but in intact skull the size of opening is reduced

to 3-4mm as it is overlapped by:

Superiorly: Uncinate process of the ethmoid and descending part of the

lacrimal bone

Inferiorly: Inferior nasal concha

Posteriorly: Perpendicular plate of palatine bone

It is further reduced in size by thick mucosa of nose. The ostium is nearer to

the roof than the floor which thus allow for natural drainage of sinus. The maxillary

sinus ostium has been noted as a posterior, superoanterior or medial opening

depending on the individual patient’s anatomy.8 In some individuals, in addition to the

main ostium, 2 or many more accessory ostia connect the sinus with the middle nasal

meatus. In 5.5 % of instances the main ostium is located within the anterior third of

the hiatus semilunaris, in 11 % within the middle third and 71.7 % within the

posterior third and in 11.3 % the ostium is found outside and in posterior position to

the hiatus semilunaris. The accessory ostia are found in 23% of these instances in the

middle meatus (Van Alyea) and occur rarely in the inferior nasal meatus (Delaney and

Morse).

13
 Anatomy

Fig. 3.2: MAXILLARY SINUS OSTIUM

In the course of development the maxillary sinus pneumatises the maxilla

beyond the boundaries of the maxillary body. Some of the processes of the maxilla

consequently become invaded by the air space. These expansions, referred to as the

recesses, are found in the alveolar process (50 % of all instances), zygomatic process

(41.5 % of all instances), frontal process (40.5 % of all instances) and palatine process

(1.75% of all instances) of the maxilla (Hajnis et al). The occurrence of the zygomatic

recess usually brings the superior alveolar neurovascular bundles into proximity with

the space of the sinus. The frontal recess invades and sometimes surrounds the content

of the infraorbital canal, whereas the alveolopalatine recesses reduce the amount of

bone between the dental apices and the sinus space. The latter development often

pneumatises the floor of the sinus adjacent to the roots of the first molar and less often

to the roots of the second premolar, first premolar and second molar, in that order of

frequency (Osmont et al). The fully developed alveolar recess is characterized by

three depressions separated by two incomplete bony septa. The anterior depression or

14
 Anatomy

fossa , corresponds to the original site of premolar buds, the middle to the molar buds

and the posterior to the third molar bud (Perovic).

ROOF OF SINUS: The roof is flat and slopes slightly anterior and laterally.

The roof of the maxillary sinus is formed by the bony orbital floor i.e. a thin

orbital plate of maxilla. The plate separates the sinus below, from the orbit and

its contents above. This thin orbital surface extends laterally as far as the

inferior orbital fissure. It slopes down from medial to lateral and the most

medial part of the roof forms the sloping wall of the ethmoidal sinuses.

Frequently the infraorbital nerve can often been seen as a ridge or groove

along the roof of the sinus as the nerve passes from a posterior to anterior

direction. Occasionally, the infraorbital nerve may be dehiscent in the roof of

the sinus, which some authors reports to be a potential cause of facial pain and

headache.8 Above the roof of the maxillary sinus is the lower part of the orbit,

containing the periorbital fat, the ophthalmic artery, the zygomatic branch of

the maxillary nerve and the inferior rectus and inferior oblique muscles.

Antral infection may invade the infraorbital vessels and nerves and malignant

tumours growing in the sinus may involve the orbit.13 Involvement of the

infraorbital nerve by invasion of the orbit in case of carcinoma of maxillary

sinus may cause anaesthesia of the skin over the maxilla.1

FLOOR: The floor of the maxillary sinus is curved and is formed by the lower

third of the medial wall and the buccoalveolar wall. The floor of the sinus

corresponds to the alveolar process of maxilla and is related to the roots of the

teeth especially the second premolar and first molar. The floor lies about 1 cm

15
 Anatomy

below the level of the floor of the nose. This level corresponds to the level of

the lower border of the ala of the nose. The floor may be subdivided by

incomplete bony septa lying between the roots of the teeth, especially in the

posterior part of the sinus.

The floor is marked by several conical elevations produced by the roots of the

upper molar and premolar. Roots may even penetrate the bony floor to lie beneath the

mucous lining. Sometimes, canine may project into the anterolateral wall. Thus the

relation of the maxillary antrum to the teeth is inconsistent.

The relationship of the maxillary teeth to the sinus varies according to the size

of the sinus and the degree of pneumatisation of the alveolar process, as well as with

the dental age. The maxillary sinus is usually separated from the molar dentition by a

layer of compact bone. Occasionally, this layer of bone may be thin or absent,

providing a direct route for odontogenic infections to spread to the sinus.8 When the

maxillary sinus is very large and the floor gets thinned out, there is risk of fracture

and a maxillary posterior teeth may displace into the sinus.6

ANTERIOR WALL: This wall is formed by the facial surface of the maxilla,

which extends from the pyriform aperture anteriorly to the

zygomaticomaxillary suture laterally and from the infraorbital rim superiorly

to the alveolar process and maxillary teeth inferiorly. The anterior wall is

depressed by the canine fossa on the anterior surface of the maxilla and is

convex towards the interior of the sinus.

16
 Anatomy

This wall is grooved internally by a delicate canal (canalis sinuosus) which

houses the anterior superior alveolar nerve and vessels as they pass forwards from the

infraorbital canal.

POSTEROLATERAL WALL: This wall is a curved plate which forms the

anterior limit of the pterygopalatine fossa and the pterygomaxillary fissure. It

also forms the oblique anterior wall of the infratemporal fossa. It is pierced by

and contains the posterior alveolar canal, which transmits the posterosuperior

alveolar nerves to supply the maxillary molars. Immediately posterior to this

wall several important structures are located within the pterygopalatine fossa

which includes the maxillary nerve, maxillary artery, sphenopalatine ganglion

and nerve to pterygoid canal.

The alveolar canals content in the sinus may produce ridges in the sinus. The

nerve supply of maxillary posterior teeth is transmitted by the nerves contents in this

wall of the maxillary sinus and therefore acute sinusitis is accompanied by pain in

multiple maxillary posterior teeth.

MEDIAL WALL: The medial wall is bounded by the nasal cavity and is

slightly convex towards the sinus. The medial wall, also referred to as the base

of the sinus is formed by the structures of the lateral nasal wall, namely the

maxillary process of the inferior nasal concha below, the perpendicular plate

of palatine bone and the uncinate process of the lacrimal bone above.

The medial wall is deficient posterosuperiorly at the maxillary hiatus, a large

opening which is partially closed in an articulated skull by the structures of the lateral

17
 Anatomy

nasal wall mentioned above and also the lacrimal bone and the overlying nasal

mucosa to form an ostium and anterior and posterior fontanelles.

The ostium usually opens into the inferior part of the ethmoidal infundibulum

and then into the middle meatus via the hiatus semilunaris (the hiatus forms the area

above the superior edge of the uncinate process). The fontanelles are covered only by

periosteum and mucosa and may contain accessory ostia which may be visible on CT

images.

The skeleton of the medial wall of the maxillary sinus is partly bony, partly

cartilaginous and partly made up only of soft tissues.

The 3 parts of the medial wall of the maxillary sinus are :

A. Bony part

B. Cartilaginous part

C. Cuticular part

ƒ BONY PART : It is formed from before backwards by:

1. Nasal bone

2. Frontal process of maxilla

3. Lacrimal bone

4. Ethmoidal labyrinth with superior and middle concha

5. Inferior nasal concha

6. Perpendicular plate of palatine bone together with its orbital and sphenoidal
process

7. Medial pterygoid plate

18
 Anatomy

ƒ CARTILAGINOUS PART : It is formed by:

1. Upper nasal cartilage

2. Lower nasal cartilage

3. 3-4 small cartilages of the ala

ƒ CUTICULAR LOWER PART: It is formed by fibrofatty tissue covering the

skin.

The various parts associated with the medial wall are :

1. Ostium of maxillary sinus

2. Nasal conchae

3. Meatuses of the nose i.e. Inferior meatus , Middle meatus and Superior meatus

4. Sphenoethmoidal recess

5. Atrium of the middle meatus

6. Vestibule of nose

7. Antronasal duct

The nasolacrimal duct passes downwards, medial to the antrum, to open into

the inferior meatus. Its lumen may be encroached upon by growths within the sinus.

Middle meatus of nose is related to the upper part of the antrum. Hence ethmoidal

labyrinth can be approached through the antrum.14 Almost half of all sinonasal

tumours arise from the lateral nasal wall (Jacobsen et al, 1997)15.

19
 Anatomy

BLOOD SUPPLY, NERVE SUPPLY AND LYMPHATIC DRAINAGE

BLOOD SUPPLY: The blood supply to the mucous membrane of the maxillary sinus

is rich but sinus mucosa is not as vascular as the oral mucosa or nasal mucosa.

Following arteries contributes to the arterial blood supply of the maxillary

sinuses:

a. Anterior , middle and posterosuperior dental arteries

b. Greater palatine artery

c. Sphenopalatine branches

d. Infraorbital artery

All above branches are of 3rd part of maxillary artery which is the branch of

external carotid artery.

e. Facial artery which is anterior branch of external carotid artery.

There are many arterial anastomoses in the region of the maxillary sinus and

this rich network of anastomotic connections accounts for the good survival of

fractured bone fragments in this part of the jaws and promotes rapid wound healing.

Branches of posterosuperior alveolar artery and infraorbital artery form an

anastomosis in the bony wall of the sinus, which also supplies mucous membrane that

lines nasal chambers. An extraosseous anastomosis frequently exists between the

posterosuperior alveolar artery and infraorbital artery. The intra and extraosseous

anastomosis form a double arterial arcade which supplies the lateral antral wall and

partly the alveolar process.

20
 Anatomy

However, because the blood supply to the maxillary sinus are from terminal

branches of peripheral vessels, significant haemorrhage during the sinus lift procedure

is rare.16

VENOUS DRAINAGE: The basic pattern of the venous drainage is to the pterygoid

venous plexus posteriorly with some to the facial vein anteriorly. The distribution of

veins is much more variable than that of the arteries. Veins run with the anterior,

middle and posterosuperior alveolar artery in their neurovascular canals on the facial

and infratemporal walls of the maxillary sinus and also pass within the membranous

fontanelles to the nasal cavity.

The anterior and middle superior dental veins drain superiorly into the

infraorbital vein and then posteriorly through the infraorbital canal, infraorbital

groove and inferior orbital fissure to the upper part of the pterygopalatine fossa.

Tributaries of the sphenopalatine veins pass from the medial wall of the

maxillary sinus via the fontanelles to the lateral wall of the nose and leave the nasal

cavity posterosuperiolaterally through the sphenopalatine foramen to enter the

pterygopalatine fossa.

The posterosuperioalveolar artery drain posteriorly in the same alveolar canals

as the arteries and nerves, travelling almost horizontally to exit through foramina on

the posterior surface of the maxilla into the pterygopalatine fossa.

From the pterygopalatine fossa the veins draining the maxillary sinus pass

laterally into the infratemporal region to enter the dense pterygoid venous plexus. The

(anterior) facial veins sends the buccal (deep facial) vein posteriorly to join the

plexus.

21
 Anatomy

The pterygoid plexus forms the short wide maxillary vein, which enters the

parotid gland and joins with the superficial temporal vein to form the retromandibular

posterior facial vein.

The pterygoid plexus communicates with the cavernous sinus by emissary

vein passing through the foramen lacerum and foramen ovale. Thus infection from the

maxillary sinus may spread to involve the cavernous sinus via any of its draining

veins.

LYMPHATIC DRAINAGE: The maxillary sinus mucosa has a superficial and deep

longitudinal lymphatic capillary network oriented toward the maxillary sinus ostium.

The density of lymphatics increases from cranial to caudal and from dorsal to ventral,

reaching the maximum density at the natural ostium.8 At this point, the lymphatic

network connects directly to the nasal vessels and travels to the nasopharynx.

Besides the ostial route of lymphatic drainage, there are lymphatic connections

over the pterygopalatine plexus to the Eustachian tube and the nasopharynx. The

primary lymphatic basis of the paranasal sinuses are the lateral cervical and

retropharyngeal lymphnodes.

NERVE SUPPLY: General sensory innervation is from branches of the maxillary

nerve, sympathetic from the superior cervical ganglion and parasympathetic from the

sphenopalatine ganglion. These fibers are distributed via the posterior and middle

superior dental and infraorbital branches of the maxillary nerve and via the greater

palatine and nasal branches from the pterygopalatine ganglion.

22
 Anatomy

The respiratory mucosa of the maxillary sinus receives a dense network of

adrenergic and cholinergic nerve fibers, which are branches of the nerves which also

supply the dental pulps of the upper teeth.

Sensory nerves: The anterior superior dental nerve is everywhere closely

related to the anterior superior dental artery. The anterior superior dental nerve plexus

supplies the roof, the facial wall and the anterior part of the medial wall of the

maxillary sinus before giving off its nasal branch. The posterosuperior dental nerve

arises from the maxillary nerve in the pterygopalatine fossa; then it descends between

the mucous membrane and the bony walls of the maxillary sinus, supplying the

posterolateral and inferior walls and then contributing to the molar part of the superior

dental plexus.

The middle superior dental nerve runs in the posterolateral and facial walls of

the sinus. It supplies the antral mucosa superiorly and laterally and contributes to the

part of the superior dental plexus supplying the upper premolar teeth.

The greater palatine branch of the sphenopalatine ganglion descends in the

greater palatine canal at the junction of the medial and posterolateral walls of the

sinus, before emerging from the greater palatine foramen.

Sympathetic: The hypothalamus controls the sympathetic nerve supply to the

maxillary sinus via synapses in the intermediolateral column of the upper thoracic

spinal cord and the superior cervical ganglion.

Parasympathetic: The hypothalamus regulates the parasympathetic inputs to the

maxillary sinus via synapses in the superior salivatory nucleus and pterygopalatine

ganglion.

23
 Anatomy

APPLIED ANATOMY

The maxillary sinus is the paranasal sinus that impacts most on the work of the

dentists as they will often be required to make a diagnosis in relation to orofacial pain

that may be sinogenic in origin. A broad spectrum of disease processes can involve

the maxillary sinus arising either from within the lining of the sinus, the adjacent

paranasal sinuses, nasal space, dental and oral tissues or in the adjacent bone with

expansion into the sinus. Approximately 10-12 % of cases of inflammatory maxillary

sinus disease are of dental origin.9 Hence, the anatomy and the applied aspects of the

maxillary sinus must be well known to a dentist.

The various applied aspects of the maxillary sinus are as follows:

1. Due to the presence of thin bone, extraction of upper posterior teeth may

damage the floor and trauma may fracture its walls. The fracture of middle

third of face involves the maxillary sinus. Fractures of zygomatic bone show

the zygomatic buttress pushed into the sinus; while fractures of middle third of

maxilla – Lefort I, II and III show disturbance in the walls of the sinus.6

2. The wall of the sinus is very thin in the area of canine fossa. This area is used

for diagnostic aspiration, as the site for Caldwell – Luc operation and

functional endoscopic sinus surgery.

3. The ostium lies approximately two third up of the medial wall of the sinus,

anatomically making drainage of the sinus inherently difficult.17

24
 Anatomy

4. Due to the close approximity of the sinus with the posterior maxillary teeth,

the neurovascular bundle of the teeth is at risk during curettage of the sinus.17

5. The nerves travel enclosed in the wall of the sinus innervating the related teeth

i.e. the maxillary posterior teeth; hence it could be difficult to distinguish pain

of dental origin from that of sinus origin. Similarly , buccal surgical

endodontic approach may involve the nerves and cause paraesthesia.17

6. The significance of the vascular drainage of the sinus lies in the fact that apart

from joining typical pathways in the maxilla to the jugular veins, it can also

drain upward into the ethmoidal and frontal sinuses and eventually reach the

cavernous sinus in the floor of the brain. Spread of infection via this route is a

serious complication of maxillary sinus infections like periorbital cellulitis,

blindness and even life threatening cavernous sinus thrombosis.

7. The position of maxillary sinus is an important consideration for the position

of neurovascular foramina from the point of view of local anaesthesia

technique, surgical approaches to impacted maxillary third molars and details

of radiographic anatomy.

8. Because of the close proximity of the posterior teeth with the sinus, the teeth

may be displaced into the sinus while extraction. The palatal root of maxillary

first molar is the most common root displaced into the sinus. As also , because

of this close relationship, root canal medicaments and filling materials are

introduced beyond the apical foramen into the maxillary sinus.17

25
 Anatomy

9. A primary odontogenic infection of the maxilla can be transferred to the orbit

via various pathways. The most common route is from the maxillary sinus.

Thus, the clinicians should not perform a tooth extraction when the patient is

in the acute stage of a maxillary sinus infection.18

10. The sphenopalatine fossa can be approached through the posterior wall of the

sinus for ligation of the maxillary artery and also for performing Vidian

neurectomy.19

11. Caldwell-Luc operation should not be performed under the age of 12 years, till

the second molar erupts, otherwise dentition may be affected.

12. The buccinator is attached to the alveolus overlying the upper parts of the

buccal roots of the upper molars. Its muscle sheet directs pus that has

perforated the mucosa and bone of the sinus floor (buccal alveolar wall) into

the buccal sulcus or on to the face.

13. Whenever intranasal antrostomy is to be carried out; the antral puncture into

the sinus cavity should be made through the middle meatus in children and in

the inferior meatus in adults.6

14. As the walls consist largely of thin bone, a tumour originating within the sinus

may expand up into the orbit, down into the mouth (usually the buccoalveolar

process), posteriorly into the pterygopalatine fossa or the infratemporal

(pterygoid) region, forward onto the cheek or medially into the nasal cavity.

26
 Anatomy

15. The walls of the maxillary sinus are often uneven, the irregularities varying

from shallow ridges of no practical importance to crescentic projections of

considerable size, occasionally a complete septum that may prevent adequate

surgical drainage.

16. The most medial part of the roof forms the sloping wall of the ethmoidal

sinuses, from which disease may spread to the maxillary sinus.

17. When packing an antrum, care must be taken to avoid pushing a fractured

bone fragment against the ophthalmic artery, causing spasm or occlusion and

subsequent blindness.

18. The relation between the tooth roots and the sinus floor influences orthodontic

movement. Where the sinus floor is vertical and there is more bone in the

direction of tooth movement there appears to be a higher degree of tipping,

whereas movement through a more horizontal sinus floor is translatory.

19. The nasolacrimal duct may be obstructed by tumours of the sinus leading to

epiphora (tears rolling down the cheek). The nasal opening of the duct is in the

inferior meatus at the junction of its anterior and middle thirds, and under

cover of the inferior turbinate. Just behind it is the area of thin bone which is

usually penetrated to create an antrostomy from the inferior meatus.

20. The greater palatine artery may be damaged during bone removal in the lower

posterior angle of the inferior meatus during antrostomy.

27
 Anatomy

21. There are many arterial anastomoses in the region of the maxillary sinus. It is

the rich network of anastomotic connections which accounts for the good

survival of fractured bone fragments in this part of the jaws, permits deliberate

down fracture of the maxilla without loss of the blood supply, and promotes

rapid wound healing.

22. Middle turbinate which joins the rest of ethmoid bone at a level halfway up the

orbit, overlies the lateral wall of the middle meatus completely and makes its

examination by direct vision difficult or even impossible.

23. Inflammation and allergy of the nasal cavity causing venous and lymphatic

congestion of the ostium results in impaired mucous drainage and secondary

sinus pathology.

24. Lymphatic drainage patterns are important because infections and malignant

tumours may spread along the lymphatic system.

25. The sensory nerves supplying the maxillary sinus, pass close to or through the

sphenopalatine ganglion, so a local anaesthetic block of the ganglion will

anaesthetize the maxillary sinus.

26. Destruction of the sphenopalatine ganglion, a common operation in the past

for hay fever and allergic conditions, is followed by a catastrophic atrophy of

the glandular tissue of the sinuses, palate and nose.

28
 Histology of the Maxillary Sinus

Histology of the Maxillary Sinus

The maxillary sinus is lined with a respiratory mucosa that is similar to and

continuous with that of the nose and other paranasal sinuses. The sinus membrane is

known as Schneiderian membrane. The lining of the maxillary sinus is a

mucoperiosteum that consist of three layers:

An epithelial covering

Lamina propria

Periosteum

The thickness of the combined layers is generally less than 1mm. The last two

layers are so intimately adherent to each other that they are often difficult to

distinguish and can be considered as one layer. The epithelium and lamina propria are

much thinner than in the nasal cavity.

29
 Histology of the Maxillary Sinus

Fig. 4.1 : HISTOLOGY OF THE MAXILLARY SINUS

The epithelium consists of single layer of pseudostratified ciliated columnar

epithelium and has fewer goblet cells which secretes mucous. The columnar epithelial

cells lining the surface contain cilia. Cilia beats towards the ostium. Cilia are more

marked near the ostium of the sinus and helps in drainage of mucous into the nasal

cavity. The medial wall of the maxillary sinus possess a mucosa that is thicker and

richer in seromucous glands than that of lateral walls.

The maxillary sinus mucosa has a high regenerative capacity after traumatic or

surgical removal or once the cause of infection is removed.

30
 Physiology and Pathophysiology

Physiology and Pathophysiology

PHYSIOLOGY

The physiology of anatomic structure is usually related to their function.

Several functions of the maxillary sinus have been proposed. They are:

1. Reduction of weight of the facial skeleton: As the maxillary sinuses are filled

with air rather than cancellous bone it therefore lightens the skull. Actually,

the weight saving is negligible. It has been estimated that if all the sinuses are

filled with cancellous bone rather than air this would only increase the weight

of the skull by approximately 1 %.

2. Phonetic resonance and auditory feedback: The sinuses may act as a

resonating box for the singing voice. The sinuses also affect the conduction of

voice to one’s own ear.

31
 Physiology and Pathophysiology

3. Insulation: The temperature of the inspired air can vary from -500c to 500 c.

The rich nasal arterial counter current on the turbinates warms the inspired air

and may absorb heat from the expired air. The sinuses may insulate the orbits

from intranasal temperature variations.

4. Air conditioning: The maxillary sinuses do contain some serous glands whose

watery secretion evaporates to humidify the contained air. The paranasal

sinuses may act as supplementary chambers, helping the nose to warm,

humidify and filter inspired air.

5. Water conservation: Moisture is critical to ciliary function. Dehydration for a

few minute will deplete the mucous blanket, stop ciliary beating and cause

ciliary degeneration. Warm air can hold more moisture than cool air. Sinuses

may act as accessory heat exchangers, warming inspired air to increase its

moisture content, than cooling expired air to decrease its water content.

6. Filtration: Slaving (1988) suggested that particulate matter which escaped

filtration by the nose may be trapped on the mucous blanket of the sinuses.

7. Dead space: The maxillary stress in the maxilla is transmitted from the

alveolar processes to the skull by three vertical buttresses whose size and

shape is dictated by their function, the maxillary sinuses are simply the dead

space in between. Help in absorbing the shock of blows to the face and

thereby limiting the facial injury from trauma.

8. Production of bactericidal lysozyme into the nasal cavity are reviewed in

detail by Latkowski, Blanton and Biggs.

32
 Physiology and Pathophysiology

9. The shape and size of maxillary sinus contribute to facial contour but there is

no physiologic function to facial contour.

PATHOPHYSIOLOGY

Following pathophysiological processes are of clinical significance:

I. Gas exchange of the maxillary sinus mucosa (Oxygenation of the maxillary

sinus): Ostia more than 2.5 mm in diameter are able to maintain the normal

oxygen concentration within the sinus. Partial or complete obstruction of the

sinus ostium occurs with either acute or chronic disease. The decrease in

oxygen content of the air in the maxillary sinus after blockage of ostium or

antronasal duct causes increased capillary permeability and formation of

transudate. This is followed by glandular metaplasia and subsequent increase

in mucous secretion into the cavity. The hyperplastic mucosa eventually

becomes edematous and polypoidal. This mucosal thickening is visible on a

radiograph.

II. Patency of the antronasal duct: Antronasal duct is 6mm long curving canal. Its

patency is a prerequisite for the efficient aeration and clearance of secretion

required to maintain a healthy maxillary sinus.

III. Mucous production and mucociliary transport: Ostium is very close to the roof

of the sinus. It’s situation is unfavourable for gravitational drainage when the

head is erect. Clearance of sinus secretion is therefore dependent on active

transport by mucociliary system. Mucociliary transport is necessary to prevent

collection of fluid in the maxillary sinus and to prevent infection also. Ciliary

33
 Physiology and Pathophysiology

propulsion begins in the base of sinus and cilia continue to beat towards the

natural ostium.

Other mechanism: The negative air pressure during inspiration assists ciliary

clearance from the maxillary sinus. Irritation of nasal mucosa which causes

sneezing may also aid in clearance of mucous.

IV. Flying and diving: Antral barotrauma occurs only if the antronasal duct is

blocked. The effect is less common but more dramatic in diving than in flying.

34
 Examination and Investigation

Examination and Investigation

Clinical examination of maxillary sinus is proceeded by patients presenting

complaint, its history and the patients general medical history.

The following points should be included in a patient’s history:

History of present illness

History of past illness

Personal history

Family history

A patient with disease of maxillary sinus presents with one or more of the

following complaint 20:

35
 Examination and Investigation

Nasal obstruction

Nasal discharge

Sneezing

Headache or Facial pain

Swelling or Deformity

Disturbances of smell

Change in voice

Eg: Purulent or mucopurulent long standing nasal discharge in sinusitis. It may

be associated with cacosmia ( i.e. any smell is experienced as foul) or alteration in

voice.

Clinical examination

The instruments helpful in examination of maxillary sinus are:

a. Bull’s eye lamp: It provides a powerful source of light. The lamp can be tilted,

rotated, raised or lowered according to the needs.

b. Head Mirror: It is a concave mirror used to reflect light from the Bull’s eye

lamp onto the part being examined.

c. Nasal Specula: The Thudicum type and Vienna type are used.

d. Post nasal mirror

e. Blunt probe: It is used for palpation in the nasal cavity.

f. Tilley’s or Hartman’s forceps: It is used for packing of the nasal cavity

g. Suction apparatus: To clear any discharge or blood.

h. Gloves

36
 Examination and Investigation

The maxillary sinus is examined by inspection and palpation. It has 5 walls

and except for the posterior wall, all other walls can be examined directly.20

Also examine:

Soft tissues of cheek, lip, lower eyelid and the molar region

Orbit, its contents and vision

Vestibule of mouth by everting the lip

Upper alveolus, teeth and palate

Nose by anterior and posterior rhinoscopy

Tenderness by pressure over the canine fossa

INSPECTION

The middle third of the face should be inspected for the presence of

asymmetry, deformity, swelling, erythema, ecchymosis or haematoma. Epiphora,

nasal obstruction, epistaxis or other discharge or odour from the nostril should be

noted. One should look for signs of inflammation over the sinuses caused by

infection, osteomyelitis and tumours.19

PALPATION

It should include palpation of the facial wall of the sinus above the premolars,

where the bone is thinnest either through the soft tissues of the cheek or more directly

intraorally. Tenderness may be elicited in acute sinusitis and swellings or fracture

lines. Tenderness is elicited on the canine fossa on the cheek.

Crepitus is indicative of surgical emphysema. It is advantageous to carry out

the palpation of the sinuses on both sides simultaneously, as their tenderness can be

compared.

37
 Examination and Investigation

Cervical lymph nodes should be palpated. The frontal and ethmoid sinuses

should also be examined because disease of this structures frequently affects the

maxillary sinus.

The following tests can be used to examine the diseases of maxillary sinus:

TRANSILLUMINATION

It is performed in a dark room by placing a lighted bulb of a torch against the

hard palate in the oral cavity. If the patient is wearing a denture, it should be removed

before performing the test. The bulb gives an infraorbital glow called the infraorbital

crescent. If the maxillary sinus is opaque because of sinusitis or tumours, the glow is

absent. But with polyps and cysts there may be a brilliant transillumination. This test

has become obsolete, as it is not reliable and radiological examination has replaced it.

RHINOSCOPY

Anterior and posterior rhinoscopy are performed. For performing rhinoscopy,

a nasal speculum, headlight or mirror are necessary which facilitates proper

examination of the nasal passages.

Anterior rhinoscopy can be used to visualise the medial wall and size of the

middle turbinate, any discharge or any mass can be visualised. Posterior rhinoscopy is

used to visualise any discharge from the middle meatus.

While examining the lateral wall of the nose, any discharge in the middle

meatus indicates infection of the maxillary sinus.20

38
 Examination and Investigation

SINUS ENDOSCOPY

Under local anaesthesia, the nasal opening of the maxillary sinus in the middle

meatus may be examined more thoroughly using a narrow fibreoptic endoscope. It is

useful for precise visualisation and diagnosis of the causes of sinusitis.19 A view of

the superior meatus and a better view of the inferior meatus are also obtained.

While CT scan provides a comprehensive evaluation of the paranasal sinuses,

it provides a little information on the appearance of the nasal mucosa with i.e. upto

10% of abnormalities at sinus endoscopy being undetectable by CT scanning. It

should therefore be seen as a second line of investigation to sinus endoscopy, in most

cases reserved for preoperative planning prior to functional endoscopic sinus

surgery.21 It may serve as a screening test for deciding which patient require CT.

NASAL MUCOCILIARY CLEARANCE TEST ( SACCHARINE TEST)

This test was first described by Anderson et al (1974) and is used to measure

mucociliary function. A particle of sachharine is placed in the anterior part of the

middle meatus. The subject swallows every 30 seconds and the time between

placement and report of a sweet taste is measure of the mucociliary function.

NASAL CILIARY BEAT FREQUENCY:

Strips of ciliated epithelium are brushed off the lateral aspect of the inferior

turbinate and examined under a phase contrast microscopy. The number of effector

strokes of the cilia per second is counted, the normal range being 12-15 Hz. Purulent

infection decreases the ciliary beat frequency as a result of the release of neutrophil

elastase and bacterial toxins specimens are also examined to determine the percentage

of immotile cilia.

39
 Examination and Investigation

RHINOMANOMETRY

Active anterior rhinomanometry is the method of choice. It consists of the

measurement of nasal air flow and pressure at the nostrils during respiration. The

main clinical application is to determine whether a patient who complains of a nasal

obstruction does indeed have one.

POSTURE TEST

It helps to differentiate between maxillary and frontal sinusitis. The patient is

examined in a sitting position and the discharge in the nose is wiped out. If the

discharge reappears in the middle meatus, it signifies that the discharge is from the

vertically draining frontal sinus. If discharge does not appear, the patient is made to

lie down on his unaffected side with the affected side of the nose at a higher level. If

the discharge reappears it is from the maxillary sinus. However, this test is hardly

used today as it is not reliable and time consuming.19

ANTRAL PUNCTURE

This procedure for drainage consists of inserting a cannula into the maxillary

sinus for pumping water into the sinus which flows through the ostium alongwith the

exudates of the sinus. The characteristics of the returning fluid help to diagnose the

maxillary lesion.

If the washings are clear, maxillary sinusitis is ruled out. Mucopurulent or

purulent washings confirms sinusitis and the bacteriological examination of the

secretions may be carried out. For ruling out malignancy, the washings are sent for

examination by means of exfoliative cytology. Detection of malignant cells confirms

the diagnosis but a negative finding does not rule it out.19

40
 Examination and Investigation

Proof puncture of the antrum is usually performed through the inferior meatus

to confirm radiological appearances. An aspirate is withdrawn into an empty syringe

and sent for bacteriological and cytological examination.

FIBREOPTIC ANTROSCOPY

Using this procedure, sinuses unresponsive to treatment or any suspicious

areas seen radiographically can be examined by direct vision through an endoscope.

It is the only definitive way to investigate the contents and lining of the

maxillary sinus. It is an optimal method for the assessment of foreign bodies such as

root filling materials and root tips that have penetrated into the maxillary sinus. It is

quick, reasonably well tolerated, has a low associated morbidity and can be performed

as an outpatient procedure under local anaesthesia. Access to the antrum is either via

an intranasal antrostomy ( inferior meatus of nose) or the canine fossa ( transoral

access). The latter, Caldwell-Luc approach is more easily tolerated by patient and

gives a better overall view of the antrum, especially the ostium. Maxillary sinus can

also be approached by the transalveolar access via already existing connections

between the oral cavity and the antrum, eg: when the antrum is exposed during

apicectomy.

Antroscopy is also said to be useful in identifying orbital blow out fractures

where clinical and radiological examination is inconclusive, although haemorrhage or

blood clot may be a problem.

The 300 and 700 endoscope has been used as an adjunct to endodontic surgery

involving maxillary and mandibular molars. In cases in which maxillary roots have

41
 Examination and Investigation

been found to penetrate into the maxillary sinus, this instrument has aided the operator

in identification and treatment of these diseased root apices following entry into the

sinus.17

BLOOD TESTS

It gives a large non-specific information in sinus disease, though findings such

as the grossly raised serum alkaline phosphatase levels in Paget’s disease or white cell

changes in lymphomatous conditions may be diagnostic of particular conditions.

ANGIOGRAPHY

It is done via catheter placed in the femoral artery and guiding fluroscopically

into the required vessel. It can be used to display the arterial supply of facial tumours

or vascular anomalies by means of digital subtraction angiography. The abnormal

vessels can then be occluded by embolization.

42
 Examination and Investigation

RADIOLOGY

Radiographic examination of the maxillary sinus may be accomplished with a

wide variety of exposures readily available in the dental radiology clinic. These

include periapical, occlusal, panoramic and facial views which may provide adequate

information to either confirm or rule out pathology.

A knowledge of normal radiological anatomy and common variations is

essential in order to distinguish pathological changes.

The essential knowledge required for the radiological interpretation of

maxillary sinus includes: 22

The anatomy of the antra, including their shape, size, normal variations and

related structures.

The usual radiographic views and investigations of the antra and which aspect

of the antra is shown well by each investigation.

The normal radiographic appearance of the antra and how to assess the

radiographs.

The radiographic features of disease within the antra.

Both intraoral and extraoral radiographs are used to examine the maxillary

sinuses. Extraoral views have the advantage of showing both sinuses on the same

radiograph so that comparisons of both the sinuses can be made. Gross changes are

readily seen and a complete lesion is usually demonstrated on one radiograph.

43
 Examination and Investigation

Intraoral views are taken with plain radiographic film, which has higher

resolution than the intensifying screen-fast film combination used in extraoral

radiography. An intraoral film therefore permits a more detailed examination of a

specific area. As well as the sinus floor and surrounding alveolar bone. Intraoral

views demonstrate crown and root pathology, which may be helpful in accurately

diagnosing disease of dental origin.

An antrum appears radiographically as a radiolucent cavity in the maxilla with

a well defined, dense, corticated radiopaque margins or walls. In general the larger the

cavity the more radiolucent it will appear. The internal bony septa and blood vessel

canals in the walls all produce their own shadows. The thin lining epithelium is not

normally seen.22

Fig. 6.1: RADIOGRAPHIC APPEARANCE OF THE MAXILLARY SINUS

The dark shadow of the antrum is not uniformly dense throughout because

there are differences in the thickness of the walls and in the width of the sinus.7 In

addition shadows of malar bone and zygomatic process, as well as of the soft tissue of

the cheek are superimposed over some parts of the sinus.

44
 Examination and Investigation

The two maxillary sinuses may be similar in shape and size or differ in both

respects. One sinus may be quite small as compared with the opposite one, in such

case the outer wall of the smaller sinus is then commonly thicker than that of the

larger, resulting in a difference in the density of the shadows of the two sinuses. The

inner antral wall is variable in thickness and this leads to differences in the appearance

of the dark shadow of the antrum.

The thicker parts through which X-Rays pass produce greater scattering and so

thick cheeks; a red face, because of the large amount of blood, has a similar effect.

Therefore in certain persons it is difficult or even impossible to obtain good quality

radiographs; in place of good radiographic contrasts, a more or less uniform grayness

obscures the finer details.7

INTRAORAL RADIOGRAPHS

The shadow of the antrum does not become visible in intraoral radiographs

until about the age of 4years. In young children, deciduous and permanent teeth

encroach on the antral space and tends to hide it.7

Both periapical and occlusal views may be useful. Despite its variable size and

shape the maxillary sinus is usually seen on occlusal and periapical radiographs of the

upper premolar and molar regions, unless it is very small.

Maxillary sinuses vary greatly in size, some being so small that evidence of

them does not appear on dental radiographs. Others are so large that they extend well

downward into the interseptal spaces of the posterior maxillary teeth and the region of

the tuberosity. The size may also vary from one side to the other in the same person.

45
 Examination and Investigation

In general, the larger the maxillary sinus the more radiolucent it is, for there is then

less bone surrounding it in proportion to the size of the air cavity.

A small maxillary sinus is expected to be situated well upward and posteriorly

and may be obscured by superimposition of the malar process.

A large maxillary sinus extends downwards and occupies all the space in the

trifurcation of the roots of the first molar and extends into the interseptal space of the

first and second molars, the third molar space and the tuberosity.

The sinus may show three important extensions:

a. The alveolar extension may extend between the roots of the first molar. After

extraction of the posterior maxillary teeth, the extension may occasionally be

seen dipping downwards between the second premolar and second molar

teeth, until the alveolar border is almost reached. In edentulous patients, the

floor of the antrum may be formed by the alveolar border.

Fig. 6.2: EXTENSION OF THE MAXILLARY SINUS

IN CASE OF MISSING TEETH

46
 Examination and Investigation

b. The palatine extension may extend as far forward as the lateral incisor or

rarely even to the median line of the palate.

c. The tuberosity extension is more common and is of considerable importance.

Due to the thinning of the walls of the antrum there is a danger of the

tuberosity being fractured during the removal of the maxillary third molar.

The borders of the maxillary sinus appear on periapical radiographs as a thin,

delicate, tenuous radiopaque line (actually a thin layer of cortical bone). In absence of

disease it appears continuous, but on close examination it can be seen to have small

interruptions in its smoothness or density. This discontinuities are probably illusions

caused by superimposition of small marrow spaces. In adults, the sinuses are usually

seen to extend from the distal aspect of the canine to the posterior wall of the maxilla

above the tuberosity. Anteriorly each sinus is restricted by the canine fossa and is

usually seen to sweep superiorly, crossing the level of the floor of the nasal cavity in

the premolar or canine region. The degree of extension of the maxillary sinus into the

alveolar process is extremely variable. In response to a loss of function (associated

with the loss of posterior teeth) the sinus may expand further into the alveolar bone,

occasionally extending to the alveolar ridge. The roots of the molars usually lie in

close apposition to the maxillary sinus. Root apices may project anatomically into the

floor of the sinus, causing small elevations or prominences. The thin layer of bone

covering the root is seen as a fusion of lamina dura and the floor of the sinus. Rarely,

defects may be present in the bony covering of the root apices in the sinus floor and a

periapical radiograph will fail to show lamina dura covering the apex.3

47
 Examination and Investigation

While the anterior aspect of the antrum may be bluntly pointed, rounded or

even flat, usually it is generally curved. On the medial aspect of the anterior wall of

the antrum at the point where this wall meets the lateral border of the nasal fossa,

frequently a slight or marked, but usually a short portion of the antral wall passes

backward and inward. The lateral wall of the nasal fossa is represented by a white line

which extends backward a little above the level of the lowest part of the nasal fossa.

Where the anterior wall of the antrum meets the floor of the nasal fossa, there appears

an inverted ‘Y-shaped’ shadow; the diverging limb of the inverted ‘Y’ representing

the antral wall and the anteriorly curving cortex of the nasal fossa and the leg of the

letter or the long line; representing the lateral cortex of the nasal fossa; passing

backward to the pharyngeal end. This ‘Y-shaped’ shadow is of value in differentiating

some dental cysts in this region, because it tends to be obliterated in such conditions.

Fig. 6.3: Y-SHAPED SHADOW

Similarly when the anterior medial wall of the sinus, crosses the lateral wall of

the nasal chamber an ‘X’ is produced. The outline of the nasal fossa is usually heavier

and more diffuse than that of the thin, delicate cortical bone denoting the sinus.7

48
 Examination and Investigation

The floors of the maxillary sinus and nasal cavity are seen on dental

radiograph at approximately the same level around the age of puberty. In older

individuals the sinus may extend farther into the alveolar process and in posterior

region of maxilla its floor may appear considerably below the level of the floor of the

nasal cavity.3

The configuration of the antral floor as seen in intraoral radiographs varies. It

may be represented by a single curve which slopes downward from the front, crosses

over the roots of the first molar and then rises upward, ending over the third molar at

the tuberosity. More commonly, the antral floor is made up of several segments of

different curves, and frequently there are wide differences in the radius of the adjacent

segments, so that an uneven undulation of the cortex forms the inferior limit of the

antrum. In other antra, there are many small segments of small area, the floor having a

rippled appearance. In some cases the free ends of the segments extend upward into

the antral cavity in a ‘U’ with divergence of the limbs. The appearance then suggests

that the antrum is separated into loculi. Some antral floor dips down between the roots

of adjacent teeth and they may approach the alveolar crest closely. This is more

commonly seen where one or more teeth have been removed, in which case the

antrum may extend into the space previously occupied by the teeth and the floor of

the sinus may be represented by the alveolar crest. It is more likely to occur when the

teeth are removed during the earlier decades of life and when the supporting bone is

healthy and normal. Such an approximation of the floor of the antrum to the alveolar

crest is due in part to the resorption of bone after the removal of the teeth; but it is

also due, in some cases, to the actual extension of the air sinus into the bone. Old

49
 Examination and Investigation

alveolar bone is resorbed in the floor of the maxillary sinus. Bony activity is minimal

at the roof.7

When the alveolar process does not contain the antrum, there is considerable

bone between the apices and the antral floor. In such case the curve of the antral floor

is such that it lies above the first bicuspid root and then passing downward and

backward, approaches close to the second bicuspid and first molar and rises over the

second and third molars. However, the floor of the sinus may come down sharply

anteriorly and cross the bicuspids and molars at the same level and end at the

tuberosity without rising. The bone which separates the roots from the antral floor

varies in thickness from 0-2 cm, so the antrum may be too high to be seen on some

periapical radiographs, particularly those taken with the long cone paralleling

technique.7

The relationship of the roots of the teeth to the antral floor is variable and the

precise situation is difficult to ascertain because of superimposition. These results

from the inclination of the X-Rays, which is likely to occur if the arch of the palate is

flat. When the rounded sinus floor dips between the buccal and palatal molar roots

and is medial to the premolar roots, the projection of the apices is superior to the

floor. This appearance conveys the impression that the roots project into the sinus

cavity, which is an illusion. As the positive vertical angle of the projection is

increased, the roots medial to the sinus appear to project farther into the sinus cavity.

In contrast, the roots lateral to the sinus appear to move either out of the sinus or

farther away from it as the angle is increased.3

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 Examination and Investigation

Frequently thin radiolucent lines of uniform width are found within the image

of the maxillary sinus. These are the shadows of the neurovascular canals or grooves

in the lateral sinus wall that accommodate the posterior superior alveolar vessels, their

branches and the accompanying superior alveolar nerves. Nutrient canals pass from

them to the apices of the upper posterior teeth. Although they may be found coursing

in any direction (including vertically), they are usually seen running a curved

posteroanterior course that is convex toward the alveolar process. Occasionally they

may be found to branch and rarely also to extend outside the image of the sinuses and

continue as an interradicular channel. As they are absent in cyst linings they are useful

in determining whether or not a cyst is present. However, unfortunately they are not

always present. These normal vascular markings are stated to be due the result of

inflammation.7 They should not be confused with fracture lines, which are less regular

and smoothly curved. Other normal anatomic features include the zygomatic buttress

which appears as a U or V shaped radiopacity in the region of the first and second

molar roots. A radiograph of the molar region will reveal the extent of pneumatisation

of the maxillary tuberosity.

Fig. 6.4: NEUROVASCULAR CANALS IN THE LATERAL WALL

OF THE MAXILLARY SINUS

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 Examination and Investigation

Often one or several radiopaque lines traverse the image of the maxillary

sinus. These septa represent folds of cortical bone projecting a few millimetres away

from the floor and wall of the antrum. They are usually oriented vertically, although

horizontal bony ridges also occur and they vary in number, thickness and length.

Septa are believed by some to have been formed through the uneven resorption of

bone as the sinus was pneumatised, but others hold that they are remnants of

incompletely fused cavities from which the sinuses formed. These septas are almost

always seen in intraoral radiography and they rarely appear on extraoral radiographs.

This is probably due to two factors: first- the better detail obtainable with intraoral

radiographs and second- probably a more significant factor- rays tend to pass along

the long axes of the septa in intraoral films and through their narrowest part in

posteroanterior projections.7 Very rarely there is complete division of the cavity into

separate loculi, in which case there must be an extra ostium leading into the nasal

cavity.

Fig. 6.5: SEPTUM IN THE MAXILLARY SINUS

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 Examination and Investigation

Septal shadows are important only because they sometimes simulate the

shadows of dental cysts. Aspiration of the cavity may be the only method that will

solve the problem. Frequently there appears in the radiographs a more or less sharply

defined dark shadow within the less dark shadow of the whole antrum. This is

because all the relatively thin areas absorb fewer X-Rays than do the adjacent thicker

bone; consequently there are differences in the darkness or grayness of the

radiographic shadows. When such a shadow is round, it resembles a cyst. There may

even seem to be a cortex surrounding the dark shadows. Thus, the appearance may

actually be a normal variation. Occasionally it is not possible to decide whether an

appearance is normal or pathologic without biopsy or a period of waiting and then re-

examination.

Ridges of bone are commonly present on the floor of the maxillary antrum.

Between these ridges there may be excavations into the alveolar process. These ridges

accentuate the radiolucency of the excavations, when projected over or very near the

apex of one of the teeth. Such appearances may be mistaken for bone disease.

Outpouching or partially segretated areas of the antrum are termed recesses.

These appear as dark or gray areas; when associated with a ridge or septum, the

combination of shadows strongly suggests that a disease process is present. One

should, therefore be aware of this normal variation while interpreting radiographs.

Small osseous excrescences resembling stalagmites are sometimes revealed in

the dental radiographs of the antral floor. These occur quite rarely in the first and

second molar areas. They stand up from the floor of the antrum as little white masses,

which seldom reach 3mm in height. They have no pathologic significance. These

53
 Examination and Investigation

must be differentiated from root tips, which they resemble in shape. In contrast to a

root fragment, which is quite homogeneous in appearance, the stalagmites often show

trabeculation and although they may be quite well defined, at certain points on their

surface they blend with the trabecular pattern of adjacent bone. In a root, a small root

canal is visible or there is a free margin at both ends of the shadow. But on rare

occasions, differentiation cannot be made. At this same site, other shadows without

any resemblance to root fragments may be seen. These may be much larger than any

root shadow and may have a different shape and greater density. These must be

regarded as normal anatomic variations.

RADIOVISUOGRAPHY ( RVG )

It has been used to examine the periapical lesions extending into the maxillary

sinus. It allows for more precise visualization of the size and extent of such areas.

OCCLUSAL RADIOGRAPHS

Apart from intraoral periapical radiographs, occlusal radiographs are also

useful. To make an occlusal radiograph, a relatively large film ( 7.7 X 5.8cm ) is

inserted between the occlusal surfaces of the teeth. Because of its size, the film allows

examination of relatively large portions of the jaws.

Occlusal views are used:

a. To demonstrate and evaluate the integrity of the anterior, medial and lateral

outlines of the maxillary sinus.

b. To determine the medial and lateral extent of the disease (eg: cysts,

osteomyelitis, malignancies) and to detect disease in the palate.

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 Examination and Investigation

Both the upper anterior topographic occlusal and upper lateral topographic

occlusal views show the anterior part of the hard palate and may reveal the full extent

of a large cyst or other lesion in this region, which cannot be completely seen on a

periapical film.

Topographic occlusal views may be helpful in differentiating a cyst from the

maxillary sinus or in locating a dislodged root, but will not demonstrate penetration of

the antral wall. Topographic anterior occlusal radiograph will only detect

radiopacities and radiolucencies outside the dental arch. The occlusal view aids in

locating a radiopacity medial to the dental arch.

XERORADIOGRAPHY

X-Rays are used to produce an image on specially charged selenium plates

instead of radiographic film. This high contrast technique differentiates areas with

subtle density differences so that bony trabeculae and tooth roots are clearly seen.

However, the plates are more expensive than conventional radiograph and have been

superseded by CT for the investigation of maxillary sinus disease.

EXTRAORAL RADIOGRAPHS

There are a number of extraoral views, using which the maxillary sinus can be

evaluated. It is, thus, important for the radiologist to know which aspect of the antrum

is shown well by each investigation. All the different views should be used together to

obtain a more accurate information.

The two views in most widespread use are Water’s projection and the

panoramic radiograph of the jaws (orthopantomograph).

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 Examination and Investigation

WATER’S VIEW

This occipitomental radiograph was first described by Waters and Waldron

(1915). It is optimal for the visualization of the paranasal sinuses including the

maxillary sinuses. Taken at varying angles (150, 300 and 350) a comparison of internal

anatomy, bony continuity and defects, as well as sinus pathology or foreign objects is

possible.17 Because of the amount of information available from the Water’s view and

the extent of the anatomy confined within it, particular emphasis must be placed on

surveying the bony margins systematically.

For this projection, the patient’s head is tipped up at an angle of approximately

400 to avoid the superimposition of the petrous portion of the temporal bone over the

inferior aspect of the sinuses. The most posterior and inferior aspect of the antra,

however may be obscured by the maxillary alveolar process and posterior teeth. The

petrous ridge of the temporal bone should be projected below the floor of the

maxillary sinus.3

While interpreting and evaluating the maxillary sinus. Identify the superior,

medial and lateral walls and the floor of the maxillary sinus. It clearly demonstrates

the superior, inferior and lateral margins of the antrum.24 This radiograph is only

taken when clinical signs and symptoms of antral disease exist. The roof of the sinus

appears 1-3 mm below and parallel to the inferior orbital rim.

When viewing occipitomental radiographs, the canals for the posterior

superior dental vessels and nerve, the infraorbital foramen and the zygomatic and

alveolar recesses should be identified as normal sinus components. The infraorbital

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 Examination and Investigation

canal near the middle of the sinus roof and the canal for the posterior superior dental

nerve and vessels on the lateral walls may mimic fractures.

The image of the zygomatic process may resemble mucosal thickening.

Unerupted molars in the tuberosity region may simulate the air/fluid level of acute

sinusitis. The superior orbital fissure, foramen rotundum, foramen ovale, the lateral

border of the posterior ethmoid and sphenoid sinuses and the inferior extension of the

temporal line are other external structures which may be superimposed on the antrum.

The temporal or innominate line, which represents the depths of the depression

on the lateral surface of the greater wing of the sphenoid bone, is superimposed on the

lateral aspect of the orbit. It is often projected inferiorly as the infratemporal extension

over the superolateral part of the sinus, ending either in a straight line or turning

medially. The posterior ethmoid air cells are superimposed on the superomedial part

of the sinus. The superior orbital fissure is projected as a tear shaped radiolucency

passing from the inferior orbital rim inferomedially and crossing the medial wall of

the sinus.

Over angled or under angled occipitomental radiographs give tangential views

of the roof of the antrum, which may be useful in cases of facial trauma. In the orbital

blow out fractures, there is an asymmetrical increase in the distance between the roof

of the sinus and inferior orbital rim. The foramen rotundum, which is always lateral to

the lower end of the superior orbital fissure and the foramen ovale may simulate a

cyst or bone erosion.23

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 Examination and Investigation

Water’s projection is not a great radiologic approach for the detection of cyst

like densities in the antrum. This is because; most of the cyst like densities present on

the floor of the maxillary sinus often gets superimposed on other thick skull bones.

Swelling of the soft tissues of the cheek overlying an antrum may cause

antrum to appear opaque, when compared with the antrum on the other side.

Nevertheless, this apparently opaque antrum will still be radiolucent when compared

with the adjacent cheek shadow, thereby indicating that it is normal and contains only

air.23

A suggested systematic approach for examining the antra is as follows: 22

Compare the antral shadows on both sides - they should be radiolucent

Check the integrity and shape of the roof and lateral walls

Check the medial wall – this is the least well defined zone and hence the most
difficult to interpret

Fig. 6.6: WATER’S PROJECTION

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 Examination and Investigation

ORTHOPANTOMOGRAPH

The panoramic radiograph depicts both maxillary sinuses, revealing greater

internal structure and parts of the inferior, posterior and anteromedial walls.3 A

panoramic projection provides greater visualization of the sinuses than do periapical

radiographs. Although the image quality is not as good as that of intraoral radiograph,

a wide area is viewed in one exposure.23 However, it is difficult to compare the

internal radiopacities of the right and left sinus in the panoramic image because of

variations that result from overlapping phantom images of other structures.

The maxillary sinuses are usually well visualized on panoramic images. They

appear as paired radiolucencies located above the apices of maxillary premolars and

molars. The floor of the maxillary sinuses is composed of dense cortical bone and

appears as a radiopaque line. It is important to identify each of the border and then

note whether they are entirely outlined with cortical bone, roughly symmetric and

comparable in radiographic density. The borders should be present and intact.

Although it is useful to compare right and left maxillary sinuses when looking for

abnormalities, it is important to remember that the sinuses are frequently non

pathologically asymmetric relative to size, shape and presence and number of septae.3,
25

The medial border of the maxillary sinus on the orthopantomograph is seen at

the angle of the anterior and medial walls. The medial border of the maxillary sinus is

the lateral border of the nasal cavity; however this interface is not demonstrated on the

panoramic image. The medial wall covers almost the entire maxillary sinus as seen in

the orthopantomograph. The lateral border of maxillary sinus consists of the

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 Examination and Investigation

maximum posterior convexity of the posterior wall. In particular, the maxillary sinus

is outlined laterally by the maximum convexity of the posterior wall and medially by

the junction of the anterior and medial walls. A part of the anterior and medial walls

can be designated as the nasoantral wall. The lateral most outline of the maxillary

sinus represents the posterior wall of the sinus. Most of the anterior and posterior

walls of the maxillary sinus are superimposed upon the medial wall in the

orthopantomograph. The lateral wall of the maxillary sinus does not cast any

identifiable image on panoramic radiograph. The anterior wall occupies the medial

two-thirds of the maxillary sinus and the posterior wall occupies the lateral one-third

of the maxillary sinus. A line vertically in the projection of the outer one-third of the

maxillary sinus is not made by a single bony structure but by the posterior surfaces of

the zygomatic process of the maxilla and the frontal process of the zygoma. The

superior border or roof of the maxillary sinus is the floor of the orbit; this interface is

demonstrated on the panoramic image in its most anterior aspect. In pantomographs

the floor of the maxillary sinus is rarely superimposed on other thick bones of the

skull, unlike the Water’s view. In addition, most of the cyst like densities is viewed

better, because these are mostly seen on the floor of the maxillary sinus. 24 The

posterior wall of the maxillary sinus in part is projected on the outer most lateral

image on the panoramic radiograph. The posterior aspect of the sinus is more opaque

because of superimposition of the zygoma. Anterior, posterior and medial walls do

not appear as anatomic landmarks on the orthopantomograph. However, these views

are quite effective for viewing radiopaque defects. Radiopaque defects in the anterior

and lateral walls, as well as in the floor of the sinus could be detected.26 Greenbaum

and associates reported that panoramic radiography was a suitable technique for the

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 Examination and Investigation

detection of posterior-wall invasion by maxillary carcinoma.27 It has been found that

panoramic radiograph can demonstrate antral malignancy at the time of diagnosis in

90 % of cases.24

Langland and Sippy reported that a special transverse projection of the

maxillary sinus was possible with the orthopantomograph if the patient’s head was

moved forward approximately 25mm. The upper half of the facial bones was well

radiographed in the ‘chin down’ position.27

In the panoramic projection of the maxillary sinus, the body of the zygomatic

bone and the temporal process of the zygomatic bone, which is the anterior half of the

zygomatic arch, will almost invariably be superimposed on the sinus. The panoramic

innominate line is a thin, vertical, radiopaque line in the posterior third of the sinus

and is so named because it is composed of the panoramic juxtapositioning of two

separate bones, the lower half consisting of the thin cortical outline of the posterior

surface of the zygomatic process of the maxilla and the upper half consisting of the

thin cortical outline of the posterior surface of the frontal process of the zygoma. The

panoramic innominate line is quite similar in appearance, but quite different in origin

from the innominate line seen in the Caldwell view. The panoramic innominate line

should not be misinterpreted as the posteromedial wall of the maxillary sinus.27

The pterygomaxillary fossa is a well corticated, tear drop shaped radiolucency,

which is outside but immediately adjacent to the posteromedial aspect of the

maxillary sinus. The posterior portion consists of the anterior cortical outline of the

lateral pterygoid plate of the sphenoid bone up to the point where it fuses with the

posterior wall of the maxillary sinus, forming the pterygomaxillary fissure. The

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 Examination and Investigation

rounded superior portion consists of the most inferior aspect of the greater wing of the

sphenoid bone, which is superimposed on the posteromedial wall of the maxillary

sinus. The anterior portion of the fossa is the posterior wall of the maxillary sinus. 3

Panoramic radiography provides an extensive overview of the sinus floor and its

relationship with the tooth roots. It allows determination of the size of periapical

lesions and cysts as well as radiodense foreign bodies.17 Lesions affecting the floor of

the maxillary sinus are better identified and localized with panoramic films than with

the Water’s projection. Panoramic radiographs have been found equal to Water’s

projection for determination of sinusitis.24

In order to apply panoramic radiography to the diagnosis of maxillary lesions

it is important not only to know the radiographic anatomy but also to know the value

and limitations of this technique. There are limitations to the use of panoramic

radiographs in the detection of maxillary sinus disease; namely only the areas within

the selected image layer will be in focus. While dealing with panoramic radiographs,

one needs to consider the possibility of ghost images being reflected well away from

the actual lesion. This is particularly the case with highly radiopaque foreign bodies

such as those associated with gunshot injuries.24

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 Examination and Investigation

Fig. 6.7: ORTHOPANTOMOGRAPH SHOWING MAXILLARY SINUS

FLAT PLANE TOMOGRAPHY

This is the simplest version of the technique: a thin (1-2mm ), sharply defined

flat plane section of the patient is displayed while structures anterior and posterior to

the section are blurred.

This tomograms are of particular benefit in blow out fractures of the orbital

floor to locate the fracture site and in establishing the extent of a tumour in the

antrum.

Hypocycloidal or spiral tomography is preferable as fine bone detail can be

demonstrated without streaking. In larger hospitals, both have been superceded by

CT.23

PANORAMIC ZONOGRAPHY

A zonography image is obtained by the utilization of movement as in

tomography, but with a narrow tomographic angle. A zonogram therefore resembles a

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 Examination and Investigation

conventional radiograph. With this technique, the maxillary sinus may be imaged in a

cylindrical, concave, 14 or 28 mm cut with the patient in the reverse Water’s position.

It has been reported that in cylindrical pantomogram, sinuses are demonstrated more

clearly than in dental pantomogram. Also, radiation dose to patient is very low.

The cystic lesions are better demonstrated. Due to tomographic technique

with zonography, walls of the sinuses are seen without obscuring shadows. The soft

tissue swelling and bony dislocation following blow out fractures of the orbital floor

are easily seen, as is damage to the lateral wall of the sinus in middle third or

zygomatic complex fractures. Thinner cuts may be taken if bony erosion is suspected

in inflammatory or neoplastic disease.23

STEREO-ORTHOPANTOMOGRAPHY

It is a reliable mode of examination when distance between periapical lesions

and the mucous membrane of the sinus, as well as interdistances of dental roots and

the floor of the sinus are to be clarified. The central radius goes almost straight toward

the longitudinal axis of the molars resulting in minimal projection error. Furthermore,

local swelling of the sinus membrane and opacities can be diagnosed.17

OTHER PLAIN VIEWS OF THE ANTRA

Caldwell view shows the anterior and posterior parts of the roof and the lateral

walls of the antra. However, it is most useful in evaluating the frontal sinuses and

ethmoid air cells.

The submentovertical view clearly demonstrates the S-shaped antral line,

which represents the posterolateral wall of the maxillary sinus. It may be useful in

evaluating the lateral and posterior borders of the maxillary sinuses.

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 Examination and Investigation

The lateral skull view allows examination of all four pairs of paranasal

sinuses, but with each member of a pair superimposed on the other, making it difficult

to tell if the pathology is located on the left or the right. The zygomatic buttress,

anterior and posterior boundaries of the medial wall of the antrum and the anterior

wall of the pterygoid process of the sphenoid bone are demonstrated. If lateral

cephalograms are taken for orthognathic or orthodontic reasons the clinicians should

still examine the sinuses.23, 3

The posteroanterior projections show the floor of the sinus. The configuration

and position of the antral floor are variable. It may be seen above the floor of the nasal

fossa, on a level with it or well below it. During the development of sinus, it may

extend into the alveolar process and from there into the palate, where it forms the

palatal recess. In such a case, the palatal recess occupies a position well below the

nasal floor and approaches the midline. In other cases, the palatal and even the

alveolar recess may be shallow or absent. Then the antral floor is seen above the

shadows of the bicuspid and molar roots.

In some anteroposterior projections of the antra, a thin dark line is situated in

the outer wall of the sinus and extends through the thickness of the wall. It is vertical

in direction and is located at the base of the malar bone where the latter joins the

maxilla. The shadow is produced by the suture and is a perfectly normal appearance.

It becomes important only when there is a history of recent injury. This shadow may

easily be mistaken for a fracture. The direction and position of the shadow, coupled

with the facts that it may be symmetrically bilateral and that it is sometimes lined on

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 Examination and Investigation

both sides by a thin cortex, enables differentiation between this shadow and that of a

fracture.7

However, the postero-anterior view is less reliable when compared with the

Water’s view, orthopantomograph or intraoral periapical views.28

COMPUTED TOMOGRAPHY

Computed tomography (CT) and Magnetic Resonance Imaging (MRI) have

become increasingly important for the evaluation of sinus disease and have virtually

replaced conventional tomography.

Data collected during multidirectional X-Ray scanning of the object is

analyzed by computer in a technique which is usually known as CT (Computed

Tomography) scanning. This provides multiple sections through the sinuses at

different planes and therefore contributes to the final diagnosis and the determination

of the extent of the disease. The most commonly used scan sections are the axial

(transverse) and coronal scans. By utilizing both axial and coronal scans, a three

dimensional image of both normal and abnormal structures can be obtained.

It is important to be familiar with both hard and soft tissue anatomy when

interpreting CT scans, as the involvement of surrounding tissues is determined by

recognized destruction and displacement of normal structures rather than by direct

visualization of abnormal tissues.

CT more clearly contrasts the air-soft tissue lining interface and the mucosa-

bone junctions in the nose and the sinuses. Most importantly, it will reveal disease

extending beyond the bony margins of the sinus into adjacent soft tissue. Contrast

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 Examination and Investigation

enhancement is useful in demonstrating the start of soft tissue spread. CT is more

sensitive than conventional tomography in the examination of paranasal sinuses

because it more consistently identifies thin spicules of bone.

Axial scans are parallel to the orbital-meatal baseline, which forms an angle of

100 with the Frankfort plane. Facial bones, paranasal sinuses, the skull base and the

post nasal space are all clearly seen in axial sections. Coronal scans are valuable for

assessing extension of paranasal sinus disease in palatal, orbital and nasal directions.

As coronal sections through dental fillings, crown and metallic restorations can result

in artefacts, axial sectioning is carried out.

The main disadvantage of CT is the cost. It is also not sensitive enough to

predict precise tissue histopathology unless the lesion is very vascular or has

undergone characteristic calcification.23, 17

Fig. 6.8: CORONAL SECTION OF CT SCAN DEMONSTRATING

MAXILLARY SINUS

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 Examination and Investigation

MAGNETIC RESONANCE IMAGING:

High resolution MRI examination is the most revealing non invasive technique

for the paranasal sinuses and adjacent structures and areas.3 The major advantage is

that no ionizing radiation is used and therefore it is free of the associated hazards.

T1 and T2 relaxation times are two measures of the energy absorbing and

releasing characteristics. In a T1 weighted image, fat gives a white bright high

intensity signal and water a dark low intensity signal. The reverse occurs in T2

weighting. As the fat and water content of different normal and abnormal tissues vary,

so does the signal they produce.23

MRI is extremely sensitive in demonstrating maxillary sinus mucosal

pathology due to the high signal intensity on T2 weighted images of almost all soft

tissue abnormalities, contrasted with the absence of signal from both the air within the

sinus and the surrounding cortical bone. While examining MRI brain scans, Moore et

al (1986) found that some incidental paranasal sinus pathology was clearly revealed.

They suggested that the technique might be useful in the study of the nature and

epidemiology of inflammatory sinus disease. However, Moser et al (1991) found that

25% of patients undergoing T2 weighted axial MRI of the brain had incidental

paranasal sinus abnormalities, considering the technique unsuitable for screening

individual patients for antral disease. They are of the opinion that it is too expensive

and too sensitive, revealing ‘normal’ changes, such as an asymptomatic retention cyst

or thickened sinus mucosa and thus should be reserved for specific clinical indications

in patients with known or suspected paranasal sinus disease.23

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 Examination and Investigation

Fig. 6.9: AXIAL SECTION OF T1 WEIGHTED MRI IMAGE

SHOWING MAXILLARY SINUS

ULTRASONOGRAPHY

Because the bony facial wall of the sinus is so thin, high power, short duration

sound waves from a transmitter are able to pass through it. They are reflected back to

the receiver when they hit an impenetrable object.

‘A’ mode Ultrasonography is a safe, quick, noninvasive technique that has

been introduced as a diagnostic screening tool for sinus pathology. In normal sinus

scans an initial reflected echo is seen at the probe/skin interface and the second echo

at the bone/air interface. The accuracy of ultrasound in detecting fluid has been well

documented. Mann et al (1977), Revonta (1980), Revonta and Suonpaa (1982) have

conducted studies on ultrasound as a diagnostic tool.

Ultrasound provides an excellent method of screening for sinus pathology at a

cost about 25% that of conventional radiographs and may be helpful in following the

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 Examination and Investigation

resolution of acute suppurative sinusitis, instead of repeated radiographs. If the scan is

abnormal, ultrasound is not a replacement for radiographic studies, which are

necessary to differentiate fluid, polyps, thick mucosa or tumours.17, 23

ISOTOPE SCANNING (SCINTIGRAPHY)

Radioactive isotopes are used diagnostically to demonstrate physiological

changes in tissue that often precede anatomical changes or therapeutically to destroy

tumour cells. Bone scans using technetium [99 TcM] phosphate analogues reflect

osteoblastic and osteoclastic responses as well as the vascularity of the tissue.

It has been used to show the extension of the antral carcinoma; generalized

bony thickening of Paget’s disease, brown tumours of the maxilla and orbit, maxillary

sinus mucocele and to differentiate localized osteoblastic reaction from

osteomyelitis.23

BIOPSY

Any persistent lesion which has no obvious cause should be biopsied. Those

contained within the sinus may be sampled via an endoscope.23

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 Diseases

Diseases

The pathogenic relationship of the maxillary sinus to the orodental complexes

is the result of the topographic arrangement and of the functional and systematic

association between the two. The transfer of pathologic condition from the sinus to

the orodental apparatus or vice versa is achieved either by mechanical connections or

by way of the blood or lymphatic pathways.4

The disease processes affecting the maxillary sinus can be broadly categorized

as follows:

A. Intrinsic diseases of the maxillary sinus

These include the disorders that originate from within the sinuses.

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 Diseases

B. Extrinsic diseases involving the maxillary sinus

These include the disorders which originate outside the boundary of the

maxillary sinus and affect the maxillary sinus, eg: causing a localized mucositis in the

adjacent floor of the maxillary antrum – causing displacement or destruction of the

sinus borders.3

Pathological lesions of the maxillary sinus are studied under the following

headings:

1. Inflammatory lesions
2. Traumatic penetration
3. Cysts
4. Tumours
a. Benign
b. Malignant
5. Miscellaneous

1 INFLAMMATORY LESIONS

Inflammation may result from a variety of causes such as infection, chemical

irritation, allergies and introduction of a foreign body or by facial trauma. Viral

infection may not cause any radiographic change in a sinus.

Inflammatory diseases of the maxillary sinus are:

A. Sinusitis
9 Acute sinusitis
9 Chronic sinusitis
9 Maxillary sinusitis in children
9 Fungal sinusitis

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 Diseases

B. Mucositis

C. Periostitis

D. Antral polyp

A. SINUSITIS

Sinusitis is a condition involving generalized inflammation of the paranasal

sinus mucosa caused by an allergen, bacteria or a virus. Sinusitis may cause blockage

of drainage through the ostiomeatal complex. Inflammatory changes may lead to

ciliary dysfunction and retention of sinus secretions. Perhaps 10 % of inflammatory

episodes of the maxillary sinuses are extensions of dental infections.3

Sinusitis can be:

Acute – refers to condition present for less than 2 weeks.

Chronic – refers to condition present for more than 3 months.

Also sinusitis may be ‘open’ or ‘closed’ type depending on whether the

inflammatory products of sinus cavity can drain freely into the nasal cavity through

the natural ostia or not. A ‘closed’sinusitis causes more severe symptoms and is also

likely to cause complications.20

Maxillary sinusitis is a common disorder and it is therefore important for

dentists to be able to recognize it and provide simple treatment. The typical triad of

sinusitis symptoms is nasal congestion or obstruction, pathological secretion and

headache. The maxillary molars and the maxillary sinus lie so close together that it is

not surprising that signs and symptoms of disease in one may be confused with signs

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 Diseases

and symptoms of disease in the other. Acute and chronic sinusitis affect all age

groups, though chronic sinusitis is much less common in children.

The bacteriology of sinusitis is not as clearly established as might be expected

in such a common condition because specimens easily become contaminated by nasal

organisms. Infections in the nose involve the sinuses because the linings of the nose

and the paranasal sinuses are continuous. The two species most commonly isolated in

acute and chronic sinusitis are Haemophilus influenza and streptococcus pneumoneae.

Anaerobes are found to predominate in chronic sinusitis.23

Sinusitis of dental origin

Infections of dental origin account for a significant proportion of cases of

acute sinusitis, ranging from 5-45%.

The dental conditions which may cause maxillary sinusitis are periapical

abscess and periapical granuloma, infected dental cysts, oroantral communication,

foreign bodies in the antrum and periodontal disease.23

Stafne (1985) estimated that 15-75% of time, sinusitis occurs through a dental

cause although the true incidence is difficult to determine accurately. Ingle (1965)

believed that contact between the maxillary sinus floor and inflammatory lesions

resulted in the development of chronic sinusitis. It is also accepted that symptoms of

maxillary sinusitis can emulate pain of dental origin.17

¾ Periapical abscess: The history of acute sinusitis due to discharge of a

periapical abscess into the antrum is shorter than that of acute sinusitis of non

odontogenic origin. The symptoms become apparent over a few hours rather

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than days and pain from a tooth is likely to precede the onset of sinusitis. The

primary pathogens are anaerobic organisms which originate from the

periapical abscess. It may also produce facial swelling, which is unusual in

acute sinusitis. Periapical radiographs will confirm the origin.

Treatment in these cases is obviously directed towards the infected tooth. It

may be possible to drain the pus through the root canals if the patient is keen

to save the tooth but the most reliable method of drainage is extraction.

Penicillin is effective against most oral anaerobes and is the drug of choice.

Amoxycillin is particularly well absorbed and metronidazole may be used as

an adjunct in severe cases. The extraction site should be reviewed and if a

fistula persists, closure should be carried out when the acute sinusitis has

resolved.23

¾ Infected dental cysts: Cysts which become infected and involve the maxillary

sinus can also cause sinusitis. They may be apical or dentigerous cysts.

¾ Oroantral fistula

¾ Dental materials in the antrum: A foreign body is introduced into the sinus

during dental treatment when displacement of root occurs during extraction or

if a root canal is overfilled and sometimes when implants are inserted. Since

the materials are inert for e.g. gutta percha point, titanium implant or silver

point, they do not always cause a reaction in the sinus and in the absence of

symptoms no treatment is necessary. However, if acute or chronic sinusitis

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develops, it will not resolve satisfactorily until the overextended root filling

has been removed and the tooth is retreated or extracted.

¾ Periodontal disease: Advanced periodontal disease may cause swelling of the

maxillary sinus mucosa and the periodontal therapy will significantly reduce

such swelling.29 Aggressive periodontal treatment is worth considering when

maxillary sinusitis does not resolve after drug therapy.23

9 ACUTE SINUSITIS

It is defined as an infection of the nose which has spread to the paranasal

sinuses, with a duration of between 1 day and 3 weeks. It involves accumulation of

pus in the antrum.

ETIOLOGY

It may result from mechanical obstruction of the ostium, direct bacterial

contamination, congenitally abnormal clearance mechanisms, immune deficiency as

well as dental diseases.23

ƒ Mechanical obstruction of the ostium: The most usual cause of ostium

obstruction is common cold. This viral infection produces inflammatory
edema of the nasal mucosa which obstructs the antronasal duct and causes
mucous to accumulate in the sinus. Trapped mucous becomes secondarily
infected by local commensal bacteria.

Allergic rhinitis (Hay fever) may cause maxillary discomfort due to edema

around the sinus ostium and retention of secretions, but frank purulent sinusitis is a

rare complication.

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Other conditions which can predispose to mechanical blockage of the ostium

are deviated nasal septum, nasal polyps and prolonged nasotracheal intubation.23

ƒ Direct bacterial contamination: Mostly this is from a dental source, but

infected material may also be introduced directly by jumping into

contaminated water without holding the nose or during diving, when pressure

changes in the nose force nasal secretions into the sinus.

ƒ
Abnormal clearance mechanisms: Ciliary function is a vital aspect of the

normal clearance of maxillary sinus secretions. Its failure will predispose to

acute sinusitis. It may also be due to poor sinus drainage related to supine

position, mostly seen in convalescing patients. Chronic respiratory tract

infection may in itself lead to a vicious circle in which continued microbial

burden and the immune response to it damages the cells responsible for

mucociliary function.23

PATHOPHYSIOLOGY:

Failure to eliminate
‘attacker’

Microbial
colonization

Amplified Release of microbial

inflammation cilioinhibitory factors

Impaired mucociliary
clearance

Progressive damage
to ‘bystander’ normal
tissue

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Immune deficiency

ƒ Immune deficiency: Sinusitis is known to occur in immune deficiency states,

in both congenital abnormalities and acquired conditions including leukemias,

lymphomas and AIDS or following the administration of cytotoxic

chemotherapy.23

ƒ Causative organisms

1. Bacteria: Most cases of acute sinusitis start as viral infection followed

soon by bacterial invasion. The bacteria most often responsible for

acute sinusitis are Streptococcus pneumonia, Haemophillus influenza,

Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus

and Klebsiella pneumonia. Anaerobic organisms and mixed infections

are seen in sinusitis of dental origin.20

2. Fungal: Generally mucor or rhizopus species of fungi are causative

organisms for acute sinusitis. Allergic fungal sinusitis may be caused

by Aspergillus. Allergic fungal sinusitis is an allergic reaction and it

presents with nasal polyposis.20

3. Viral: Rhinovirus infection may be responsible.19

PRESENTING COMPLAINT AND HISTORY

Typically, there is severe pain located in the cheek and the posterior maxillary

teeth, nasal blockage, purulent rhinorrhoea and postnasal drip with fever and malaise.

Pain may be exacerbated by stooping or lowering the head and may be localized to

the cheek and maxillary teeth of one side if only one sinus is affected. The pain is

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often increased by biting on the affected side but is unaffected by drinking hot, cold or

sweet fluids. The dentist should suspect sinusitis as a cause of symptoms if a patient

with pain in the upper buccal segment and no obvious dental cause has had a recent

upper respiratory tract infection. Acute bacterial sinusitis is the most frequent

complication of the common cold.

A history of bloody discharge is a potentially sinister sign as it may represent

an acute infection of an underlying malignant lesion.23

EXAMINATION

Extraoral

The general appearance of the face should be assessed, looking particularly for

asymmetrical swelling and erythema of the cheeks. There may also be erythema of

skin around the nose.

The cheeks should be palpated bilaterally to detect any tenderness. As the

anterolateral and posterolateral walls are thinnest in the area above the tooth roots,

thumb pressure on the cheek here is the best way to elicit tenderness.

The nasal mucosa of the anterior nares may show reddening and inflammation

and pus may be present.

Intraoral

Careful clinical examination of the teeth, supplemented by thermal or

electrical testing and periapical radiography, will identify caries, defective restoration,

non vital or cracked teeth and acute periapical or periodontal disease. Pain from any

of these sources may be confused with sinus pain. Mobility of one or more maxillary

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molar or premolar teeth, with swelling and tenderness over an apex usually indicates

local dental disease. Gentle percussion of the maxillary teeth may elicit tenderness of

one or two teeth and suggest a dental source of the problem but tenderness of whole

buccal segment is indicative of sinusitis.

Pus originating from the maxillary sinus may be seen in the oropharynx as a

postnasal drip.23

Symptoms: 19

1. Initially, discomfort in the nasopharyngeal region.

2. Pain in the maxillary region, which may radiate to the teeth, eyes, frontal sinus

and the ear. It is aggravated on bending down, coughing and sneezing.

3. Nasal discharge is mucoid initially. It soon becomes purulent. Sometimes it

may be blood stained. The discharge tends to go backwards to the pharynx

along the hiatus semilunaris, but later it appears anteriorly. Foul smelling

discharge is suggestive of dental origin.

4. Nasal blockage on the affected side occurs due to congestion and edema of the

nasal mucosa.

5. Change in nasal resonance.

6. Dry cough

7. Epistaxis may occasionally be present

8. Constitutional symptoms: malaise, headache, fever

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Signs: 19

1. Inspection: Slight edema of the affected area is seen at times in children.

2. Palpation: Tenderness over the canine fossa

3. Congestion of the nasal mucosa and turbinates

4. Purulent discharge trickling down through the choana.

INVESTIGATIONS

Early in the acute episode of sinusitis, radiographs may show no abnormality.

Radiographs may be unnecessary if the diagnosis is obvious on clinical examination.

The occipitomental view (Water’s projection), taken in the upright position is

usually the radiograph of choice. Periapical, occlusal or panoramic views may be of

use in identifying a dental cause for the acute sinusitis. CT scanning demonstrates

mucosal abnormalities in the nose and sinuses very clearly.

If radiological appearances are equivocal, proof puncture via the inferior

meatus or the canine fossa is useful for providing material for bacteriological culture

and sensitivity.

Direct visualization of the sinus mucosa by antroscopy through the canine

fossa will absolutely confirm the diagnosis.23

COMPLICATIONS

Serious complications from acute maxillary sinusitis are now rare because

most severe infections are treated promptly and effectively.23 Some of the

complications of acute sinusitis are:

1. Pansinusitis: The infection may spread to other sinuses.

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2. Middle ear infection may occur.

3. Pharyngitis, laryngitis and tracheobronchitis may follow.

4. Ophthalmic complications: Periorbital and orbital cellulites or abscess may

follow acute maxillary sinusitis

5. Osteomyelitis of the maxilla is a rare complication and is characterised by

increased pain and swelling in the maxillary region. Radiological examination

in such case may show bony necrosis.

6. Asthma may be aggravated by sinusitis.

7. Mucocele or pyocele may occur.

TREATMENT

General Treatment

a. Antibiotics have completely altered the gravity of this condition.

Effective antibiotics include doxycycline hydrochloride (vibramycin)

100mg daily, following a loading dose of 200mg for adults. Penicillin,

amoxicillin or cotrimazole may also be used and are preferred for

children. Antibacterial chemotherapy alone is insufficient treatment of

sinusitis.23

b. Decongestants reduce the congestion and swelling of the mucosa of the

nose and sinuses and improve the drainage of the sinuses.

Decongestant nasal drops contain sympathomimetic drugs. The

vasoconstriction of the nasal mucosa and antral fontanelles reduces

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vascular engorgement and therefore reduces the mucosal swellings.

Ephedrine nasal drops (0.5%) are most commonly used and can give

relief for several hours. 1-2 drops instilled 8 hourly are usually

adequate. Xylometazoline (0.1%) is an alternative to ephedrine.

Systemic decongestants are of no proved value.23

c. Analgesics make the patient comfortable.

d. Antihistamines may be useful in patients with allergy.

Local Treatment

a. Steam inhalation provides fomentation and thins the secretions which

may flow out easily. They may act by hydrating the mucous blanket,

making it less viscous and thereby encouraging normal ciliary

clearance of the antrum. Various additives like tincture benzoin,

eucalyptus oil or menthol act mainly as flavouring agents. The main

active ingredient is the steam.

b. Fomentation or short wave diathermy on the sinus is soothing.

c. Adrenaline may be applied in the region of the middle meatus to

decongest the mucosa and improve the sinus drainage. But better new

local decongestants have made this treatment obsolete.

If antibiotics and nasal drops fail to resolve the condition, pus must be

removed from the antrum. Pus is removed by antral lavage, which may need to be

repeated several times on a weekly basis until clear fluid rather than mucous pus is

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returned in the washings. Antibiotics and nasal decongestants are subsequently

prescribed.

The keystones of therapy are the provision of drainage to remove the pus and

reaerate the sinus mucosa and removal of the cause. Failure to do either effectively,

can lead to establishment of a chronic sinusitis.

Drainage is preferably achieved by supporting and restoring the natural

drainage mechanism through the antronasal duct with antibiotics and nasal

decongestant. However, if the cause is dental, drainage is achieved at the same time

when the casue is removed. The communication may heal spontaneously.

Further in case of recurrent acute sinusitis surgical management through

inferior meatal antrostomy may be needed.23

9 Chronic Sinusitis

It is poorly defined but is best considered as persistent, incompletely resolved

acute sinusitis. However, it is also commonly due to the persistence of external

aggravating factors such as nasal polyposis, septal deviation and allergic rhinitis and

even perhaps chronic marginal periodontitis which can cause antral mucosal

thickening.

Chronic nasal obstruction, a long standing purulent nasal discharge, headache,

facial pain or a sensation of pressure and a dull ache over the sinuses together with

history of previous sinusitis, all suggest chronic sinusitis. Sinus radiographs or

sinuscopy demonstrate persistent local or generalized mucosal swelling.

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Chronic maxillary sinusitis of dental origin has been associated with oroantral
fistula, non vital teeth, inflammatory periapical or periodontal lesions and even the
follicles of impacted teeth involved in a periodontal or periapical lesions; dental
causes accounting for 40% of the cases.

Proof puncture and subsequent culture may reveal a causative organism

resistant to antibiotic therapy. Anaerobes are the most important pathogens. They are
isolated only in inflamed mucosa, whereas aerobes are found even in the absence of
inflammation.

PATHOPHYSIOLOGY

In chronic infections, process of destruction and attempts at healing proceed

simultaneously. Sinus mucosa becomes thick and polypoidal (hypertrophic sinusitis)
or undergoes atrophy (atrophic sinusitis). Surface epithelium may show
desquamation, regeneration or metaplasia. Submucosa is infiltrated with lymphocytes
and plasma cells and may show microabscesses, granulations, fibrosis or polyp
formation.20

Pollution, chemicals, infections

Loss of cilia

Polyp, Impaired drainage Mucosal changes Allergy

Adenoids,
Tumours

Infection

Inadequate therapy of acute sinusitis

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CLINICAL FEATURES

The clinical features are often vague and similar to those of acute sinusitis but

of lesser severity. The condition sometimes is asymptomatic.6 Purulent nasal

discharge is the commonest complaint. Foul smelling discharge suggests anaerobic

infection. Local pain and headache are often not marked except in acute

exacerbations. Some patients complaints of nasal stuffiness and anosmia.

TREATMENT

The treatment must depend on identification of cause. Removal of local

factors such as a dental cause, the cause of ostium obstruction or the source of direct

bacterial contamination together with control of any infection present should lead to

cure.

Surgical management may be required. Inferior meatal antrostomy is used in

the treatment of chronic sinusitis. With this method it is hoped that the damaged

mucosa will return to normal by a combination of aeration and gravitational drainage.

Transnasal endoscopic surgery requires special equipment and training and is

associated with less morbidity than traditional methods. Access is easily gained from

the buccal approach in this method.

RADIOGRAPHIC FEATURES OF SINUSITIS

Radiographic diagnosis depends on alteration in the density of the dark

shadows- “air spaces” and “adjacent bony structures”. Any fluid be it blood, pus,

mucous or normal saline and any soft tissue absorbs more X-Ray than does the air

contained in the normal antrum. These results in alteration in the radiographic

appearances. The normal dark shadow is replaced by the gray one.7

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Thickening of sinus mucosa and the accumulation of secretions that

accompany sinusitis reduce the air content of the sinus and cause it to become

increasingly radiopaque. The most common radiopaque patterns that occur in the

Water’s view are localized mucosal thickening along the sinus floor, generalized

thickening of the mucosal lining around the entire wall of the sinus and near-complete

or complete radiopacification of the sinus. Mucosal thickening in just the base of the

sinus may not represent sinusitis but rather represent the more localized thickening

that can occur in association with rarefying osteitis from a tooth with a nonvital pulp,

which may progress to involve the entire sinus. In the case of an allergic reaction, the

mucosa tends to be more lobulated. In contrast, in cases of infection, the thickened

mucosal outline tends to be smoother, with its contour following that of the sinus

wall.

An air-fluid level resulting from the accumulation of secretions may also be

present. Because the radiopacities of transudates, exudates, blood and pathologically

altered mucosa are similar, the differentiation among them relies on their shape and

distribution. When present, fluid appears radiopaque and occupies the inferior aspect

of the sinus. The border between the radiopaque fluid and the relatively radiolucent

antrum is horizontal and straight or with a meniscus. It is possible to confirm that one

is viewing an air-fluid interface by tilting the head and making another radiograph.

This changes the orientation of the fluid level, which eliminates any doubt as to its

fluid nature. However, when attempting to verify this, sufficient time should be

allowed between the first and second exposures for the fluid level to change. If a

significant proportion of the fluid is mucous, some minutes may be required before it

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attains its new level. To demonstrate an air-fluid level, the central ray of the X-Ray

beam must be horizontal to the level of the air-fluid interface.

Fig. 7.1: Water’s view demonstrating complete radiopacification of the left

maxillary sinus. An air-fluid level is visible in the right maxillary sinus (arrows)

Chronic sinusitis may result in persistent radiopacification of the sinus with

sclerosis and thickening of the sinus wall. However, resorption of the bony border is

unusual.

The resolution of acute sinusitis becomes apparent on the radiograph as a

gradual increase in the radiolucency of the sinus. This can first be recognized when a

small clear area appears in the interior of the sinus; the thickened mucous membrane

gradually shrinks so that it begins to follow the outline of the bony wall. In time the

mucous membrane again becomes radiographically invisible and the sinus appears

normal. In chronic sinusitis the inflammation may stimulate the sinus periosteum to

produce bone, resulting in thick sclerotic borders of the maxillary antrum.

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9 MAXILLARY SINUSITIS IN CHILDREN

The developing maxillary sinuses are smaller than those of the adults and have

a less unfavourable gravitational drainage site. The deciduous teeth are separated from

the sinus by the permanent tooth germs and are therefore less likely to cause infection.

Both acute and chronic maxillary sinusitis are less common in children than in

adults, but they do occur and with potentially very serious consequences like

periorbital cellulitis. It may be caused by maxillary sinusitis. From the maxillary

sinus, infection can spread along venous system as periphlebitis or thrombophlebitis

resulting in a purulent infection of the orbital tissues or directly through the thin bone

of the orbit.

The signs and symptoms of chronic sinusitis in children are not pathognomic.

Most common ones are purulent rhinorrhoea and chronic cough. The mainstay of

treatment is with antibiotics and should be maintained for atleast 3-4 weeks.

Augmentin, ceftin, suprax and pediazola are used. Topical steroids may be given in

resistant cases. Role of decongestants is not yet clear.

9 FUNGAL SINUSITIS

ASPERGILLOSIS

It may become pathogenic in man in certain circumstances. The most frequent

infecting species is A.fumigatus. Treatment of the solitary aspergillosis consists of

removal of the mycotic mass. As the antral mucosa remains largely intact, antimycotic

therapy is considered unnecessary.

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MUCORMYCOSIS

Mucormycosis or phycomycosis is a rare fungal infection but it is reported

with increasing frequency in immunocompromised patients and is potentially lethal. It

is commonly accompanied by a triad of symptoms- uncontrolled diabetes mellitus,

periorbital infection and meningoencephalitis.

Treatment involves control of the underlying predisposing factors, surgical

excision if the lesion is localized and antibiotic therapy, the drug of choice being

amphotericin B. Even so, the disease can spread rapidly and result in a fatal mycotic

infection.23

B. MUCOSITIS

Normal sinus mucosa is not visualized on radiographs; however, when the

mucosa becomes inflamed from either an infectious or allergic process, it may

increase in thickness 10 to 15 times, which may be seen radiographically. This

inflammatory change is referred to as mucositis.

CLINICAL FEATURES

The thickness of sinus mucosa in an asymptomatic individual may vary

considerably over a relatively short period of time. Consequently, the discovery of

thickened sinus mucosa in an individual who is otherwise asymptomatic does not

necessarily imply that further investigations are warranted or that treatment is

required. Most of the inflammatory episodes that result in thickening of the mucosal

lining of the sinuses are unrecognized by the patient and are discovered only

incidentally on a radiograph.

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RADIOGRAPHIC FEATURES

The image of thickened mucosa is readily detectable in the radiograph as a

noncorticated band noticeably more radiopaque than the air filled sinus, paralleling

the bony wall of the sinus.

Fig. 7.2: Radiographic appearance of mucositis

C. PERIOSTITIS

The inflammatory exudates from dental inflammatory lesions can extend into

the maxillary antrum. The exudates can strip and elevate the periosteal lining of the

cortical bone. The presence of inflammatory products next to the periosteum

stimulates the periosteum to produce a thin elevated layer of new bone adjacent to the

root apex of the involved tooth. The presence of one or more halo like layers of new

bone indicates inflammation of the periosteum.

RADIOGRAPHIC FEATURES

Although the periosteal tissue is not visible on the radiograph per se, this is

referred to as periosteal new bone formation. This new bone may take the form of one

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or more thin radiopaque lines or the line may be very thick. This new bone should be

centered directly above the inflammatory lesion.

Fig. 7.3: Halolike appearance of periostitis

D. ANTRAL POLYP

The thickened mucous membrane of a chronically inflamed sinus frequently

forms into irregular folds called polyps. Polyposis of the sinus musosa may develop in

an isolated area or in a number of areas throughout the sinus.

CLINICAL FEATURES

Polyps may cause displacement or destruction of bone.

RADIOGRAPHIC FEATURES

A polyp may be differentiated from a retention pseudocyst on a radiograph by

noting that a polyp usually occurs with a thickened mucous membrane lining because

the polypoid mass is no more than an accentuation of the mucosal thickening. In the

case of a retention pseudocyst, however, the adjacent mucous membrane lining is not

usually apparent. If multiple retention pseudocysts are seen within a sinus, the

possibility of sinus polyposis should be entertained.

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The radiographic image of the bone displacement or destruction associated

with polyps may mimic a benign or malignant neoplasm. Because many sinus

neoplasms are asymptomatic, examination of a paranasal sinus that reveals bone

destruction associated with radiopacification is an indication for biopsy and should

not be delayed by initial conservative treatment.

II. TRAUMATIC PENETRATION

As a result of the relationship of the maxillary sinus with the maxillary teeth

and surrounding structures, the tooth may get displaced into the sinus leading to

oroantral communication, sometimes further complicated by displacement of a root.

Fracture of the maxillary tuberosity may also occur and produce a large opening into

the sinus. Zygomatic complex, orbital floor and middle third fractures inevitably

involve it and it is also exposed during maxillary down-fracture procedures for

correction of facial deformities.

The traumatic penetration can occur by any one of the following conditions:

A. Oroantral fistula (OAF)

B. Root/foreign body in antra

C. Fractures

D. Pneumocele and cheek emphysema

E. Orthognathic surgery

A. OROANTRAL FISTULA

It is an abnormal communication between oral cavity and maxillary sinus

which can result due to several causes such as extraction of teeth, massive trauma,

surgery of maxillary sinus, osteomyelitis of maxilla, gumma involving palate, infected

upper implant dentures and rarely malignant granuloma.6

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ETIOLOGY

Oroantral communication is more likely to occur when there is periapical

pathology, a large antrum or a lone standing molar. In younger patients, where the

antrum is not fully formed, it is most unlikely.

Thick buccal bone overlying an upper first molar in an intact arch may come

with the tooth, resulting in a communication. If unusual resistance is encountered

during extraction it is better to resort to surgical bone removal or division of the tooth

than to apply further force.

Elderly patients with few remaining maxillary teeth have larger sinuses.

Extraction in these cases should be undertaken with extra care and the patient must be

warned that it may be impossible to avoid a communication with the antrum.

Preoperative radiographic examination may prompt a warning to the patient and

perhaps encourage extra care, but otherwise does not alter the risk of perforating the

antrum.23

PATHOGENESIS

Some communications will close spontaneously, but prediction is difficult.

Perforation is likely to persist if its diameter is greater than 4mm or depth of the

surrounding alveolar bone is less than 5mm, but no examples are given to support this

view. Healing depends upon size and shape of the perforation, a deep socket being

more favourable.

DIAGNOSIS

All extracted upper posterior teeth should be examined. If the roots are

covered with a thin plate of bone or adherent sinus mucosa, a communication may be

present.

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The patient should be asked to attempt to blow air into the pinched nose with

the mouth open. If an oroantral defect is present, bubbles appear in the extraction

socket. A false negative result may be obtained. This is Luc-Caldwell test.

Gentle probing of the socket with a blunt instrument, such as a ball ended

periodontal probe, will confirm the bone defect without perforating an intact lining.

Diagnostic steps for suspected oroantral communication: 30

Extraction of an
upper tooth

Extracted tooth
Operative Root
O
search of the cannot
intact
root be found

Root in situ

Probing
excochleation of
alveola
Alveolar fundus
cannot be felt
A
Luc-Caldwell test Air penetrates the
alveola
Negative
Alveolar fundus
Probing
Negative
cannot be felt C
??
Diagnosis of maxillary sinus
No OAC

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Radiographic evidence of an oroantral fistula depends to some extent on the

cause. Where a small root fragment has been adjacent to the floor of the antrum and

opening has been made during its removal, all that may be seen is disalignment of a

small portion of the cortical layer of bone, a small fragment having been displaced,

much like the trap door. More often there is an obvious gap in the continuity of the

white line which represents the cortex of the antrum.

Fig. 7.4: Radiographic appearance of oroantral communication

Often the only radiographic sign of a fistula is a thickening of mucosa over the

perforation. There may be prolapse of the sinus lining into the oral cavity, which may

be seen radiographically as a soft tissue shadow.

The margins of the orifice vary depending on the cause of the fistulous

opening and how long it has been present. A long continued fistula in the bone tends

to develop a cortical covering, but this is not invariable. Other fistulas have smooth

but uncorticated walls or they may be irregular when they are recent, especially if

associated with bone disease. Openings in the antral floor, produced by malignant

disease, have irregular bony margins due to infiltration by tumour.

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A difficulty arises when a tooth socket in close relationship with the antral

floor reveals discontinuity of its apical portion. It is difficult to distinguish from

periapical osteitis which existed before the tooth extraction. It may be determined

when the shape of the defect in the lamina dura corresponds with the adjacent

radiolucent area of the osteitis. If this radiolucent area is not present then the defect in

the lamina dura may not be distinguished from a fistulous opening.7

TREATMENT

The sooner the diagnosis is made, the easier and more comfortable to the

patient is the therapy. The aim of treatment of a communication created by extraction

is to provide support for the socket blood clot so that it will organize, be relapsed by

bone and epithelialize on its oral and antral surfaces.23 Operative closure of an

oroantral communication can be done only when the maxillary sinus shows no signs

of inflammation. However, if sinusitis has been found, this means first treating the

sinusitis and then closing the communication after the sinus is free of inflammation.30

Provided there is no purulent discharge, the oroantral communication should be

closed as soon as it is recognized. No material should be put into the socket as this

will delay healing.23

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Oroantral communication: therapy conspectus 30

Diagnosis of OAC

Diagnosis of maxillary sinus

No hold for sinusitis Clinical and radiographic

symptoms of sinusitis

(Primary) Conservative treatment

13%

Decrease of No improvement
inflammation

Operation of maxillary
Operative closure of (Secondary)
sinus combined with
OAC 13 %
closure of OAC

The most successful methods of oroantral communication closure are the

buccal advancement flap and the palatal rotation flap. The former has been criticized

because of the postoperative decrease in sulcus depth. Other procedures include the

use of implantable materials to cover the defect like the use of collagen implant. With

collagen implant, a second operation is not required to remove the material.

Postoperative care should be done by giving antibiotics, steam inhalations and nasal

decongestants. 23

B. ROOT/FOREIGN BODY IN ANTRA

The inadvertent introduction of a dental root into the maxillary antrum after

tooth fracture during attempted extraction is not an uncommon occurrence.

Anatomically, the apices of the maxillary first permanent molar tooth lie closer to the

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floor of the antrum and it is the palatal root of this tooth that is most often displaced

into the antrum. Sometimes whole tooth, especially the third molar may also be

displaced into the antrum.

The sequelae of such displacement may be summarized as follows:

1. The tooth or root may remain symptomless either within the antral lumen or

beneath the antral mucoperiosteum.

2. It may be associated with acute maxillary sinusitis.

3. It may result in chronic sinusitis, thickening of the antral lining and/or polyp

formation.

4. It may be associated with the formation of benign mucosal cysts of the antrum.

5. It may be discharged into the mouth through a patent oroantral fistula.

6. It may be associated with antrolith formation.

7. It may be displaced via the ostium or fistula into the nose and subsequently it

might be:

ƒ Expelled via the anterior nares on sneezing or nose blowing

ƒ Swallowed to pass through the GI tract

ƒ Inhaled

DIAGNOSIS

When displacement is suspected, careful inspection with the aid of well

directed light and a fine suction tip and palpation of the socket area should be carried

out to make sure that the root is stil not in the socket or beneath the buccal or palatal

mucosa.

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A periapical or occlusal radiograph will usually show a root within the sinus

just above the extraction socket. A panoramic radiograph is a useful additional view if

the root is not visible on intraoral films.23

RADIOLOGY

These include tooth roots, whole teeth, broken fragments of instruments,

drainage tubes, dressings, fragments of root canal filling materials and metallic

objects such as pellets, bullets and fragments of shells or bombs. Of these by far most

common are fragments of tooth roots which have been displaced during an attempted

extraction.

For radiographic examination, IOPA should be used. It is valuable to have

multiple IOPAs from different angles. It is often advisable to make an extraoral

radiograph (Water’s mostly), even though the foreign body can be seen in the

periapical projection. Intraoral occlusal films which take in a wider area than the

periapical, are of great value in some cases.

Foreign bodies other than roots are usually easily recognized as such, although

the precise nature may be in doubt. The history is often of great value but is not

entirely reliable. Most tooth roots reveal some evidence of the root canal but this is

not variable. The shape, density of the shadow and the presence of root canal lead to

the determination, that a root is present.

Having determined the presence of root, it is now important to know its

position. It can be in the socket or out of it. A root within its socket has the shadows

of the lamina dura and periodontal membrane space around it, unless disease has

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destroyed the adjacent bone. In most cases a root having an abnormal position and

devoid of its lamina dura shadow is displaced from its socket.

Once it is established that the root is out of the socket, its relationship to the

maxillary antrum should be determined. The shadow of the root within the sinus does

not indicate that the root is actually within the sinus. The shadows may be

superimposed and there may be no actual inclusion of the root in the sinus. Usually,

however, the superimpositions of the two shadows, together with the absence of the

lamina dura means that the root is in the antrum. But other evidence e.g. breach in the

continuity of the antral floor must be sought to confirm the suspicion.

The direction of some of the palatal roots of first molars is directed upwards

and medially. When displaced upwards, they come out of the socket to be situated

between the antral mucosa and the wall of the maxillary sinus. This gives a similar

radiographic picture as that of the root within the antrum. However, roots that lie

exposed in the maxillary sinus tend to gather calcific deposits on their surfaces in

sufficient amounts to be discernible on radiographs. A root situated under the antral

mucosa would not gather such calcific deposits.

A very rare and perplexing situation is one in which a root and a portion of the

alveolus is forced into the sinus, so that the root is in an abnormal position and yet

there is a normal lamina dura and periodontal membrane shadow. The clinical

findings, history and radiographic demonstration enable the correct interpretation.

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Small bony excrescences arise from the floor of the antrum as normal

appearances and sometimes resemble root very closely. There is no evidence of any

root canal in such cases.7

MANAGEMENT

There are two surgical approaches to the root, either through the site of the

socket or through the canine fossa by the so-called Caldwell-Luc approach. With

either approach, a radiograph is essential immediately before surgery, as a mobile root

may be difficult to find. A good light source and efficient surgical suction apparatus

are also absolute requirements. Occasionally the root can be retrieved using the

suction tip alone, but more often it has to be visualized and then grasped with suitable

forceps.23

OTHER FOREIGN BODIES:

¾ Traumatic foreign body - airgun bullet, pieces of glass, stones and wood,

grasses, match sticks.

¾ Iatrogenic foreign body – dental cement, pieces of broken forceps, gutta

percha, burs.

C. FRACTURES

¾ FRACTURED TUBEROSITY: This occurs most frequently when extracting a

lone maxillary third molar. If the bone is found to be moving with the tooth

during extraction, the operator should stop immediately. It may be easier to

leave the tooth in place and allow the fracture to heal before making further

attempt to remove it. Surgical removal from the healed intact bone is

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considerably easier than removing the tooth from mobile bone, which itself

may be difficult to retain. The healed bone remains weak and attempted

forceps extraction can recreate the original problem. Tuberosity fracture

inevitably involves the maxillary sinus. Antibiotics, nasal drops and

inhalations are therefore prescribed to help prevent development of chronic

oroantral fistula. 23

¾ ZYGOMATIC COMPLEX FRACTURES: Assaults often result in fracture of

the zygomatic complex. The fractures occur at lines of weakness and pass

through the orbital floor, usually medial to the zygomaticomaxillary suture

and therefore inevitably involve the sinus. Occipitomental views are the most

helpful in diagnosing a fracture of the zygomatic complex. Simply elevating

the malar may suffice, but if malar is unstable, fixation is required. This may

be achieved by transosseous wiring or plating. The use of pins is associated

with fewer complications than antral packs. Any foreign body within the sinus

should be removed. Even though there may be considerable comminution of

the anterolateral and posterolateral walls of the sinus, they heal satisfactorily

without intervention.

¾ Le Fort I FRACTURE: This low level fracture splits the dentoalveolar portion

from the rest of the maxilla. It is an extension of the fractured tuberosity and

can occur unilaterally with a palatal split or bilaterally. Lateral radiographs

show the line of fracture passing just above the floor of the antrum.

¾ Le Fort II FRACTURE: This is a higher level ‘pyramidal’ fracture of the mid

face.

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¾ Le Fort III FRACTURE: This is still at a higher level than the Le Fort II

fracture and causes complete dislocation of the facial skeleton from the cranial

base. Theoretically the maxillary sinus would be unaffected, but in practice

some fracture lines may involve sinuses.

¾ ORBITAL FLOOR BLOW OUT FRACTURES: The orbital cavity is cone

shaped and sudden pressure on the globe from an object pushes the orbital

contents backwards. The rapid increase in intraorbital pressure is transmitted

to the orbital walls and fracture occurs at the thinnest parts. There is herniation

of periorbital fat and extravasated blood from the ruptured periosteum into the

maxillary sinus. Most useful radiographs are the tomograms taken at varying

depths of cut. ‘Hanging drop’ may be seen. Treatment involves retrieving the

orbital contents from the antrum and repairing the orbital floor defect. 23

RADIOLOGY

Various maxillary fractures involve the nose and paranasal sinuses. These

involve the zygomatic complex fractures, Lefort I, II, III fractures of the maxilla and

orbital blow out fracture.

Occipitomental views are the most helpful in diagnosing the maxillary

fractures, although lateral radiographs show the fracture line sometimes. A breach in

the continuity of the antral walls may be seen with or without displacement. There

may be partial or complete opacification of the sinus caused by haemorrhage.

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A blow to the orbit sometimes causes a fracture or blowout of thin portions of

the bony lining of the orbit. According to Hames and Rakoff there are three

radiographic findings (best seen in Water’s view):

Orbital emphysema

Partial to complete opacification of the maxillary sinus caused by

haemorrhage.

Hanging drop opacity into the superior portion of the maxillary sinus due to

herniation of orbital structures through the fractured orbital floor.

Tomograms are sometimes required to verify the clinical impression of a blow

out fracture. Perhaps the most consistent finding is the complete opacification of the

sinus. This should be considered in the differential diagnosis of sinus opacification,

along with mucocele, complete tumorification of the antrum and opacification due to

the superimposition of anatomic structures.

D. PNEUMOCELE AND CHEEK EMPHYSEMA

A pneumocele of the orbit occurs following forceful blowing of the nose when

there is a small bony defect in the roof of the sinus. The patient should be given

antibiotics and observed for developing orbital cellulitis.

Air emphysema of the cheek may also follow fracture of the facial wall of the

sinus which can be associated with trauma to the inferior orbital rim. 23

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E. ORTHOGNATHIC SURGERY

Lefort I osteotomies are carried out for the correction of various types of

maxillary deformities and involve bone cuts directly into the maxillary sinuses with

down fracture of the maxilla.

Radiographically the air fluid level is no longer visible after 2-4 weeks and the

mucosal reaction gradually diminishes. Despite the direct surgical trauma to the antral

lining and presumed disturbance of the physiological clearance mechanism of the

sinus, infections are rare when antibiotics are used. 23

III. CYSTS

Cysts are abnormal fluid filled cavities usually lined by epithelium. A great

variety of cysts can be found in the maxillary sinus, arising either from the maxillary

alveolus and encroaching on the sinus or directly from the lining of the sinus itself.

Cysts can be asymptomatic and so reach a considerable size before diagnosis. They

come to attention either because of the effects of growth of a space-occupying lesion

or as incidental findings on radiographic examination. Occasionally they become

infected and lead to acute symptoms.

I. Cysts can be classified as: 23

1. Nonodontogenic Cysts (Cysts arising in the Maxillary Sinus)

Mucosal antral cysts
Surgical maxillary cysts

2. Odontogenic Cysts (Cysts Encroaching the Maxillary Sinus)

Periapical cysts
Residual cysts
Dentigerous cysts

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Odontogenic keratocysts
Calcifying epithelial odontogenic cysts

3. Cyst of controversial origin

Globulomaxillary cyst

II. Lindsay’s classification (modified): 32

1. Non secreting cysts (no epithelium, thus pseudocyst)

2. Secreting cyst (retention cysts)

3. Mucoceles

Thus based on this classification, cysts and cyst like processes arising from the

sinus mucosa may be:

Pseudocysts

Retention cysts

Mucoceles

MUCOSAL ANTRAL CYSTS

Synonyms

Antral pseudocyst, benign mucous cyst, mucous retention cyst, mesothelial

cyst, pseudocyst, interstitial cyst, false cyst, lymphangiectatic cyst, retention cyst of

the maxillary sinus, benign cyst of the antrum, benign mucosal cyst of the sinus,

serous non-secretory retention pseudocyst, retention pseudocyst 3

These are the most common lesions affecting the maxillary antrum. The

variety of names given to these lesions reflects the obscurity of their pathogenesis.

The reported incidence in radiographic surveys varies from 2-10% of the population

studied. 23

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PATHOGENESIS

The actual pathogenesis of these lesions is controversial however one theory

suggests that blockage of the secretory ducts of seromucous glands in the sinus

mucosa may result in a pathologic submucosal accumulation of secretions, resulting

in swelling of the tissue. A second theory suggests that the serous nonsecretory

retention cyst arises as a result of cystic degeneration within an inflamed, thickened

sinus lining.

Mucosal cysts of the maxillary sinus are primarily non secretory type. This is

based on the fact that there is no difference in the distribution of transilluminated light

on affected and non affected sides. 33

The non secretory type or mucous extravasation cyst, occurs when fluid

accumulates in the subepithelial tissues. Capillary damage permits protein leakage

into the sinus mucosa which has become edematous due to infection or allergy. These

dome shaped radiopaque shadows frequently seen on the floor of the maxillary sinus

and sometimes inaccurately referred to as antral mucosa appear to represent focal

accumulation of inflammatory exudate that lifts the epithelial lining of the sinus.

There is no epithelium lined cavity present beneath the sinus mucosa, consequently

the term pseudocyst of the mucosa. 32

Basic approach in handling these cases involve periodic radiographic

checkups, if the lesion can be diagnosed as being non secreting mucosal cyst. If the

diagnosis cannot be made, a partial (for biopsy) or complete removal of the lesion is
33
recommended. Excision of the cyst is indicated if specific symptoms or persistent

clinical features are present; otherwise non intervention is recommended.

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The secreting type or mucous retention cyst, probably arises from obstruction

of a gland outlet during a period of altered secretion in response to sinus infection or

allergy. Continued secretion causes dilatation of the gland, resulting in a cyst lined

with epithelium. 23 These represents dilation of the duct of a seromucinous gland and

is therefore lined with epithelium. 32

It has been emphasized that majority of secretory cysts are symptomless and

found on routine radiography. The following features, though not unequivocal,

support the diagnosis of a secretory cyst. There is a radiopaque dome shaped area in

marked contrast with the radiolucent maxillary sinus. An odontogenic cyst expanding

the antral floor would give a similar appearance but the angle formed by the antral

floor and the cyst wall would be less acute. It is generally believed that the mucous

retention cyst is a self limiting condition.

CLINICAL FEATURES

It is not uncommon and occurs in all age groups. These may vary in size from

minute to very large and in some instances may occupy the entire maxillary sinus.

Their growth rate is unknown, but a large cyst may take months or years to achieve

maximum expansion. When the cyst fills the maxillary sinus completely, it may

eventually prolapsed through the nasal ostium. It frequently ruptures as a result of

abrupt pressure changes caused by sneezing or blowing of nose. The pseudocyst may

be present on radiographic examination, perhaps absent a few days later only to

reappear on subsequent examinations. The maxillary sinus is the most common site of

pseudocysts. These are not related to extractions or periapical disease. 3

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SIGNS AND SYMPTOMS:

These cysts are usually asymptomatic and are found by chance on

radiography. Spontaneous discharge or prolapsed into the nose is common and

therefore bone expansion is rare.

Large cysts produce symptoms of headache, usually described as a heavy

feeling in the orbital or frontal region on the affected side, whereas small cysts are

occasionally symptomatic. There may be a sense of fullness and numbness in the

cheek exacerbated by pressure on the skin overlying maxillary sinus. Nasal

obstruction, post nasal discharge and frontal headaches may be observed. Pain mainly

arises due to cyst pressure and subsides with its rupture. 23

RADIOLOGY: 3, 37

Location: Usually project from the floor of the sinus, although some may form

on the lateral walls. The size may vary from that of a finger tip to a size large enough

to completely fill the sinus and make it radiopaque.

Periphery and shape: Usually appear as noncorticated, smooth, dome shaped

radiopaque mass. There is no osseous border surrounding it. The base of the lesion

may be narrow or more commonly broad.

Internal structure: It is homogeneous and more radiopaque than the

surrounding air of the antrum. It is such that normal anatomic structures could be

detected through the mass. Transillumination is normal even when a large cyst is

present.

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Effect on surrounding structures: The sinus is usually clear of all pathology

including expansion and perforation. The sinus floor is intact.

Fig. 7.5: Radiographic appearance of a pseudocyst

In making a correct diagnosis, the Orthopantomogram has been more or less

excelled by antroscopy.

Differential diagnosis

Odontogenic cyst: These have a thin marginal radiopaque line. It is more

rounded or tear drop shaped. The lamina dura of the teeth associated with

radicular cyst is not intact in the apical area; it may be continuous with the

corticated outline of the cyst. Also, the floor of the antrum is missing or

displaced.

Antral polyps: They are often multiple having an infectious or allergic origin.

They are rare and not necessarily seen over the antral floor.

Normal anatomic structures e.g. inferior concha

Neoplasms

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TREATMENT

Asymptomatic maxillary mucosal antral cysts usually do not require treatment.

Sometimes, spontaneous rupture causes the cyst to disappear rapidly. Symptomatic

cysts may be decompressed by antral puncture or intranasal antrostomy or removed

via the canine fossa approach. The cysts have a very thin bluish wall and tend to

puncture and collapse on removal. The collapsed cyst can be separated from the

surrounding antral mucosa by simple traction.

SURGICAL MAXILLARY CYST

Synonyms

Post operative mucocele, post operative maxillary cyst, surgical ciliated cysts

of the maxilla

This cyst develops in epithelium trapped in the wound at operation for

sinusitis. Patients who have had surgery 10-30 years previously, present with buccal

swelling with pain and purulent discharge.

RADIOLOGY

These do not affect the sinus initially. Consequently, they appear as well

circumscribed radiolucency or fairly radiopaque structure in the antrum, separate from

unaffected part of the sinus. The lesions are essentially spherical, but this shape is

modified by normal bony structures. However, they lack the typical dome shaped

appearance of cyst of the antrum. As they enlarge, the sinus wall becomes thinned and

eventually perforated. Gradually, the lesion expands beyond the original boundaries

of the sinus. Once they have destroyed bone, some form of malignant condition must

be considered in the differential diagnosis. An important radiographic distinction is

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that these do not enhance (become more radiopaque) after the administration of

contrast material while most tumours will enhance to a variable degree.

Radiographically a well defined radiolucency is seen but apart from the lack of

association of a tooth there are no distinctive features to differentiate it from a cyst of

dental origin.

TREATMENT: IS BY ENUCLEATION. 23

MUCOCELE

Synonyms

Pyocele, mucopyocele

They are usually benign, slowly enlarging expansile swellings caused by the

accumulation and retention of mucous secretions within the sinus. It results from a

blocked sinus ostium. Over a period of time the entire sinus cavity is filled and is
34
airless. Antral mucoceles destroy bone. They distend the bony wall of the sinus as

the intraluminal pressure increases and eventually erode the bone by pressure

resorption. When this happens, the mucous herniates into adjacent cavities such as
35
cranium or orbit or onto the skin surfaces. If the mucoceles become infected, they

are called pyocele or mucopyocele. 3

CLINICAL FEATURES

It is most common in frontal sinus. It may cause radiating pain due to pressure

on the superior alveolar nerves. Patient may complain of a sensation of fullness in the

cheek and the area may swell. If the lesion expands inferiorly, it may cause loosening

of the posterior teeth. It may also cause nasal obstruction, diplopia or proptosis

depending on the direction of spread. 3

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Radiographic evidence can be extremely helpful in the diagnosis of these

lesions. Infact, mucoceles are most often noticed or suspected on the basis of

radiographic findings. Unlike malignancy, there are smooth clear cut margins of bone

erosions occurring in the sinus walls. 34

RADIOLOGY:

Location: Rare in maxillary sinus, more common in frontal and ethmoidal sinuses.

Periphery and shape: The normal shape of the sinus is changed into more circular,

“hydraulic shape” as the mucocele enlarges.3

Internal structure: In its early stage, a mucocele that involves the entire antrum

appears as a uniformly “cloudy” mass. This appearance is not specific. However,

longer standing lesions may well appear more radiolucent since the increased bone

destruction more than cancels out the increase in fluid density. Scattered calcifications

may be seen.

Effects on surrounding structures: Causes enlargement of the sinus cavity and

thinning of the bony walls, resulting in the loss of scalloped margins. Pressure

deformity rather than invasion is seen. The shape of the sinus changes with the bony

expansion. Septa and the bony walls may be thinned or even perforated. There may be

displacement of teeth or root resorption. 34, 35

Differential diagnosis

Neoplasm: Usually destroys and eventually perforates the antral wall. It has an

irregular outline.

Cysts: No evidence of thinning.

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TREATMENT
It is usually surgical, using a Caldwell-Luc operation to allow excision of the

lesion. The prognosis is excellent. 3

GLOBULOMAXILLARY CYST
Globulomaxillary cysts have a tendency to involve the maxillary sinus or

extend to the roof of the mouth or both. They are usually asymptomatic and are found

incidentally on radiographs. They appear as a well defined radiolucency, shaped like

an inverted pear, between the roots of the upper lateral incisor and canine. Teeth are

vital to pulp testing. 23

However it is believed that cysts in the globulomaxillary region are

odontogenic rather than fissural in origin. In a study of a case series of

globulomaxillary radiolucencies, all the cases could be classified histopathologically

as some other distinct entities like radicular cyst, periapical granuloma, lateral

periodontal cyst, odontogenic keratocyst, central giant granuloma, odontogenic

myxoma.

The cyst is enucleated and submitted for histological examination. The

diagnosis will determine the further management of the patient. 23

ODONTOGENIC CYSTS
All odontogenic cysts arise from odontogenic epithelium but at different

stages of tooth development.

9 PERIAPICAL CYSTS
These inflammatory odontogenic cysts are the most common of all cysts of the

oral region. They are found 3 times more often in the maxilla than in the mandible.

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An apical cyst from an upper canine, premolar or molar and occasionally even a

lateral incisor, may enlarge sufficiently to encroach on the maxillary sinus.

There is a history of caries, infection or trauma to the involved tooth. If

uninfected, they may remain asymptomatic. The associated tooth will be non-vital and

may be discoloured.

When the cyst enlarges into the maxillary sinus, it can reach a considerable

size before causing symptoms. As growth of the cyst continues, the sinus floor

becomes gradually thinned and the cyst bulges into the lumen and eventually contacts

and adheres to the mucoperiosteal lining. The whole sinus cavity can become

occupied by the cyst and occasionally there may be expansion and even erosion of its

walls.

Radiographically, the cyst appear initially as a radiolucency within bone but

when they enlarge into the antrum, they appear as relatively radiopaque. They are

oval or circular in outline with a well defined radiopaque margin indicating a

surrounding lamina of bone. The associated tooth lacks an intact lamina dura at its

apex. Periapical and anterior or oblique occlusal radiographs are useful for

demonstrating the details.

Fig. 7.6 : Radiographic appearance of a periapical cyst

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RESIDUAL CYSTS

They are cysts which remain after the associated tooth is exfoliated or

extracted or a periapical cyst is incompletely removed. They are therefore more

common in older patient and are also more common in the maxilla than the mandible.

TREATMENT

Enucleation of the cyst and root filling or extraction of the involved teeth will

usually produce bone regeneration and healing. Marsupulization of the maxillary

apical cysts is unsatisfactory. Healing is usually uneventful and the antrum reverts to

its size prior to the presence of the cyst.

DENTIGEROUS CYST

It is the next most common odontogenic cyst after the apical cyst. It arises by

the enlargement of the follicular space about the whole or part of the crown of a tooth.

Cystic expansion is rapid and an upper third molar may be displaced up the

posterolateral wall and an upper canine up the facial wall of the maxillary sinus to its

roof. The tooth may also be displaced medially. However, it is usually the facial or

posterolateral wall of the sinus, which is eroded. Often the cyst is extensive at

diagnosis.The lesions are often asymptomatic and a well defined unilocular

radiolucency associated with the crown of an unerupted tooth is noticed incidentally

on a radiograph. An aggressive cyst may produce bony expansion sufficient to cause

facial asymmetry, extreme tooth displacement, root resorption and pain.

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Fig. 7.7: A series of images showing displacement of the left maxillary

sinus floor as a result of developing dentigerous cyst associated with
the maxillary left third molar. The corticated periphery is well seen
in the panoramic, occlusal and Water’s images

TREATMENT

It is usually by enucleation, although marsupulization may be performed if the

tooth is to be retained in the hope of eruption.

ODONTOGENIC KERATOCYST

There are no pathognomic clinical features but bony expansion is common.

The diagnosis is histological. Recognition of this type of cyst is important because of

its high recurrence rate. It has many features in common with the ameloblastoma.

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Radiographically this cyst has a thin sclerotic border produced by reactive

bone formation. It may be smooth or scalloped, unilocular or multilocular. It

sometimes causes root resorption of nearby teeth.

TREATMENT

Is usually by marsupulization or enucleation. Years of postoperative review

are necessary because of the high recurrence rate.

CALCIFYING EPITHELIAL ODONTOGENIC CYST

Radiographically they usually appear as a well defined radiolucency

containing variable amounts of calcification. They may grow very large and involve

the maxillary sinus but do not recur after complete excision.23

RADIOLOGY :

A cyst of dental origin which closely resemble the antrum with an area of

radiolucency confined by a thin white cortical layer of bone. When the cyst is in

proximity with the antrum, it is often difficult to differentiate it radiographically.

There are certain points of value in attempting to differentiate the normal

antrum from a cyst:

a. The cortex of a cyst is usually sharper and more clearly etched than the cortex

of the antrum

b. The cyst wall tends to be smoother and evenly curved, while the antral margin

tends to be undulating not part of one curve but of several or many curves.

c. The cortical wall of the cyst tends to be slightly wider than the antral wall.

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d. The antral wall has very small interruptions in its continuity. These are not

true interruptions but result from the superimposition of small marrow spaces

over the antral cortex. They do not appear in the cyst wall.

e. Normal antrum shows the shadow of the grooves which transmit the branches

of the middle and posterior branches of the superior maxillary artery. It is not

seen in a cyst.

f. Partial loculation of the normal antrum is common. This type of appearance is

highly suggestive of a cyst; controversely, a cyst may simulate a partial

loculation of the air sinus. The presence of a root or a tooth in the site may be

of assistance in diagnosing a cyst.

These cysts that originate outside the maxillary sinus encroach on the space of

the sinuses by displacing the sinus borders. The cyst cortex and the sinus wall may be

indistinguishable from one another and thus as the cyst enlarges the sinus decrease in

size. The result is a radiopaque line between the cyst and the air space of the sinus;

dividing the contents of the cyst from the internal aspect of the sinus. Therefore the

cyst may be said to invaginate rather than involve the air sinus. 7

I II III

Fig. 7.8: A: The odontogenic cyst starts near the sinus (I). As it enlarges, the cyst
encroaches on the border of the maxillary sinus (II) and displaces the sinus
border as it continues to enlarge (III)

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Fig. 7.8: B: The odontogenic cyst, as it continues to enlarge, may

encroach on almost all the space of the sinus, leaving a small saddle-like
arc space over the cyst (arrow)

Periphery and shape: It has a curved or oval shape defined by a corticated

border.

Internal structure: It is homogeneous and radiopaque relative to the sinus cavity. The

degree of radiopacity may appear to be that of bone resulting from the extreme

contrast to the radiolucent air within the sinus.

Effects on surrounding structure: The cyst may displace the floor of the maxillary

antrum. Sometimes it enlarges to the point that it has encroached on almost the entire

sinus and the residual sinus space may appear as a thin saddle over the cyst.

Differential diagnosis

Retention pseudocyst: Can have the same shape but does not have a cortex at

the periphery. However, if the odontogenic cyst becomes infected, the cortex

may be lost. In most cases, careful scrutiny will reveal some remaining cyst

cortex. Also, the relationship to neighbouring teeth may help to make a

decision.

Antral loculation: it is more radiolucent than a cyst.3

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III. TUMOURS

Tumours of the maxillary sinus are divided into

a. Benign tumours

b. Malignant tumours

A. BENIGN TUMOURS

Benign tumours in the sinus may arise from the lining as polyps and

papillomas, from the bone as osteomas or from the maxillary teeth as odontogenic

tumours.

These lesions are notable for the lack of symptoms which they cause while

contained within the sinus. They are often incidental finding on radiographs taken for

the diagnosis of sinusitis or dental disease. Some benign polyps or papillomas extend

through the ostium into the nose causing obstruction there. Other lesions may come to

light only after they have grown to such a size as to obliterate the sinus completely

and expand beyond its confines.

ANTRAL PAPILLOMA

It is a rare neoplasm of respiratory epithelium. It may cause unilateral nasal

obstruction, nasal discharge and pain. The patient may complain of recurrent sinusitis

for years. It occurs predominantly in men.

Radiographic features may not be specific and the diagnosis can be made only

by histopathological examination. It appears as a homogeneous radiopaque mass of

soft tissue density. Pressure erosion may cause bone destruction. 3

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OSTEOMA

It is the most common of the mesenchymal neoplasms in the paranasal

sinuses. However, osteoma involving the maxillary sinus is rare and most commonly

involves the frontal and ethmoidal sinuses. They are almost twice as common in

males as females and are most common in 2-4 decades of life. Most of them are

usually asymptomatic and slow growing and are usually detected as an incidental

finding in an examination made for another purpose When symptoms do occur, they

are the result of obstruction of the sinus ostium or infundibulum or as a result of

erosion or deformity, orbital involvement or intracranial extension. Those growing in

the maxillary sinus may extend into the nose and cause nasal obstruction or swelling

on the side of the nose. They may expand the sinus and produce swelling of the cheek

or hard palate. In some cases, external fistula have occurred.

The osteoma are lobulated or rounded and has a sharply defined margin and

are extremely radiopaque.

Differential diagnosis includes antrolith, mycolith, teeth, odontomas or

odontogenic neoplasms although these are all usually not as homogeneous in

appearance as the osteoma. 3

The treatment includes surgical removal using the Caldwell–Luc approach.

OSSIFYING FIBROMA

This condition can occur in the maxilla and encroach on the sinus. It is a form

of fibroosseous lesion which tends to be well demarcated from surrounding normal

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bone and it has a variable tendency for growth. Some cases are aggressive while

others reach a steady state and become densely calcified. 23

ANTROLITH

Most antroliths result from the complete or partial or encrustation of a foreign

body in the maxillary sinus with calcareous material. The foreign body may be of

endogenous or exogenous origin and it forms the central nucleus upon which mineral

salts especially calcium phosphate, calcium carbonate and magnesium are deposited

to form a rough blackish grey surface. If the nidus is endogenous it may be a blood

clot, inspissated pus or mucus, bone fragment or root. Exogenous foreign bodies like

paper or snuff may be the cause.

The smaller antroliths are asymptomatic. If they continue to grow, the patient

may experience an associated sinusitis, blood stained nasal discharge, nasal

obstruction or facial pain.

Radiographically they appear as well defined radiopacities having a smooth or

irregular shape.

Fig. 7.9: Radiographic appearance of an antrolith

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They should be differentiated from rhinoliths and maxillary retention cysts. A

key feature is intrinsic location within one of the sinus cavities, which differentiates it

from the rhinoliths or odontomes. It will be considerably more radiopaque than a

comparable sized soft tissue mass, such as a cyst, as it is composed of calcium

phosphate and calcium carbonate salts.

Symptomatic antroliths are surgically removed by Caldwell-Luc approach. 3, 38

OTHER BENIGN TUMOURS: Ameloblastoma, Haemangioma, fibromyxoma,

lymphangioma, neurofibroma and salivary gland tumours derived from minor salivary

glands on palate.

B. MALIGNANT TUMOURS

Carcinoma of any paranasal sinus is rare and accounts for about 0.2-0.8% of

all malignancies, with 80% of lesions arising in the maxillary sinus. Of the malignant

neoplasm arising from the maxillary sinus, 80% are squamous cell carcinomas.

Adenocarcinomas and undifferentiated carcinomas are much less common.

Melanoma, neuroblastoma, sarcoma and lymphoma also rarely occur. 23

ETIOLOGY

Respiratory epithelium is known to undergo squamous metaplasia in the

presence of infection and chronic sinusitis may therefore be a predisposing factor for

antral carcinoma.

Adenocarcinoma of the nasal passages are an occupational hazard for furniture

makers and footwear industry workers. This is assumed to be due to inhaled

carcinogens in the dust produced during the manufacturing processes. The use of

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indigenous snuff and the smoky atmosphere may be causative factors for carcinoma

of the paranasal sinuses.

SIGNS AND SYMPTOMS

As the maxillary sinus is a closed and concealed site, neoplasms within it can

reach a considerable size before signs or symptoms develop.

It can produce paraesthesia of the cheek, when it involves the infraorbital

nerve. Epistaxis may also be present due to erosion of blood vessels by the tumour.

Once the sinus walls are expanded or destroyed symptoms arise from the involvement

of neighbouring structures. The primary site and direction of spread govern the

pattern of symptoms. 23

Key symptoms related to direction of tumour spread

Oral Swelling, ulceration, mobility of teeth

Nasal Obstruction, bloody discharge, epiphora

Orbital Proptosis, diplopia

Infratemporal Trismus, pain

Facial Swelling, pain, infraorbital paraesthesia

Unlike oral malignancies, dull pain seems to be a frequent symptom. This may

be accounted for by the late presentation, the obstructive consequences of tissue bulk

in the sinus cavity and its almost inevitable infection.

Spread to the regional lymph nodes is uncommon if the tumour is confined to

the sinus. Metastasis occurs relatively late, the upper jugular lymph nodes being the

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first to be affected. Palpable lower deep cervical lymph nodes indicate advanced

spread.

Any symptoms in the region of the maxillary sinus for which an obvious cause

cannot be found should be regarded with suspicion.23

TNM classification for squamous cell carcinoma of the maxillary sinus: 20

Tumour (T)

T1 Tumour limited to maxillary sinus mucosa with no erosion or destruction

of bone

T2 Tumour causing bone erosion or destruction including extension into the

hard palate and/or middle nasal meatus except extension to posterior wall of maxillary

sinus and pterygoid plates

T3 Tumour invades any of the following: bone of the posterior wall of

maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa

and ethmoid sinuses

T4a Tumour invades anterior orbital contents, skin of cheek, pterygoid plates,

infratemporal fossa, cribriform plate, sphenoid or frontal sinuses

T4b Tumour invades any of the following: orbital apex, dura, brain, middle

cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2),

nasopharynx or clivus

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Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in a single ipsilateral lymph node 3cm or less in greatest dimension

N2 Metastasis in a single ipsilateral lymph node more than 3cm but not more than

6cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than

6cm ingreatest dimension; or in bilateral or contralateral lymph nodes, none more

than 6cm ingreatest dimension

N2a Metastasis in a single ipsilateral lymph node more than 3cm but not more than

6cm in greatest dimension

N2b Metastasis in multiple ipsilateral lymph nodes none more than 6cm in greatest

dimension

N2c Metastasis in bilateral or contralateral lymph nodes none more than 6cm in

greatest dimension

N3 Metastasis in a lymph node more than 6cm in greatest dimension

Distant metastasis (M)

MX Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

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Stage grouping of cancer of maxillary sinus

Stage I T1 N0 M0

Stage II T2 N0M0

Stage III T3N0M0

T1 or T2 or T3 with N1 M0

Stage IV A T4N0M0

T4N1M0

Stage IV B Any T N2 M0

Any T N3 M0

Stage IV C Any T Any N M1

RADIOLOGY

An antral carcinoma may appear radiographically as a “cloudy” antrum, a

diffuse opacity or an irregular soft tissue outline. In advanced disease, bony erosion

and destruction of the sinus wall may be evident.

The panoramic view of the jaws defines the alveolar-sinus interface better than

a Water’s view. However, most of the facial and posterolateral walls of the sinus are

superimposed on the medial wall.

The occipitomental (Water’s) view is most commonly used initially to search

for evidence of malignant disease in the antrum. Loss of fine linear outline of the

lateral wall is a particularly sensitive sign of bone destruction.

Computed tomography (CT) has been very useful. Axial and coronal scans

permit precise anatomical localization of tumour. Contrast enhancement may be

useful in assessing soft tissue involvement. Erosion of bone, involvement of soft

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tissues and posterosuperior extension into the orbit, pterygopalatine fossa and cranial

cavity can be defined.

MRI permits scanning in three planes and has the potential for accurate

differentiation of invading tumour from a mucocele.

The radiographic appearance are similar to those of a soft tissue mass within

the antrum. If the antral cavity is filled, there is nothing to distinguish the appearance

from any other soft tissue mass. With bone involvement, it may be possible to identify

the nature of the lesion. The earliest radiographic intimation of malignancy is bone

destruction, loss of some portion of the floor, or one of the walls of the sinus. The

cortical layer of bone is lost. If there is evidence of irregular destruction of bone,

suspicion of malignancy is increased, particularly if bony infiltration is seen. The

lateral, medial and posterior walls of the antrum have thin bones, thus the infiltration

is difficult to recognize.

The internal aspect has a soft tissue radiopaque appearance.

Effects on surrounding structures: As the lesion enlarges, it may destroy sinus

walls and in general cause irregular radiolucent areas in the surrounding bone.

Adjacent alveolar process may reveal bone destruction around the teeth or irregular

widening of the periodontal membrane space. Frequently the medial wall of the sinus

is thinned or destroyed. In addition to loss of the medial wall, it may extend into the

nasal cavity.3, 7

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Fig. 7.10: Orthopantomograph showing loss of definition of the cortex

of the left maxillary sinus, nasal floor and alveolar crest in case of
malignancy involving the maxillary sinus

Fig. 7.11: Water’s view showing loss of integrity of the cortex of the
lateral wall of the left maxilla and radiopacification of the left
maxillary sinus in case of malignancy

BIOPSY

Definitive diagnosis of malignancy depends on histopathology. Access to the

antrum is obtained via a Caldwell-Luc approach or via an intranasal antrostomy and

using endoscopic instrumentation. Tumours extending into the mouth can easily be

biopsied. When an ulcerated mass is present, it is important to do biopsy from

adjacent non-ulcerated area.

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PROGNOSIS

Direction and extent of spread are probably the most important factor in

prognosis and these in turn are related to tumour site and size at diagnosis. Factors

that contribute to a poor prognosis include the advanced stage of the disease when it is

finally diagnosed and lies close in proximity of vital anatomic structures. Melanotic

melanoma is particularly likely to be rapidly fatal.

Tumour invasion of the orbital contents (T4) carries a poorer prognosis than

tumours with limited invasion of the orbital walls (T3). Posterior extension carries the

worst prognosis because the tumour reaches the base of the skull relatively quickly

and clinical signs are absent until it is well advanced.

TREATMENT

Treatment whether curative or palliative is required as there is disfiguration

followed by a slow, painful death.

Radiotherapy is the main mode of treatment. If this cannot control the disease

upto the expectation, excision of the maxilla should be performed. If cercvical lymph

nodes are involved block dissection of the neck should be done.39 Melanomas require

radical surgery and radiotherapy is indicated only if the excision is incomplete or the

tumour is inoperable or for recurrence. 23, 3

IV. MISCELLANEOUS DISEASES 23, 40, 41, 42

Certain rare diseases can affect the maxillary sinus. These include:

1. Crouzon syndrome

2. Treacher Collin syndrome

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3. Binder syndrome

4. Haemangioma

5. Fibrous dysplasia

6. Paget’s disease

7. Cherubism

8. Tropical diseases

9. Granulomatoses

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Bibliography

1. Chaurasia BD. The Nose and Paranasal Sinuses. Human Anatomy. 4th ED.

Ch.15, 233-235

2. Drake R, Vogl W, Mitchell A. Nose, Nasal Cavity and Paranasal Sinuses.

Gray’s Anatomy. 1st ED. Ch, 970-972

3. White S, Pharoah M. Paranasal Sinuses. Oral Radiology: Principles and

Interpretation. 6th ED. Ch. 27, 506-525

4. Bhaskar S. Maxillary Sinus. Orban’s Oral Histology and Embryology. 11th

ED. Ch.14, 418-434

134
 Bibliography

5. Dayal P, Kubavat H, Singh N. Odontogenic Maxillary Sinusitis. A Diagnostic

Study by Applying Intraoral Periapical Radiography. JIAOMR 2001; 12(1):

5-9

6. Malik N. Maxillary Sinus and its Implications. Textbook of Oral and

Maxillofacial Surgery. 2nd ED. Ch. 39, 563-584

7. Worth H. The Abnormal Maxillary Antrum. Principles and Practice of Oral

Radiologic Interpretation. 1st ED. Ch.19, 697-715

8. Becker S, Duncavage J. Surgical Anatomy and Embryology of the Maxillary

Sinus and Surrounding Structures. The Maxillary Sinus: Medical and Surgical

Management. 1st ED. Ch.1, 1-7

9. Bell G, Joshi B, Macleod R. Maxillary Sinus Disease: Diagnosis and

Treatment. Br Dent J 2011; 210(3):113-118

10. Avery J. Histology of the Nasal Mucosa and Paranasal Sinuses.Oral

Development and Histology. 3rd ED. Ch. 19, 344-347

11. Erdem T, Aktas D, Erdem G, Miman M, Ozturan O. Maxillary Sinus

Hypoplasia. Rhinology 2002; 40:150-153

12. Tasar M, Cankal F, Bozlar U, Hidir Y, Salgam M and Ors F. Bilateral

Maxillary Sinus Hypoplasia and Aplasia: Radiological and Clinical Findings:

Case Report. Dentomaxillofacial Radiology 2007; 36:412-415

135
 Bibliography

13. Karjodkar F. Disorders of the Maxillary Sinus. Textbook of Dental and

Maxillofacial Radiology. 2nd ED. Ch.3, 751-773

14. Grovers J, Gray R. Anatomy of the Nose and Paranasal Sinuses. A Synopsis of

Otolaryngology. 4th ED. Ch. 30, 153

15. Watkinson J, Gaze M, Wilson J. Tumours of the Nose and Sinuses. Stell and

Maran’s Head and Neck Surgery. 4th ED. Ch. 19, 378

16. Woo I, Le B. Maxillary Sinus Floor Elevation: Review of Anatomy and Two

Techniques. Implant Dentistry 2004; 13(1): 28-32

17. Hauman C, Chandler N, Tong D. Endodontic Implications of the Maxillary

Sinus: A Review. International Endodontic Journal 2002, 35:127-141.

18. Stubinger S, Leiggener C, Sader R, Kunz C. Infraorbital Abscess: A Rare

Complication after Maxillary Molar Extraction. JADA, 2005; 136:921-925

19. Bhargava. Sinusitis. A Short Book of ENT Diseases. Ch. 31,

195-196

20. Dhingra P, Dhingra S. Chronic Sinusitis. Diseases of E, N and T. 5th ED.

Ch.37, 208-210

21. Lipworth B, White P. Allergic inflammation in the unified airway: start with

the nose. Thorax 2000; 55:878–881

22. Whaites E. The Maxillary Antra. Dental Radiography and Radiology. 4th ED.

Ch. 29, 373-386

136
 Bibliography

23. McGowan D, Baxter P, James J. The Maxillary Sinus and its Dental

Implications. Wright Publications, 1993

24. Farman A, Nortje C. Pathologic Conditions of the Maxillary Sinus. Panoramic

Imaging News. 2 (3)

25. Haring J, Howerton L. Normal Anatomy and Film Mounting Basics. Dental

Radiography: Principles and Techniques. 3rd ED. Ch. 28, 411

26. Ohba T, Katayama H. Panoramic Roentgen Anatomy of the Maxillary Sinus.

OOO 1975; 39(4):658-664

27. Katayama H, Ohba T, Ogawa Y. Panoramic Innominate Line and Related

Roentgen Anatomy of the Facial Bones. OOO 1974;37(1):131- 137

28. Perez C, Farman A. Diagnostic Radiology of Maxillary Sinus Defects. OOO

1988;66(4):507-512

29. Engstrom H, Chamberlain D, Kiger R, Egelberg J. Radiographic Evaluation of

the Effect of Initial Periodontal Therapy on Thickness of the Maxillary Sinus

Mucosa. J of Periodon 1988;59:604-608

30. Ehrl P. Oroantral Communication. Int J Oral Surg 1980;9:351-358

31. Rahman A. Foreign Bodies in the Maxillary Antrum. Br Dent J 1982;153:308

32. Gardner D. Pseudocysts and Retention Cysts of the Maxillary Sinus. OOO

1984;58(5):561-567

137
 Bibliography

33. Gothberg K, Little J, King D, Bean L. A Clinical Study of Cysts Arising from

Mucosa of the Maxillary Sinus. OOO 1976;41(1):

52-58

34. Barsley R, Thunthy K, Weir J. Maxillary Sinus Mucocele. OOO

1984;58(4):499-505

35. Gardner D, Gullane P. Mucoceles of the Maxillary Sinus. OOO

1986;62(5):538-543

36. Wysocki G. The Differential Diagnosis of Globulomaxillary Radiolucencies.

OOO 1981;51(3):281-286

37. Allard R, Kwast A, Waal V. Mucosal Antral Cysts. 1981;51(1):2-9

38. Blaschke D, Brady F. The Maxillary Antrolith. OOO 1979;48:

187-189

39. Das S. Swellings of the Jaw. A Coincise Textbook of Surgery. 5th ED. Ch.32,

573-574

40. Afshin H, Sharmin R. Haemangioma Involving the Maxillary Sinus. OOO

1974;38(2):204-208

41. Darlow L, Berrios R, Feldman R. Arteriovenous Malformation of the

Maxillary Sinus: An Unusual Clinical Presentation. OOO 1988;66(1):21-23

42. Osborne T, Levy B, Baltimore. Odontoma Containing Ghost Cells in the

Maxillary Sinus. OOO 1974;38(5):819-823

138