Maxillary Air Sinus Oral Surgery

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MAXILLARY AIR SINUS:IntroductionFunction of air sinusAnatomy & Histology of maxillary air sinusClinical importance of maxillary air sinusDisease of the maxillary sinusInfection- 1. Acute maxillary sinusitis2. subacute maxillary sinusitis3. Chronic maxillary sinusiticommunication- 1. Acute oroantral fistula

2. Chronic oroantral fistula- Etiology- clinical features- Investigation- management


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AIR SINUSThese are air filled hollow space present within the bone around thenasal cavity called as paranasal air sinuses.The sinuses are (1) Frontal air sinus

(2) Maxillary air sinus(3) Sphenoidal air sinus(4) Ethmoidal air sinus

These sinus forms various boundaries of the nasal cavity & all thesesinus communicate with each other and open into the lateral wall ofthe nasal cavity.


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FUNCTION OF AIR SINUS :The function of air sinus are(1)Humidification of inspired air(2) It provides resonance to voice.(3) It lightens the bone.(4) It act as thermal insulator to protect organ such as the eye andcranium from variation in intranasal temperature.(5) Sinus increase the surface area of the skull.


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MAXILLARY AIR SINUS :Definition: An antrum is a hallow cavity within the bone calledmaxillary air sinus.

Maxillary air sinus known as antrum of Highmore,named after an english antomist Nathaniel Highmore who wasdescribed it.It is one of the largest paranasal sinus.ANATOMY OF THE MAXILLARY AIR SINUS :

It is basically pyramidal in shape with the base of the pyramidforming the lateral nasal wall and apex at the root of the zygoma.Capacity : 10-15 ml (in adult antrum)Size : Dimension of sinus are

Height 3.5 cmWidth 2.5 cm


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ROOF OF THE ANTRUM :- Formed by floor of the orbit.- Thin plate of orbital plate of maxilla.- It lodges the infraorbital canal and groove

which lodges the infraorbital nerve.FLOOR OF THE SINUS :

- Alveolar process of the maxilla.- its level is lower than the level of the floor of the nose.- Closely related to root apices of the maxillary premolar and molar.


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ANTERIOR WALL:-Formed by the facial surface of the maxilla.- Canine fossa is an important structure of this wall.POSTERIOR W ALL:- Formed by sphenomaxillary wall.- A thin plate of bone separate the antral cavity from theinfratemporal fossa.

MEDIAL WALL :- Lateral wall of the nasal cavity.- the opening of the antrum in the middle meatus at the lower part ofthe hitus semilunaris.- The opening of the sinus is closer to the roof and thus at a highrlevel than the floor.


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HISTOLOGY OF THE MAXILLARY AIR SINUS :- the sinus is lined by respiratory mucosa which is lined by ciliatedcolumnar epithelium.-The ciliated movement help in removal of mucus secretion towards theosteum.BLOOD AND NERVE SUPPLY:Arterial supply : - Facial artery

- Infraorbital artery- Greater palatine artery

Venous drainage: - Facial vein- pterygoid venous plexus


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Lymphatic Drainage : - sumbmandibular lymph node.Nerve supply: - Infraorbital nerve

- Anterior superior alveolar nerve- Middle superior alveolar nerve- posterior superior alveolar nerve


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EMBRYLOGY: The sinus are rudimentary or even absent at birth. They enlarge rapidly at the age of 6 to 7 months. The maxillary air sinus formed first among the other paranasalsinus. It start as a shallow groove on the medial surface of the maxilladuring the fourth month of intrauterian life. Present as small cavity at birth. From birth to adult life the growth of sinus due to enlargment ofbone. It reach maximum size by around 18 years of age. In old age it enlarge due to resorption of the surrounding cancellousbone.


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CLINICAL IMPOTANCE ; Dental infection: Infection from the maxillary premolar andmolars can easily communicate and infect the maxillary antrum. Oroantral Communication: Traumatic extraction of maxillaryteethcan cause oroantral communication. Root Pieces: Root pieces of maxillary teeth may sometimes beaccidentally forced into the maxillary antrum.Maxillary Sinusitis : Because of the thickned and inflammedsinus lining compresses the nerve supply of the maxillary posteriorteeth causing tenderness of the maxillary teeth. The Maxillary Artery can be approached through the posterior wallof the maxillry antrum for ligation. The infraorbital and superior alveolar vessels are freqently rupturedin maxillary fracture causing the hemotoma formation in the


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MAXILLRY SINUSITISmaxillary sinusitis: It is the inflammation of the maxillary sinus.

Maxillary sinusitsAcute Subacute Chronic

ACUTE SINUSITIS: It may be supurrative or non supurrative inflammation of theantral mucosa. It is the most freqently infected of the paranasal sinus.


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ETIOLOGY:(1)Nasal Infection (most common) : Viral rhinitis and influenza arethe common infection.(2) Dental Infection:

Infection from the maxillary posterior teeth can easily spread to themaxillary sinus as the plate of bone dividing the root apices from thesinus .(3)Contaminated Swimming water :Diving in such water forcibly directs water into the nasal cavity andthen into the sinus.(4) Trauma:

Fracture of the maxilla or zygoma, gun shot wound or penitrstinginjuries can lead to sinusits.


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PATHOGENESIE :During early phase of inflammation, intial vasodilation leads toincreases production of mucosa from the mucosa gland.The mucosa concequently exert pressure within the lumen of theantrum.


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CLINICAL FEATURES :The patient gives history of `catching cold 3 to 4 days earlier.Nasal block secondary to rhinitis.Increase in purulent, thick, discoloured and foul smelling nasaldischarge is prominenant features.A sense of fullness and pain on cheek on bending forward.Patient producing cough secondary to the nasal discharge withonset of pharyngitis.The related maxillary teeth are tender on percussion.Nasal resonance- change in the voice due to blocking of sinus.Constitutional symptoms Fever, Headache, Malaise, Difficultyin breathing.


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DIAGNOSIS;(1) Water view radiograph.(2) Transillumination test: Shows opacity involved sinus.

(3) Culture: Nasal secretion may be for culture sensitivity test to seethe organisam involved.MANAGEMENT:

MEDICACAL SURGICALMANAGEMENT MANAGEMENT


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MEDICAL MANAGEMENT:1) Antibiotics: Broad spectrum antibiotics.2) Decongestant: Decreases the congestion and edema of the nasalsinus. Help in the drainage of the sinus.3) Analgesics: Paracetamol provide symptomatic relief.4)Steam inhalation: Steam+ Menthol+ Tincture.After Decongestion for 15 to 20 minutes.Helps in drainage.5) Hot Fomentation: Local heat application is soothing to the

inflamed sinus.


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SURGICAL MANAGEMENT:Antral levage:

Acute maxillary sinusitis usually responds well to medication.It is basically involves inserting a canula into the maxillarysinus trough the inferior meat us.Luke warm water is irrigated through the sinus and this drainsout through the osteum along with the sinus exudates.COMPLICATION

- Chronic sinusitis- Osteomylelitis of the maxilla- Orbital cellulites

- Middle ear infection- Spread to the other sinus.


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SUBACUTE MAXILLARY SINUSITIS :It is the intermediate stage between acute and chronic sinusitis.There is pain only in the form of the local discomfort.patient has persistent discharge.The voice is nasal, throat is sore with constant irritating cough.Patient can not sleep well.The disease may take a long course over week or months.


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CHRONIC SINUSITISInfection of the that last for months or year is called chronicsinusitis.It is most commonly is an extension of an acute sinusitis whichfailed to resolve completely.CAUSATIVE ORGANISM: - Aerobic organism

- Anaerobic organism.


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PATHOPHISIOLOGY:After infection

Ciliated epithelium gets destroyedPrevent drainage of secretion from the maxillapooling and stangnation of mucopurulent in sinusProgression of infectionMucosa changesCilliary damaged and edemaMucosa may become thick and polypoidal.


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Clinical Features:Symptoms are non specific unlike acute sinusitis.patient not having pain or tenderness.Purulent nasal discharge may be foul smelling.Block of nasal and change in voice due to loss of resonance.Ansomia.

INVESTIGATIONWaters view radiograph.Culture of the discharge from the sinus.Transillumination test.


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MANAGEMENT:Medical management:1) Antibiotics: Broad spectrum antibiotics.2) Analgesics: Paracetamol providing relief.3) Decongestant .4) Steam inhalation.5) Hot fomentatiom.


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SURGICAL MANAGEMENT:I. Treat any dental infection if present.II. Antral leavage: If more than three successive punture have purulentfluid than the treatment should be more radical.III. Intra nasal Antrostomy : A window or opening is created in theinferior meatus of facilltates drainage of the sinus.IV. Cold Well luck Operation.


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CALDWELL LUC OPERATION:This is the procedure by which the antrum is entered intraorllythrough the anterior wall and all irreversible disease is removed.This is followed by an antrostomy to promote permanent cure.

INDICATION:Chronic maxillary sinusitis.Removal of foreign bodies in the antrum such as root pieces.Treatment of oroantral fistula that fails to heal.treatment of benign dental cyst tumor.Biopsy procedure for a suspected malignancy in the antrum.Recurrent antrachoanal polyp.Approach to pterygopalatine fossa, sphenoidal sinus, ethmoidalsinus.


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4) Exposure: A full thickness mucoperiostel flap is reflected upto theinfraorbital nerve.Care is taken to protect the infraorbital nerve.5) Approach to the antrum : A micromotor with the large round burr isused to create a window about 1.5 to 2 cm in the anteroir wall of theantrum.The sinus mucosa is seen below the bone.6) Antral lesion: The lesion may be delt with. A biopsy may be doneor sinus mucosa is removed with the help of the curette as the casedemand.7) Antrostomy: A opening is made in the medial wall in the lower

most and anterior aspect of the inferior meatus.


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(8) Packing: The sinus cavity may be packed with the ribbongauze impregnated with vaseline. The gauze is packed in layerand the free end is brought out through the created antrostomyopening.(9)Sutures: The bone margin is smoothened and the flap isreplaced. The flap may be sutured using resorbable suture material.


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POST OPERATIVE CARE:- Ice pack over the cheek for first few hour after surgery. Sinus packis removed after 24 to 48 hours.- Avoid blowing of the nose for at least 2 week after surgery.COMPLICATION:Intraoperative complication: Bleeding Damaged to infraorbital nerve. Damaged to orbital content- Due to perforation into the thin orbitalfloor during curettage of the superior wall of the trauma.Postoperative complication; Reactionary Heamorrhage. Infection. Numbness in the infraorbital region. Recurrence of the lesion. Antrstomy opening. Oroantral Fistula (rarely)


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ETIOLOGY:1) Extraction of teeth:- Occurs as a result of a traumatic extraction of maxillaryposterior teeth whose root may be inclose proximity to the floor of themaxillary antrum.- Tuberosity fracture as a result of upper third molar extraction.- In advert curettage of maxillary tooth socket.2) Facial Trauma: Maxillofacial trauma and penitrating injury.3) Surgical removal of the cyst and tumor associated with themaxillary alveolar region extending into the antrum.4) Osteomylities of the maxilla or following irradication.5) palatal gumma (syphilis)6) Malignant tumor such as wegeneres granulomatosis wich mayperforate the palate.7) Implant surgery in the maxillary posterior region.


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ACUTE OROANTRAL FISTULA:Clinical features:Symptoms- History of recurrent surgery in the vicinity of maxillarysinus.Escape of air and fluids through the nose and mouth.Unilateral epsitaxis.pain may be severe throbbing ordull aching pain.Enhanced column of air causing change in the vocal resonance andconsequently change in the voice.IMIDIATED SIGN-The part of the bony part of the sinus may be adhearent to the root tip

on extraction.Maxillary tuberosity fracture.Root tip in the maxillary antrum.


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DELAYED SIGN OF OROANTRAL FISTULA:Discharging of foul smelling pus from the fistula.Maxillary sinusitis.Infraobital region is tender on palpation.Infraorbital edema.Teeth an affected side will be tender on percussion.Nasal congestation around the osteum.Pus in the posterior wall of the pharynx.Antral polyp in the oral cavity.


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DIAGNOSIS OF OROANTRAL FISTULA :- A large fistula is easily seen on inspection.- Nose blowing test: The patient is placed to close his nostril and blowgently down the nose with nose open.Whistling sound as air passes down the fistula in the oralcavity.- cotton wisp test: The escape of air through the nose can be tested byplacing a wisp of cotton near the orrifice.- Mouth mirror fogging test: A mouth mirror placed at the oroantralfistula causing the fogging of the mirror.- Unilateral epistaxis may sometimes be seen- some time the oroantral fistula can blocked by the an antral polyp.


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CHRONIC OROANTRAL FISTULA:This occur due to the persistence of the communication between theoral cavity and the maxillary antrum.CLINICAL FEATURES:- Persistent unilatral foul discharge.- Post nasal drip with the discharge trickle down the phrynx from the

posterior nares resulting in foul smell and unpleasent test.- Systemic sequeles due to swallowed pus in the form of- -Pyrexia, malaise, Headache, Ansomnia,Anroxia.- Pain is diminish consiberabely.- Polyp projecting form the antrum into the oral cavity prevents thefistulous tract to heal spontaneosly.


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INVESTIGATION:- Intra oral periapical radiograph is taken with the silver probe placedinto the fistula tract to determine the frequency of the tract.

- Maxillary sinus radiograph of the skull.- Routine evalution.

MANAGEMENT

SURGICAL SUPPORTIVEMETHOD METHOD

SURGICAL METHOD


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If fistulous persist for more than 2 to 3 months the fistula tractwould have been epithelized.METHOD OF CLOSURE TECHQUINE;LACAL FLAP1. Buccal flap Buccal advancement flap- Buccal sliding trepezoid flap- Bipedic flap2. Palatal Flap- Palatal advancement flap- Palatal rotational advancement flapSubmucosal connective tissue pedicle- Pedicle island flap

- Anterior based flap3. Combination of buccal and palatal flapDISTANT FLAPGRAFT- Buccal fat pad- Bone graft.


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PRINCIPLE :1. Blood supply should be adequate so that the flap does not necrose.2. Suture line is well supported by normal bone.3. Wound is sutured in tension.4. All basic requirement should be fullfilled.

BUCCAL ADVANCEMENT FLAP: (VON REHRMANN FLAP)Described by Von Rehrmann in 1936.Mostly is used method.TECHQUINE:1. Excise the tissue lining the oroantral fitula.2. Two vertical divergent incision are made oneither side of the fistula on the buccal gingiva.3. A broad based mucoperiosteum flap then elevated from the underlying bone and flap is mobilized to cover the oroantralcommunication.

4. If the extent of the flap is inadequate the periosteum and the inner


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side of the flap may be incised horizontaly.the flap now be sutured more easiley.5. The flap is made to cover the opening and is sutured to the palataltissue.ADVANTAGE:1. Simple and easily to perform.2. Flap is usually has a good blood supply due to broad base.3. Well tolerated by the most patient.4. Denture may be placed immediatelyDISADVANTAGES:Reduction in the buccal vestibular depth.

PALATAL ADVANCEMENT FLAP:


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Procedure:The palatal tissue surrounding the oroantaral communication may beadvanced and sutured to the buccal tissue o cover the defect.The surface marking is midway between the free gingival marginand midline of the palate.The palatal mucoperiosteal flap with greater palatine vessles is raisedits bed and roteted across the fistula with greater palatine foramenas the center of rotationIncision is made with the B.P. blade no. 11, the fistulous tract at least2mm away from the epithelized surface.It is desected and removed out.

Surface line rest on the normal bone.Flap design and length of the flap are determined.Depending on the length of the flap is raised carefully since thesurvival of the flap entirely depends on the vuscularitiey.The flap is rotated buccaly with greater palatine foramen as the centreo rotation to the extent needd to cover the istula.

DISADVANTAGE:


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


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SUBMUCOSAL CONNECTIVE TISSUE PEDICLE:


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The submucosa on the palatal is used to cover the oroantralcommunication.The mucosa layer or the epithelial layeris then packed back on thedonor site.Therefore there is no row surface on the palatal unlike the previousprocedure.The dissection of the submucosa is however is difficulty procedureand required great care.

COMBINATION PROCEDURE:


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A combination has been described where in alveolar bone basedbuccal flap is reversed and sutured with palatal margin.This replace the living part of the wound.The palatal flap is rotated and palaced in the usual manner.Thus the row surface of both the flaps are placed against each other.this is two layerd closure.

DISTANT FLAP :


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Tongue Flap:Highly vascular and provide adequate bulk for the closure of largedefects without tension.Disadvantages:Mobility of the tongue which can result in failure of flap.

GRAFT PROCEDURE :


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1. Buccal fat pad- small to medium sized defect can be closed with abuccal fat pad graft.It is simple surgical technique with the donor site being closed toarea of closure.2. Bone graftAllopalstic material :- Gold foil / gold plate : Gold foil can be used to bridge between thebuccal and palatal flap till the defect heals.- soft polymethylmethacrylate- Hydroxyapatite blocks


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References

Textbook of oral and maxillofacial surgery - chitra chakravarty

Text book of oral and maxillofacial surgery - B.shrinivasan

Text book of oral medicine - Anil govindrao Ghom

Maxillary Air Sinus Oral Surgery

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