6. Paranasal Sinus Disease

Question 1

Paranasal Sinus Anatomy

Sinuses – invaginations from the nasal cavity into the surrounding ____
All sinuses are lined with ____
Shapes and sizes ____ considerably

Functions:
• ____, humidification and filtering of inspired air
• Accessory olfactory organs
• Contribute to ____ response
• Reduce skull weight
• Voice ____
• Assist with intracranial pressure regulation
• Enhance craniofacial resistance to shock

Answer 1

bones
respiratory epithelium
vary
warming
immune
resonance

Question 2

Paranasal Sinuses
• Air-filled cavities in the ____ complex
• ____ paired paranasal sinuses
• Part or all of the structures may appear on ____ commonly taken by dentists
– ____ radiograph
b – ____ radiograph

• All of the paranasal sinuses can appear
– ____ skull radiograph
– ____ cephalometric skull radiograph
3– All of ____ volumes

Answer 2

craniofacial
four
radiographs
panoramic
maxillary PA

lateral ceph
posterior-anterior
CBCT

Question 3

Lateral ceph view

• note here you can also see ____ sinus

Answer 3

sphenoid

Question 4

• Here is an example of what you ll be seeing on a day to day basis
On FMX:
• you can appreciate these maxillary posterior views, you see:
◦ ____ and a hint of the ____ ( you
will appreciate the maxillary sinus, specially in your ____ PA)

Answer 4

zygomatic process
maxillary sinus
post max

Question 5

•
On the panoramic film, you can appreciate the ____ more (in orange)
◦ there will be some ____, ghosting, and air spaces on the pano because how it matches a 3D image on a ____ image
◦ Pano is regarded as a ____. study of the sinuses. What you really wanna do is …

Answer 5

maxillary sinus
distortion
2D
prelim

Question 6

• ..is look at the sinuses w/ ____
These pics below highlight normal sinus anatomy
• Another view that you can get is a normal occlusal view ◦ this involves telling the pt to bite down on a large
____ film and we shoot the rays –> can appreciate the max sinus (orange)

• Here what dr Mel would want us to appreciate is that although this looks like pathology, it is NOT!
• #13 is root canal treated and there was an inflammation at the apex of root
◦ infiltrate from inflammation will go to the max. sinus and lift the ____ layer –> have new ____ formation
◦ NOT a pathology, sort of a reaction!

Answer 6

CBCT
occlusal

periosteal
bone

Question 7

Post-developmental pneumatization of maxillary sinus

• this is another example of something normal
• At first, she though that this was a cyst.. but in fact it is a ____ of the maxillary sinus due to an ____ space; no tooth to prevent the sinus from dipping into the empty space.
◦ this is rather extreme occurrence!

• this here. although looks like the maxillary sinus, it is actually the floor of the nasal fossa (purple)

Answer 7

pneumatization

edentulous

Question 8

MDCT - coronal views showing normal variations

• Here we have some MDCT coronal views showing some normal variations of the sinuses
(A) frontal sinus is more ____
(B).. more exuberant frontal sinus here (maybe due to different slicing, shows the frontal sinus going up)
(C) here we have a more ____ frontal sinus (blue) and enlarged ethmoid air cells (green)

These are all normal, NOT pathology!!

Answer 8

conservative

exuberant

Question 9

CBCT- ethmoid sinus anatomy

• Just to review some ethmoid sinus anatomy in CBCT
(A) this is a sagittal view; cut this way d you can appreciate the ethmoid sinus, frontal sinus, and behind that the sphenoid sinus, and the sphenoethmoidal recess
◦ You can appreciate that it is well aerated, ____ because of the
air

(B) This is an axial view; can, again appreciate well aerated sinuses: the ____ bisecting (NS, dividing the ethmoid sinus into anterior and posterior see the label)
• * –> indicates the sphenoethmoidal recess
• Can see the sphenoid sinus (labeled SpS)
• Can also see the carotid canal (labeled CC)

Answer 9

hypo dense

nasal septum

Question 10

Coronal CBCT - pneumatized lateral recesses of sphenoid sinus

• Here is a coronal CBCT –> showing *reads the title
• So you can see SpS here (see name label below) pneumatized ____
• ..and what this picture is trying to point out that the SpS is so pneumatized that ____=is bulging into the sinus.

• So this is all normal anatomy, with a lot of variations from individual to individual

Answer 10

laterally

foramen rotundum

Question 11

Hypoplastic right max sinus

• Here is an example of a hypoplastic max sinus.
◦ On the left, the maxillary sinus is normal size ( ) and
the ethmoid sinus looks well aerated
◦ on the right tho, the max sinus is ____, not well-
developed
‣ NOT a ____!! just variation from normal
anatomy

Pneumatized means larger
◦ Again, pnuematized sinuses are not due to a pathology,
just ____ from normal

Answer 11

smaller
pathology
variation

Question 12

Spheno-ethmoidal disease

• Remember in the normal CBCT, it was a little more dark cause you could see the aeration.

• Here, this is demonstrating ethmoidal sinus disease. You can see inflammation of the soft tissue, or perhaps fluid (like for example, you have a stuffy nose). Here is some anterior posterior ethmoid sinus disease.
◦ (A) In axial view –> pointed to ethmoid sinus (small white arrows)

◦ (B) In the sagittal view –> you can appreciate the presence of inflammatory fluid.
‣ points to SpS and ethmoid sinus
‣ Arrows –> pointing to the drainage; not able to ____ very well
so you have some backup of the ____ (note the grayish areas)

Answer 12

drain

mucus

Question 13

Mucositis vs Antrolith

• So what do u see in a PA film, something that you might encounter as a dentist.
• This is a a maxillary PA premolar-molar view.
Normally when you see this area (max sinus) it is more radiolucent. However, what you see here is a radiopaque area.
◦ The arrows indicate –> mucositis, a slightly ____ mucosa.
‣ Pt won’t know they have it. it tends to be an ____ finding,
when you taking a FMS. You don’t have to do ____ about it

•
So if the mucosa in pic A has mucus plugs that are ____ –> you get antrolith
◦ you might find it in the max. sinus ◦ there is no need to treat an antrolith

Answer 13

inflamed
incidental
anything
calcified

Question 14

CBCT mucositis

• The gold standard for diagnosing a mucositis is ____ and here is an axial view.
• You can appreciate that its not just on the floor of the sinus, but you see in the PA film, its following the contours of the ____ cavity

Answer 14

CBCT

max sinus

Question 15

Antroliths

• •
Here just more examples of antroliths that you may see on your ____ (more whitish compared to surrounding sinus).
You can appreciate the slight ____ areas in the max sinus

Answer 15

films

radiodense

Question 16

MDCT coronal view

• Here is an MDCT coronal view
◦ Normal max sinus on the right; well-aerated, ethmoid sinus here,
◦ On Left, you can see the mucositis (orange arrow) ◦ Antrolith (black arrow)

Answer 16

ya

Question 17

Sagittal MDCT: antrolith or ???

• On this sagittal MDCT, we have a hyper-dense area in the max sinus, do you think its an antrolith or something else??
◦ Ans: its a ____ in the max sinus
◦ you can appreciate that the tooth is not uniform in density due to its
variation in its structures (enamel, dentin,..)

Answer 17

tooth

Question 18

Tooth within the left sinus

•
How would that look (from previous slide) on a pano; you can see normal max sinus and there you see a particular dense area, with radiopacity similar to that of rest of teeth
•
◦ tooth within the left sinus (green circle)

Someone asks a question:
◦ A: for an antrolith, you have to have a history of mucositis, but you
don’t have to have mucositis concurrent with the antrolith
◦ Mucositis and the antrolith may ____; we do not treat them

Answer 18

resolve

Question 19

Dentigerous cysts with teeth in the sinus

• •
This is just to show us what dentigerous cysts looks like in the max sinus
We can see in the soft tissue window coronal view this is a tooth (in green, where arrows is pointing)
◦ Can actually say its a cyst because there is ____ in the area.
◦ Both together make a dentigerous cyst

Here is a different pt in the bone window in the axial view
We know its a cyst cause its filled w/ fluid (black arrow)
Cysts are benign; they tend to ____ adjacent structures not destroy it (unlike ____ which cause destruction of structures). Can tell that this is expanded compared to the sinus on the other side

Answer 19

fluid
expand
malignancies

Question 20

Odontoma

• This is an example of an odontoma
• Odontoma will be ____ (more white) on the
CBCT
• This is the normal max sinus and you see the odontoma here
• On the sagittal view, we can also see an odontoma

• We call it complex odontoma –> cause we do NOT see ____ within it
◦ Called compound odontoma if there IS ____ associated w/ it

Answer 20

hyperdense
teeth
teeth

Question 21

Odontoma

• This is how an odontoma looks like on a pano. Here is a rather exuberant odontoma on the left
• This will probably be complex cause I don’t see ____-like structure there

Answer 21

tooth

Question 22

CT coronal view

Here is an example of coronal CT view
Everything looks normal but in the max sinus, you notice a mucus retention cyst on the right (orange arrow):
◦ this is cyst-like; generally appears ____-like
◦ there is no ____ to it; if you sneeze or blow your nose, it might go away
◦ incidental finding

•
On the left, you can see a cyst that probably is chronic, and ultimately became ____ (green arrow)
◦ we don’t know whether its:
‣ Radicular cyst –> has ____ associated w/ it OR
‣ Residual cyst –> has no ____ associated; from a tooth that has been
extracted

mucous retention cyst
always look for the ____-like shape

calcified radicular or residual cyst
◦ radicular cyst that had been calcified
◦ looks ____ like a mushroom

Answer 22

dome
treatment

calcified
tooth
tooth

dome
pedunculated

Question 23

Bilateral mucous retention cysts

• This is how a mucous retention cyst will look like on a pano film; its pretty subtle.
• You can appreciate the dome-like appearance of the cyst (present within both max. sinuses L & R; just R circled below)
• in this case, you see the ridge; there is a lot ____ where the sinus is very close to the ridge

Answer 23

pneumatization

Question 24

CBCT & endoscopy views of left and right sinuses

• Here is an example of CBCT, and you find these strange objects in the max sinus. They don’t really look like teeth, they are quite ____ so you do an ____ ..
• each colored pic highlights the endoscopy of the right and left sides of the sinus on the CBCT
• Anybody have any idea of what these (white areas) are?
◦ what do you commonly put in the maxilla to restore a teeth and you went too far…. Ans: an implant that went wrong!!
Most common foreign body found in the maxillary sinus is an ____

Answer 24

hypo-dense
endoscopy
implant

Question 25

Paranasal Sinus Neoplasms
• Benign
– Other than inflammatory polyps, very ____
– Radiographic changes are ____
– May cause ____ of adjacent sinus borders

• Malignant
– Most common is ____
– Usually ____ sinus
– Bone ____

Answer 25

rare
non specific
displacement

squamous cell carcinoma
maxillary
destruction

Question 26

CBCT - polyp

• This is just an example of polyp in the coronal slice
◦ I think you d be able to recognize pathology, as you should look for
asymmetry, while keeping in mind your normal anatomy.
• Here you see a bleb on the side (see blue arrow)
• Nasal polps tend to be a bit ____ and may cause bone ____; should refer to an ENT and have it removed

Answer 26

reactive

reabsorptions

Question 27

Neoplasm - malignant

• Here we have max sinus malignancy. We have never seen bony destructions yet , now we see it, as shown in the white arrow pic on the Right
◦ Bony destructions the hallmark of ____

• MRI of the same pt, we can see the bony destruction
◦ We can see the tumor –> more ____ (outlined in blue, w/ white
arrow)
◦ We can also see the non-enhancing secretions –> less ____ area
filling the max sinus
◦ You can see its destroying the bone and obliterating the nasal cavity here and here
◦ when you see this, you know its not benign as in cyst- its a
____!!

Answer 27

malignancy
hyper-dense
hypo-dense
malignancy

Question 28

Trauma - blow out fracture

• Here is an example of what you might see w/ trauma
◦
a blowout fracture is when you are hit in the eye w/ an object ____ than eye.
‣ There is no space for fluid in the eyes to go other than into the ____. sinus.
‣ So the inferior border of the orbit will collapse and will look like a ____ (see the black circle on L); its supposed to be closed (compare to orbit on R) opens up after the hit and all the contents flow into the max sinus

and here is another blowout fracture, more of ____ Drop appearance (the fluid is hanging into the max sinus).
Both are coronal views.

Answer 28

bigger
max
trap door
hanging

Question 29

Status post RCT #6 with persistent pain in the right maxilla

i
• Pt presents to you w/ persistent pain in the maxilla. You take a PA and this it what you see.
◦ The pt have had a RC. You wanna make sure pain is not odontogenic in orgin.
◦ So when you take the PA, you wanna make sure that RC is well-done by looking if the apex is patent.??? (i am assuming sealed and not perforating into sinus)
‣ upon examination of the PA, this is a really good RC, and you can follow the ____ all along.
• You can see the max sinus

Answer 29

periodontal ligament

Question 30

• ..so when you take a CBCT of the pt above, you can see that the root apex is really close to the sinus (note the white dot and white arrow), but not really into the sinus yet
◦ you can see that the sinus looks a little ____ compared to the other one

Answer 30

cloudy

Question 31

Acute maxillary sinusitis

◦ ..SO what we have is acute maxillary sinusitis not caused by the tooth. the tooth looks fine and RC is well-done
◦ and when you look here, you see a sinusitis (grayish fluid in the sinus)
◦ all the pt needs is a ____ and they will be out of their pain
◦ because sometimes when you have sinusitis, you could have ____ top the teeth

Answer 31

decongestant

referred pain

Question 32

CBCT slice showing maxillary sinusitis: showing the air-fluid levels

• Here is a CBCT showing max sinusitis and its basically on both sides (note the the air-fluid levels/ black-gray)
◦ this pt has sinusitis on both the left and the right (note the gray fluid within the more hypo-dense sinus)
◦ If you can appreciate it, there is an air-bubble in the fluid on the left (green arrow) –> this is usually indicative of an ____ process

Answer 32

infectious

Question 33

Odontogenic infection

• Here we have a sinusitis that is most likely caused by a tooth –> odontogenic infection
◦ We can say that because you can see the PDL is quite ____ here (note the 3 white arrows). There seems to be something going on at the apex and the tooth has perforated the max sinus
• We can confidently say that this is ____ in origin

Answer 33

widened

odontogenic

Question 34

• A and B–> normal
◦ floor of max sinus is less than ____mm (normal limit) ◦ PDL intact not perforating the sinus
• C –> restoration and disrepair and periodical pathology
◦ infection perforating the max sinus; its right above the
tooth so we can confidently say its a sinusitis of ____ origin

• D and E –> teeth that are heavily restored and root canaled
◦ PDL looks intact; not perforating the sinus
- this sinusitis is of ____ origin

• F –> infection, heavily restored teeth and disrepair
◦ you have large sinusitis but you cannot really pinpoint
it to a tooth
◦ so this is just sinusitis of ____ origin

Answer 34

2
odontogenic
non-odontogenic
indeterminate

Question 35

Odontogenic sinusitis

• These are just some examples
◦ red arrow = carious root tips w/ peri-apical pathology in the
sinus
◦ green arrow = peri-apical pathology and badly restored teeth –>
localized thickening of the mucosa
• These both are ____ as they are associated w/ teeth

Answer 35

odontogenic

Question 36

Non-odontogenic sinusitis

• Here we have a restoration and root canal of good quality,
• NO peri-apical pathology as the apex doesn’t look like its poking
into the max sinus
• So we have a ____ sinusitis
• again air-bubbles –> where red arrow is pointing is indication of ____ process

Answer 36

non-odontogenic

infection

Question 37

Sinusitis of indeterminate origin

• You have heavily restored teeth, roots that perforate max. sinus and localization of inflammation is impossible –> sinus is completely ____ = sinusitis of indeterminate origin

Answer 37

obliterated