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Surgical anatomy of maxillary
     sinus – note on OAF




                  - Dr. Dona Bhattacharya
Contents
1.    Introduction
2.    Embryology of maxillary sinus
3.    Anatomy of maxillary sinus
4.    Vascularization & innervation
5.    Microscopic anatomy
6.    Physiologic nature of mucus layer
7.    Drainage of sinus
8.    Functions of sinus
9.    Maxillary sinusitis
10.   Oroantral fistula
11.   Conclusion
12.   References
Introduction
 Paranasal sinuses
   Air containing bony spaces present
     around the nasal cavity

   Usually lined by respiratory
     mucus membrane

   Four paired
Maxillary sinus
 Pneumatic space lodged in the
 body of maxilla that
 communicates with the external
 environment by way of middle
 meatus and nasal vestibule - by
 Orban’s

 Also known as antrum of
 Highmore (1651)
Embryology
 First sinus to develop


 Initial development of sinus follows number of morphogenic
  events in differentiation of nasal cavity
Embryology
  Horizontal shift of palatal shelves and
        fusion with one another



   Nasal septum separates 20 Oral cavity
           from nasal chambers



  Influence expansion of lateral nasal wall
          and 3 walls begin to fold
                                                 Superior & inferior
                                              - Shallow depression for
                                                   half of IU Life
            3 conchae & meatus
                                                       Middle
                                              - Expansion in lateral wall
                                               and in inferior direction
Embryology
 Development of sinus begins as
  evagination of mucus
  membrane in lateral wall of
  middle meatus when nasal
  epithelium invades maxillary
  mesenchyme ( Kitamura, 1989)

 Growth of sinus takes place by
  pneumatization
    Primary (10th weeks)
    Secondary (5th month)
Embryology
 Maxillary sinus has biphasic growth 0-3 years and 7-12
  years
 Post natally grows @ 2 mm vertically and 3 mm AP
 Radiographically; triangular area medial to IOF (5th
  month)
 3 growth spurts
   a) 0-2.5 years
   b) 7.5-10 years
   c) 12-14 years
Embryology
Embryology
Embryology
Embryology
 Developmental anomalies
  1. Agenesis
  2. Aplasia
  3. Hypoplasia
  4. Supernumary maxillary sinus
Anatomy
 Largest of PNS,communicate
  with other sinuses through
  lateral nasal wall.
 Horizontal Pyramidal shaped
         Base

         Apex

         4 walls
                        superior
                        inferior
                        lateral
                     anterior
    Wall thickness varies with
     individual
Anatomy
 Various shapes
            Hyperbolic-47%
            Paraboloid-30%
            Semi-ellipsoid-15%
            Cone shaped-8%

    Dimensions (Therner, 1902)
        H: 3.5cm
        W: 2.5cm
        L: 3.25cm


        Vol:15-30 ml
Anatomy
   Receses-
          Alveolar
          Zygomatic
          Palatal
          Frontal


   Teeth in proximity
  2nd, 1st , molar>3rd molar>2nd pm>1st pm>canine
Medial wall
 Formed by lat nasal wall
   Below-inf nasal conchae
   Behind-palatine bone
   Above-uncinate process
    of ethmoid,lacrimal bone

 Contains double layer of
  mucous membrane(pars
  membranacea)
Medial wall
 Imp structures
       Sinus ostium
       Hiatus semilunaris
       Ethmoidal bulla
       Uncinate process
       Infundibulum


 Applied aspect
Natural ostium
 Located in posterior ½ of
    infundibulum or behind
    lower1/3 of uncinate process.
   Tunnel shaped, length: 1-
    22mm;3-6mm diameter
   Not detected endoscopically
   Unfavorable position for
    gravity dependent drainage
   Post edge-continuous with
    lamina papyracea(imp for
    surgical dissection)
Accessory ostium
 2-3 in no.(30-40%)
 Bony dehiscences covered by mucosa(ant/post
 frontanelles)
Superior wall
 Forms roof of sinus and floor of orbit
 Imp structures
       Infraorbital canal
       Infraorbital foramen
       ASA nerve


 Applied aspect
       Vulnerable to trauma
       Erosion of this wall by tumor
Posterolateral wall
 Made of zygomatic and greater wing of sphenoid
  bone(maxillary tuberosity)
 Thick laterally,thin medially
 Imp structures
        PSA nerve
        Maxillary artery
        Maxillary nerve
        Pterygopalatine ganglion
        Nerve of pterygoid canal

 Applied aspect
        Involvement of PSA-pain in post teeth
        Surgical access by careful removal of segment of wall
Anterior wall
 Extends from pyriform aperture anteriorly to ZM suture
    & IO rim superiorly to alveolar process inferiorly.
   Convexity towards sinus
   Thinnest in canine fossa
   Imp structures
          Infraorbital foramen

          ASA, MSA nerves

          Levator labii, obicularis oculi muscles

   Applied aspect
Floor of sinus
 Formed by junction of anterior
  sinus wall and lateral nasal wall
 1-1.2 cm below nasal floor
 Close relationship between sinus
  and teeth facilitate spread of
  pathology
 Inner surface is rough by bony
  septa
    Retrieval of root fragment
    Interferes with sinus drainage
Vascularization & innervation
                          a) Nasal Mucosal Vasculature

                          SP, Ethmoid
      Arterial Supply
                          b) Osseous Vasculature

                          IO, PSA, ASA, GP, Facial
                          a) Medial wall - SP
     Venous Drainage
                          b) Other walls – Pterygomaxillary Plexus
    Lymphatic Drainage    Collecting vessels in middle meatus
     Nerve Innervation    ION, GP, PSA, MSA, ASA

 Clinical significance
 PO2 of sinus = 116 mm Hg
Vascularization & innervation
Microscopic anatomy
 3 layers
    Epithelium
    Basal lamina
    Sub epithelium
Epithelium
 Pseudostratified columnar ciliated epithelium
 Cells
    Columnar ciliated
    Goblet
    Basal
    Non – ciliated
Ciliated epithelium
 100 motile and no. of immotile microvilli present
    along apical surface
   Function: mucus clearance along with entrapped
    debris from nose and PNS
   Ciliary motility dependent on ATP driven molecular
    motors cause outer doublets of axoneme to slide over
    each other
   All cilia beat together to form metachronous wave
   Each cilia has power stroke followed by recovery stroke
Ciliated epithelium
Microvilli
 Hair like projection of actin filament
 Length 1-2 mm
 Function:
    Increase surface area of cell
    Prevent drying of surface
Physiologic nature of mucus layer
 Sino nasal epithelium covered by mucus blanket
 Traps particles>0.5-1 um
 Composition
    Water (95%)
    Others (5 %)
       Peptides
       Salts
       Debris
 Ph = 5.5-6.5
Physiologic nature of mucus layer

                           2 layers


       Inner sol                        Outer gel
       - Continuous                    -Discontinuous
        - Low viscosity                - High viscosity
 - Surrounds shafts of cilia          -Along ciliary tips
Drainage of sinus
 Mucus transported from nose and PNS to
  nasopharynx, ingested and presented to GIT
  (Messerklinger)
 Forms basis of fess
Drainage of sinus
                Flow of mucus superiorly against gravity


  Upward course along walls of entire cavity and then towards natural
                    ostium in superomedial wall


                Drainage into ethmoidal infumdibulum


 Mucus coursing along lateral wall, carried medially along roof to reach
                               ostrium


  Mucociliary flow from anterior sinuses converge at OMC, carried to
    posterior nasopharynx & inferiorly to eustachian tube orifice

                                              By Donald et al & Antunes et al
Drainage of sinus
Drainage of sinus
 Mucociliary flow         Smooth:0.85 cm/minute


                        Jerky: 0.3 cm/minute


                     Mucostasis: <0.3 cm/minute
Basal lamina & subepithelium
 Contains serous glands and blood vessels
 Subepithelium – 10 serous
 Mucosa removal – 73% decrease in serous glands and
 30% in goblet cells
Functions of sinus
1.    Decrease skull weight
2.    Impart resonance to voice
3.    Mucus production and storage
4.    Humidify and warm inhaled air
5.    Define facial contour
6.    Immunodefensive action
7.    Conserve heat from nasal fossae
8.    Moisturize air
9.    Filters debris
10.   Dampen pressure differential during inspiration
11.   Limit extent of facial injury from trauma
12.   Serves as accessory olfactory organ
Maxillary sinusitis

 Group of diseases
  mainly inflammation &
  infection which affect
  the nasal mucosa and
  PNS
Maxillary sinusitis
Maxillary sinusitis
 Anatomical variations influencing
  the development of sinusitis
    a) Variations of uncinate process
    b) Variations in bulla ethmoidalis
    c) Variations of middle turbinate
    d) Accessory ostium
    e) Deviated nasal septum
    f) Nasal masses
    g) Haller cell
Maxillary sinusitis
 Extrinsic                          Intrinsic
  causes     1. Infectious causes    causes     1. Genetic
             a) Bacterial                       a) Structural
             b) Viral                           b) Immunodeficiency
             c) Fungal                          c) Mucociliary
             d) Parasitic                       abnormality
             2. Non infectious                  (cystic
             causes                             fibrosis, dismotility)
             a) Allergic                        2. Acquired
             b) Non allergic                    a) Aspirin
                                                hypersensitivity
             c) Pharmocologic
                                                b) Autonomic
             d) Irritants                       dysregulation
                                                c) Hormonal
             3. Disruption of
             mucociliary drainage               d) Structural
                                                (Tumors, cysts)
             a) Surgery
                                                e)Idiopathic/
             b) Infection                       autoimmune
             c) Trauma                          f) Immunodeficiency
Maxillary sinusitis
 Diagnosis
  1.   History
  2.   Physical examination
             Inspection
             Palpation
             Percussion
             Diagnostic techniques
             a.  Rhinoscopy
             b.  Endoscopy
             c.  Nasal valve examination
             d.  Culture and sensitivity
Maxillary sinusitis
    Major & Minor Factor Associated with the Diagnosis of
                  Chronic Rhinosinusitis
    Major Factors                  Minor Factors
    Facial pain/pressure           Headache
    Facial congestion/fullness     Fever (non-acute cases)
    Nasal obstruction/blockage     Halitosis
    Nasal                          Fatigue
    discharge/purgulence/discol
    ored postnasal discharge
    Hyposmia/anosmia               Dental pain
    Purulence in nasal cavity on   Cough
    examination
    Fever (in acute rhinosinusitis Ear pain/pressure/fullness
    only)
Maxillary sinusitis
3.  Radiological examination
   a) OM view
   b) Caldwell view
   c) Lateral view
   d) CT scan
   e) MRI
4. Tests for mucociliary functions
   a) Nasomucociliary clearance
   b) Ciliary beat frequency
   c) NO measurement
   d) Rhinomanometry
5. Test for olfaction
Maxillary sinusitis
                                     Management




                    Medical                                     Surgical


1. Antibiotics                              1. sinus aspiration and lavage
2. Steroids                                 2. Maxillary needle sinusotomy
3. Decongestants                            3. Caldwell luc
4. Analgesics                               4. FESS
5. Antihistamines
6. Nasal spray & saline irrigation
7. Hydration
8. Mucolytics(guaifenesin,KI)
Antibiotics
           Antibiotic                    Micro factors                         Pediatric dosage
First line therapy
Amoxicillin                  45 mg/kg/day or 90 mg/kg/day divided       500 g BID
Second line therapy
Amoxicillin/potassium        22.5-45 mg/kg/day divided (dose based on
                                                                        500-875 mg BID
calvulanate                  amoxicillin component)
                             10 mg/kg/day on day 1, then 5 mg/kg/day    500 mg QID on day 1, then 250 mg
Azithromycin
                             on days 2-5                                QID on days 2-5
Cefdinir                     14 mg/kg/day                               300 mg BID
Cefpodoxime                  10 mg/kg/QID                               200 mg BID
Cefprozil                    15 mg/kg/QID                               250-500 mg BID
Cefuroxime                   15 mg/kg/QID                               250 mg BID
Ciprofloxacin                                                           500 mg BID
Clarithromycin               7.5 mg/kg/day                              500 mg BID
Cindamycin                   8-20 mg/kg/day divided QID                 150-450 mg BID
Doxycycline                                                             100-200 mg QID

Garifloxacin                                                            400 mg QID

Levofloxacin                                                            500 mg QID
Sulfamethoxazole/trimethop   6-12 mg/kg/day divided (based on
                                                                        800-160 mg BID
rim                          trimethoprim)
Steroids
 1st line of therapy: topical intranasal
  (betamethasone, dexamethasone, triamcinolone)

 Systemic steroids:
        Prednisolone:0.5-1mg/kg x3-4 days
Decongestants
 Systemic (phenylpropanolamine, pseudoephidrine):
       Contraindications: hypertension, hyperthyroidism, asthma


 Topical: phenylepinephrine HCl, oxymetazoline HCl
       Adv. Effects- rhinitis medicamentosa
Analgesics & antihistamines
 Analgesics:
        Opoid: acetaminophen, codeine
        NSAIDS:


 Antihistamines:
        Mequitazine, terfenad
        Contraindicated in bacterial sinusitis
        Adv effect: sedation
Nasal lavage & sprays
 m/a:
        Removes debris & dead tissue
        Washes inflammatory secretions
        Eliminates nutrient source


 Methods:
        Lavage pot
        Syringe
        Irrigating bulb
Nasal lavage & sprays




 Techniques of nasal sprays
       1. Moffet position
       2. Mygind technique
Surgical management
        Indications           Contraindications

   • Bilateral chronic       • Presence of
     sinusitis with polyps     extensive polyps
   • Fungal sinusitis        • Pt withc/c of
   • Presence of               headache and
     complications             midfacial pain
   • Tumor of PNS            • Medically
   • Csf rhinorrhea            compromised
                             • Hypoplastic sinuses
Sinus aspiration & lavage
 Direct removal of bacteria laden secretions
 Indication: no response to medical therapy
 D/A
Maxillary needle sinusotomy
                           d/a
                                     Requires force to enter anterior wall
  Preparation of site

                              Alternatives:
                                         Mallet
   Infiltration of LA
                                         Steinmann pin

                           Complications:
   Transcutaneous
                                     Bleeding
 puncture ant & post to
   canine eminence                   Infection
                                     Dental injury
                                     Sensory nerve disturbance
                                     Instrument breakage
Caldwell luc sinusotomy
 By George Caldwell (1893) & Henry Luc (1897)
 Indications
       Fungal sinusitis
       Multiple antral lesions
       Antrochoanal polyp
       Excision of tumor
       Closure of OAF
       Removal of antral foreign body
       Antral revision procedures
       surgical approach for transantral sphenoethmoidectomy, orbital
        decompression
Caldwell luc sinusotomy
Caldwell luc sinusotomy

 Modifications
 Complications
       Bleeding
       Dental sensitivity
       Infraorbital neuralgia
       Osseous defect in anterolateral wall
       Entrapment of inferior rectus muscle
FESS
 Coined by Kennedy


 Intranasal endoscopic
  technique that allows
  establishment of adequate
  sinus drainage without
  negative impact on sinus
  mucosa physiology and
  function.

 Principle: stop the cycle that
  begins with ostium blockage
  that leads to chronic sinusitis
  via stagnated
  secretions, tissue
  inflammation and bacterial
FESS
 Armamentarium
FESS
FESS
                        Complications




 Intracranial hemorrhage
 Brain injury
 CSF leak                        Minor hemorrhage
 Diplopia                        Hyposmia
 Blindness                       Adhesions
 Anosmia                         Periorbital emphysema
 Epistaxis
 NL duct injury
 Meningitis
Sinusitis
 Complications:
         Facial cellulitis
         Orbital extension
         Intracranial
          extension
Oroantral fistula
 Fistular canal between oral cavity and sinal
  mucous membrane covered with epithelium which
  may or may not be filled with granulation tissue or
  polyposis.

 Duration and width of lumen contributes to
  infection of sinus.
 OAC               OAF(incidence: 0.3-3.8 %)
Oroantral fistula
 OAC                       OAF
       Defect > 5mm diameter
       No approximation of gingival tissues
       Post op regime not followed
       Loss of clot or wound dehiscence
       Cyst enucleation
       Smoking, drinking
Oroantral fistula
 Etiology
  • Iatrogenic (50%)
  • Presence of periapical lesions
  • Injudicious use of instruments
  • During attempted extraction
  • Trauma(7.5%)
  • Chronic infections(11%)
  • Malignant diseases(18.5%)
  • Infected maxillary dentures(3.7%)
  • h/o sinus surgery(7.5%)
Oroantral fistula
 Predisposing factors

      •   Proximity of sinus floor / tuberosity
      •   Thickened tooth cement / tooth fused to jaw bone
      •   Infected teeth / long-standing decay
      •   Marked periodontitis / gum disease
      •   Lone-standing
      •   Previous history of OAC’s.
Oroantral fistula
                   Acute                                      Chronic
1. Escape of air and fluids through nose &   1.Pain, tenderness over cheeks
mouth
2. Epistaxis                                 2. Purulent discharge
3. Excruciating pain                         3. Post nasal drip
4. Altered voice                             4. Presence of polyps
5. h/o surgery in vicinity of sinus          5. Generalized constitutional symptoms



                    Common in males,2nd-3rd decade
                    Immediate sign:

                        Displaced root /tooth

                        Tuberosity #
Oroantral fistula
 Diagnosis
         h/o previous extraction
         Valsavin test
         Mouth mirror test
         Cotton wisp test
         Inspection
         Radiological
               IOPA
               OPG
               OM
Oroantral fistula
 Management
  • 3mm-5mm heals spontaneously(HANAZANE)
  • Ideal treatment :immediate surgery followed by Ab
    prophylaxis
  • Acute OAF: closure by simple reduction of buccal and
    palatal socket walls, followed by acrylic splint.
  • Treatment for small opening
Oroantral fistula
1) antibiotics : Pn & derivatives
2) nasal decongestants:
         Ephedrine drops

         Inhalations(steam,benzoin ,menthol)

3) Analgesics:
         Aspirin 500mg

         Paracetamol 500mg

         Ibuprofen 400 mg

4)      Antral lavage
Oroantral fistula
 Antral lavage
Oroantral fistula
 Whitehead’s varnish
Oroantral fistula
• Acrylic plates
Surgical closure




          •Temporalis
            flap
          •Forehead
          flap




  Overview of the treatment modalities of Oro-Antral Communications
 Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J Oral Maxillofac
                                       Surg68:1384-1391, 2010
Surgical closure
 Factors determining flap selection
       Size of communication
       Timeline of diagnosing
       Presence of infection
Buccal flap
•   Advantages
•   Disadvantages
•   Modifications
     • Moczaic
     • Laskin & Robinson
Palatal flap
Palatal pedicle flap
A) Ito & Hara
   modification
B) Island flap
      Gullane & Arene
       modification
Combined flap
Distant flaps




            BUCCAL FAT PAD
Tongue flap




Introduced by lexer,1909
Technique
Advantages
Disadvantages
Grafts
Grafts
                    GRAFTS




AUTOGENOUS        ALLOGENOUS       XENOGRAFTS
Iliac crest       Collagen sheet   Porcine dermis
                  Fibrin glue      Bio guide & Bio oss
Chin              Gold foil
Retromolar area   Tantalum
Zygoma            PMMA
                  Hydroxyapatite
Sandwich Technique
Other techniques
 Third molar transplantation(kitagawa et al)
 Interseptal alveolotomy(hori et al)
 GTR(Waldrop & Semba)
 Prolamine gel(Gotzfried & Kaduk)
 Laser light(Janas)
 Splints for immunocompromised pts(llogan and coates)
Conclusion
 Due to close proximity of maxillary sinus to orbit, alveolar
  ridge, maxillary teeth, diseases involving these structures may produce
  confusing symptoms. Hence a precise information about the surgical
  anatomy is essential to surgeons.



 The oroantral fistula is a problem that requires detailed attention to the
  management of a flap in the mouth. For the sake of obtaining the best
  results and to give the patient the benefit , proper knowledge about the
  different types of modalities and their limitations is necessary.
References
•   ECAB: Clinical update-otorhinolaryngology-Paranasal sinuses and
    rhinosinusitis-V.P Sood

•   OMFSClinics of North America-Diagnosis & treatment of disorders of
    maxillary sinus-Laskin

•   Principles of oral and maxillofacial surgery-Peterson

•   Textbook of oral and maxillofacial surgery-Killey and kay

•   Maxillary sinus and its dental implications:dental practice handbook-Killey
    and Kay

•   Review of oral and maxillofacial surgery-Ghosh
References
•   Open access atlas of otolaryngology, head & neck operative surgery -johan
    fagan

•   Treatment of Oroantral Fistula-Klara Sokler et al, Acta Stomatol Croat, Vol.
    36, br. 1, 2002

•   Oronasal fistula closure by tongue flap-Manimaran K et al, JIADS,Jan-mar 2011

•   A New Surgical Management for Oro-antral Communication,The Resorbable
    Guided Tissue Regeneration Membrane – Bone Substitute Sandwich
    Technique-C Ogunsalu, West Indian Med J 2005; 54 (4): 261
Thank You

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Surgical anatomy of maxillary sinus – note on (2)

  • 1. Surgical anatomy of maxillary sinus – note on OAF - Dr. Dona Bhattacharya
  • 2. Contents 1. Introduction 2. Embryology of maxillary sinus 3. Anatomy of maxillary sinus 4. Vascularization & innervation 5. Microscopic anatomy 6. Physiologic nature of mucus layer 7. Drainage of sinus 8. Functions of sinus 9. Maxillary sinusitis 10. Oroantral fistula 11. Conclusion 12. References
  • 3. Introduction  Paranasal sinuses  Air containing bony spaces present around the nasal cavity  Usually lined by respiratory mucus membrane  Four paired
  • 4. Maxillary sinus  Pneumatic space lodged in the body of maxilla that communicates with the external environment by way of middle meatus and nasal vestibule - by Orban’s  Also known as antrum of Highmore (1651)
  • 5. Embryology  First sinus to develop  Initial development of sinus follows number of morphogenic events in differentiation of nasal cavity
  • 6. Embryology Horizontal shift of palatal shelves and fusion with one another Nasal septum separates 20 Oral cavity from nasal chambers Influence expansion of lateral nasal wall and 3 walls begin to fold Superior & inferior - Shallow depression for half of IU Life 3 conchae & meatus Middle - Expansion in lateral wall and in inferior direction
  • 7. Embryology  Development of sinus begins as evagination of mucus membrane in lateral wall of middle meatus when nasal epithelium invades maxillary mesenchyme ( Kitamura, 1989)  Growth of sinus takes place by pneumatization  Primary (10th weeks)  Secondary (5th month)
  • 8. Embryology  Maxillary sinus has biphasic growth 0-3 years and 7-12 years  Post natally grows @ 2 mm vertically and 3 mm AP  Radiographically; triangular area medial to IOF (5th month)  3 growth spurts a) 0-2.5 years b) 7.5-10 years c) 12-14 years
  • 12. Embryology  Developmental anomalies 1. Agenesis 2. Aplasia 3. Hypoplasia 4. Supernumary maxillary sinus
  • 13. Anatomy  Largest of PNS,communicate with other sinuses through lateral nasal wall.  Horizontal Pyramidal shaped  Base  Apex  4 walls superior inferior lateral anterior  Wall thickness varies with individual
  • 14. Anatomy  Various shapes  Hyperbolic-47%  Paraboloid-30%  Semi-ellipsoid-15%  Cone shaped-8%  Dimensions (Therner, 1902)  H: 3.5cm  W: 2.5cm  L: 3.25cm  Vol:15-30 ml
  • 15. Anatomy  Receses-  Alveolar  Zygomatic  Palatal  Frontal  Teeth in proximity 2nd, 1st , molar>3rd molar>2nd pm>1st pm>canine
  • 16. Medial wall  Formed by lat nasal wall  Below-inf nasal conchae  Behind-palatine bone  Above-uncinate process of ethmoid,lacrimal bone  Contains double layer of mucous membrane(pars membranacea)
  • 17. Medial wall  Imp structures  Sinus ostium  Hiatus semilunaris  Ethmoidal bulla  Uncinate process  Infundibulum  Applied aspect
  • 18. Natural ostium  Located in posterior ½ of infundibulum or behind lower1/3 of uncinate process.  Tunnel shaped, length: 1- 22mm;3-6mm diameter  Not detected endoscopically  Unfavorable position for gravity dependent drainage  Post edge-continuous with lamina papyracea(imp for surgical dissection)
  • 19. Accessory ostium  2-3 in no.(30-40%)  Bony dehiscences covered by mucosa(ant/post frontanelles)
  • 20. Superior wall  Forms roof of sinus and floor of orbit  Imp structures  Infraorbital canal  Infraorbital foramen  ASA nerve  Applied aspect  Vulnerable to trauma  Erosion of this wall by tumor
  • 21. Posterolateral wall  Made of zygomatic and greater wing of sphenoid bone(maxillary tuberosity)  Thick laterally,thin medially  Imp structures  PSA nerve  Maxillary artery  Maxillary nerve  Pterygopalatine ganglion  Nerve of pterygoid canal  Applied aspect  Involvement of PSA-pain in post teeth  Surgical access by careful removal of segment of wall
  • 22. Anterior wall  Extends from pyriform aperture anteriorly to ZM suture & IO rim superiorly to alveolar process inferiorly.  Convexity towards sinus  Thinnest in canine fossa  Imp structures  Infraorbital foramen  ASA, MSA nerves  Levator labii, obicularis oculi muscles  Applied aspect
  • 23. Floor of sinus  Formed by junction of anterior sinus wall and lateral nasal wall  1-1.2 cm below nasal floor  Close relationship between sinus and teeth facilitate spread of pathology  Inner surface is rough by bony septa  Retrieval of root fragment  Interferes with sinus drainage
  • 24. Vascularization & innervation a) Nasal Mucosal Vasculature SP, Ethmoid Arterial Supply b) Osseous Vasculature IO, PSA, ASA, GP, Facial a) Medial wall - SP Venous Drainage b) Other walls – Pterygomaxillary Plexus Lymphatic Drainage Collecting vessels in middle meatus Nerve Innervation ION, GP, PSA, MSA, ASA  Clinical significance  PO2 of sinus = 116 mm Hg
  • 26. Microscopic anatomy  3 layers  Epithelium  Basal lamina  Sub epithelium
  • 27. Epithelium  Pseudostratified columnar ciliated epithelium  Cells  Columnar ciliated  Goblet  Basal  Non – ciliated
  • 28. Ciliated epithelium  100 motile and no. of immotile microvilli present along apical surface  Function: mucus clearance along with entrapped debris from nose and PNS  Ciliary motility dependent on ATP driven molecular motors cause outer doublets of axoneme to slide over each other  All cilia beat together to form metachronous wave  Each cilia has power stroke followed by recovery stroke
  • 30. Microvilli  Hair like projection of actin filament  Length 1-2 mm  Function:  Increase surface area of cell  Prevent drying of surface
  • 31. Physiologic nature of mucus layer  Sino nasal epithelium covered by mucus blanket  Traps particles>0.5-1 um  Composition  Water (95%)  Others (5 %)  Peptides  Salts  Debris  Ph = 5.5-6.5
  • 32. Physiologic nature of mucus layer 2 layers Inner sol Outer gel - Continuous -Discontinuous - Low viscosity - High viscosity - Surrounds shafts of cilia -Along ciliary tips
  • 33. Drainage of sinus  Mucus transported from nose and PNS to nasopharynx, ingested and presented to GIT (Messerklinger)  Forms basis of fess
  • 34. Drainage of sinus Flow of mucus superiorly against gravity Upward course along walls of entire cavity and then towards natural ostium in superomedial wall Drainage into ethmoidal infumdibulum Mucus coursing along lateral wall, carried medially along roof to reach ostrium Mucociliary flow from anterior sinuses converge at OMC, carried to posterior nasopharynx & inferiorly to eustachian tube orifice By Donald et al & Antunes et al
  • 36. Drainage of sinus  Mucociliary flow Smooth:0.85 cm/minute Jerky: 0.3 cm/minute Mucostasis: <0.3 cm/minute
  • 37. Basal lamina & subepithelium  Contains serous glands and blood vessels  Subepithelium – 10 serous  Mucosa removal – 73% decrease in serous glands and 30% in goblet cells
  • 38. Functions of sinus 1. Decrease skull weight 2. Impart resonance to voice 3. Mucus production and storage 4. Humidify and warm inhaled air 5. Define facial contour 6. Immunodefensive action 7. Conserve heat from nasal fossae 8. Moisturize air 9. Filters debris 10. Dampen pressure differential during inspiration 11. Limit extent of facial injury from trauma 12. Serves as accessory olfactory organ
  • 39. Maxillary sinusitis  Group of diseases mainly inflammation & infection which affect the nasal mucosa and PNS
  • 41. Maxillary sinusitis  Anatomical variations influencing the development of sinusitis a) Variations of uncinate process b) Variations in bulla ethmoidalis c) Variations of middle turbinate d) Accessory ostium e) Deviated nasal septum f) Nasal masses g) Haller cell
  • 42. Maxillary sinusitis Extrinsic Intrinsic causes 1. Infectious causes causes 1. Genetic a) Bacterial a) Structural b) Viral b) Immunodeficiency c) Fungal c) Mucociliary d) Parasitic abnormality 2. Non infectious (cystic causes fibrosis, dismotility) a) Allergic 2. Acquired b) Non allergic a) Aspirin hypersensitivity c) Pharmocologic b) Autonomic d) Irritants dysregulation c) Hormonal 3. Disruption of mucociliary drainage d) Structural (Tumors, cysts) a) Surgery e)Idiopathic/ b) Infection autoimmune c) Trauma f) Immunodeficiency
  • 43. Maxillary sinusitis  Diagnosis 1. History 2. Physical examination  Inspection  Palpation  Percussion  Diagnostic techniques a. Rhinoscopy b. Endoscopy c. Nasal valve examination d. Culture and sensitivity
  • 44. Maxillary sinusitis Major & Minor Factor Associated with the Diagnosis of Chronic Rhinosinusitis Major Factors Minor Factors Facial pain/pressure Headache Facial congestion/fullness Fever (non-acute cases) Nasal obstruction/blockage Halitosis Nasal Fatigue discharge/purgulence/discol ored postnasal discharge Hyposmia/anosmia Dental pain Purulence in nasal cavity on Cough examination Fever (in acute rhinosinusitis Ear pain/pressure/fullness only)
  • 45. Maxillary sinusitis 3. Radiological examination a) OM view b) Caldwell view c) Lateral view d) CT scan e) MRI 4. Tests for mucociliary functions a) Nasomucociliary clearance b) Ciliary beat frequency c) NO measurement d) Rhinomanometry 5. Test for olfaction
  • 46. Maxillary sinusitis Management Medical Surgical 1. Antibiotics 1. sinus aspiration and lavage 2. Steroids 2. Maxillary needle sinusotomy 3. Decongestants 3. Caldwell luc 4. Analgesics 4. FESS 5. Antihistamines 6. Nasal spray & saline irrigation 7. Hydration 8. Mucolytics(guaifenesin,KI)
  • 47. Antibiotics Antibiotic Micro factors Pediatric dosage First line therapy Amoxicillin 45 mg/kg/day or 90 mg/kg/day divided 500 g BID Second line therapy Amoxicillin/potassium 22.5-45 mg/kg/day divided (dose based on 500-875 mg BID calvulanate amoxicillin component) 10 mg/kg/day on day 1, then 5 mg/kg/day 500 mg QID on day 1, then 250 mg Azithromycin on days 2-5 QID on days 2-5 Cefdinir 14 mg/kg/day 300 mg BID Cefpodoxime 10 mg/kg/QID 200 mg BID Cefprozil 15 mg/kg/QID 250-500 mg BID Cefuroxime 15 mg/kg/QID 250 mg BID Ciprofloxacin 500 mg BID Clarithromycin 7.5 mg/kg/day 500 mg BID Cindamycin 8-20 mg/kg/day divided QID 150-450 mg BID Doxycycline 100-200 mg QID Garifloxacin 400 mg QID Levofloxacin 500 mg QID Sulfamethoxazole/trimethop 6-12 mg/kg/day divided (based on 800-160 mg BID rim trimethoprim)
  • 48. Steroids  1st line of therapy: topical intranasal (betamethasone, dexamethasone, triamcinolone)  Systemic steroids:  Prednisolone:0.5-1mg/kg x3-4 days
  • 49. Decongestants  Systemic (phenylpropanolamine, pseudoephidrine):  Contraindications: hypertension, hyperthyroidism, asthma  Topical: phenylepinephrine HCl, oxymetazoline HCl  Adv. Effects- rhinitis medicamentosa
  • 50. Analgesics & antihistamines  Analgesics:  Opoid: acetaminophen, codeine  NSAIDS:  Antihistamines:  Mequitazine, terfenad  Contraindicated in bacterial sinusitis  Adv effect: sedation
  • 51. Nasal lavage & sprays  m/a:  Removes debris & dead tissue  Washes inflammatory secretions  Eliminates nutrient source  Methods:  Lavage pot  Syringe  Irrigating bulb
  • 52. Nasal lavage & sprays Techniques of nasal sprays 1. Moffet position 2. Mygind technique
  • 53. Surgical management Indications Contraindications • Bilateral chronic • Presence of sinusitis with polyps extensive polyps • Fungal sinusitis • Pt withc/c of • Presence of headache and complications midfacial pain • Tumor of PNS • Medically • Csf rhinorrhea compromised • Hypoplastic sinuses
  • 54. Sinus aspiration & lavage  Direct removal of bacteria laden secretions  Indication: no response to medical therapy  D/A
  • 55. Maxillary needle sinusotomy  d/a  Requires force to enter anterior wall Preparation of site  Alternatives:  Mallet Infiltration of LA  Steinmann pin  Complications: Transcutaneous  Bleeding puncture ant & post to canine eminence  Infection  Dental injury  Sensory nerve disturbance  Instrument breakage
  • 56. Caldwell luc sinusotomy  By George Caldwell (1893) & Henry Luc (1897)  Indications  Fungal sinusitis  Multiple antral lesions  Antrochoanal polyp  Excision of tumor  Closure of OAF  Removal of antral foreign body  Antral revision procedures  surgical approach for transantral sphenoethmoidectomy, orbital decompression
  • 58. Caldwell luc sinusotomy  Modifications  Complications  Bleeding  Dental sensitivity  Infraorbital neuralgia  Osseous defect in anterolateral wall  Entrapment of inferior rectus muscle
  • 59. FESS  Coined by Kennedy  Intranasal endoscopic technique that allows establishment of adequate sinus drainage without negative impact on sinus mucosa physiology and function.  Principle: stop the cycle that begins with ostium blockage that leads to chronic sinusitis via stagnated secretions, tissue inflammation and bacterial
  • 61. FESS
  • 62. FESS Complications Intracranial hemorrhage Brain injury CSF leak Minor hemorrhage Diplopia Hyposmia Blindness Adhesions Anosmia Periorbital emphysema Epistaxis NL duct injury Meningitis
  • 63. Sinusitis  Complications:  Facial cellulitis  Orbital extension  Intracranial extension
  • 64. Oroantral fistula  Fistular canal between oral cavity and sinal mucous membrane covered with epithelium which may or may not be filled with granulation tissue or polyposis.  Duration and width of lumen contributes to infection of sinus.  OAC OAF(incidence: 0.3-3.8 %)
  • 65. Oroantral fistula  OAC OAF  Defect > 5mm diameter  No approximation of gingival tissues  Post op regime not followed  Loss of clot or wound dehiscence  Cyst enucleation  Smoking, drinking
  • 66. Oroantral fistula  Etiology • Iatrogenic (50%) • Presence of periapical lesions • Injudicious use of instruments • During attempted extraction • Trauma(7.5%) • Chronic infections(11%) • Malignant diseases(18.5%) • Infected maxillary dentures(3.7%) • h/o sinus surgery(7.5%)
  • 67. Oroantral fistula  Predisposing factors • Proximity of sinus floor / tuberosity • Thickened tooth cement / tooth fused to jaw bone • Infected teeth / long-standing decay • Marked periodontitis / gum disease • Lone-standing • Previous history of OAC’s.
  • 68. Oroantral fistula Acute Chronic 1. Escape of air and fluids through nose & 1.Pain, tenderness over cheeks mouth 2. Epistaxis 2. Purulent discharge 3. Excruciating pain 3. Post nasal drip 4. Altered voice 4. Presence of polyps 5. h/o surgery in vicinity of sinus 5. Generalized constitutional symptoms  Common in males,2nd-3rd decade  Immediate sign:  Displaced root /tooth  Tuberosity #
  • 69. Oroantral fistula  Diagnosis  h/o previous extraction  Valsavin test  Mouth mirror test  Cotton wisp test  Inspection  Radiological  IOPA  OPG  OM
  • 70. Oroantral fistula  Management • 3mm-5mm heals spontaneously(HANAZANE) • Ideal treatment :immediate surgery followed by Ab prophylaxis • Acute OAF: closure by simple reduction of buccal and palatal socket walls, followed by acrylic splint. • Treatment for small opening
  • 71. Oroantral fistula 1) antibiotics : Pn & derivatives 2) nasal decongestants:  Ephedrine drops  Inhalations(steam,benzoin ,menthol) 3) Analgesics:  Aspirin 500mg  Paracetamol 500mg  Ibuprofen 400 mg 4) Antral lavage
  • 75. Surgical closure •Temporalis flap •Forehead flap Overview of the treatment modalities of Oro-Antral Communications Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J Oral Maxillofac Surg68:1384-1391, 2010
  • 76. Surgical closure  Factors determining flap selection  Size of communication  Timeline of diagnosing  Presence of infection
  • 77. Buccal flap • Advantages • Disadvantages • Modifications • Moczaic • Laskin & Robinson
  • 79. Palatal pedicle flap A) Ito & Hara modification B) Island flap  Gullane & Arene modification
  • 81. Distant flaps BUCCAL FAT PAD
  • 82. Tongue flap Introduced by lexer,1909 Technique Advantages Disadvantages
  • 84. Grafts GRAFTS AUTOGENOUS ALLOGENOUS XENOGRAFTS Iliac crest Collagen sheet Porcine dermis Fibrin glue Bio guide & Bio oss Chin Gold foil Retromolar area Tantalum Zygoma PMMA Hydroxyapatite
  • 86. Other techniques  Third molar transplantation(kitagawa et al)  Interseptal alveolotomy(hori et al)  GTR(Waldrop & Semba)  Prolamine gel(Gotzfried & Kaduk)  Laser light(Janas)  Splints for immunocompromised pts(llogan and coates)
  • 87. Conclusion  Due to close proximity of maxillary sinus to orbit, alveolar ridge, maxillary teeth, diseases involving these structures may produce confusing symptoms. Hence a precise information about the surgical anatomy is essential to surgeons.  The oroantral fistula is a problem that requires detailed attention to the management of a flap in the mouth. For the sake of obtaining the best results and to give the patient the benefit , proper knowledge about the different types of modalities and their limitations is necessary.
  • 88. References • ECAB: Clinical update-otorhinolaryngology-Paranasal sinuses and rhinosinusitis-V.P Sood • OMFSClinics of North America-Diagnosis & treatment of disorders of maxillary sinus-Laskin • Principles of oral and maxillofacial surgery-Peterson • Textbook of oral and maxillofacial surgery-Killey and kay • Maxillary sinus and its dental implications:dental practice handbook-Killey and Kay • Review of oral and maxillofacial surgery-Ghosh
  • 89. References • Open access atlas of otolaryngology, head & neck operative surgery -johan fagan • Treatment of Oroantral Fistula-Klara Sokler et al, Acta Stomatol Croat, Vol. 36, br. 1, 2002 • Oronasal fistula closure by tongue flap-Manimaran K et al, JIADS,Jan-mar 2011 • A New Surgical Management for Oro-antral Communication,The Resorbable Guided Tissue Regeneration Membrane – Bone Substitute Sandwich Technique-C Ogunsalu, West Indian Med J 2005; 54 (4): 261