DIFFERENTIAL DIAGNOSIS OF MAXILLARY SINUS PATHOLOGY

Presented by, Shiji margaret

BDS-cRRI

DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY

CONTENTs•CLASSIFICATION•ETIOLOGY•PATHOGENESIS•CLINICAL FEATURES•RADIOLOGICAL FEATURES•DIAGNOSIS•TREATMENT•COMPLICATION•conclusion•REFERENCE

Classification1.Inflammatory•Acute and chronic sinusitis•Mucositis•Antral polyp•Osteomyelitis2.cyst•Mucus retention cyst(mucocele)•Pseudo cyst•Surgical ciliated cyst •Radicular cyst 3.Neoplasm•Adenoameloblastoma•Exostosis•Enostosis•Squamous cell carcinoma•Midline lethal granuloma

4. Developemental•Crouzon syndrome•Treacher Collin’s syndrome•Binder syndrome 5. Calcification •Anthroliths 6. Traumatic•Fracture of maxilla, tuberosity, nasal bone, zygoma and orbital floor•Hematoma due to traumatic injury•Foreign bodies displace into the sinus- fractured tooth/root•Oral antral fistula•Sinus contusion

Inflammatory diseaseAcute and chronic sinusitis

Inflammation of the mucosa of the paranasal sinuses is referred to as sinusitis.when maxillary sinus is involved, it is called as maxillary sinusitis.when all the sinuses are involved it is called as pansinusitis.

EtiologyDental causes•Periapical infection from the teeth: it may follow dental infection particularly from upper molars and premolars teeth•Oroantral fistula: the accidental opening in the floor of the maxillary sinus during dental extraction is called as oroantral opening.•Periodontitis: it may spread from a deep pocket of marginal periodontitis.•Traumatic: injury of facial bones especially nasal bones and malar bones•Dental material in the antrum: perforation of endodontic filling substance. If root canal is overfilled then there are more changes of gutta purcha points to be inserted into the maxillary sinus.•Implant: implants are used in upper edentulous jaw to aid the retention of dentures or bridges or replace missing teeth.implants are also used when there is insufficiency of bone to support the denture.in these cases as bone is thin,implant can penetrate the nose or sinus.

Clinical features•Acute sinusitis•this is a complication of common cold and is accompanied by clear nasal discharge or pharyngeal drainage,which may eventually become green or greenish-yellow colored.•After a few days the stuffiness increases and the patient complaints of pain and tenderness to pressure or swelling over the involved sinus•There will be signs of sepsis;fever,chills,malaise and an elevated leukocyte count.•Pain may be referred to the premolars and molar teeth on the affected side and these teeth may also be sensitive to percussion

•Chronic sinusitis•This is a sequel of the former two,which has failed to resolve by 3 months.•There are no external signs, except in case of an acute exaceberation when increased pain and discomfort is apparent.•This type is usually associated with anatomical derangements that inhibit the outflow of mucous,like;deviation of the nasal septam and presence of concha bullosa.

Radiographic features•Radiodensity: radiographically,the thickening of the mucous membrane and the accumulation of secreations that accompany sinusitis reduce the air content and it will appear as radiopaque.•Allergic sinusitis: in the case of allergy,mucosa will be more lobulated in contrast to that in infection where it is straighter and parallel to the sinus wall.

Diagnosis•Transillumination test: affected sinus will be found opaque.•Radiograph: water’s view and OPG can be taken

Management•Acute sinusitis•Anti-histamines for allergy•Phenylephrine 2-4 times/day •Amoxicillin 500 mg tid for 10-14 days•Topical nasal spray (unlimited daily use) •Ipatropium•Chorinic sinusitis•Nasal steroid spray

Mucositis (Thickened mucous membrane)The normal mucosal lining of the para nasal sinus is composed of respiratory epithelium and is approximately 1mm thick, and is not visualized on the radiograph. When the mucosa becomes inflamed from either an infectious or allergic process, it may increase in thickness 10 to 15 times and is then seen on the radiograph. This thickening is called mucositis. Any thickening greater than 3mm is most likely to pathological.Clinical features•It is usually asymptomatic and is discovered on a routine radiograph.Radiographic features•It is seen as a non-corticated band noticeably more radiopaque than the air filled sinus, paralleling the bony wall of sinus. Mucosal thickening seen distinctly on denta scan imagesManagement•Removal of the cause.

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Antral polyp

The thickened mucosa of chronically inflamed sinus frequently form irregular folds called as ‘polyps’.polypoid atrophy of mucosa may develop into an isolated area or number of ares throughout the sinus. Antrochoanal polyps, are solitary polyps arising from the maxillary antrum. They were first described by Killian in 1906. Although their etiology remains unknown, allergy has been implicated

. Clinical features•Age: it usually occurs in young persons.•Site: maxillary sinus is more involved as compared to other sinus.in maxillary sinus they may arise from any part of the sinus wall and occasionally pass through the ostium to appear in the nose as antrochoanal polyps.Symptoms: patients present with nasal obstruction,pain is very mild on pressure as mass present inside the nose.

Radiological features •Appearance: it appear as homogenous soft mass with smooth,outwardly convex borders.single or multiple lesions may be present.if polyp occurs in the roof of the maxillary sinus in a patient with a history of trauma,the plain film examination may simulate a blow out fracture.•Destruction of walls of sinus: polyps may cause destruction or displacement of bone. They can displace or destroy medial or lateral wall.•CT features: have mucoid attenuation with mucosal enhancement seen at polyps surface. It appears as smooth homogenous mass.•MRI features: mucosa adjacent to polyps will enhance as compared to polyps

ManagementNon surgical•Oral and topical nasal steroid •Corticosteroids Surgical•polypectomy •Endoscopic sinus surgery

OsteomyelitisOsteomyelitis (osteo- derived from the Greek word osteon, meaning bone, myelo- meaning marrow, and -itis meaning inflammation) simply means an infection of the bone or bone marrow. It can be usefully subclassified on the basis of the causative organism (pyogenic bacteria or mycobacteria), the route, duration and anatomic location of the infection.

Types•Infantile osteomyelitis•Tuberculous osteomyelitis

Infentile osteomyelitisIt is a rare type of osteomyelitis seen in infants in few weeks after birth.it usually involves maxilla.

Clinical features•Site: it is more common in maxilla due to hematogenous route.•Symptoms: fever, anorexia, dehydration in some cases, convulsants, and vomiting may occur.•Signs: redness and edema of eyelids, alveolar bone and palate of the effected side.

Radiographic features•Radiodensity: about 10 days after acute infection, the density of trabeculae will be decreased, with blurred and fuzzy.•Trabecular pattern: the earliest radiographic change is that trabeculae in involved area are thin,of poor density and slightly unsharp or blurred.the trabeculae soon loose their continuity as well as the little density present.individual trabeculae become fuzzy and indistinct.•Multiple radiolucency: subsequently, multiple radiolucencies appear which become apparent on radiograph.•Lamina dura: there is loss of continuity of lamina dura,which is seen in more than one tooth.

DiagnosisClinical diagnosis: fever, pain with maxillary involvement in the infant will give clue to the diagnosis

Management •Bacterial sampling and culture•Vigorous (empirical) antibiotic treatment•Drainage•Give specific antibiotics based on culture and sensitivities•Give analgesics•Debridement•Remove source of infection, if possible

Cyst involving maxillary sinusMucous retention cyst (mucocele)A mucocele is an expanding,destructive lesion that results from a blocked sinus ostium. The blockage may result from intra-antral or intra nasal inflammation,polyp or neoplasm.the entire sinus thus becomes the pathologic cavity. As mucous secritions accumulate and the sinus cavity fills, the increase in intra-antral pressure results in thinning,displacement,and in some cases destruction of sinus walls. When the cavity is filled with pus,it is termed an empyema,pyocele or mucopyocele.

Clinical features•90% of mucoceles occur in the ethmoidal and the frontal sinus and are rare in the maxillary sphenoidal sinus•In the maxillary sinus it may exert pressurenon the superior alveolar nerves causing radiating pain, with a swelling and fullness of the cheek.the swelling may first observed over the anterioinferior aspect of the antrum where the wall may be thinned or destroyed.•If the lesion expands inferiorly,it may cause loosening of the posterior teeth.•If the medial wall of the sinus is expanded the lateral wall of the nasal cavity will deform and the nasal airway may be observed.•If it expands into the orbit,it cause diplopia or proptosis.

Radiographic features•The normal shape of the maxillary sinus is changed into a more circular shape as the mucocele enlarges.•The scalloped border of the frontal sinus is usually smoothed by expansion, and the intersinus septum may be displaced.•In the ethmoidal air cells, displacement of the lamina papyracea may occur, displacing the contents of the orbit.•In the sphenoid sinus the expansion may be in the superioe direction, suggesting a pituitary neoplasm.•The sinus cavities appear uniformly radiopaque.

Differential diagnosis•Cyst•Benign tumor•Malignancy•Any suggestion of a lesion associated with occluded ostium should be a mucocele. A large odontogenic cyst displacing the maxillary antral floor may mimic a mucocele.

Treatment•Surgical removal.

ComplicationsThere are usually no complications.

Surgical ciliated cyst

It is a delayed complication arising years after surgery involving maxilla.

Clinical features•It is usually occurs in the 4th and 5th decades of life•Mostly seen in males•The patient may complain of pain,discomfort or swelling of face or intra oral swelling of the palate or alveolus, with pus discharge

Radiological features

•it is seen as a well defined radiolucency closely related to maxillary sinus.•There is sclerosis of the surrounding bone.•As the cyst enlarges it produces pressure effects, with thinning of the sinus walls which may eventually perforate•There may be resorption of mallxillary alveolar process.•There is no communication between the cyst and maxillary sinus which may be demonstated by injecting the sinus with radiopaque material.

Treatment•Enucleation

Pseudo cyst Pseudocysts are like cysts, but lack epithelial or endothelial cells. Initial management consists of general supportive care. Symptoms and complications caused by pseudocysts require surgery. Computed tomography (CT) scans are used for initial imaging of cysts, and endoscopic ultrasounds are used in differentiating between cysts and pseudocysts. Endoscopic drainage is a popular and effective method of treating pseudocysts. This has not to be confused with the so-called 'pseudocystic appearance', mainly radiographically, of other lesions, such as Stafne static bone cyst and aneurysmal bone cyst of the jaws.

SymptomsPseudocysts are often asymptomatic. Symptoms are more common in larger pseudocysts, though the size and time present usually are poor indicators of potential complications.

Clinical features•it is mainly seen in 2nd and 3rd decades of life.•Males are most commonly effected than female.•Mostly involved sites are the antral floor and lateral wall of maxillary sinus.•There may be localized dull pain in the antral region or fullness and numbness of cheek.•There may be pain in the teeth and over the face over or near the sinus.•Sometimes antral swelling may also occur.

Radiographic features•it is homogenous mass that is more radiopaque than the surrounding sinus cavity.•It appears as a soft tissue mass rather than a calcified area so that medial and lateral landmarks can generally be visualized through the lesion.•It is found projecting from the floor of the sinus, although some may form on the lateral walls.•The cyst appers as spherical ,ovoid,or dome shaped•It has a uniform and a smooth outline.•They may have narrow or broad base•They vary in size from minute to very large.•There is no resorption of adjacent bone.•Mucous type will associated with thickened mucosa while serous type is appears normal.

Treatment. •Surgical drainage.•Endoscopic drainage•laproscopy

Radicular cystA radicular cyst is a cyst that most likely results when rests of epithelial cells (Malassez) in the periodontal ligament are stimulated to proliferate and undergo cystic degeneration by inflammatory products from a non-vital tooth.

Clinical features•Most common type of cyst of the jaws.•Rarely seen before the age of 10.•Most frequent between 20 and 60 years.•More common in males than females 3 to 2.•Maxilla affected more than 3 times the mandible. •Cause slowly progressive painless swelling.

PathogenesisThe main factors in the pathogenesis of cyst formation are:•Proliferation of epithelial lining and fibrous capsule•Hydrostatic pressure of cyst fluid•Resorption of Surrounding bone •Infection from the pulp chamber induces inflammation and proliferation of the epithelial rest of Malassez.

•Radicular cyst expand in balloon-like fashion, wherever the local anatomy permits, indicates that internal pressure is a factor in their growth•Consistent with the inflammation usually present in cyst walls, cyst fluid may contain cholesterol, breakdown products of blood cells, exfoliated epithelial cells, and fibrin. •Collagenases are present in the walls of keratocysts, but their contribution to cyst growth is also unclear.•All stages can be seen from a periapical granuloma containing a few strands of proliferation epithelium derived from the epithelial rest of Malassez, to an enlarging cyst with a hyperplastic epithelial lining and dense inflammatory infiltrate.•Epithelial proliferation results from irritant products leaking from an infected root canal to cause periapical inflammation. •The epithelial lining consists of stratified squamous epithelium of variable thickness

Radiological features•In most cases the epicenter of a radicular cyst is located approximately at the apex of a nonvital tooth•Occasionally it appears on the mesial or distal surface of a tooth root, at the opening of an accessory canal or infrequently in a deep periodontal pocket •Most radicular cysts (60%) are found in the Maxilla, especially around incisors and caninesManagementTreatment of a tooth with a radicular cyst may include:•Extraction, •Endodontic therapy,•Apical surgery (Enucleation/Marsupilisation)

NeoplasmAdenoameloblastoma (AOT) Adenoameloblastoma is a lesion that is often found in the upper jaw. Some consider it a non-cancerous tumor, others a hamartoma (tumor-like growth) or cyst. Often, an early sign of the lesion is painless swelling. These tumors are rarely found outside of the jaw.It is mostly seen in the maxillaSymptoms:Some of the symptoms of Adenoameloblastoma incude:•Jaw cyst •Jaw tumor •Sinus cyst •Sinus tumor •Dental cystEtiologyIt is fairly uncommon, but It is seen more in young people. Two thirds of the cases are found in females

Clinical featuresClinical features generally focus on complaints regarding a missing tooth. The lesion usually present as asymptomatic swelling which is slowly growing and often associated with an unerupted tooth. However, the rare peripheral variant occurs primarily in the gingival tissue of tooth-bearing areas. Unerupted permanent canine are the theeth most often involved in adenoameloblastoma

Radiological featuresThe radiographic findings of AOT frequently resemble other odontogenic lesions such as dentigerous cysts, calcifying odontogenic cysts, calcifying odontogenic tumors, globule-maxillary cysts, ameloblastomas, odontogenic keratocysts and periapical disease . Whereas the follicular variant shows a well-circumscribed unilocular radiolucency associated with the crown and often part of the root of an unerupted tooth, the radiolucency of the extrafollicular type is located between, above or superimposed upon the roots of erupted permanent teeth. Displacement of neighbouring teeth due to tumor expansion is much more common than root resorptions

Treatment Conservative surgical enucleation is the treatment modality of choice. For periodontal intrabony defects caused by AOT guided tissue regeneration with membrane technique is suggested after complete removal of the tumor. Recurrence of AOT is exceptionally rare. Only three cases in Japanese patients are reported in which

the recurrence of this tumor occurred. Therefore, the prognosis is excellent.

Exostosis An exostosis (plural: exostoses) is the formation of new bone on the surface of a bone. Exostoses can cause chronic pain ranging from mild to debilitatingly severe, depending on the shape, size, and location of the lesion. If an exostosis is thought to be present your podiatrist will most likely have an x-ray taken of your foot to evaluate it. The underlying cause of forming the exostosis needs to be addressed. An exostosis can be treated conservatively or surgically depending on location and symptoms. If a surgery is performed where the exostosis is removed this is termed an exostectomy.Clinical featuresThe clinical features of osteochondromata are:•swelling - usually, at the metaphysis of a long bone•lesions may be single or multiple•rarely painful•the lump is bony hardRadiographic featuresRadiologically, the osteochondroma is well-defined. Often the lesion may look smaller than it feels because the cartilage cap is invisible.There are two main varieties that are seen:•conical•cauliflower shapedThere may be partial calcification of the osteochondroma.

Treatment & PrognosisSurgical excision

Enostosis A hyperplasia of bone within the jaws. Also referred to as a dense bony island.Clinical features•The lesions were all at least 1.5 cm. in diameter. •Pain, drainage, or localized expansion of the jaw was present •Womens are mostely effected

Causes•genetics• stress•infection •Metabolism

Clinical featuresMales are more commonly affected than females.

Radiographic Features•Location: Anywhere throughout the maxilla and mandible.•Edge: Well-defined to Well-localized, continuous with the surrounding bone trabeculae.•Shape: Does not always have a given shape, but may appear round, ovoid or irregular in shape.•Internal: Radiopaque, radiopacity of cancellous bone.

DiagnosisDiagnosis is made by pain on palpation of the long bones of the limbs. X-rays may show an increased density in the medullary cavity of the affected bones, often near the nutrient foramen (where the blood vessels enter the bone). This evidence may not be present for up to ten days after lameness begins.Differential diagnosisIn the vast majority of cases, bone islands have a pathognomonic appearance. Larger lesions may sometimes pose a diagnostic dillema, particularly in the setting of known malignancy. Differential considerations include:•osteoblastic metastasis•osteoma•osteoid osteoma•low grade osteosarcoma

Squamous cell carcinoma This originates from metaplastic epithelium of the sinus mucosal lining

Clinical features•The males are commonly effected.•The most common symptom is facial pain or swelling, nasal obstruction and lesion in the oral cavity.•Lymphnodes are involved in most of the case.•Erosion of the medial wall causes nasal obstruction, nasal discharge, bleeding and pain.•Expansion of the alveolar process in the maxillary sinus•Sinus root and floor of the orbit causes symptoms related to eye diplopia and proptosis, pain and hyperesthesia or anesthesia and pain over the cheek and upper teeth.

Radiographic featuresThe medial wall of the sinus is best seen on the waters projection As the lesion enlarges it may destroy the sinus walls and in general cause irregular radiolucent areas in the surrounding boneAdjacent alveolar process may show bone destruction around the teeth or irregular widening of periodontal ligament space.

•The medial wall of the sinus maynbe thinned or destroyed and it may also extend into the nasal cavity.•Destruction of the floor and anterior and posterior walls may be dectected.

Differential diagnosis•Sinusitis• odontogenic cyst•Large retention cyst

Treatment•Debridement of sinus•Antifungal

a) Amphotericin bb) Rifampin

Syndromes associated with maxillary sinusCrouzon’s syndromeCrouzon syndrome is a genetic disorder known as a branchial arch syndrome. Specifically, this syndrome affects the first branchial (or pharyngeal) arch, which is the precursor of the maxilla and mandible. Since the branchial arches are important developmental features in a growing embryo, disturbances in their development create lasting and widespread effects. HeredityCrouzon syndrome is autosomal dominant; children of a patient have a 50% chance of being affectedSymptomsAs a result of the changes to the developing embryo, the symptoms are very pronounced features, especially in the face. Low-set ears are a typical characteristic, as in all of the disorders which are called branchial arch syndromes. The reason for this abnormality is that ears on a fetus are much lower than those on an adult. During normal development, the ears "travel" upward on the head; however, in Crouzon patients, this pattern of development is disrupted. Ear canal malformations are extremely common, generally resulting in some hearing loss.

DiagnosisDiagnosis of Crouzon syndrome usually can occur at birth by assessing the signs and symptoms of the baby. Further analysis, including radiographs, magnetic resonance imaging (MRI) scans, genetic testing, X-rays and CT scans can be used to confirm the diagnosis of Crouzon syndrome.

Treatment•Surgery

Dental significanceFor dentists, this disorder is important to understand since many of the physical abnormalities are present in the head, and particularly the oral cavity. Common features are a narrow/high-arched palate, posterior bilateral crossbite, hypodontia (missing some teeth), and crowding of teeth. Due to maxillary hypoplasia, Crouzon patients generally have a considerable permanent underbite and subsequently cannot chew using their incisors.

Binder syndrome (maxilla nasal dysplasia)Binder's Syndrome/Binder Syndrome (Maxillo-Nasal Dysplasia) is a developmental disorder primarily affecting the anterior part of the maxilla and nasal complex (nose and jaw). It is a rare disorder and the causes are unclear. Hereditary and vitamin D deficiency during embryonic growth have been researched as possible causes.

clinical Characteristics•arhinoid face, •intermaxillary hypoplasia, •abnormal position of nasal bones, •atrophy of nasal mucosa, reduced • absent anterior nasal spine, • absence of frontal sinus (not obligatory).

Synonyms: •Maxillo-nasal dysplasia. •Maxillo-nasal dysostosis. •Naso-maxillo-vertebral syndrome (Binder syndrome).

Prognosis: The prognosis is good if there is no other problem associated.

Management: •Orthodontic therapy •osteotomy when the children were older

AnthrolithsAn antrolith is a calcified mass within the maxillary sinus. The origin of the nidus of calcification may be extrinsic (foreign body in sinus) or intrinsic (stagnant mucus, fungal ball). Most antroliths are small and asympotomatic. Larger ones may present as sinusitis with symptoms like pain and discharge.

Radiographic features•Location: Maxillary sinuses.•Edge: Well-defined, smooth or irregular outline.•Shape: Round, ovoid.•Internal: Radiopaque, may have a ‘laminated’ appearance with radiopaque and radiolucent bands evident due to continued laying down of calcium salts. (This looks similar to layers of an onion.)•Number: May be single of multiple.

Differential diagnosis Aspergillosis infection

Treatmentsurgical removelendoscopic sinus surgery

Traumatic injuries of maxillary sinusesTooth roots may be fractured as a result of various forms, including iatrogenic reasons. fractured roots may be forced into the sinus during extraction or subsequent attemps to retrieve them.Excess root canal filling material may be forced through the apex of an upper posterior tooth during endodontic therapy. Foreign materials may be pushed into the antrum via an existing oro antral fistula. Metallic objects such as pellets, bullets and fragments of shells or bombs may be found if patients has been exposed to the same.

Clinical features•no visible signs and symptoms if the roots is displaced recently.•Ask the patient to hold the nose while attempting to breathe out through, similar to a valsalva maneuver, it will cause bubbles to appear within the blood contained within the fresh extraction.•If the patient has the root or tooth in the sinus for a number of days, he may present with sinusitis•The associated roots are usually of molars and premolars as the sinus is in close proximity to these teeth.

Radiographic features•The dislodged fragments are usually found near the floor of the sinus because of the gravity. Sometimes the displaced structure may be mucosal, between the osseous wall of the sinus and the periosteum. The floor of the sinus and periosteum.•The foor of the sinus may break due to the displacement of the tooth fragment into the sinus.Differential diagnosisExostoses of the sinus wall or the floor and the septa within the sinus, may mimic dental root fragments or even whole teeth.Anthroliths 

TreatmentSurgical removal

THERE IS A ROOT FRAGMENT LOCATED OBLIQUELY AND APICAL TO THE APEX LINE

CT finding which showed that the tooth was located close to mesial wall of the sinus and roots

Sinus contusionThis occurs due to a blow to the face that damages the lining of the paranasal sinuses without fracturing the facial bone. There may be green stick fracture of the sinus with a resultant tearing injury to the mucosal lining.Clinical features•There is a bloody nasal discharge, extreme tenderness of the involved sinus on pressure.•There is rapid resolution of the soft tissue changes.Radiographic features•Haziness of the sinus due to edema.•An opaque sinus or fluid level resulting from hemorrhage from the mucosal tear.Differential diagnosis•Sinusitis

Blow-out fractureThis results from sudden increase in the intraorbital pressure, due to may be a direct blow to the eye.Clinical features•The pressure of the blow forces the inferior orbital content through the fracture.•It results in diplopia when the victim look upward and enophthalmus following reduction of edema and fat atropy.Radiographic features•Opacification of the sinus with or without a fluid level.•There will be shadow of soft tissue mass in the upper portion of the sinus and shadows of the depressed bone fragments into the sinus.•A tear drop shaped radiopacity is produced in the upper part of the sinus, due to the herniation of the orbital content downward into the sinus following the collapse of the antral roof.•The depression fracture of the orbit may be accompanied by the fracture of the antrum wall of the maxillary sinus.

Isolated fracture•This involves a single wall which may appear as a bright line on the radiograph.•The most common sites are the anterolateral wall of the antrum and the floor of the antrum, during extraction of the upper posterior teeth whose roots are in close proximity to the antrall floor.

Zygomatic complex fracture

This fractures occurs at the line of weakness and passes through the orbital floor, usually medial to the zygomaticomaxillary suture.

Clinical features•The fractured zygoma is forced into sinus.•There may be tearing of the lining membrane with subsequent bleeding into antrum.

Radiographic features•the antrum appers cloudy or will show a fluid level.

Standard occipitomental showing fracture of the right zygomatic complex with a break of antral roof

Oroantral fistula

This is a pathological pathway connecting the oral cavity and the maxillary sinus. It may be caused due to extraction of teeth having chronic periapical infection, extraction of solitary tooth. Extraction of teeth having apices very close to the antral floor, blind instrumentation, surgical removal of large lesions in the upper jaws, malignant tumors,osteomyelitis, syphilis, malignant granulomatous lesion, facial trauma and inadequate blood clot formation.

Clinical features•immediate history of recent traumatic extraction or disappearance of the roots during extraction.•Passage of fluid into the nose from the oral cavity•Inability to blow the cheek or smoke.•Unilateral epitaxis, due to blood in the antrum escaping through the nasal ostium.•Alteration in vocal resonance.

Radiographic features•There will be a break in the continuity of the floor of the maxillary sinus, which may be seen as a disalignment of a small portion of cortical layer of bone•Radiographic features of acute or chronic sinusitis are present.

•There may be evidence of the displaced root or tooth,and a second view of the sinus with the head in a different position may be required to asceration the the exact location of the displace object

Treatment•It consist of repair and surgical closure under antibiotic therapy.

Periapical showing a discontinuity of the antral foor

Conclusion

Unilateral maxillary sinus opacification is a relatively common finding. Early identification of inverting papilomas and mucocele may avoid delay in surgical inervation,whereas acute/chronic sinusitis and nasal polyps can initially be managed medically. careful history, endoscopic examination and radiographic studies can often determine the responsible disease process.

Reference•Dental and maxillofacial radiology: freny r kajodkar ,2nd edition, jaypee 2009 ; page 751 to 773•Text book of oral medicine: anil govidharao editors, ghom,2nd edition, jaypee 2010 , page 677 to696•Text book of oral and maxillo facial surgery: chitra chakravarthy editor,2nd edition, paras publishers 2011 ,page 246 to 263•Oral & Maxillofacial Pathology: Neville, B, et al. editors,3rd Ed. Saunders 2002 ,page 219 to 226•Text book of medicine; pramod john r editor,2nd edition,jaypee 2005,page 284 to 288

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